MEDICALLY REVIEWED BY ALIDA IACOBELLIS, REGISTERED DIETITIAN (RD), MHSC

WRITING AND RESEARCH CONTRIBUTIONS BY ADELE Lewis

When athletes sign up to participate in sports, they expect to gain many benefits. Some include physical fitness, being a part of a team, enhancing their skills, and building self-esteem [1]. Many don’t know that they are also signing up for an increased risk of developing a serious mental health diagnosis – an eating disorder. 

For athletes, admitting that they are struggling and asking for help can mean they are sidelined in training or may even lose their spot on a team. This can come with financial repercussions such as losing sponsorship or a scholarship. The stakes can be incredibly high. The stigma surrounding mental health is a further barrier to coming forward. 

It wasn’t until recently that the issue of eating disorders in athletes made headlines. This was after a few incredibly brave Canadian athletes came forward and shared their stories. You can read them here, here, and here. 

Eating Disorders in Athletes Statistics

Up to 45% of female athletes and 19% of male athletes suffer from an eating disorder [2]. These numbers are far larger than the 2-3% we see in the general population [3,4]. 

Research suggests that athletes are at a greater risk for eating disorder development for a number of reasons. Some include chronic dieting, perfectionism, injuries, and the age at which the athlete starts training for a sport. An eating disorder-informed support system is key to helping the athlete develop healthy habits, while also minimizing their eating disorder risk. 

Sport Culture and Eating Disorder Risk 

The daily training environment can heavily influence an athlete’s relationship with food and their body. For example, an athlete may learn helpful lessons about the importance of proper nutrition and hydration. They may even develop an appreciation for their health and wellbeing if a coach and/or parent prioritizes these things alongside performance. 

However, sport culture’s emphasis on performance above all else can often result in a lack of focus and attention on the bigger picture of an athlete’s overall health and wellbeing. This mentality can quickly lead to obsessive and extreme weight manipulation tactics, eating habits, and exercise regimens disguised as pursuing excellence and optimizing performance. This in part, explains the increased number of eating disorders seen in athletes compared to the general population.

Pressure around weight 

Many athletes experience pressure to have a specific body weight and/or shape that will provide a competitive advantage in their sport. This is due to the common belief that the lower an athlete’s body weight and body fat, the better they can perform. As a result, athletes are often pushed to alter their body composition at the expense of their health [1]. Sometimes this ‘ideal’ body weight/shape is at odds with what is healthy for the athlete.

This pressure around weight can sometimes come from coaches, but it can also come from athletes comparing themselves to others in their sport who are competing at the highest level. It’s easy to assume that if you look like the person winning gold medals, you too will have a better chance at those medals yourself. 

Coaches, judges, family members, and peers may unknowingly encourage and normalize disordered eating behaviours by praising and complimenting weight loss and appearance. This positive reinforcement only encourages the athlete to keep doing what they are doing – even if it is disordered. This culture makes it challenging for them to recognize that what they are doing is harmful and eventually seek help before the disorder progresses [5].

Body composition testing 

Athletes are exposed to an increased focus and attention on their bodies through comments from coaches, judges, and routine body composition testing. This is especially an issue in sports that require athletes to attain a certain weight to compete and ones that judge physical appearances as part of competition scoring. Some examples include dance, gymnastics and bodybuilding. 

Body composition testing is another common aspect of sports culture. This involves measuring the amounts of different types of tissues in the body, including bone, fat, and lean mass, also known as muscle. Body composition testing can be done by using a bioelectrical impedance scale, DEXA scan, skinfold measures, or a BOD POD to name a few examples. 

Body composition testing can provide helpful information for the athlete and their support system to make changes to diet and training to optimize performance. At the same time, the process of going through these tests and seeing the results can also come with some risks, especially when being done on adolescent athletes. In order to minimize risk, it is important that athletes be screened for disordered eating habits and body image concerns before being subject to body composition testing to determine whether or not it is safe and appropriate.

The dark side of sport culture 

Sport culture can push some athletes to turn to disordered eating behaviours. These can include highly restrictive diets, excessive exercise routines (even beyond what is recommended by coaches), self-induced vomiting, and the abuse of supplements to change body composition [6,7]. 

Individual behaviours like these do not fit the full criteria for an eating disorder diagnosis, but they increase the athlete’s risk of developing one down the road. Without proper treatment and early intervention, eating disorders can negatively impact the mental and physical health of athletes, as well as their ability to perform. 

Read on to learn about other risk factors, signs and symptoms of eating disorders in athletes, and what you can do to help.  

7 Factors that Increase Athletes’ Risk of an Eating Disorder

There is no single cause of eating disorders among athletes. There are a number of different factors that put an athlete at an increased risk compared to the general population [5]. 

1. Sport Type

Athletes who participate in sports that emphasize appearance and leanness have a higher eating disorder risk than other sports types [1,5,8]. These are called aesthetic and weight class sports. Aesthetic sports types focus on the athlete’s appearance. Some examples include gymnastics, figure skating, dance, and diving. On the other hand, weight-class sports require athletes to attain a specific weight to compete. Some examples are rowing, weight lifting, taekwondo, sailing, and wrestling [1,5]. 

Staying in a certain weight class or making weight for a competition can provide real and perceived performance advantages for athletes. However, if the athlete is only able to achieve this weight by means of disordered eating behaviours, they are putting their mental and physical health at risk. And when mental and physical health is impacted, performance will also eventually suffer [1,8]. 

2. Gender

Athletes of all gender identities are at risk of developing eating disorders. Despite this, there is a widespread stereotype that eating disorders mainly occur in girls and women. This makes it hard for people who fall outside of the stereotype like men, transgender and non-binary folks to recognize they are struggling and get the help they deserve. 

Eating disorders in males

Cis-gender male athletes’ unique experiences are often overlooked because eating disorder awareness is generally centred around women’s experiences [9].  Cis-gender female athletes are more likely to pursue thinness and are most at risk in aesthetic sports types. Men are more likely to experience muscle dysmorphia, which is the preoccupation with being more muscular and lean [5]. Muscle dysmorphia can lead to extreme dieting behaviour, over-exercising, and the use of steroids and other drugs to increase leanness and muscle mass. 

Unfortunately, men also face multiple barriers in seeking eating disorder treatment [6,7,9]. Men who do seek help have reported facing dismissal, stigmatization and lack of awareness from health professionals [9]. This often results in the eating disorder being left untreated until the symptoms impact their health or performance to an even greater extent [9]. 

Eating disorders in transgender, non-binary, and others on the gender spectrum

People in the LGBTQIA+ community such as transgender, non-binary, and others on the gender spectrum are more likely to struggle with an eating disorder compared to their cisgender counterparts [10]. Research shows that they engage in more disordered eating behaviours like fasting, restricted eating, binging, purging, and the use of diet pills, laxatives and steroids to alter their body [10].

Added stress from stigma, discrimination, body dissatisfaction and gender dysphoria all increase their eating disorder risk. Although there is limited research available on non-binary groups and others on the gender spectrum, transgender individuals have been shown to struggle with body dissatisfaction, which increases the risk of eating disorder development. 

This is related to gender dysphoria, which describes the distress experienced when one’s gender identity and outward appearance do not match. For example, a transgender woman with a larger body frame may experience dysphoria. To suppress characteristics related to her birth sex and align more with her true gender identity, she may engage in disordered eating patterns to shrink her body [10]. 

3. Stage of Growth and Development

The younger an athlete starts training for a sport, the higher their risk of developing an eating disorder. Children and adolescents are in an impressionable stage of life where they are especially vulnerable to sports culture and the messages they receive in their daily training environment [5]. 

Going through puberty puts young athletes at increased risk due to it being a time of transition with body changes, including height and weight gain. Body size and composition changes often lead to changes in performance and feelings of fear and loss of control. To numb intense emotions and regain a sense of power, young athletes may turn to disordered eating behaviours. The likelihood of a young athlete engaging in disordered eating is higher when they have seen a fellow teammate engaging in similar behaviours.

4. Chronic Dieting 

Long-term dieting increases an athlete’s risk for eating disorder development [5]. This may look like calorie counting or tracking every bite of food in an app, measuring and weighing portions, skipping meals, or cutting out specific foods or larger groups of foods like carbs or fat. This is incredibly common in some sports types, with up to 94% of elite athletes in weight class sports and 40% in aesthetic sports resorting to disordered eating behaviours to achieve a competitive target weight [11]. 

An athlete who experiences their first weight loss may see a slight increase in performance, and receive positive feedback from peers and coaches, which can lead them to engage in a vicious cycle of chronic dieting. If they lose weight and don’t see any performance improvements, the athlete may mistakenly think that they didn’t lose enough weight and double down on their efforts to lose even more [5]. The effects of disordered eating behaviours go beyond one athlete. Other athletes on the team who observe this initial success may model these behaviours in hopes that they will have similar results [5]. 

5. Perfectionism 

Perfectionism is a common personality trait found in both athletes and people with eating disorders [5]. Some of the traits that can make an athlete great at their sport can also contribute negatively to their body image and lead to disordered eating. Drive for perfection can lead athletes to develop rigid beliefs and behaviours about appearance, what they eat, and how much they work out in order to influence their body image or enhance performance. 

There’s a difference between striving for excellence and full-blown perfectionism. Athletes who strive for excellence have realistic standards and are okay with not always being the best at what they do. They have rational beliefs about exercise and experience a motivating and self-satisfying process of athletic growth. On the other hand, athletes who are perfectionistic strive for unreachable goals and need to always be the best. This comes with an intense fear of failure, black and white thinking, and irrational beliefs about exercise.

6. Injuries

Injured athletes who are not able to train for weeks or months may experience weight gain and changes in body composition. To cope and gain a sense of control, these athletes may turn to disordered eating behaviours [5]. In turn, disordered eating behaviours increase an athlete’s risk of developing more injuries down the line and can slow down the recovery and rehabilitation process. 

7. Body dissatisfaction 

Athletes often find themselves stuck between wanting to look more athletic because it gives them credibility in their sport, and also wanting to match the ideal beauty standards. The standards of beauty seen throughout popular culture are constantly changing and don’t often match up with an athletic body type. This can make it hard for athletes to feel confident and satisfied with the way they look.

To find some relief from this body dissatisfaction, athletes may enter into a cycle of over-exercising and restrictive eating, which ultimately increases their risk for eating disorder development. Contrary to popular belief, body image concerns do not disappear when weight loss occurs. However, weight loss can come with external validation from peers, teammates and coaches, which ultimately reinforces disordered eating behaviours [1,5]. 

Warning Signs and Symptoms of Eating Disorders in Athletes 

Spotting the warning signs and symptoms can help detect an eating disorder early on, making treatment and recovery easier [12].

An athlete with an eating disorder may experience decreased: [1]

• Concentration
• Energy
• Body weight
• Body fat percentage
• Muscle function
• Coordination
• Speed 
• Endurance  
• Heart rate
• Blood pressure 
• Body temperature 
• Involvement with coaches and teammates 
• Regularity of periods  

An athlete with an eating disorder may experience increased:  [1]

• Rapid shifts in weight 
• Frequency of injury including muscle strains, sprains, and/or fractures  
• Sensitivity to cold (cold hands and feet, or always needing to wear many layers of clothing)  
• Dental erosion and/or avoidance of dental visits 
• Light-headedness, dizziness
• Preoccupation with food and/or avoidance of certain foods 
• Body image concerns
• Use of weight-loss drugs (laxatives, diuretics, steroids, stimulants and appetite suppressants)
• Frequency of weight-monitoring or body composition testing
• Fatigue 
• Dehydration, electrolyte imbalance 
• Muscle cramps 
• Length of time needed to recover after activity
• Binge eating 
• Abdominal pain  
• Impatience, agitation, social isolation  
• Excessive exercise/difficulty taking days off from exercise 
• Avoidance of water or excessive water intake 

The Impact of Eating Disorders on Athlete Well-being and Performance

Eating disorders can seriously affect an athlete’s health and sport performance [6,12]. If an athlete isn’t eating enough, the body does not have enough energy to support everyday body functions on top of the demands of sport [6]. In adolescents, this can result in delays in their growth and development. When the body isn’t provided with enough energy to support its needs, this puts the body under a lot of stress and can cause a condition called RED-S which stands for Relative Energy Deficiency in Sport. RED-S results in a range of physical, mental, and sports performance effects. 

​​Physical Health

• Low bone mineral density
• Stress fractures
• A weakened immune system
• Gastrointestinal discomfort
• Low heart rate
• Loss of menstrual period 
• Muscle loss [13] 

Mental Health

• Depression
• Anxiety
• Irritability
• Reduced ability to manage stress
• Social insecurity
• Introversion
• Fears of weight gain
• Eating disorders [13] 

Sport Performance 

• Early fatigue
• Poor recovery from training
• Frequent or recurring injuries
• Dehydration and electrolyte imbalances
• Decreased strength, power, endurance
• Reduced coordination and concentration [14,15]

Read on for tips on how you can minimize eating disorder risk in athletes as a parent or coach, and what to do if you suspect an athlete is struggling. 

The Role of Coaches in the Prevention of Eating Disorders

Coaches and parents play a huge role in creating a healthy sport environment [1,5]. For example, some research shows that coaches who mainly focus on performance and an athlete’s body weight can increase the risk of body image issues and restrictive dieting  [1,5]. In contrast, a supportive coaching style that focuses on the athlete as a whole person and supports their efforts regardless of the results may reduce the risk of them developing an eating disorder [1]. 

Coaches are in close contact with athletes and can help identify warning signs that may indicate an eating disorder. Observant coaches may notice a change in the athlete’s diet, decreases in performance and increased rates of injury, which may prompt them to address this with the athlete [15]. 

It’s very important to identify eating disorder warning signs as soon as possible. The longer an eating disorder goes on, the more difficult the recovery is for athletes [1]. If not addressed early on, disordered-eating habits can become pervasive in a team [1]. 

Reducing Eating Disorder Risk in Athletes: Tips for Coaches and Parents

What to do: 

• Take warning signs and eating-disordered behaviours very seriously [1]. 
• Monitor warning signs and help them access resources for treatment when needed [8].
• Set realistic, individual goals with each athlete. 
• Focus on enhancing aspects of performance other than weight such as motivation, strength and endurance.
• Remind the athlete that becoming thinner does not necessarily equal stronger, faster, or more agile, and proper nourishment is what’s important for long-term improved performance [8]. 
• Encourage your athletes to strive for balance rather than perfection in exercise and eating. 
• Prioritize an athlete’s health and well-being over their performance [1].

What not to do:

• Make comments about the athlete’s body, even if you intend to complement them. 
• Make comparisons between athletes in terms of their diets and body size or shape. This can cause other teammates to experience “competitive thinness”. 
• Advise athletes to change their weight to improve performance. 
• Dismiss an athlete’s warning signs and eating-disordered behaviours [1]. 

How to Approach an Athlete You Suspect May Be Struggling with Food and Body Image

• Approach them sensitively in a private place. Express your concerns about the behaviours that you have been noticing.
• Withhold judgment and criticism. Emphasize your priorities as worrying about their  well-being.  Your goal should be to guide the athlete in getting help.
• Help support them in seeking treatment. Refer them to a healthcare expert who specializes in eating disorders. This can include physicians, therapists, and dietitians [1].

What to do if an Athlete Refuses Help (CARE)

• Communicate openly with your athlete, and ask them what they think would help with their recovery.
• Advocate for the athlete’s health by connecting with the treatment team to explore some options. Ask about the possibility of temporarily suspending participation until the athlete can safely participate. If you are still unclear, get a second opinion. 
• Reassure the athlete that this is not a punishment, and their position on the team will not be threatened by getting help.  
• Emphasize that their health is your priority, and is more important than the sport [1].

The Bottom Line 

Involvement in sports can be an extremely enriching and health-promoting experience for athletes. At the same time, there are many aspects of the daily training environment and sport culture that can promote unhealthy behaviours around food and exercise, leading to eating disorders. 

Parents and coaches should carefully monitor their athlete’s behaviours in case they become obsessive or are taken to an extreme. If you notice warning signs that may indicate an eating disorder, don’t delay in addressing this with your athlete and helping them get the support they need. 

Athletes should be reminded that becoming thinner, leaner, or more toned does not necessarily equal stronger, faster, or more agile. It’s important to create a sport culture where focusing on mental and physical health is seen as a way to elevate performance and not something that distracts from it.

Eating Disorder and Body Image Resources for Parents and Coaches

Body Positive Guidelines

A PDF guide developed by Skate Canada. While this resource is sport specific, it provides helpful information about fostering positive body image in athletes, as well as key considerations for adolescent athletes who are growing that can be applied across many different sports. You will also find tips around language and communication as well as recommendations to help prevent the development of eating disorders in athletes.

https://skatecanada.ca/wp-content/uploads/2020/09/BodyPositiveGuidelines_EN_Dec2.pdf

BodySense: A Positive Body Image Initiative for Athletes

A website with great resources and tools to help support the development of positive body image and promote the building of safe and healthy sport environments. BodySense is offered jointly by the Canadian Centre for Ethics in Sport and the True Sport Foundation.

www.bodysense.ca

Hungry for Gold

A video series developed by the International Olympic Committee aimed at athletes, parents, coaches and support staff. Through the experiences of fictional athletes, viewers can learn about healthy eating and exercise habits, understand the importance of a healthy body image, and find out how to prevent the development of the female athlete triad (RED-s).

https://www.olympic.org/hbi

Long Term Athlete Development Model 

A PDF guide developed by Sport for Life. This resource provides a framework for the development of every child, youth, and adult to enable optimal participation in sport and physical activity. The objective of the framework is to promote both sporting excellence at the highest international level and life-long engagement in health-enhancing physical activity.

https://sportforlife.ca/portfolio-view/long-term-development-in-sport-and-physical-activity-3-0/

RED-S Screening Tool

A clinical assessment tool for the evaluation of athletes and active individuals suspected of having RED-S and for guiding return to play decisions. This tool is designed for use by a medical professional in the clinical evaluation and management of athletes with this syndrome. The diagnosis of RED-S is a medical diagnosis to be made by a trained health care professional.

https://bjsm.bmj.com/content/bjsports/49/7/421.full.pdf 

Eating Attitudes Screening Tool

This is a screening measure to help you determine whether you might have an eating disorder that
needs professional attention. This screening measure is not designed to make a diagnosis of an eating disorder or
take the place of a professional consultation.

https://www.seattlechildrens.org/globalassets/documents/healthcare-professionals/pal/ratings/eat-26-rating-scale.pdf 

Safe Exercise at Every Stage

Guidelines developed to help address and safely mange dysfunctional exercise during the treatment of an eating disorder. Developed for use by clinicians in determining the level of exercise appropriate for each individual based upon their current level of physical and psychological well-being.

https://www.safeexerciseateverystage.com/access-sees-guidelines

REFERENCES 

[1] Matsumoto, N. (n.d). Coach and Athletic Trainer Toolkit. National Eating Disorders Association.  Retrieved from: https://www.nationaleatingdisorders.org/sites/default/files/nedaw18/3.%20CoachandTrainerToolkit%20-%20Copy.pdf 

[2] Conviser, J. H., Schlitzer Tierney, A., Nickols, R. (2018). Essential for best practice: treatment approaches for athletes with eating disorders. Journal of Clinical Sports Psychology, 12.

[3] National Initiative for Eating disorders. (2016).  Eating disorders in Canada. National Initiative for Eating disorders. Retrieved from: https://nied.ca/about-eating-disorders-in-canada/ 

[4] Canadian Mental Health Association. (n.d). One Size Doesn’t Fit All. Canadian Mental Health Association. https://cmhakelowna.com/eating-disorder-awareness-week/ 

[5] Bratland-Sanda, S., & Sundgot-Borgen, J. (2013). Eating disorders in athletes: Overview of prevalence, risk factors and recommendations for prevention and treatment. European Journal of Sport Science, 13(5), 499-508. https://doi.org/10.1080/17461391.2012.740504

[6] Eichstadt, M., Luzier, J., Cho, D., & Weisenmuller, C. (2020). Eating Disorders in Male Athletes. Sports health, 12(4), 327–333. https://doi.org/10.1177/1941738120928991 

[7]  Karrer, Y., Halioua, R., Mötteli, S., Iff, S., Seifritz, E., Jäger, M., & Claussen, M. C. (2020). Disordered eating and eating disorders in male elite athletes: a scoping review. BMJ open sport & exercise medicine, 6(1), e000801. https://doi.org/10.1136/bmjsem-2020-000801 

[8] Mancine, R.P., Gusfa, D.W., Moshrefi, A. (2020). Prevalence of disordered eating in athletes categorized by emphasis on leanness and activity type – a systematic review. Journal of Eating Disorders, 8, 47 retrieved from:https://doi.org/10.1186/s40337-020-00323-2

[9] Bomben, R., Robertson, N., & Allan, S. (2021). Barriers to help-seeking for eating disorders in men: A mixed-methods systematic review. Psychology of Men & Masculinity, https://doi.org/10.1037/men0000382

[10] Parker, L.L., Harriger, J.A. (2020). Eating disorders and disordered eating behaviors in the LGBT population: a review of the literature. Journal of Eating Disorders,  8, 51. https://doi.org/10.1186/s40337-020-00327-y 

[11] Coelho, G. M., Gomes, A. I., Ribeiro, B. G., & Soares, E. (2014). Prevention of eating disorders in female athletes. Open access journal of sports medicine, 5, 105–113. https://doi.org/10.2147/OAJSM.S36528

[12] Baldó Vela, D., Villarino Marín, A. L., Bonfanti, N., & Lázaro Martínez, J. L. (2021). Prevalence of eating disorders on male team sports players. BMJ open sport & exercise medicine, 7(4), e001161. https://doi.org/10.1136/bmjsem-2021-001161 

[13] Mountjoy M., Sundgot-Borgen J.K., Burke L.M. (2018). IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. British Journal of Sports Medicine, 52:687-697. 

[14] El Ghoch, M., Soave, F., Calugi, S., & Dalle Grave, R. (2013). Eating disorders, physical fitness and sport performance: A systematic review. Nutrients, 5(12), 5140-5160. https://doi.org/10.3390/nu5125140

[15] Mancine, R., Kennedy, S., Stephan, P., & Ley, A. (2020). Disordered Eating and Eating Disorders in Adolescent Athletes. Spartan medical research journal, 4(2), 11595. https://doi.org/10.51894/001c.11595