Oct 28, 2020
Discussing Eating Disorders in Athletes
Stacey Fairey, MPH, RD

With the uncertainty created by the COVID-19 pandemic, athletes at all levels of competition are facing challenges to their physical and mental health. Social isolation, limited access to training facilities, fewer food options, and delays of competition are just a few of the stressors impacting athletes. These disruptions may increase weight and fitness concerns, causing many to put extra focus on their eating and exercise behaviors. 

This has the potential to worsen existing eating disorders, or even cause new cases, in a group that already experiences higher rates than the general population. A recent survey of just under 6,000 NCAA student-athletes found that 11 percent and 29 percent of male and female athletes, respectively, reported disordered eating along with high levels of body dissatisfaction due to COVID-19. These rates are likely even higher when considering the wide range of athletes impacted by the ongoing pandemic.

Photo: Susan von Struensee / Creative Commons

Eating disorders have major implications on the physical health and performance of athletes, and the clinical symptoms can present differently from person to person. Electrolyte imbalances, hormonal disruptions, and repeated stress fractures and other injuries are just a few possible symptoms. Most concerning, eating disorders also have the second-highest mortality rate of all mental health disorders. This further highlights that all professionals who work with athletes have the responsibility to educate themselves on the risks, know how to identify warning signs, and offer needed support and referral as early as possible to prevent damage to both health and performance.

What Are Some Warning Signs?

One of the top contributors to the high rates of eating disorders in athletes is the pressure associated with the sport. Competitiveness and a drive for perfectionism are often expected and praised in athletes, but these traits can also trigger disordered eating and exercise behaviors that may intentionally or unintentionally lead to inadequate energy intake. The expectation to fit the idealized “athletic body” increases the risk of body image dissatisfaction, a main contributor to the development of eating disorders. Although commonly thought to only affect female athletes, male athletes are also at risk of both body image dissatisfaction and eating disorders, with almost equal rates of subclinical disordered eating behaviors as females. The highest rates have been found across both genders in weight-class sports, aesthetic sports, and sports that emphasize a lean physique. Athletes who participate in other sports are still at risk, however, and should not be overlooked.

To many, it may seem easy to identify the athlete with the eating disorder, as we tend to picture an often described thin body. But in reality, eating disorders come in all shapes and sizes and can be hard to detect. Not only may there be secrecy and shame, but fixating on food and body weight is unfortunately often normalized in sport culture. Athletes with eating disorders may be able to maintain a high level of physical performance while restricting their energy intake and reducing their body mass, and sports professionals may be the first line of defense when it comes to identifying these athletes and offering support.

Knowledge of the clinical presentations and diagnostic criteria for the most common eating disorders is important for all who work with athletes (see sidebar), but there remains a wide spectrum of disordered eating behaviors that may not match the specific criteria of an eating disorder. Athletes may not ever receive a formal diagnosis, yet they can still suffer just as severely. Some points to be on the lookout for include:

  • Elimination of certain food groups (e.g. carbohydrates, fats, etc.)
  • Intentional or unintentional inadequate caloric intake
  • Following extreme diets, or not eating in front of others
  • Obsession with healthy eating
  • Unusual weighing, or rapid changes in weight
  • Fatigue, dizziness, complaints of abdominal pain
  • Excessive and compulsive exercise
  • Changes in performance, recovery, or expected adaptation
  • Withdrawal from social activities 

Additionally, dialogue that is self-critical, focused on weight and physical appearance, and any other mood or behavior changes that seem sudden and alarming may be signs that the athlete needs help. If not already, you will encounter athletes with these behaviors, and having the confidence to recognize them, offer support, and refer when necessary can have a huge impact on both the athlete’s athletic success as well as their overall health.

So What Do You Do When You Suspect an Athlete of Disordered Eating?

Not everyone will have access to a licensed professional to treat these athletes, but there are still steps to take to ensure the athlete is seen and cared for. If possible, using a proactive screening tool within your sports medicine team can be helpful in assessing the degree of risk and treatment plan the athlete may need. For athletes who do need treatment, a multi-disciplinary team that includes a physician, registered dietitian, and psychologist is recommended to most effectively support the athlete.

In approaching the athlete, understand that this can be a sensitive topic. Be informed on eating disorders and the facts and myths on weight, nutrition, and exercise so that you can have a productive conversation. Set a time and location with privacy to create a safe environment.

  1. Use “I” statements to express your own personal concerns. “I’m worried about you, I have noticed you aren’t eating with the team.” “I care about you and your wellness. I wanted to talk about how you are doing lately.” This helps open the communication rather than making harsh statements or stating rumors shared by others.
  2. Remind the athlete you care about them. Your actions can show this too, for example by being patient and listening to what they have to say.
  3. Offer referral. Provide the athlete with outside resources and encourage them or directly assist them to seek help. Avoid offering simplistic solutions, such as, “You just need to eat more.” Be prepared for defensiveness and negative reactions, and let them know that you care and are there to help.

Equally as important as identifying these athletes is creating an atmosphere that supports positive body image and eating behaviors to prevent disordered eating practices. Professionals in sport have a tremendous influence on athletes and should be conscious of their attitudes, behaviors, and language-related to these areas. Avoid commenting on weight and physical appearance or encouraging any potentially restrictive behaviors. Instead, focus on athletic performance and abilities. While it may be tempting to praise the extra effort in the gym or the rigid training routines, be mindful of your language and emphasize the role of rest and recovery in the adaptation as much as the hard work. If there are concerns about nutrition or eating behaviors that may be out of your scope of practice, refer to a registered dietitian.

» ALSO SEE: Strength Coach Roundtable Discussion

Unfortunately, eating disorders are not new to the athlete population; however, the recognized rates during COVID-19 emphasize the role of all professionals who work with athletes to sharpen their awareness and ability to identify those at risk. It is important that we all increase our knowledge of the risks and existing resources and strive to develop an environment that supports optimal relationships with exercise and food for our athletes that will continue beyond the pandemic.

Eating Disorder Resources:

Written by a Collegiate and Professional Sports Dietitians Association Registered Dietitian (RD). To learn more about sports nutrition and CPSDA, go to www.sportsrd.org.

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