Thin Doesn't Win, Eating Disorders in Sports

Written by Trudy Mickel, M.A., Doctoral Student, Clinical Psychology, University of Denver

It feels like yesterday when I was standing at the top of the World Cup Finals mogul course in Megeve, France, cheering fans below, reporters and TV cameras surrounding me, and Perrine Laffont, Olympic Gold Medalist, in the start gate next to me. At 17 years old, I had achieved my dream: representing the United States on the world ski stage. This was one of the best days of my life. Yet just six months later, I was living in a nightmare. That October, I stood on the scale at Children's Hospital in Colorado, holding my breath to capture “more weight” as I saw a frightfully small number emerge. An EKG test revealed a faint, slow heartbeat, and I was admitted to the emergency room. How could I go from the best day to the worst in less than a year? The answer: Anorexia Nervosa. A perfect storm of biological, psychological, social, and cultural expectations within my athletic life had driven me too close to death. Anorexia Nervosa, known as the silent killer, impacts physical health and mental well-being; it has the highest mortality rate among all mental disorders (Arcelus et al., 2011; Meczekalski et al., 2013). 

Mental health was a foreign concept throughout my athletic career; a lack of education and open conversation led to a widespread misunderstanding. I had only encountered it in passing, through news stories or social media, and never imagined it could affect me personally. To the world, I was living the dream: strong, both physically and mentally, and successful, at least when it came to skiing. I equated athletic strength with mental strength and failed to acknowledge the reality that even professional athletes like me can struggle. 

What is Disordered Eating?

Disordered eating is defined as a large spectrum of harmful and often ineffective eating behaviors and distorted attitudes towards food, weight, shape, and appearance, including but not limited to dieting, skipping meals, restricting food intake, binge eating, laxative misuse, and excessive use of weight loss medications. Relatedly, eating disorders are classified by similar behaviors and attitudes that reach severity and frequency of the DSM-5TR (NEDA).

Prevalence and Risk

Eating disorders are common among all individuals, affecting about 9% of the population worldwide (Harvard Report, 2024). Among athletes, prevalence rates for eating disorders vary widely due to measurement difficulties. In sports, efforts to control body shape and weight are utilized to maximize performance, thus blurring distinctions between athletic edge and pathology. The absence of knowledge about mental disorders, common among coaches and sports personnel, further perpetuates these challenges (Currie, 2010). Despite these measurement limitations, there is evidence that rates of eating disorders and pathological eating are even higher among athletes than in the general population. Some studies suggest rates of eating disorder behaviors as high as 45% in female athletes (Sungot-Borgen and Torstvei, 2004). 

Consequences of Disordered Eating 

Significant weight loss can lead to dehydration, energy depletion, reduced muscle strength and aerobic capacity, and disruption of the endocrine system (Weiss et al., 2017). Physical risks include osteoporosis, energy deficiency, amenorrhea, and increased injury (Cabre et al., 2022). Cognitive abilities and memory may also be hindered as a result of malnourishment (Choma, Sforzo, and Keller, 1998; Kussman and Nattiv, 2016). Body image concerns and rapid weight loss are also associated with increased anxiety and stress, negative thought patterns, temporary mood disturbances, and preoccupation with food and appearance, all of which may contribute to poorer athletic performance (Choma, Sforzo, and Keller, 1998; Hart, Leary, and Rejeski, 1989; Felsten et al., 1993).

The risk for both clinical and subclinical eating disorders is elevated in sports that emphasize leanness, including aesthetic sports such as figure skating, dance, and gymnastics. Athletes in these disciplines report higher levels of body dissatisfaction (Kristjánsdóttir et al., 2019), which is among the strongest predictors of eating disorder development in high school and collegiate athletes (Greenleaf et al., 2009; Milligan et al., 2006). Additionally, weight-class sports often normalize rapid weight-reduction practices before competition, many of which are unhealthy behaviors. Research on female powerlifters, for example, revealed substantial pressure to cut weight embedded within the sport’s culture. In some cases, extreme food restriction before competition is framed as an accomplishment, followed by large food intake or binge eating after weigh-ins (Vargas and Winter, 2020). Emphasizing the relation between body size, appearance, and performance may therefore increase vulnerability to disordered eating. 

There is evidence that a variety of complex, interacting factors contribute to the development of eating disorders in athletes, including coaches’ behaviors and attitudes; team culture, such as frequent weight measurements, exposure to dieting, and pressure to lose weight; and individual personality traits, particularly perfectionism and mental toughness (Smolak, Murnen, & Ruble, 2000; Sundgot-Borgen, 1994). In other words, certain sports environments and athletic pressure can predispose athletes to increased risk for disordered eating cognitions and behaviors (Currie, 2010; Voelker and Galli, 2019).

Developmental Pathways

Coaches Role

Many factors play into the development of eating disorders. Coaches are in a powerful position to influence developmental trajectories, given their frequent messaging and interaction with athletes. Since coaches are often successful athletes themselves or have coached others to success, their influence may be beyond that of other adults in athletes’ lives. Coaches play an important role in recognizing and helping athletes balance and manage training and competition demands within athletics. Higher levels of sports involvement, such as team travel and team camps, often increase coaches’ influence on athletes. Research highlights that coaches' attitudes and messaging about mental health may play a particularly important role (Bissett et al., 2020). Some studies report that up to 60% of elite athletes reported pressure from coaches regarding body shape (Kong & Harris, 2015), and several studies have reported that athletes receive encouragement to make body changes to improve performance and reach podium-levels (Sterling & Kerr, 2012; Voelker & Reel, 2015). Building on this work, in their systematic review, Voelker and colleagues (2022) found that athletes experiencing eating pathology were more likely to report receiving directives from their coaches that encouraged weight loss and thinness for optimal performance. Although it is difficult to disentangle coaches' direct influence from broader team culture and attitudes, the authors of this work highlight that, according to athletes, a focus on losing weight and/or an ‘ideal’ shape to improve performance was related to their eating pathology.

 Coaches are role models: Developing athletes often place deep trust in coaches, spend significant time with them, and strive to gain their approval and validation. Often, they are the adult whom developing athletes trust, spend significant time with, and strive to gain approval from. As an athlete, I truly believed my coaches knew best. Despite intentions to improve my performance, as a malleable teenage girl, I experienced consistent comments on weight and “correct” eating habits, as well as body measurements, and messaging around an “ideal weight”.  Each of these sprouted harmful internal messages in my developing brain. I soon associated weight as a potential obstacle to achieving my Olympic dreams and reaching my athletic potential. Coaches need to be educated on disordered eating symptoms to recognize them early and prevent clinical levels.

Team Culture

Coaches are in a position of power and have direct relationships with athletes, while simultaneously shaping team culture. For several years, I was surrounded by a culture of athletes walking a fine line between skinny and strong. I distinctly remember teammates strategizing what they would, or would not eat and drink, before structured skin folds; a harmful body-fat test that is too often conflated with athletic potential and success. Instead of focusing on fueling properly to perform best on athletic testing, the focus was wrongfully on the number on the scale or the skin-folds test. In alignment with my experience, results, and body weight-focused coaching leads to athletes’ increased body image anxiety, dieting, and fear of fatness (Biesecker and Martz, 1999). Across multiple studies, findings suggest an emphasis on leanness or “thin wins” increases the risk of eating disorders even more (Kristjánsdóttir et al., 2019; Krentz and Warschburger, 2011). Additionally, sports and performance enhancement were the largest single reasons for dieting among athletes (Martinsen et al., 2010). Unfortunately, a small increase in performance from minimal weight loss can quickly spiral into a career-hindering or career-ending disorder, as well as longer-term health consequences. The reinforcement of these destructive tests and damaging messages linking weight with performance needs to end in sport culture.

Individual Characteristics

Individual traits that often contribute to athletic success simultaneously increase risk for eating disorders. For instance, individual motivation and attentiveness to small details, consistent with perfectionism, is correlated with eating disorders (Stirling & Kerr., 2012; Forsberg and Lock, 2006; Vacca, 2021). Personality traits often emphasized in successful athletes that may lead to high achievement, such as mental toughness, discipline, high pain tolerance, and persistence, may also heighten risk (Atiye et al., 2015). In my case, if losing weight, eating a specific way, or exercising more correlated with better performance and being a “better athlete”, I was all in. Could it be: the same traits that made me a successful athlete at such a young age also predisposed me to developing an eating disorder? Understanding individual differences and characteristics that predispose athletes to be at risk for developing an eating disorder may also be leveraged in ways that contribute to athletic success. But athletes’ well-being must be prioritized above performance. 

Gender identity and sex likely also impact how eating disorder risk manifests in sports contexts. Historically, eating disorders have been reported at higher rates among female athletes, particularly in sports that emphasize leanness, aesthetics, or weight categories (e.g., gymnastics, distance running, figure skating), where thinness is often implicitly or explicitly linked to performance (Sundgot-Borgen & Torstveit, 2004). However, emerging research suggests that disordered eating behaviors in male athletes may be underreported and underrecognized. Male athletes may experience pressures to achieve a different body ideal, one emphasizing muscularity, low body fat, and strength, which can lead to restrictive eating, compulsive exercise, and weight-controlling behaviors, similar to those observed in female athletes (Petrie & Greenleaf, 2007; Murray et al., 2016). In addition, stigma and gender norms may discourage male athletes from acknowledging body image concerns or seeking help, contributing to lower detection rates (Yoon & Petrie, 2023). Recent research also highlights that athletes whose gender identity falls outside of traditional binary categories may face unique vulnerabilities due to minority stress, body dysmorphia, and sports environments structured around rigid gender categorization (Nagata et al., 2020). Together, these findings suggest that while the expression of disordered eating may differ across sexes and gender identities, the underlying pressures related to performance, body ideals, and identity formation in sport environments can place many athletes at risk.

What next?

Although this essay focuses on professional sports, the influence of coaches and sports environments begins much earlier in athletes’ development and can exist across a range of competitive levels. Coaching behaviors, team culture, and individual expectations shape athletes’ experiences during formative developmental stages in childhood and adolescence, well before athletes reach elite levels (Smolak, Muren, & Ruble, 2000; Petrie & Greenleaf, 2007). Additionally, while the present essay centers on eating disorders among athletes, the pressures associated with elite sports participation are linked to a range of physical and psychological challenges (Reardon et al., 2019). These outcomes are likely shaped by a variety of interacting factors discussed, such as coaching behaviors, sports culture, and individual differences such as perfectionism and identity-related factors (Joy et al., 2016; Petrie & Greenleaf, 2007; Sundgot-Borgen & Torstveit, 2004). 

Protective Factors and Resources

Coaches

Coaches can play a preventative role in the development of clinical and subclinical eating disorders by posing as a positive role model, encouraging healthy eating and exercise, and emphasizing health and well-being over results. Encouragingly, a supportive and caring coaching style may reduce the risk of eating disorders (Biesecker & Martz, 1999; Currie, 2010). If you are a coach, consider seeking further education on mental health in sports, evaluate your team culture and messaging to athletes, and promote conversations about mental health in your team. There are excellent resources designed to support coaches to identify warning signs, create healthy team cultures, and know when/how to refer athletes to experts. 

• Coach and Trainer Toolkit to support athletes who may be affected by an eating disorder 

• NEDA – The role of coaches in eating disorders  

• NCAA Coaches Handbook – Managing the Female Athlete Triad 

Athletes and Parents

If you are an athlete, you are not alone and you can get better. You have nothing to be ashamed of. If you are a parent, it’s not your fault. Your child can recover.

If you or someone you know is struggling, there are many resources available. 

• NEDA – information and recommendations specific to eating disorders in sports

• McCallum Place – an eating disorder treatment embracing athletes and their unique struggles and symptomatology enhanced through sports pressures and environments.

•  UCSanDiego – information on current research and treatment approaches for athletes with eating disorders. 

Mental Health Providers

Clinicians working with athletes should be aware of unique presentations and symptoms specific to athletes. Athlete-specific tools and evidence-based treatments must cater towards varying needs of athletes. 

• Athlete-specific eating disorder screening tools 

• Guide to the Mental Health of Athletes

• Children’s Hospital – Relative Energy Deficiency in Sports (REDs) 

Clinical care. Eating disorders are complex and often require multidisciplinary support from a psychologist, physician, dietician, and coaches to support athletes in return-to-play, fueling management, and positive sports culture. 

Conclusion

Eating disorders and mental health disorders are very prevalent in our society. Athletes are not exceptions to these battles. And just like physical health, mental health requires support and treatment to heal. It’s time we come together to create conversations, increase awareness, and reduce stigma surrounding mental health in sports. Early intervention and treatment can save athletic careers and even lives. As an athlete I was always strong, but accepting, fighting, and choosing recovery from Anorexia has made me even stronger.

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