Eating disorders in athletes: how can we tackle them?

How common are eating disorders in athletes?

Studies suggest there is an increased prevalence of eating disorders in athletes compared with the general population. Prevalence refers to the proportion of people in a given group who have a condition at any one time. In the UK, about 1.25 million people have an eating disorder - a prevalence of about 1.8%. However, a study of elite athletes found an overall prevalence of eating disorders of 13.5%. Eating disorders are more common in female athletes, at 20.1%, with 7.7% of male athletes struggling. But, the prevalence of eating disorders in male athletes is about 16 times higher than in male non-athletes.

What sports are eating disorders most common in?

Eating disorders have often been found to occur in endurance sports, such as long-distance running. A study of distance runners in the UK found that, out of 184 female athletes, 16% had an eating disorder. Of these, 3.8% had anorexia nervosa, 1.1% had bulimia nervosa and 10% had a subclinical disorder or EDNOS (eating disorder not otherwise specified). This may be an underestimate - using measures such as weight or body mass index (BMI) may miss many people with eating disorders, and 'average' BMIs may not apply to high performance athletes anyway.

Are eating disorders common in disabled atheletes?

However, little research has been done into the prevalence of eating disorders in disabled athletes. Coaches are not always able to spot the signs of eating disorders in athletes with disabilities because, unlike able-bodied athletes, there are no 'norms' around healthy weight: height ratios and what weight might aid optimum performance.

Sports with the highest risk of eating disorders

Gill Wilson, a therapist specialising in eating disorders, works with clients in a wide variety of high-performance sports. She often sees eating disorders appear in netball, hockey, running, triathlons, rugby and cheerleading. The age group is around 15-30.

According to UK Sport, the sports with the highest risk of eating disorders are:

• Swimming.

• Running.

• Gymnastics.

• Diving.

• Synchronised swimming.

• Wrestling.

• Judo.

• Lightweight rowing.

Famous examples of eating disorders in athletes

Living with an eating disorder can be very isolating, especially as an athlete since disordered eating can be normalised or even encouraged in sports to 'enhance performance.' Wider society may not be fully aware of how eating disorders can destroy the careers of sportspeople. However, there is a multitude of examples of sports stars who have had eating disorders.

Kadeena Cox

The two times Paralympics champion in athletics and cycling struggled with an eating disorder for a long time and said it returned following an injury. She went public with it in 2019 and started seeking help.

Adam Rippon

The figure skater compared himself to his competitors and started restricting meals as a result. Rippon suspects this contributed to him breaking his foot in training. He believed a thinner body would be "more aesthetically pleasing" to judges.

Alice Merryweather

The alpine skier battled anorexia nervosa, by controlling her diet in a bid to manage stress. She rebuilt her relationship with food after being partially hospitalised and receiving therapy.

Dame Sarah Storey

Known as Britain's greatest female Paralympic athlete as a 14-time champion, she controlled her food to cope with being bullied. She saw her GP and was encouraged to start keeping a food diary so they could support her in getting better.

Rachel Morris

Rowing champion Morris once claimed her sport became an "eating disorder factory" after seeing many fellow athletes develop eating disorders to meet weight categories for races. The gold medallist developed anorexia then bulimia as a teenager and said she wasn't given support from her coaches.

Are eating disorders encouraged in sport?

It is argued that eating disorders are 'normalised' in sport and encouraged by coaches and trainers.

"While eating disorders are complex mental illnesses that have a variety of causes, we do know that athletes have a higher chance of developing an eating disorder. There are several sporting practices that can harm people with or vulnerable to eating disorders," says eating disorder charity Beat.

"These practices include daily weigh-ins or weight monitoring. These can cause fixation on weight and encourage people who are unwell to engage in eating disorder behaviours, such as over-exercising or restricting food intake."

There are a number of reasons why athletes develop eating disorders. However, there seem to be several common factors, these include:

• Pressure to perform.

• Aesthetics and comparison with competitors.

• Strict diets and training regimes.

• The idea that elite athletes must be 'healthy.'

• Pursuit of certain body aesthetics (like in gymnastics).

• The need to be in a certain weight categorisation in order to compete (like in judo).

• Goal-orientated diets and exercise routines.

Olympic diver Tom Daley has spoken publicly about how restrictive eating was encouraged within his sport and led to his body image issues. He has said that he felt ashamed of the things he ate and "struggled with body image." He is adamant that these issues came from within his sport as "it was hammered into him that he was overweight and needed to lose weight in order to perform."

The impact of body shaming on children

Wilson worries that the promotion of disordered eating and body shaming in sport is harming children and influencing their views.

Just recently, an elite swimming club in Ellesmere was shut down after coaches repeatedly weighed girls as young as 10 and wrote their weights up on a board, shaming them if their weight increased. The coaches would control the girls' food intake and tell them they would be better swimmers if they were thinner. Many of the girls developed eating disorders and lasting mental health problems.

"I was asked to run a workshop on body image for primary school children recently. The boys were commenting on the girls' legs in PE and it reached a point where the girls no longer wanted to attend. These incorrect messages of how our bodies 'should' look start very young, and we need to address this," adds Wilson.

Why are eating disorders in athletes so common?

UK Sport explains how, until the early 1980s, most people, including professionals in mental health, had only a vague notion of bulimia nervosa, even though anorexia nervosa had been recognised since the 1800s.

However, eating disorders in athletes were rarely documented. Although people were aware of some athletes being 'too thin to win' or 'fit but fragile,' little was done.

As beliefs circulated that you had to be of a certain body type to succeed at sport, some athletes and coaches held the belief that a reduction in weight would always enhance performance. Traditions were then handed down in certain sports, from generation to generation, about the best ways to lose weight.

Historically there has been less information available about nutrition practices and how to fuel the body for sports.

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Eating disorders in female atheletes

Wilson emphasises how many sports, particularly for women, put competitors' bodies on full display with "unnecessarily skimpy outfits." These sports include gymnastics, cheerleading and beach volleyball.

"The pressure for sportspeople to look a certain way can be immense. Not just for the aesthetics, but also because it is suggested that being thinner leads to success.

"I have heard countless anecdotes of coaches commenting on athletes' bodies, and even talking about one athlete's body to another athlete. This sends a message that body shape and size is important to the coach. For someone in such a powerful position and with control over career prospects, it's understandable why athletes want to impress and care what their coach thinks."

How can we prevent eating disorders in athletes?

Starting conversations

Wilson says the first step to tackling eating disorders in athletes and body shaming in sport is talking about them, especially as a lack of dialogue has likely contributed to the problem escalating up to now. She says the subject is often left unspoken which can perpetuate shame.

The National Eating Disorders Collaboration (NEDC) encourages promoting mental health awareness within clubs and teams. This may help coaches to identify athletes who are suffering from an eating disorder and encourage communication about the issue.

Educating coaches on eating disorders and how to create safe spaces for athletes to have open conversations may help with early intervention. This can be key to ensuring recovery from an eating disorder.

"Awareness of eating disorders appears to be increasing in sport, fitness and dance. This is important because sports professionals are in a powerful position to help with efforts to promote mental health awareness by modelling appropriate attitudes and behaviours," says NEDC.

Beat adds: "If an athlete is worried about their own health, the first step would be to confide in a loved one or someone they trust. They should then contact their GP. If they are worried about someone else having a suspected eating disorder, they should encourage them to reach out for support and consult their own GP. The sooner somebody gets support for their eating disorder, the better their chances of recovery, and so it is important to reach out at the earliest opportunity."

They recommend that sporting institutions invest in eating disorder training to ensure sports professionals can quickly identify early signs of these serious mental illnesses, and signpost athletes to treatment.

Promoting nourishment and health

"Surprisingly, there seems to be little education on nutrition and fuelling the body adequately for your sport. This leaves athletes to find their own ways with little advice and guidance," says Wilson.

"There is often a culture of leanness equals fitness, and there is very little acceptance of health at every size (HAES)." To promote awareness and acceptance of this, she recommends more body diversity in advertising and promotional material for sportspeople.

UK Sport emphasises that nutritional practice is a key strategy in the prevention of eating disorders in athletes, and in general. All practitioners should encourage an ethos of appropriate nutrition within their squads. They say the ideal diet of an athlete must fulfil two criteria:

1. To maintain health.

2. To ensure nutrition for performance.

Safe weight monitoring

Beat encourages sporting institutions to ensure weight monitoring is done in a supportive environment if it is necessary.

This should be undertaken away from other athletes and with the option for the person not to hear about their own weight if this is something they find difficult.

"It's important to recognise that each body is different, and what is an achievable and healthy goal for one person, will not be for another," they say.

Athletes should take advice from a registered sports dietitian if they need help in shaping their diet and including the appropriate nutrients.