Why We Need to Address Eating Disorders in Athletes

Clement Coetzee/peopleimages.com/AdobeStock

“So, I hear you broke a bone or 2 in your foot. Is that right?”
“Well, it’s actually my third. I guess I’ve been training a little too much.”
“Oh no. Have you ever had a DEXA scan?”
“No, what’s that?”
“It’s like an X-ray that measures bone density. When your body isn’t getting enough nutrition, you can lose bone mass, which increases the risk of fractures. Let’s go ahead and get one ordered.”

I cannot tell you how many times I have had this conversation with polite, cooperative, but perfectionistic athletes in my office—often alarmingly thin, or what we call cachectic. Unfortunately, eating disorders are far too common in elite sports, with prevalence rates ranging from 6% to 45% in female athletes and up to 19% in males.^1-3 And that is just what has been reported!

In general, athletes are an underserved population in mental health care. Historically, sports have not created the safest environment for athletes to openly discuss mental health struggles. Phrases like “power through,” “toughen up,” or “don’t show weakness” are still common in locker rooms and on sidelines. Even within sports medicine, mental health has often been an afterthought—wellness checks are still referred to as “preseason physicals,” which reinforces the idea that only physical health matters. I much prefer the term preparticipation exam because it reflects a more inclusive approach, recognizing that mental health is an essential part of total wellness. Language matters.

Athletes may seem superhuman for their on-field performances, but they experience mental health challenges like everyone else—though their specific risks differ. While they tend to have lower rates of substance use and suicidality, they face higher rates of sleep disorders, gambling issues, attention-deficit/hyperactivity disorder, and eating disorders. Seeking help can be especially difficult for athletes, given the negative messaging around mental health and the sense that they do not quite fit within traditional treatment settings.⁴ Many worry that practitioners “won’t get” them. Psychiatry has historically paid little attention to sports medicine—and vice versa—leading to a gap where mental health care has been handled by sport psychologists, often through a performance-focused lens.

However, the landscape is shifting. As prominent athletes like Simone Biles and Michael Phelps have opened up about their struggles, conversations about mental health in sports have become more normalized. In 2019, the International Olympic Committee launched a mental health working group that developed the first standardized screening tool for athletes: the SMHAT-1. Identifying symptoms is just the first step; ensuring athletes are referred to the right psychiatric care presents a separate challenge. Delivering effective care requires becoming “athlete-informed,” much like developing cultural competence. This involves understanding the complexities of elite sport and the influence of the broader sports ecosystem—coaches, administrators, sponsors, and others—which is key for building rapport and making sound clinical decisions.

Recognizing this need, the American Board of Sports & Performance Psychiatry was formed to educate and train psychiatrists to become athlete-informed clinicians. The goal is to prepare these professionals to become vital members of sports medicine teams, helping bridge the gap between mental health and performance care. With psychiatrists playing a more prominent role, we are ensuring athletes receive holistic treatment that addresses both mind and body.

When it comes to treating eating disorders, athlete-specific factors are critical. Some sports—like gymnastics and figure skating—emphasize aesthetics, while others, such as cycling or cross-country running, favor a lean body type. Weight-class sports like wrestling or rowing present additional risks. Not all athletes with eating disorders are motivated by a desire for thinness; some overtrain to meet the physical demands of their sport, leading to low energy availability. When the body is under-fueled and overexerted, it can enter a starvation state known as relative energy deficiency in sport (RED-S). This condition can impair performance through early glycogen depletion, dehydration, fatigue, and muscle breakdown, increasing the risk of injury. Fortunately, with proper nutrition, these effects are reversible.

Effectively treating athletes with eating disorders requires a multidisciplinary team. Having a primary therapist, dietitian, psychiatrist, and mental performance coach all working together is essential for a comprehensive recovery. Each team member plays a specific role: the therapist helps address underlying psychological factors, the dietitian ensures nutritional needs are met, the psychiatrist manages cooccurring mental health conditions, and the mental performance coach provides strategies to rebuild confidence and mental resilience for returning to sport. This collaborative approach helps athletes not only recover physically but also rediscover a healthy relationship with food, exercise, and competition.

Unfortunately, most eating disorder programs focus solely on nutrition, overlooking the athlete’s relationship with exercise. This is problematic, as athletes often seek treatment with the goal of returning to their sport. Addressing unhealthy exercise patterns and guiding a healthy return to training is crucial. In 2018, a group of experts developed the Safe Exercise at Every Stage protocol, which provides step-by-step guidelines for returning to exercise in a safe, structured way. Athletes respond well to this kind of coaching and objective, data-driven feedback. Using tools like the Athlete’s Relationship to Training to assess psychological readiness, or the RED-S Clinical Assessment Tool to coordinate care across a sports medicine team, can motivate recovery and help athletes transition back to training effectively.

Finally, helping athletes find a sense of identity and purpose outside of their sport is essential. For many, their sport has been not only their passion but also their primary coping mechanism. If that is taken away due to an eating disorder, the road to recovery involves more than just physical healing—it requires rediscovering who they are beyond their athletic achievements.

Dr Allen is a child and adolescent sport psychiatrist and the Chairman of the Board of Directors for the American Board of Sports and Performance Psychiatry.

References

1. Glazer JL. Eating disorders among male athletes. Curr Sports Med Rep. 2008;7(6):332-337.

2. Martinsen M, Sundgot-Borgen J. Higher prevalence of eating disorders among adolescent elite athletes than controls. Med Sci Sports Exerc. 2013;45(6):1188-1197.

3. Sundgot-Borgen J, Torstveit MK, Skårderud F. Eating disorders among athletes. Tidsskr Nor Laegeforen. 2004;124(16):2126-2129.

4. Plateau C, Arcelus J, Leung N, et al. Female athlete experiences of seeking and receiving treatment for an eating disorder. Eating Disorders. 2017;25(3):1-5.