Eating Disorders in Female Athletes

Eating disorders in female athletes are often higher then the general population.  This is especially true for female athletes in aesthetic based sports such as dance, gymnastics, swim, volleyball as well as track and field.  Where in the general population the prevalence of eating disorders is ~2%, in female athletes it can be as high as ~40%, dependent on sport and level of play.  Female athletes are often driven with discipline, strength, and determination, pushing their physical limits to achieve success in their sport. While the pressure and drive to excel can be an asset, it can also take a toll on their health and relationship with their body image.  Having an eating disorder as a female athlete can hinder performance, disrupt hormones and damage health.  This blog post will discuss the types of eating disorders , risk factors, warning signs and how to help an athlete with a suspected eating disorders.

Types of Eating Disorders

Eating disorders in female athletes can present as one of the many type of eating disorders.  An eating disorder is a diagnosable mental health condition defined by the Diagnostic Statistical Manual V (DSM-V).  If you have heard of the term disordered eating, it is defined as engaging in restrictive eating such as skipping meals or food groups, compulsive eating or exercise, and restriction of calories without meeting the DSM-V criteria for an eating disorder.

Below are three of the highlighted eating disorders defined by the DSM-V:

1) Anorexia Nervosa: A brain-based eating disorder characterized by severe calorie restriction and an intense fear of weight gain, anorexia can lead to malnutrition, fatigue, and a decline in athletic performance. Female athletes with anorexia may go to extreme lengths to maintain a low weight, even at the expense of their overall well-being.  AN is treatable and reversible. 

2) Bulimia Nervosa: Bulimia involves recurrent episodes of binge eating followed by compensatory behaviors such as forced vomiting, excessive exercise, or the use of laxatives. This cycle of binging and purging can have detrimental effects on both physical and mental health, impacting performance and overall quality of life.

3) Binge Eating Disorder: While not as commonly discussed in athletic circles, binge eating disorder can also affect female athletes. This disorder is characterized by consuming large amounts of food in a short period and experiencing a lack of control over eating. Binge eating disorders can result in weight gain, poor nutrition, and negative psychological effects.

Risk Factors for Eating Disorders in Female Athletes

Female athletes face unique expectations when it comes to body image and performance. Societal pressures often dictate that successful athletes must possess certain body types to excel in their chosen sport. For instance, gymnastics and figure skating tend to emphasize a lean physique, while sports like weightlifting or shot put require more muscular build. These unrealistic body ideals often drive female athletes to resort to extreme measures.

Several factors contribute to the development of eating disorders in female athletes:

Performance Pressure: The focus on achieving specific body ideals to meet competitive standards can lead to a decreased sense of self-worth and body dissatisfaction.  While there is some evidence that an athletes body fat percentage can impact performance, there has been no standard set for each sports.  Female athletes and their coaching staff should focus on performance and adequately fueling their training.  

Coaches and Peers: The attitudes, comments, and behaviors of coaches and teammates can significantly impact an athlete's relationship with their body. Coaches are at times are providing athletes with misinformation and guidance around nutrition, body composition and weight.  In many aesthetic based sports, weight and body shape is tightly monitored by staff who does not have the education and credentials to provide guidance or information.  Pressure from these sources can exacerbate disordered eating behaviors.

Social Media Influence: Constant exposure to social media, showcasing images of "ideal" athletic bodies, can distort perceptions of reality and contribute to the development of eating disorders.  Social media for female athletes is often providing misguided information on nutrition plans and food choices.  Exposure to social media, specifically body and weight loss focused content, showcasing bodies, can be harmful to a female athletes self-esteem and body image.  

Warning Signs and an Eating Disorder in Female Athletes 

1) Restriction of Intake: This can look innocently as an attempt to lose weight.  Unfortunately, many weight loss tactics are riddled with eating disorder behaviors such as obsessive tracking, excessive exercise, and reducing calorie intake purposefully.  Restriction can look like restriction of calories but also specific foods and food groups.  This can include cutting carbohydrate rich foods, sugars, foods higher in fat, cutting out dairy and/or gluten containing foods.  

Following specific fad diets to “improve health” can also fall under restriction.  This can include:

• Intermittent Fasting: A diet with an intention for weight loss where an individual restricts the hours of the day in which they eat. Many claim they are engaging for health benefits, but no proven benefits for athletes have been shown. For female athletes, their nutrition timing is very specific and crucial to their performance. Intermittent fasting is not a way to fuel to perform and engaging in it can be a sign of disordered eating.

• Ketogenic: A ketogenic diet is a low-carb, high-fat diet that involves reducing carbohydrate intake and replacing it with fat. For athletes, carbohydrates are critical to health and performance. Carbohydrates are often one of the most restricted food groups in eating disorders. Yet, restricting carbohydrates is the most harmful.

• Paleo: Very popular in the weight lifting and crossfit community. The diet focuses on unprocessed meats, fish, eggs, vegetables, fruits, nuts, seeds, and healthy fats, while avoiding processed foods, sugar, grains, and dairy products. While it is a seemingly healthful diet, a key hallmark of some eating disorders is restriction, and this is important to pay attention to.

2) Absence of or Irregular Periods: Female athletes menstrual cycle can be impacted by low calorie intake and well as binge eating disorder. Altered nutrition intake can disrupt the normal fluctuations of sex hormones such as estrogen and luteinizing hormone. These key hormones in regulating a normal menstrual cycle, when disrupted, can result in irregular cycles (oligomenorrea) and loss of period for 2 or more months (amenorrhea).

A normal menstrual cycle is not just important for fertility, but many aspects of womens health, including:

• Bone mineral density

• Cardiac Health

• Healthy body composition

• Iron status

3) Increased injuries and illnesses: Suppression of nutrient intake and imbalance of nutrient intake can impair the immune system. Nutrients, particularly proteins and micronutrients, compose a large part of your immune system. Low intake of nutrients, inflammation in the body from binge-purge and damage to the body tissues from eating disorders can distrupt immune function. As for injuries, athletes with low calorie intake and high energy output are at high risk for injuries, including stress fractures and regular fractures. Stress fractures can be contributed to impaired bone mineral density caused by lower estrogen levels. A missing or irregular period is also connected to this. This is part of a condition known as the Female Athlete Triad and part of Relative Energy Deficiency in Sport (RED-S).

4) Weight loss and fluctuations: Changes in weight can be a result of a variety of factors. When someone has an eating disorder, weight changes are often drastic and over a shorter period of time. Weight changes can be loss, gain or fluctuate between both. Weigh fluctuations are a cause for concern, and have health risks. It is important to note that any eating disorder can exist at all body shapes and sizes. Those of normal or higher weights often go missed since they do not “look like they have an eating disorder”. This is untrue and can continue to harm the individual.

5) Decrease in performance markers: With inadequate nutrition, both calories and nutrients, athletes performance can suffer. This includes skills in their respective sport, decrease in speed, power and strength. You may also notice their cognitive performance can suffer, as well as mood swings and change of character.

Getting Your Athlete Help

Eating disorders are a treatable disorder. If you suspect your athlete may have an eating disorder, book a discovery call. Here we can discuss how a Registered Dietitian specializing in female athletes with eating disorders can help with recovery. Most treatments do best with a team. This team is comprised of a Registered Dietitian, Therapist and Physician. The team works together to collaborate on a treatment plan to get the athlete recovered, healed and back to training. The goal is to ensure adequate nutrition intake and reduce eating disorder symptoms. The team will discuss when and if training is appropriate as multiple factors contribute to back to play.