Eating Disorders in Sport

The recognised eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant or restrictive food intake disorder (ARFID), and other specified feeding or eating disorders, alongside a wider spectrum of disordered eating that falls short of a full diagnosis but still carries risk. Eating disorders, low energy availability and relative energy deficiency in sport overlap but are not the same thing: an athlete can have low energy availability without an eating disorder, and the reverse, though they often occur together. Risk is higher in weight-sensitive sports, broadly the endurance, aesthetic, weight-category and gravitational sports, where a lower body weight is believed, rightly or wrongly, to help performance or to meet an aesthetic or category requirement. Drivers include performance and body-image pressure, aesthetic judging, making weight, perfectionism, and sometimes well-meaning but harmful comments about weight or physique from within the sport. Eating disorders affect male athletes too and are easily missed in them, and they often coexist with anxiety and depression rather than occurring in isolation.

The clues are behavioural and physical, and the clinician stays alert to the pattern rather than any single sign. Behavioural clues include a preoccupation with food, weight or body shape, rigid or secretive eating, distress around meals, and exercise that goes beyond training needs or continues through injury and illness. Physical clues include recurrent bone stress injuries or stress fractures, fatigue and poor recovery, menstrual disturbance, gastrointestinal or dental problems, and feeling cold. Mood changes, social withdrawal, and safeguarding concerns, particularly in a young athlete, also matter. Because many of these overlap with the effects of hard training, the SEM clinician is well placed to notice when the picture does not fit, and to ask about eating, body image and energy in a calm, non-judgemental way. The signs of medical instability in the red flags above, which align with the Medical Emergencies in Eating Disorders (MEED) guidance, point to a medical emergency that needs urgent assessment.

Assessment is clinical, sensitive and best done without judgement, since shame and secrecy are common. Brief screening questionnaires can help start the conversation: the general SCOFF questionnaire is widely used, and sport-specific tools such as the Brief Eating Disorder in Athletes Questionnaire (BEDA-Q) were developed for athletes, though the BEDA-Q was developed mainly in female elite athletes, which limits how far it generalises to male athletes and other groups. Screening supports but does not replace a proper clinical assessment. Alongside the mental health assessment, the clinician assesses the physical consequences: weight trajectory, pulse, blood pressure including any postural drop, temperature, hydration, and, where indicated, an electrocardiogram (ECG) and targeted blood tests, while looking for relative energy deficiency in sport. A normal body mass index or normal blood results do not exclude serious illness, and body mass index alone must not determine treatment. Collateral history, with the athlete's consent, adds context, and the aim is to identify both the disorder and any medical risk and to bring in the right specialists early.

Eating disorders are treated by a specialist, multidisciplinary team, and are not managed alone by the SEM clinician, whose role is to recognise the problem, assess medical risk, refer and support ongoing physical monitoring. When an eating disorder is suspected, refer immediately to an age-appropriate specialist eating disorder service and do not adopt watchful waiting. Treatment is coordinated and combines eating-disorder-specific psychological therapy, nutritional rehabilitation guided by specialists rather than generic diet or exercise advice, and medical monitoring and stabilisation; for anorexia nervosa, safely restoring weight is a central goal of specialist treatment. Any coexisting low energy availability and relative energy deficiency in sport are addressed as part of this. Medical instability requires training and competition to be restricted, and decisions are made with the team and the athlete, putting health first. Confidentiality is respected within its usual limits, and safeguarding takes priority for children and young athletes. Coaches and support staff are involved with the athlete's consent, and prevention matters too, through a supportive team culture that avoids harmful messages about weight. Some medicines and substances misused in eating disorders are also prohibited in sport, a further reason to involve the right professionals. Return to full training and competition is individualised and considers physical risk, nutritional progress, compulsive exercise and psychological readiness, with multidisciplinary review, medical clearance and a relapse-prevention plan.

• •International Olympic Committee consensus statements on relative energy deficiency in sport and on mental health in elite athletes set out the risks and principles of care.
• •Current NICE guidance on eating disorders informs recognition and treatment, including that body mass index alone should not determine whether treatment is offered.
• •The Medical Emergencies in Eating Disorders (MEED) guidance sets out how to recognise and manage the physical risks of a severe eating disorder.
• •The eating disorder charity Beat and the National Health Service provide information, support and routes to help.

• •Eating disorders carry high medical risk and affect male as well as female athletes.
• •Eating disorders, low energy availability and relative energy deficiency in sport overlap but are not the same.
• •The first clues are often physical, such as recurrent bone stress injuries, poor recovery or menstrual disturbance.
• •Signs of medical instability, a slow heart rate, low or postural blood pressure, low temperature, fainting, or electrolyte or electrocardiogram changes, need urgent assessment.
• •A normal body mass index or normal bloods do not exclude serious illness, and body mass index alone must not determine treatment.
• •Refer immediately to a specialist service without watchful waiting, and restrict training when medically unstable.