Eating Disorders Among Athletes: Diagnosis And Treatment

Eating disorders can affect people of all age groups and walks of life, including athletes. This group can face immense pressure to conform to certain body size and weight expectations and enhance their performance. Below, find statistics on eating disorders among athletes and treatment options available for this group. 

Athletes and eating disorders: Risk factors

While anyone can develop an eating disorder, some people may be faced with more risk factors, such as a personal or family history of mental illness. Anxiety, depression, or obsessive-compulsive disorder (OCD) may put individuals at a higher risk of eating disorders. In addition, research suggests that a history of trauma, abuse, or childhood obesity can also lead to a higher risk. 

Common eating disorders impacting athletes: Anorexia nervosa and bulimia nervosa 

While there are several eating disorders, anorexia nervosa and bulimia nervosa tend to be among the most common eating disorders among athletes.  

Anorexia nervosa

Anorexia nervosa is typically characterized by restriction of food intake and fear of weight gain. While some people may think they can detect anorexia in an athlete or non-athlete based only on appearance, there are specific criteria a person must meet to be diagnosed. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) lists the following criteria: 

• Restrictive eating and energy-related behaviors leading to low body weight for one’s age, gender, and developmental stage 
• An intense fear of gaining weight with behaviors aimed at doing whatever possible not to gain weight 
• Difficulty correctly perceiving how one looks concerning weight and body shape, as well as a lack of understanding of the severity of weight loss or restrictive behavior 

The DSM-5-TR also states that there are two types of anorexia: the binge eating and purging type and the restricting type. The binge eating and purging type is diagnosed when, in the last three months, a person has engaged in binging, which consists of eating an extensive amount in a short period, followed by purging through self-induced vomiting or the use of diuretics, laxatives, or enemas. A person may be diagnosed with the restricting type if there have not been recurrent episodes of binging or purging in the last three months. 

Bulimia nervosa

Bulimia nervosa is typically characterized by binge eating and purging to avoid weight gain. The following are the DSM-5-TR criteria for a diagnosis of bulimia nervosa:

• Recurrent binge eating episodes characterized by eating a significant amount of food in any two-hour period that is larger than what most individuals would eat in a similar period under similar circumstances 
• A sense that one lacks control over one's eating during the episode
• Compensating behaviors to avoid weight gain, such as the use of laxatives, excessive exercise, purging (self-induced vomiting), diuretics, fasting, medications, and other techniques 

For a diagnosis to be made, these behaviors must occur at least once a week for three months and be influenced by the desire to change one’s body shape and weight. In addition, the behavior must not be due to episodes of binge-purge-type anorexia. 

Preoccupation with food, body weight, and weight loss

Athletes who don’t meet the criteria for an eating disorder diagnosis may experience pressure to lose weight, especially at elite levels. However, pressure can occur at any competition level, including among child athletes. According to Stanford Medicine, young athletes may be more likely to develop an eating disorder if they play sports that emphasize appearance, diet, and weight requirements. The following are some examples of such sports:

• Swimming
• Diving 
• Rowing (crew)
• Running
• Beach volleyball
• Wrestling
• Gymnastics
• Dancing
• Figure skating

Behaviors associated with body weight concerns

To maintain a certain body weight, some athletes may limit their food intake to limit their calorie consumption. Limited caloric intake can lead to electrolyte imbalances, lean body mass, dehydration, loss of fat, and dehydration, which may hinder their athletic performance. 

Athletes experiencing disordered eating may also engage in compensatory behaviors to avoid gaining weight. These behaviors may include compulsive exercise, which can increase their risk of injury, including broken bones. 

Signs of eating disorders in athletes

Coaches and athletic staff members may not always notice warning signs of eating disorders, as athletes may engage in certain behaviors in secret. However, coaches, parents, or loved ones may still notice signs. The following are a few possible signs of eating disorders in athletes:

• Changes in body weight
• An obsession with weight loss
• Changes in hair, skin, or nails
• Gastrointestinal problems
• Muscle cramps
• Problems with teeth
• Amenorrhea (missed periods)
• Skipped meals
• Frequent use of the restroom

How to talk to an athlete about an eating disorder

Coaches, parents, and loved ones may not know how to communicate with an athlete who may be experiencing an eating disorder. The topic can be a challenge to address. However, there may be ways to caringly broach the topic without hurting the person, including the following techniques. 

Avoid talking about appearance, body weight, or weight loss

While family and friends may be tempted to tell someone with an eating disorder that they look thin, try to avoid making comments about appearance. Such comments may incite harmful thoughts about food and exercise, which could lead to further behaviors to lose weight. 

Use “I” statements when discussing food or other concerns

Even if someone has proof of disordered eating, avoid making accusations. The National Eating Disorders Association (NEDA) suggests that rather than accusing a person of not eating, begin with “I” statements, such as “I have missed seeing you at dinner lately.” Doing so may make the person understand others’ concerns about them without believing they are being accused.

Be prepared for defensiveness before discussing athletes and eating disorders.

Another strategy the National Eating Disorders Association recommends is for loved ones to prepare for negative reactions. Some people may react with anger if they are approached about possible signs of an eating disorder. Coaches and loved ones can prepare themselves by knowing this can be a common reaction that has nothing to do with them. They can still communicate their concern in a non-judgmental way. 

Getting help for eating disorders

Athletes may benefit from speaking with a doctor about eating disorders. A doctor may be able to provide personalized recommendations that take into account nutrition and energy expenditure during training. They may also recommend speaking with a registered dietitian and a therapist during recovery. 

Therapy for athletes with eating disorders

A therapist can guide athletes through any underlying concerns about stress, performance, and body image that may be contributing to eating disorders. Therapists may use cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), interpersonal therapy, or other approaches for various eating disorders, such as anorexia, bulimia, or binge eating disorder. Some therapists may also use family-based therapy to include an athlete’s family in the treatment process.

Alternative therapy for athletes at risk of eating disorders

For athletes who don’t have time for traditional in-person therapy, online therapy through a platform like BetterHelp may be a more convenient option. This option can allow them to connect with a licensed therapist from home or anywhere with an internet connection via audio, videoconferencing, or live chat. Also, online therapy allows athletes to contact their therapist through in-app messaging, and the therapist can respond when they are available. This option may prove to be helpful for athletes who experience stress or concerns about food or body weight in between therapy sessions. 

Research shows that online therapy can be effective for individuals experiencing eating disorders. One study published in 2022 looked at the effectiveness of telehealth therapy for eating disorders, substance use disorders, child mental health conditions, and chronic conditions. The study found no significant differences between telehealth and traditional in-person therapy regarding symptom severity, including at follow-up.