Signs And Symptoms Of Eating Disorders In Female Athletes

Eating disorders often involve unhealthy eating-related behaviors stemming from a preoccupation with body weight or shape. These eating disorders tend to be more common among adolescent girls and young adult women, largely because of societal pressure for women to look a particular way to meet beauty standards. 

In girls and women who are also athletes, this pressure can be coupled with additional pressure to meet standards related to their sport and to perform well in competitions. As a result, female athletes in many sports tend to experience a higher rate of disordered eating than their non-athlete counterparts. 

In this article, we share more specific reasons female athletes may develop an eating disorder, identify common eating disorders in female athletes, and discuss eating disorder signs in female athletes. Identifying and treating eating disorders as early as possible can be crucial due to the potential health consequences. Eating disorders can wreak havoc on the body and mind, and they are the mental health disorders with the highest mortality rate. If you’re living with an eating disorder, consider reaching out to a licensed mental health professional for guidance and support.

Reasons female athletes may develop an eating disorder

In general, adolescent girls and young adult women are the groups of people most likely to develop eating disorders. Some research suggests that eating disorders can be even more common in female athletes, potentially due to the following factors: 

• Ideal body for sport: What is currently viewed as the ideal body size and shape for athletes in a specific sport may make eating disorders more common among the athletes who compete in that sport. For example, being slim or petite may be particularly valued in distance running, gymnastics, and figure skating. Female athletes in these sports may experience more pressure to maintain a lower body weight than those who play sports where a larger size is more common, like volleyball or basketball.
• Individual sport type: Research has found that athletes participating in individual sports may be more likely to develop eating disorders than those participating in team sports. Individual sports include running, cycling, swimming, and triathlons, among others. Sports that have weight categories may also increase disordered eating, as the athletes are often incentivized to lose weight in order to qualify for a lower weight bracket. 
• Sports uniforms: Sports with more revealing uniforms may promote a specific body ideal and affect an athlete's body image. Research has found that athletes with a negative body image tend to be more likely to develop an eating disorder. Sports that involve revealing uniforms typically include swimming, running, gymnastics, and figure skating.
• Coaching style: Research suggests that the way a person's coach trains them may influence whether they develop an eating disorder. A coach focusing more on performance than on the person may increase the risk of eating disorders. Similarly, having conflicts with a coach may increase the risk of eating disorders. Finally, a coach who focuses on weight or pushes strict eating habits may lead an athlete to engage in disordered eating.
• Puberty: Sometimes, eating disorders in female athletes develop around puberty, as the athletes attempt to stave off the weight gain associated with the natural biological changes that usually happen at that time. Approximately one-third of the weight gain during puberty is fat, so female athletes may turn to disordered eating to prevent this fat gain and maintain the aesthetic ideal within their sport.
• Performance level: As an athlete begins to compete at higher performance levels, the pressure on them may increase and, in turn, the risk of an eating disorder may rise. However, disordered eating generally leads to a decrease in both energy and muscle, which tends to negatively impact performance.

Common eating disorders in female athletes

Three eating disorder categories may be most common among female athletes: anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified. While updated evidence may be needed, researchers have found that around 15% to 31% of athletes experience these disorders, compared to 5% to 13% of the general population, with females usually facing higher rates than males. We explore what each type of eating disorder entails.

Anorexia nervosa

People with anorexia nervosa may greatly restrict their food intake relative to what their body requires, which typically causes weight loss. Anorexia nervosa normally involves a fear of weight gain, along with a distorted body image. Often, a person with anorexia nervosa cannot recognize that they have become underweight (although not everyone with anorexia is underweight). In some cases, a person with anorexia nervosa may also binge and purge.

Some experts use the non-clinical term "anorexia athletica" to describe athletes who have some symptoms of anorexia nervosa, but do not meet diagnostic criteria. People with anorexia athletica usually still restrict their food intake, but not to the point that it negatively impacts their athletic performance. They may experience negative effects of low energy intake, such as the loss of menstrual periods (amenorrhea) or lower bone density.

Bulimia nervosa

Bulimia nervosa generally involves binge eating, followed by behavior meant to compensate for the binge eating and prevent weight gain. Compensatory behaviors may include vomiting, taking laxatives, fasting, or over-exercising. While binge eating, a person with bulimia nervosa often senses they are out of control and that they cannot stop eating. Afterward, they may feel guilty or ashamed for having eaten so much.

Other specified feeding or eating disorders (OSFED)

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the category of “other specified feeding or eating disorders (OSFED)” includes disordered eating behaviors that do not meet the criteria of established eating disorders or have detailed diagnostic criteria of their own, but that can still seriously affect a person. 

People who have symptoms of anorexia nervosa but are not underweight can fall into this category and may be given the label of “atypical anorexia nervosa.” Similarly, people who binge eat and engage in compensatory behavior but don't fulfill all the criteria for bulimia nervosa may fall into this category.

Although it's not listed in the DSM-5, many experts view orthorexia as a type of OSFED. In general, orthorexia is an eating disorder in which a person becomes obsessively focused on healthy eating. They may eliminate entire food groups or only eat foods that meet their specific criteria in terms of ingredients, ingredient sourcing, or processing, while viewing all other foods as unhealthy.

Signs and symptoms of eating disorders

The most common signs and symptoms of eating disorders usually involve a preoccupation with weight loss, food, dieting, or calorie counting, along with excuses to avoid eating around others, unusual food rituals, noticeable weight changes, and gastrointestinal complaints. 

Since some of these symptoms can be more common among athletes, screenings for physical health problems are sometimes what uncover eating disorders in this group. 

How eating disorder signs and symptoms can go unrecognized in female athletes

Eating disorder signs and symptoms may go unrecognized in a female athlete when the signs and symptoms are considered normal for their sport. For example, calorie counting or macronutrient tracking probably won't be viewed as a symptom of a disorder if it's part of a plan given to an athlete by their coach or trainer. 

Similarly, avoiding certain food groups or engaging in eating patterns that are unusual in the general population wouldn't necessarily be viewed as unusual if all of an athlete's peers are doing the same thing.

Body image in female athletes

As previously mentioned, a negative body image is often linked to eating disorders in female athletes. Girls and women, in general, tend to face the risk of developing a negative body image due to a culture that typically promotes thin and often unrealistic beauty standards. Athletes may face a more specific risk if they participate in a sport with specific thin body ideals, like distance running, figure skating, or gymnastics. Messages about the ideal body for their sport may come from the media, peers, parents, significant others, and coaches.

Building a positive body image

Some research suggests that physical activity can be linked to a positive body image. However, this may depend on the type of physical activity and the context in which it is engaged. People participating in physical activity for their own enjoyment and health may experience a more positive body image than those engaging in physical activity to achieve a certain body ideal. Coaches and athletes may be able to foster a more positive body image among female athletes by changing the conversations within their sport and reducing talk related to weight and size.

Eating disorders and the female athlete triad

The concept of the "female athlete triad" often arises in conversations about eating disorders among female athletes. Sports medicine has identified this phenomenon, which can cause long-term damage to a female athlete's health. The female athlete triad is a condition that often goes together with disordered eating and involves the following three criteria:

1. Low energy availability: When an athlete doesn't eat enough to properly fuel their body given the activity in which they engage, they typically experience low energy availability. Many people with eating disorders are at risk of low energy availability.
2. Menstrual dysfunction: When energy stores are low or a person experiences low body fat, hormones can be affected. These hormonal changes can result in changes to the menstrual cycle or complete amenorrhea, when menstrual periods stop.
3. Low bone mineral density (BMD): Low energy availability and changes in hormones can also impact the bones, decreasing their density. Low bone density generally increases the risk of fractures.

Eating disorders and relative energy deficiency in sport (RED-S)

Research on the female athlete triad led to the recognition of another overlapping condition that is a bit broader in its criteria. Relative energy deficiency in sport (RED-S) generally stems from low energy availability, which can result from disordered eating. 

While the female athlete triad makes clear that low energy availability can lead to an energy deficiency, menstrual dysfunction, and low bone mineral density, RED-S encompasses the many other potential negative effects of low energy availability. 

For example, RED-S may involve negative impacts on the endocrine, cardiovascular, gastrointestinal, metabolic, and immunological systems, among others. Female athletes with RED-S tend to be more likely to be injured, develop severe medical issues, and experience decreased performance quality.

Therapy for eating disorders

If you suspect you have or may be at risk of developing an eating disorder, therapy is an option you could consider for support. Remote therapy, in particular, can empower you to talk with a therapist from the safe space of your choice without having to travel to an office. BetterHelp is a remote therapy platform that can usually connect you with a licensed professional in as little as 48 hours.

Research on eating disorders and therapy

Researchers haven't focused much on remote therapy for treating eating disorders in athletes. However, some studies have focused on therapy more generally for athletes. A 2023 systematic review on nutrition counseling looked at 10 studies, including several that involved cognitive behavioral therapy (CBT) and other psychotherapy techniques. The study authors concluded that cognitive behavioral therapy was the most common technique for treating eating disorders in athletes, and that treatments usually led to improvement in eating disorder symptoms among athletes with eating disorders. 

Additional research suggests that online CBT tends to be just as effective as its in-person counterpart, which could mean that online treatment for eating disorders can produce the same outcomes as traditional in-office treatment.