Eating Disorders in Female Athletes
Content warning: Discussion of eating disorders, body image, and weight
Participation in sports has countless benefits for physical and mental health. However, athletes — particularly female athletes — are at increased risk for eating disorders.
“There’s a focus on thinness and fitness in the general population, especially for women. Female athletes have the additional pressures of performing well. They are encouraged to train hard, build muscle, and lose fat,” says Kendra Becker, PhD, a Mass General Brigham clinical psychologist for the Women’s Sports Medicine Program and director of translational research for the Eating Disorders Clinical and Research Program at Massachusetts General Hospital.
Anorexia nervosa and bulimia nervosa, two eating disorders defined by body image dissatisfaction, affect approximately 1.6% of U.S. adults and about 2% of U.S. adolescents. Among female athletes, those numbers increase dramatically — as high as 42% — depending on age, type of sport, and competitive level. Furthermore, up to 70% of female athletes may engage in behaviors that can develop into an eating disorder, such as restricting food and trying to lose weight.
Athletes most at risk for eating disorders
Female athletes are at higher risk for eating disorders if they participate in a sport with a focus on individual performance. Examples include running, swimming, cycling, and cross-country, where having a lower body weight may be considered an advantage.
Another risk factor is participation in sports with a subjective or judging component, including ballet, gymnastics, diving, and figure skating. In addition, the more competitive a person is at a higher level, the more likely they are to be seeking every advantage, such as weight loss.
“People who are very dedicated to their sport are really trying to become better and better at this activity. They’re correcting minor flaws in their execution and performance. That can lead to a heightened risk for perfectionist thinking and disordered eating,” Dr. Becker says.
On the other hand, team activities such as volleyball and softball can have a protective effect against eating disorders, she adds.
Health consequences of restrictive eating in athletes
Dr. Becker emphasizes that becoming too thin for your own body impacts performance and health over time. “Athletes need a lot of nutrition to do what they’re doing. You must be eating enough calories, fats, and nutrients from across the food groups in order to do the types of activities that we’re talking about — and to perform your best.”
Female athletes who overtrain may experience relative energy deficiency in sport (RED-S). This condition occurs when a person doesn’t consume enough calories to provide the energy needed for their exercise levels. RED-S can result in:
Low energy, which can impact performance and increase the risk of injuries
Low levels of estrogen, which can interfere with normal menstrual periods and can damage long-term reproductive health as well as brain and heart function
Decreased bone mineral density, which is essential to healthy bones and results in increased risk for broken bones
Compromised immune function, leading to reduced ability to fight infections
Gastrointestinal problems such as bloating and constipation
Increased risk for depression and anxiety
“If you’re not getting enough nutrition, your body will start to steal it from other areas of your body. That’s why bone health suffers. That’s why brain health suffers. Your body will mount a response to try and keep you functioning,” Dr. Becker says. “If you’re young, some of these things are so far away that it doesn’t seem that important, compared to being a little bit faster or getting a higher score from a judge. But the impact can be long-lasting.”
How to recognize an eating disorder
Signs of an eating disorder in an athlete may include:
Weight loss: Weight loss can be a warning sign of disordered eating in an athlete, particularly in teens.
Anxiety: Many people who develop eating disorders have symptoms of an anxiety disorder, such as perfectionistic thinking, social anxiety, or worry about feeling embarrassed or negatively evaluated by others.
Clear shifts in mood: Athletes with eating disorders may also stop enjoying their sport.
No longer eating favorite foods: Athletes often try to optimize their nutrition, such as working with a dietitian. But cutting out favorite foods or entire food groups may be a red flag.
No longer eating with other people: If an athlete avoids eating with friends, family, or teammates, that may be a warning sign.
Training all the time: An athlete who believes they need to train constantly may raise concern. For example, they try to add exercises during non-active times or don’t rest.
Dr. Becker emphasizes that not every person with an eating disorder has the same behaviors. For example, a person with “atypical anorexia” has symptoms of anorexia, such as a very restricted diet, but is not underweight. She also stresses that although female athletes are at increased risk, eating disorders can affect every gender at any age — from children to older adults.
How to help an athlete with an eating disorder
Dr. Becker encourages parents, coaches, and teammates to emphasize skill and de-emphasize weight and body shape. “Create a safe space where it’s okay for each athlete to have the body they have. Praise the wonderful things athletes can do — you can run that fast, you can flip that many times, you have impressive stamina.”
For loved ones, friends, or coaches who are concerned about an athlete’s eating, she offers the following advice. “First, try to remember that eating disorders are not a choice. It’s not someone being vain. An eating disorder involves complex neurobiology, genetics, personality styles, and more,” she says. It’s important to approach every athlete with compassion, understanding, and support versus criticism or judgment.
In addition, reassure the athlete that you care about them despite their sports performance. “One of the best ways to fight an eating disorder is to express that, regardless of their talents in a certain area, they’re valuable as a person,” Dr. Becker says. “Tell them, ‘I’m worried about you, not because I think you’re going to not do well in your next performance, meet, match, or race. But because I actually care about you as a person and you don’t seem like yourself. I care about you, and I want you to stay well enough to do the things that you love, whatever they may be.’”
Dr. Becker suggests the following resources for female athletes, their loved ones, and their teammates:
EQUIP, a virtual treatment program
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