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Overview

There is a widely held misconception that eating disorders are a choice of lifestyle. However, eating disorders are serious and often fatal illnesses. Eating disorders are associated with severe disturbances in people's eating behaviors and related thoughts and feelings. Preoccupation with food, body weight, and shape may indicate an eating disorder. Common eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder.⁵Additionally, Orthorexia and Relative Energy Deficiency in Sports (RED-S) are related disorders affecting athletes in particular. Athletes need to fuel properly in order to achieve overall wellness and optimal performance in sport. Unhealthy eating habits and disordered eating impact psychological well-being, bone health, muscular strength, power, and endurance, and concentration abilities. Such effects limit the athlete's ability to be successful in academic and athletic performance.

Disordered Eating: Athletes

Athletes experience similar stressors that other students experience during college, with the added demands of sports and added visibility to others through social media. This visibility can influence eating behavior and body image.² In the health domain, student-athletes are particularly vulnerable to eating disorders.¹Disturbance in eating behavior can occur across all sports, but sports that are judged in part on aesthetics where body size and shape can influence the score, and those that believe lower weight will increase athletic performance, are at increased risk.²Developing and maintaining healthy eating habits and body image are important for athlete well-being and performance in academics and sport.

Athletic injuries are a key risk factor for disordered eating. Injuries are a common occurrence among student-athletes at the collegiate level. Typical emotional responses to injury may include sadness, isolation, irritation, lack of motivation, anger, frustration, changes in appetite, sleep disturbances, and disengagement. However, problematic reactions can also happen. These are emotional responses that do not resolve, worsen over time, or seem excessive in severity. In the eating domain, alterations to appetite followed by disordered eating can occur. An example of how this may happen after an injury is in the event that an injured athlete restricts their caloric intake because they feel they 'do not deserve to eat' due to their injury. Restricting calories could trigger an eating disorder, especially if the athlete was already at risk for eating disorders.³ It is important to note that athletic injury can trigger several mental health concerns, and disordered eating is one of them.

Athlete experience with eating disorders:

Jessie Diggins: https://www.espn.com/espnw/voices/story/_/id/26112613/olympic-gold-medalist-jessie-diggins-confronting-eating-disorder-recovery
Mandy Dimarzo: https://www.youtube.com/watch?v=1-fU6ysqJFU
Logan Davis: https://wamu.org/story/19/03/03/underdiagnosed-male-eating-disorders-are-becoming-increasingly-identified/
Patrick Devenny, TEDx Talk: "When clean eating became an eating disorder" My journey from pursuing the NFL to being a recovery bulimic.

Relative Energy Deficiency in Sports (RED-S)

RED-S is an often unrecognized disorder that can include low energy availability (inadequate caloric intake); with or without disordered eating; amenorrhea (lack of menstrual periods); and low bone mineral density.⁷ Inadequate caloric intake can occur as a result of poor eating habits and too intense exercise. This under-consumption of calories can happen intentionally or unintentionally, and negatively impacts wellness and athletic performance. RED-S is typically found among physically active persons, especially among athletes with a competitive nature and strong sense of discipline. Competitive athletes (such as those competing at a collegiate level) may be at an increased risk compared to more casual athletes due to the rigorous training schedule and the "play-to-win" nature of elite sports. Athletes who compete in endurance sports (such as cross-country running and nordic ski), aesthetic sports (such as cheer and spirit squad), and sports which require formfitting uniforms are at an increased risk for RED-S. Further, an emphasis on a certain athletic "look" and the belief that carrying less weight will universally improve performance in sport increases the risk for RED-S.7

Impact on Performance

RED-S can negatively impact sport performance and overall wellness among athletes.⁷ The lowered energy availability impairs performance because the muscles are not fueled properly. This is universal across sports. If under-fueling continues after initial signs of fatigue, the skeletal muscle will actually reduce in size because the body begins to break it down. It is also important to note that every organ in the body requires energy to keep operating properly. This includes the brain, which means that under-fueling also impacts the athlete's ability to concentrate on academic work and athletics. This low concentration can increase the athlete's risk for injury and then prolong the injury recovery time. Next, amenorrhea (loss of menstrual period) among female athletes signals a change in the body's intricate and complicated hormone system. Under-fueling can trigger lower estrogen production. The most recognizable health effect of low estrogen is bone loss, which can result in bone stress fractures. Please note that amenorrhea is NOT a normal part of athletic training, no matter what sport the athlete competes in. It is a sign of improper fueling. Finally, low bone mineral density is a trademark sign of RED-S and can place the athlete at high risk for injuries. Athletes with repeated stress fractures should be evaluated further because this is a red flag for RED-S.⁷

Signs & Symptoms

1. Physical/Medical Signs and Symptoms⁷

Amenorrhea
Dehydration
Gastrointestinal problems
Hypothermia (cold intolerance)
Cardiac abnormalities: bradycardia (low heart rate), orthostasis (abnormal changes in heart rate and/or blood pressure during positional changes)
Stress fractures (and overuse injuries)
Significant weight loss
Muscle cramps, weakness, or fatigue
Dental and gum problems.

2. Psychological/Behavioral Signs and Symptoms⁷

Anxiety or depression
Claims of "feeling fat" despite being thin
Exercising beyond what's expected/required
Excessive use of the restroom
Unfocused, difficulty concentrating
Preoccupation with weight and eating
Avoidance of eating and eating situations
Use of laxatives, diet pills, etc.

Female Athlete Triad

The female athlete triad is part of RED-S under another name, and refers to a combination of 3 clinical entities found in young athletes who have a menstrual cycle:

Menstrual dysfunction: Loss or irregularity of menstrual cycle,
Low energy availability (with or without an eating disorder): lacking the energy to complete daily tasks,
Decreased bone mineral density (osteopenia): weak/brittle bones resulting from loss of bone mass.⁴

In women who compete in sports that emphasize aesthetics or leanness, such as ballet or running, the prevalence of secondary loss of menstrual cycle can be as high as 69%, compared with 2% to 5% in the general population. In addition, disordered eating often associated with low energy availability in the female athlete triad has serious psychological implications, including depression, low self-esteem, and various anxiety disorders. Many athletes with low bone density and/or menstrual irregularity also experience an increased risk of stress fractures. Female athletes with menstrual dysfunction have a 2 to 4 times greater risk for stress fracture than their peers with regular menstrual cycles. The female athlete triad negatively impacts well-being and performance among student-athletes, and it is important to seek help and take the necessary steps to reach recovery. No matter how severe the symptoms stemming from the components of the triad are, it is important for health care professionals, coaches, and nutritionists involved in these female athletes' care to be aware of the risks and potential consequences of the syndrome⁴.

Do I have an eating disorder?

Complete a screening: CAPS"--maybe better to use NEDA's screener anyway?

Resources

Athletic Nutrition Department: https://msubobcats.com/sports/2020/5/13/nutrition-appointment-booking.aspx
MSU On-Campus Resources: https://msubobcats.com/sports/2021/1/20/on-campus-resources.aspx
Off-Campus Resources: https://msubobcats.com/sports/2021/1/21/off-campus-resources
Emily Program: https://www.emilyprogram.com/
- The Emily Program offers individualized care leading to recovery from eating disorders. They hope to foster peaceful relationships with food, weight, and body image, where everyone with an eating disorder can experience recovery. On their website, they have videos, podcasts, a blog, and more information about eating disorders.
The National Eating Disorders Association (NEDA): https://www.nationaleatingdisorders.org/identity-eating-disorders
- A nonprofit organization dedicated to supporting individuals and families affected by eating disorders. NEDA provides education materials, screening tools, treatment options, blogs, forums, and connections.
National Association of Anorexia Nervosa and Associated Disorders (ANAD): https://anad.org/about/history/
- ANAD is the oldest organization aimed at fighting eating disorders in the United States. ANAD assists people struggling with eating disorders and also provides resources for families, schools, and the eating disorder community.

More information

"Mind, Body and Sport: Eating disorders" An excerpt from the Sport Science Institute's guide to understanding and supporting student-athlete mental wellness
Podcasts: Food Psych, Body Kindness, Peace Meal

References

1. Barnard, J., D. (2016). Student-athletes' perceptions of mental illness and attitudes toward help-seeking. Journal of College Student Psychotherapy, 30(3), 161-175, doi: 10.1080/87568225.2016.1177421
2. Egan, K. (2019). Supporting mental health and well-being among student-athletes. Clinical Sports Medicine, 38, 537-544. doi: 10.1016/j.csm.2019.05.003
3. Putukian, M. (2016). The psychological response to injury in student athletes: a narrative review with a focus on mental health. British Journal of Sports Medicine, 50(3), 145-148. doi: 10.1136/bjsports-2015-095586
4. Nazem, T. G., & Ackerman, K. E. (2012). The female athlete triad. Sports health, 4(4), 302–311. https://doi.org/10.1177/1941738112439685
5. U.S. Department of Health and Human Services, National Institute of Mental Health. (2016). Eating Disorders. Retrieved from: https://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml#part_145414
6. National Eating Disorders Association. (2018). Orthorexia. Retrieved from: https://www.nationaleatingdisorders.org/learn/by-eating-disorder/other/orthorexia
7. Brown University Sports Nutrition Department. (2015). Relative Energy Deficiency in Sport (RED-S). Retrieved from: https://www.brown.edu/campus-life/health/services/promotion/nutrition-eating-concerns-sports-nutrition/relative-energy-deficiency-sport-red-s

Developed 2021 by Quinn DeStefano, OTD Student
Updated 2026 by Dr. B.T. Cooper, MSU Sport Psychologist

Eating Disorders