Eating Disorders in Athletes

As an athlete from childhood through college, Kathrine Patterson, PsyD, NCC, LPC, experienced firsthand the pressures and demands that can be part of participating in sports. During her graduate internship, she worked at a clinic that specialized in the treatment of eating disorders, and her passion for athletics collided with her passion for mental health care. 

For the past 8 years, Dr. Patterson has specialized in the treatment of eating disorders and co-occurring disorders in a variety of settings. She helped develop a residential treatment program and tailored services lines for Binge Eating Disorder (BED) and Avoidant Restrictive Food Intake Disorder (ARFID). Many of her clients are high school and college age and have included wrestlers, body builders, soccer players, dancers, volleyball players, and others. She recently shared her insights about considerations when working with athletes with eating disorders.

In your experience, what are some of the more common eating disorders that athletes may present?

Eating disorders do not discriminate, but the most common eating disorder diagnoses among athletes include anorexia nervosa and bulimia nervosa. Another unique presentation seen among athletes is orthorexia. Although not a formal DSM diagnosis, orthorexia refers to an obsession with “healthy” eating and quality of nutrition. Common signs and symptoms seen among athletes include perfectionism; high performance expectations; preoccupation with health and fitness; fear of gaining weight; desire to change their weight, shape, or size; overexercising; recurrent injuries; distorted body image; and more. Eating disorders among athletes also commonly present with other mental health challenges such as anxiety. Low energy, difficulty with attention and concentration, and changes in mood may also occur.

Why are athletes particularly at risk for developing these disorders? Is this preventable?

Because of the various pressures related to the sports environment. They may result from personal, familial, teammate, and coach relationships, or competitiveness. Athletes, especially those performing at competitive levels, typically have innately high expectations for themselves, and when this is paired with pressures or expectations from family, teammates, and coaching staff, it can be the perfect storm to obsess over health, fitness, nutrition, and performance. This may lead to disordered behaviors that they believe will enhance their performance. Aesthetic and weight-sensitive sports that have tight or revealing uniforms, have weight classes, or require weigh-ins may increase emphasis on body shape or size and cutting weight, which increase risks for disordered eating behaviors.

Eating disorders may be preventable and decreased among athlete populations through increased education about eating disorders, sport environment pressures, and overall promotion of mental wellness to handle stressors and performance expectations. Not only would this information benefit the athletes themselves, but additional education and training for academic institutions, coaching staff, and athletic trainers could also decrease risk of eating disorder development. Often, teachers, coaches, and trainers have a limited understanding of eating disorders, nutrition, and the risks associated. Eating disorders have one of the highest mortality rates among mental health disorders. If athletes and their support systems are better educated and trained to assess for eating disorder symptoms, this would allow for early intervention. This intervention is crucial in helping the athlete learn more adaptive ways to cope, challenge distortions, and overall enhance both their academic and athletic performance as well as their mental well-being.

How may eating disorders affect an athlete’s mental health? 

The impacts of eating disorders can be significant on an athlete’s mental health. Often, these co-occur with other mental health challenges such as anxiety, depression, OCD, and more. In addition, inadequate nutrition can lead to mood changes, irritability, memory issues, problems with attention and concentration, fatigue, lack of motivation, social withdrawal, and decreased distress tolerance. Not only do eating disorders have effects on one’s mental health, they can cause serious impacts on physical health due to restricting, overexercising, and purging, which can be extremely dangerous and affect one’s metabolism, electrolyte levels, and heart. 

How may these clients tend to present themselves to counselors?

Often, athletes may not recognize when they have an eating disorder. Symptoms and their impact may be minimized or rationalized as something other than an eating disorder. Athletes may present as concerned about athletic performance, feeling low energy, or coping with injuries. Additionally, they may seek treatment due to recommendations or encouragement from family, friends, or coaches. If there is little insight to the problem, they may not fully understand or accept if there is a bigger issue looming that is related to disordered eating, malnutrition, or their health. However, other athletes may recognize that their symptoms are having negative impacts on their life and present to treatment motivated for change.

How can we help athletes become motivated to address these issues, particularly if they feel as though their eating patterns have been beneficial to their performance?

If there is minimal insight into the disordered eating patterns or risks to their health and performance, it’s important that treatment providers provide psychoeducation and utilize motivational interviewing techniques to help the client identify reasons to change. Often, athletes have misconceptions that their behaviors may benefit their performance. As such, it is crucial that they understand not only the psychological, but the physiological impacts of eating disorder behaviors. For example, malnutrition can cause fatigue, which in turn may result in slower reaction time, lower energy, cognitive fog, leading to overall decreased performance. Malnutrition may also result in higher risk of injury, as it could lead to decreased bone density and risk of fracture. It’s important for athletes to understand the effects on the brain and body to assist with buy in to treatment, which could lead to enhanced performance and overall, more time spent playing the sport they love. 

What are some of the more common approaches when working with these clients?

Evidence-based treatment approaches include cognitive behavioral therapy, dialectical behavior therapy, and family-based treatment. In addition, psychoeducation can be beneficial to help the athlete understand their eating disorder and also challenge myths or misconceptions they may have about performance and how this relates to nutrition and exercise. With appropriate consent, it can also be helpful to include the athlete’s support system, such as roommates, friends, family, or coaches, so the client has support outside of the treatment setting within the home and sport environment.

Are there any resources you’d recommend to counselors who may work with athletes who have eating disorders?

The Association for Applied Sport Psychology has several resources available on their website regarding signs, symptoms, risks, treatment, and more as it relates to athletes and feeding and eating disorders. 

The National Eating Disorders Association also has useful information about eating disorders and athletes and provides a coach and trainer toolkit that can help coaching and training staff to better understand and recognize eating disorders among athletes to promote earlier intervention.

Dr. Jennifer Gaudiani’s book, “Sick Enough,” is another eye-opening and useful resource when working with anyone with an eating disorder.

Finally, there are several podcasts that provide information, education, and intervention strategies that may be helpful for clinicians to explore for their own education but also with their clients. Some of these include:

• Athletes and Eating Disorders with Lauren Anton
• The Emily Program: Eating Disorders in Running with Rachael Steil
• The Eating Disorder Recovery Podcast

Kathrine Patterson, PsyD, NCC, LPC, is the director of behavioral health for N.E.W. Community Clinic, an outpatient clinic that provides care to the underserved, underinsured, uninsured, and homeless population in the Green Bay, Wisconsin, area. She earned her Doctor of Psychology in clinical psychology from California Southern University and received her master’s in clinical mental health counseling from Walden University.