Food and nutrition play a significant role in an athlete’s life, and for a range of reasons, and some athletes may introduce changes in, or adhere to, set or clearly defined diets. Diet strategies may relate to changes in body shape for a particular sport or to aid performance. However, some eating and weight control patterns are problematic and can lead to significant health problems, and in the context of sport and fitness, can cause someone to stop training and performing.

An athlete may, at first, notice an improvement in performance after weight loss or a change in body composition and this can be experienced as rewarding or positive. However, the consequences of an eating disorder in a sporting context are significant – including a negative impact on health, physical fitness and in turn, athlete performance.

Myths

• Menstrual dysfunction is normal in female endurance athletes
• Dehydration helps weight loss
• Low body fat means better performance
• Leanness equates to better athletic performance
• ‘Clean eating’ is the holy grail for optimal health and performance
• Reoccurring injuries (e.g. stress fractures) and illnesses (colds and flus) are normal for high performing athletes

Potential sport-specific factors
• Internalisation of athletic ideal/shape and status (toned abdomen, firmer lower body and muscular upper body) may predict dieting, symptoms of bulimia and compulsive exercise
• Race length, appearance and performance related body dissatisfaction for adult runners
• Self-consciousness relating to weight and appearance, body dissatisfaction in general and in sport
• Overweight perception (believe themselves to be overweight) and social physique anxiety
• Pressure from coaches, family or sporting peers

Athletes at risk
• Sports involving aesthetic judgement and/or revealing uniforms: ballet dancing, gymnastics, figure skating, aquatics – diving, synchronized swimming
• Sports that are weight-sensitive, have weight requirements or weight classes: wrestling, horse racing
• Anti-gravitation sports: high-jumping and pole-vaulting
• Endurance sports: running
• Social pressures: adherence to sport ideal body, perceived norm of sport body appearance, perceived performance benefits from weight control
• Competitive thinness, body competitiveness, wishing to outperform others – losing weight after meeting someone else who may be thinner
• Weight, performance and body image pressures from teammates, coaches, fans and judges
• Adverse life events and career dissatisfaction
• Level of participation
• When an athlete is subjectively evaluated – judges

Athletes who participate in non-lean sports, or regardless of sports affiliation, may also use unhealthy and risky weight control behaviours. Eating disorders can occur amongst overweight athletes – an emphasis on bulk, to be a larger size, may contribute to binge eating and anabolic steroid use.

Low energy availability (LEA)
Essentially, LEA is understood as, and occurs, due to a mismatch between energy intake and the exercise expended during training, exercise or competition. LEA, including prolonged dietary restriction, impairs physiological function and ultimately the ability to perform. Psychological issues can occur before or as a consequence of LEA. LEA is not always a consequence of an eating disorder or dysfunctional eating behaviours and an athlete who is weight stable may be energy deficient. Alternative explanations for LEA include intensified training loads, or where nutrition is considered as an afterthought and/or timing of training sessions that conflict with eating opportunities during a typical training day.

LEA is common to both the female athlete triad and relative energy deficiency in sport (RED-S) models. Regardless of the terminology used, an athlete is not eating enough to meet their needs, in terms of energy expenditure during training/exercise.

Health impact of RED-S
• Poor bone health
• Menstrual dysfunction
• Metabolic issues
• Cardiovascular impairment
• Impaired judgement
• Decreased training response and muscle strength
• Decreased coordination and concentration
• Decreased endurance performance
• Irritability
• Increased risk of injury
• Depression

Athletes and recovery
For some athletes, the negative consequences associated with an eating disorder, along with a desire to be healthy enough to return to play, can be a turning point towards recovery. Other key points include insight and self-realisation, sport performance and support or concern from others.

Factors which are helpful in an recovery
• Identifying triggers
• Social supports
• Education of coaches
• Emotional support from parents and increased autonomy
• Hope for recovery
• Open communication
• Associating eating with personal strength
• The desire to become healthy enough to perform in sport
• A shift in values and beliefs
• Developing new coping mechanisms
• Learning to cope within a sporting context
• Seeking professional care
• Making cognitive and behavioural changes
• Focusing on overall health, not just weight
• Compassion
• Education about effects of the disorder

Factors which can hinder treatment and recovery
• Sport pressures
• Negative thoughts and feelings
• Ambivalence towards psychotherapy, feeling it is generic
• Feeling out of place, or uncomfortable in treatment
• Feeling their eating disorder is atypical
• Lack of acknowledgement of athlete status by treatment staff
• Difficulty trusting others with disclosure of eating disorder
• Stigma – that disordered eating inherently contradicts a person’s athletic identity
• Stigma amongst male athletes due to the perception that an eating disorder is a female illness
• Being stereotyped, eating disorder is trivialised
• Harmful comments about weight
• Lack of sport-specific support whilst in treatment
• Isolation

Key elements for clinicians
• Knowledge of healthy and healthy weight control methods
• Advising athletes as to the impact of acute weight loss methods and potential adverse health effects
• History taking to ascertain diet and physical activity patterns
• Engage services of registered dietitian (RD) familiar with athletes for those with complex weight control issues
• Monitoring athletes with weight-control issues every 1 to 3 months can aid the physician in detecting excessive weight loss
• Encourage gradual weight changes, where appropriate
• Community education with coaches and qualified athletic trainers

Role of organisations
Sport organisations can support recovery by:
• Developing an individual care plan to provide ongoing support
• Setting realistic goals for returning to sport following a period of absence
• Ensuring emotional health is not neglected
By clarifying
• Who acts as the primary support person when communicating with the athlete
• Who will communicate with the family (if confidentiality allows)
• Who will communicate with the health professionals providing treatment (if confidentiality allows)
Exercise protocols
• Exercise protocols for athletes should be developed in collaboration with specialist medical and healthcare professionals who have knowledge and training in eating disorders.

Returning to training
Key factors
1. Medical stability
2. Nutritional stability
3. Occurrence of eating disorder behaviours
4. Absence or presence of significant stressors
A multidisciplinary and collaborative approach can determine these issues and their potential impact. Decision making is dynamic and ongoing evaluation of an athlete’s stability is important as training is reintroduced or increased.

The decision to return to play should take into account:
• Evaluation of health status: medical factors and history, psychological state
• Evaluation of participation risk – sport risk modifiers: type of sport, position, competitive level
• Decision modification: timing and season, pressure from athlete, external pressure, masking the injury

It is important to remember that eating disorders are not about vanity or attention seeking. A person may feel overwhelmed and compelled to engage in behaviours in order to feel OK. Keep in mind that the causes of eating disorders are complex and not necessarily something someone may wish discuss with you as a coach.

Supportive strategies from coaches
• Being proactive in seeking support
• Being aware of where to signpost someone for further support
• Working in partnership with an athlete
• Having strong interpersonal skills and open lines of communication
• Having clear objectives when working with an athlete
• Changing training routines to motivate athletes to recover

In 2021, Bodywhys partnered with Athletics Ireland and Sport Ireland to deliver a three part coach education webinar series ‘Supporting athletes with fuelling for performance and health’.

You can access the recordings below:

• Recognising and responding to the challenges of RED-S – Jessie Barr, Julianne Ryan, Dr Danielle Logue

• Let’s talk about problematic eating behaviour in sport – Dr Siobhain McArdle

• The coach and athlete perspective, with Dr Jessica Piasecki and Steve Vernon and a panel discussion on the role of the coach.