Anorexia nervosa is a serious and potentially fatal eating disorder. The individual’s perception of her body image is distorted to the point that the individual develops an obsession with losing weight often to the physical and psychological detriment of the individual. While individuals with anorexia nervosa are seen in non-athletic populations, there appears to be a higher incidence of anorexia nervosa and subclinical anorexia nervosa in athletes.

So the question becomes does participation in athletics correlate with the development of eating disorders in some athletes? This question is more difficult to answer than it appears because this question raises more questions.

The first question is: are there some sports that attract individuals who either have eating disorders or are at risk for the development of eating disorders? Or, does participation in sports cause eating disorders? Last, does the participation in sports place at risk individuals into situations that serve as a precursor to the development of an eating disorder or disordered eating behaviors?

These are good questions posed by Thompson, R.A. and Trattner Sherman, R. (1999) in their book Helping Athletes with Eating Disorders. Unfortunately the answers have not been identified in the research, but the answers probably fall somewhere along the lines of positive responses to each question.

So just what might be the factors in sport that may drive, precipitate, or encourage disordered eating behaviors in athletes? According to Ray, R. & Wiese-Bjornstal, D.M., (1999) there are multiple factors that may be involved including:

• Weight restrictions either by sport or by coach
• Judging criteria that emphasize thin and stereotypically attractive body builds
• Performance demands that encourage very low percentage body fat
• Coaches applying pressure to lose weight
• Peer pressure to try pathogenic weight loss techniques

For female athletes, the message that a lean body correlates to improved performance seems to be one of the driving forces that may start an athlete on the cycle of losing weight. Whether the message is correct or not becomes irrelevant. The only significant perception is what the athlete believes to be correct. A single comment by a coach that an athlete needs to lose weight can start an athlete on a dangerous path.

Even if a coach does not apply pressure to a female athlete to lose weight, sometimes the sport itself will apply the pressure. For example, there are a group of sports known as “thin-build” sports. These are sports in which low body weight is thought to give a competitive edge to the performer (Beals, K.A., 2004).

These include sports in which the performer is judged as in gymnastics, diving, figure skating and competitive cheerleading as well as sports in which a low body weight is thought to provide an edge to the performer as in distance running, swimming, and cross-country skiing. In these sports, athletes may apply pressure to themselves to reduce weight for either appearance or performance.

Although there are healthy and safe ways to lose weight, these methods take time and may take weeks to accomplish. Unfortunately, individuals who are told to lose weight or who believe they need to lose weight to improve performance may opt for quicker, unhealthier methods. Severe caloric restriction is one unhealthy method to losing weight quickly.

Initially, losing weight may make the athlete feel accomplished and may improve performance. However, over time, the initial caloric restriction can turn into an unhealthy obsession towards restricting food intake and weight loss and then can lead to either subclinical or clinical anorexia nervosa.

The condition is prevalent enough in the athletic population that a diagnostic term of “anorexia athletic” was developed (1993) and characterized by “weight loss which is brought about by severe restrictions in dietary intake, and intense fears associated with gaining weight and becoming fat” (Ray, R. & Wiese-Bjornstal, D.M., 1999). The criteria for anorexia athletica include the following:

• Weight loss (greater than 5% of body weight)
• Delayed puberty
• Menstrual dysfunction
• Gastrointestinal complaints
• Absence of medical illness or affective disorder explaining weight reduction
• Disturbance in body image
• Excessive fear of becoming obese
• Restriction of caloric intake (i.e., less than 1200 calories)
• Use of purging methods (vomiting, laxatives, diuretics)
• Binge eating
• Compulsive exercising

Unfortunately, the characteristics that are present in an individual at risk for anorexia are also those that may drive an athlete to become an exceptional athlete. For example, one of the characteristics of an individual with anorexia nervosa is a perfectionist personality. It is exactly this type of personality trait that can drive an athlete to push themselves harder than their peers to become a top performer.

Being goal-oriented is another trait that is prevalent in individuals with anorexia nervosa. Like perfectionism, being goal-oriented is seen as a positive trait in athletes who want to improve by setting both short-term and long-term goals for performance.

The sports environment provides a place for athletes with anorexia nervosa to blend in with their peers and not be noticed as easily as non-athletes. Non-athletes who are anorexic may be noticed or stand out because of their lean appearance. However, athletes suffering from anorexia nervosa may be able to blend in with other athletes whose body types are also lean.

Compulsive exercise is another criteria of anorexia athletica that can be disguised as normal behavior for an athlete. A non-athlete may have difficulty explaining to others her extreme exercise behaviors. However, extreme exercise behaviors are the norm in the world of athletics. Often, athletes will complete a full practice with their team and then workout after practice on their own.

Besides being harder to identify, athletes may also rationalize their disordered eating behaviors as being necessary because of their sport. It is not uncommon for athletes to not eat or eat very light before competitions because it may upset their stomachs. This practice may help hide possible disordered eating.

Athletes with anorexia may also rationalize not eating after competition because they do not have time to eat (i.e., need to go to class, study, other commitment). Because these athletes are adept at disguising their eating disorder, they can seamlessly blend in with other athletes if no one is paying close enough attention.

Another problem is that when an athlete initially begins to lose weight, her performance may initially improve. This provides a boost to her self-esteem and encourages more weight loss. Since low self-esteem is another primary characteristic of an individual with anorexia, any boost in self-esteem (however short lived) is a driving force for repeating the behavior.

Although initial weight loss may improve performance, over time as the athlete continues to lose both body fat and lean muscle tissue, performance will begin to decrease. However, the mindset of the athlete will be to blame the decrease in performance on lack of effort rather than on loss of critical muscle tissue.

Compounding the problem is the misperception and distortion of the athlete’s body image. Rather than seeing a skeleton with skin in the mirror, an athlete with anorexia nervosa may still perceive herself as being too heavy. The cycle continues because the anorexic athlete continues to pursue a distorted image of herself that she can never achieve.

Eventually, the starvation and excessive exercise will catch up to the athlete and her performance will start to be effected. Some of the physical symptoms of athletes with anorexia nervosa include the following (Thompson, R.A.& Trattner Sherman, R., 1999):

• Amenorrhea
• Dehydration, especially in absence of training or competition
• Fatigue beyond that normally expected in training or competition
• Gastrointestinal problems (i.e., constipation, diarrhea, bloating)
• Hyperactivity
• Hypothermia (cold intolerance)
• Lanugo (fine hair on face and arms)
• Muscle weakness
• Overuse injuries
• Stress fractures
• Significant weight loss beyond that necessary for adequate sport performance

What many athletes do not understand is that the body uses carbohydrates as the primary source of fuel to provide energy during exercise. Carbohydrates are broken down into glucose and then used by the body for energy. Glucose that is not immediately used is stored as glycogen in the muscles. When an athlete begins to exercise, the body will first use the glucose in the bloodstream. When this source is depleted, the body will pull from the muscle glycogen stores.

Athletes with anorexia nervosa tend to limit their caloric intake (specifically carbohydrates). If carbohydrates are not consumed, the body is not able to store the necessary glycogen needed to fuel the body during exercise resulting in extreme fatigue by the athlete.

After muscle glycogen and stored fat are depleted in the athlete, the athlete’s body will begin to breakdown and use its own muscle tissue as fuel. The end result is muscle atrophy and weakness which will in turn have a negative effect on performance.

As well as a generalized loss in skeletal muscle strength, the cardiac muscle may also suffer from atrophy reducing the size and strength of the heart. This reduction will in turn result in a reduced capacity of the heart to pump blood throughout the body. With less oxygen provided to the muscles and vital organs, the athlete will fatigue quicker.

Along with losses in muscle strength, the athlete may also suffer from decreases in endurance, speed and coordination due to the effects from dehydration. Dehydration can also place the athlete at risk for muscle cramping and heat illness.

Last, the skeletal bones may be affected because of a lack of dietary minerals in the diet. The lack of minerals (calcium) can result in bones that are weaker and more susceptible to injuries including stress fractures. A lack of dietary minerals combined with excessive exercise is a bad combination for weight-bearing bones.

One of the physical symptoms of anorexia athletic is hyperactivity. While hyperactivity may help an athlete to be energized for a time even when the athlete is depleted of nutrients, eventually the athlete will run out of energy. Because of this, it is not uncommon for these athletes to turn to the use of stimulants to override the effects of fatigue.

To get the energy to keep up in school and participate in sports without consuming enough nutrients to supply the body’s needs, these individuals may resort to diet pills or large amounts of caffeine. Desperate athletes are adept at deception and may obtain diet pills or other forms of stimulants as needed to maintain their façade.

Further enabling athletes with this problem is the recent explosion of energy drinks. Many of the energy drinks marketed to young people (including athletes) have two to three times the amount of caffeine as in a normal cup of coffee.

Compounding this problem is that many healthy athletes use energy drinks on a regular basis. Again, this is another aspect of the sport environment in which athletes with anorexia may blend in with other athletes without being noticed.

The danger with stimulants is that they are designed to increase the heart rate. An increased heart rate in an individual with a weakened heart is a dangerous combination. This may explain why the fatalities in individuals with anorexia nervosa tend to be from cardiac arrest.

The downside of an athlete with anorexia nervosa participating in sports is that the competitive nature of athletics can provide an atmosphere in which the athlete can rationalize and hide disordered eating behaviors. However, hiding the physiological effects of anorexia can only be done for a short time. Eventually, the physiological effects of the anorexia will affect her overall health. Both her health and performance will begin to deteriorate.

Recognizing the behaviors of disordered eating and the physiological effects that an athlete may experience are an important step in identifying and referring the athlete for appropriate medical help.

If you have any concerns or questions about your nutritional needs, seek the consultation of a local sports nutritionist for appropriate care. To locate a top sports nutritionist in your area, please visit our Find a Sports Nutritionist Near You section.

Beals, K.A. (2004). Disordered Eating Among Athletes: A Comprehensive Guide for Health Professionals. Human Kinetics: Champaign, IL.

Ray, R. & Wiese-Bjornstal, D.M. (1999). Counseling in Sports Medicine. Human Kinetics: Champaign, IL.

Thompson, R.A. & Trattner Sherman, R. (1993). Helping Athletes with Eating Disorders. Human Kinetics: Champaign, IL.