Disordered Eating in Female

Athletes
By Marisa Deichert
2016

April 8,

The human mind works in interesting ways when individuals try to rationalize a certain
situation or decision, what one thinks is right sometimes may seem taboo to another. Mental
disorders are similar to this train of thought, affecting the mood, thinking, and behavior of the
affected individual and leading too poor or irrational choices. Eating disorders, a type of mental
disorder, are paradoxical in that the individual is trying so hard in order to make themselves
healthier, fitter, leaner, faster, and stronger that they end up overkilling the situation and become
unhealthy, unfit, too lean, and weak. Since eating disorders are the mental illness with the highest
mortality rate,1 there needs to be better implementation of preventative and rehabilitation
programs in order to combat this serious mental illness.
The issue of eating disorders is a global problem that affects all genders, ages, and races.
The majority of cultures today value thinness, which puts the stress of the expectation of thinness
on most of the population. However, there is an added stress of being thin placed on female
athletes. The psychological and physical stress of athletic competition are added to the cultural
emphasis on thinness, causing there to be an increase in disordered eating. Both male and female
athletes are at risk for disordered eating, especially those in sports that emphasize diet,
appearance, and weight. However, an extra stress is put on female athletes; over one-third of
female athletes in a study of Division 1 NCAA athletes had symptoms and attitudes that put them
at risk for anorexia nervosa.2
1|Page

The

Female Athlete Triad

The added stress placed on the female athlete even deems its own name to describe the
disorder: the female athlete triad. The three components of this triad are menstrual dysfunction,
low energy availability (with or without an eating disorder), and decreased bone mineral density
(BMD).4 According to an article written for Sports Health, secondary amenorrhea for women
who participate in sports such as ballet or running, which emphasize leanness, is 69%, which is
much higher than the 2% to 5% of the general population affected by secondary amenorrhea.5
Disordered eating is prevalent in the athletic community, with up to 70% of elite athletes in
weight class sports which show signs of disordered eating in order to achieve weight loss. For
female elite athletes, eating disorders are found in 16% to 47% of athletes (the large range is due
to variability in research and testing criteria).6 The amount of athletes with disordered eating is
quite higher than the 0.5% and 10% of nonathletic men and women respectively in the general
population who suffer from disordered eating.7 The third prong of the female athlete triad, low

2|Page

bone mineral density, is also higher for female athletes as compared to the average population. In
female athletes, osteopenia is reported in 22% to 50%, and osteoporosis in 0% to 13%.8 In the
average population, osteopenia is recorded 12% and osteoporosis 2.3%.9

Consequences of Eating Disorders and the Female Athlete Triad

The female triad and the consequences that come with them are important issues that
need to be resolved because they affect the female athlete both in the short term as well as the
long term. However, the female athlete does not need to be suffering from all three aspects of the
triad in order to be affected by the health consequences of the triad; the three components of the
triad also may present themselves at different times in the females life.10
The short term effects of living with an eating disorder include severe dehydration,
fainting, fatigue, overall weakness, dry hear and skin, hair loss, and growth lanugo all over the
body, a downy layer of hair, in order to keep the body warm.11
The long term effects of living with prolonged malnutrition include brain and muscle
atrophy, low blood pressure, low heart rate, and severe fluid and electrolyte imbalances, which
can cause seizures, arrhythmias, heart failure, kidney and multiple organ failure.12
The triad builds one off of each other. Initially, a lack of nutrition from disordered eating
causes a female to lose several or more periods. The loss of menstrual cycles causes calcium to
pull from the bones, causing bone loss and an increased risk of stress fractures. Each of the
consequences of the triad are an extreme medical condition that could potentially be life
threatening.13 Due to prolonged malnutrition, an individual with an eating disorder may die from
sudden heart attack, multiple organ failure, and other deadly consequences, in addition to a high
risk of suicide.14
Recovery of Bone Mineral Density

3|Page

PROCESS: Years

Recovery of Menstrual Status

PROCESS: Months

OUTCOMES:

PROCESS: Days or Weeks

OUTCOMES:

Estrogen continues to

OUTCOMES:

Reproductive hormones

inhibit bone resorption

Energy status will stimulate anabolic

Estrogen exerts an anti-

Energy status will

hormones (IGF-1) and bone formation

resorptive effect on bone

stimulate anabolic

Recovery of Energy Status

Energy status will reverse energy

conservation adaptations

hormones (IGF-1) and

15

bone formation

Psychological Side of Female

Athlete Triad
In addition to the physical ramifications of the female athlete triad, there is a large
psychological component as well. With the low energy availability, individuals with an eating
disorder are also at risk for suffering from depression, low self-esteem, and other anxiety
disorders, as well as poor body image.16
Because of the large psychological component of eating disorders, it becomes necessary
to also treat this element during the recovery process. Because athletes tend to be determined,
competitive people who want to succeed and do whatever it takes, and have perfectionist
personalities, changing this characteristic of the individual becomes difficult. Altering ones diet
and exercise regimen from a disordered one to a healthy one can come with much dissatisfaction
from the patient as well as much conflict. Therefore, appropriate mental healthcare is necessary,
which can include psychiatric medication prescription and cognitive behavioral therapy.17

4|Page

These types of attitudes that make it hard to correct eating disorders in female athletes are
also constitute the tendencies that initiate the female athlete triad in the first place. Women in
society face the pressure that thin is in. Therefore, these young women and girls, typically also
being goal-oriented perfectionists, who feel the societal pressures of being thin strive to achieve
the lean appearance and/or athletic success through compulsive dieting and exercise. The
compulsive acts lead the female into the path of disordered eating, menstrual dysfunction, and
lowered bone mass formation, and thus the female athlete triad.18

At Risk Individuals for Eating Disorders and Female Athlete Triad

Someone at risk for an eating disorder includes individuals who participate in sports that
emphasize appearance, weight requirements, muscularity, or focus on the individual rather than
the entire team. Also, endurance sports, sports that believe that lower body weight will improve
performance, and elite athletes are also at high risk. Female athletes have three risk factors
specifically for them: social influences emphasizing thinness, performance anxiety and negative
self-appraisal of athletic achievement.19
An individual who would fit the criteria for a female athlete at risk for the triad would be
one who shows signs of disordered eating or caloric intake much less than the recommended
daily intake specific for her, has skipped months during her menstrual cycle or not started her
menstrual cycle at an age that is deemed unhealthy, or has low bone density or common and
reoccurring stress fractures.

Solutions to the Issue

In order to decrease the occurrence of the female athlete triad, a number of various
directions can be taken. Preliminarily, coaches can be more positive, person-oriented as opposed
5|Page

to negative, performance-oriented; can emphasize motivation and enthusiasm as opposed to body

weight and shape; and can, in conjunction with family, discuss the changing female body.20
Another solution to this issue is to make sure that other student-athletes, coaches, and
other individuals who oversee athletics are able to detect symptoms of eating disorders. This can
be done in various ways, at various age groups. Initially, an exposure of eating disorders and
their repercussions should be taught at an adolescent age, or middle school-aged students. It is
important to introduce eating disorders to individuals of this age because they have the power to
make blind decisions that could potentially affect their lives forever. This could be integrated by
including eating disorders and their consequences both short term and long term as a topic in
middle school health classes. Also, middle school coaches
should take time to discuss eating disorders and their
effect on athletics. The coaches should also be educated
in order to detect eating disorders in their athletes by
becoming familiar with the basic signs of an individual
21

struggling with an eating disorder. Middle school age is

where most adolescents go through major changes in both height and weight. For example, girls
can gain an average of 40 pounds (lb.) from age 11 to 14 and thats normal. A girl or boy who
puts on weight before having a growth spurt in height may look plump, while a student who
grows taller but not heavier may appear rather thin.22 This makes middle school-aged students
more prone to disordered eating habits because of the great deal of bodily changes occurring at
this time, and at different rates, leading to inaccurate comparisons between their peers.
Additionally, eating disorders should be discussed at the high school age. Although they
were already discussed at the middle school age, repetition is key to teaching important

6|Page

concepts.23 Also, the reasons for eating disorders social pressures, the changing female body,
and increase competition in sports become more apparent and change from the reasons in
middle school. Coaches should be more formally taught on the signs and symptoms of eating
disorders in athletes; this can be done by having district-wide or state-wide conferences in order
to educate the coaches of the signs of eating disorders as well as ways in which to coach
effectively without being the cause of the disordered eating. Starting at the high school level,
regular dual x-ray absorptiometry (DXA) scan should be administered every year to every two
years as part of the physical in order to establish a baseline in athletes as well as monitor if there
is any bone loss. Although this scanning might take more resources both time and money this
would be beneficial to athletes, especially female athletes, in the long run.
At the collegiate level, student-athletes are able to be monitored by more professionals
than at the middle school or high school level. Similar to high school coaches, collegiate coaches
should attend conference-wide forums that teach coaches the signs and symptoms of eating
disorders, as well as how to promote the ideal body type for their athletes without causing
restrictive and unhealthy eating behaviors. Additionally, the DXA scan should be continued in
order to continue monitoring the bone health of the athlete. The athletes should also be taught
about eating disorders and their long-term consequences for a potential short-term gain. Eating
disorder signs and symptoms could be taught in student-athlete required classes that most
colleges have, and if additional help is needed, most collegiate teams have nutritionists that
student-athletes have access to.

Personal Narrative of the Female Athlete Triad

Knowledge about eating disorders and their consequences that lead to the female athlete
triad by implementing these solutions could positively affect individuals. For example, I have
7|Page

personally completed the female athlete triad. I was a very athletic person; I ran cross country
and track and field, and played soccer, basketball, volleyball, and was on an equestrian team
throughout my middle school/high school years (although not all in one year). When I was in
seventh grade, I started to develop restrictive eating behaviors as well as started excessively
exercising. I had done so with the perception in mind that I would become faster if I weighed
less. I continued to lose weight, and would not take the advice of my parents, friends, family and
doctors. The summer before my eighth grade year, I was put into an intensive eating disorder
recovery program by Hershey Medical Center in Hershey, PA. I have formally recovered, but
like anyone who has experienced an eating disorder, I still know the thoughts of this type of
behavior; an eating disorder lives with you forever. Flash forward to my senior year of high
school, I have still never started her menstrual cycle. I was put onto an oral contraceptive (birth
control) in order to increase the amount of estrogen in my body in order to menstruate. Things
seemed to be moving swiftly, but in the spring of my senior year of high school, I got a stress
fracture in my left femoral shaft. I was devastated, and couldnt wait for it to heal and run again.
Fast forward to fall of my freshman year of college, I got a stress reaction in my right femoral
shaft. Since I got two stress-related injuries in a seven-month time span, my family and I decided
that it was important to look into the root of the issue in order to prevent any further injury. Igot a
DXA scan of my bone mineral density, which showed that I was in the osteopenia range for bone
density. Since, I have taken greater measures to make sure I am getting the required amounts of
calcium and vitamin D, as well as training smart by gradually increasing amount and intensity of
running and strengthening muscle groups that help to protect easily fractured areas, such as the
spine and hips. I wish that I had more knowledge of the consequences of the mistakes I made in

8|Page

seventh grade in regards to my nutrition; had I known then the life long consequences of an
eating disorder, perhaps I would have thought more about the restrictive choices I made.

9|Page

Endnotes
1. R. Douglas Fields, The Deadliest Disorder: There is nothing wrong with me.,
Psychology Today (2011), available at https://www.psychologytoday.com/blog/the-newbrain/201103/the-deadliest-disorder-0 (last accessed March 2016)
2. National Eating Disorder Association, Athletes and Eating Disorders, available at
https://www.nationaleatingdisorders.org/athletes-and-eating-disorders (last accessed
March 2016)
3. Ryan Andrews, All about disordered eating: Understanding and addressing eating
disorders, Precision Nutrition, available at http://www.precisionnutrition.com/all-aboutdisordered-eating (last accessed April 2016)
4. Taraneh Gharib Nazem and Kathryn E. Ackerman, The Female Athlete Triad, Sports
Health (2012), available at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3435916/#bibr118-1941738112439685
(last accessed March 2016)
5. Nazem and Kathryn E. Ackerman, The Female Athlete Triad.; Secondary
amenorrhea refers to a loss of menses after menarche (first menses).; Abraham SF,
Beumont PJ, Fraser IS, Llewellyn-Jones D, Body weight, exercise and menstrual status
among ballet dancers in training, Br J Obstet Gynaecol (1982): 507-510, available at
http://www.ncbi.nlm.nih.gov/pubmed/7093163 (last accessed March 2016); Bachmann
GA, Kemmann E, Prevalence of oligomenorrhea and amenorrhea in a college
population, Am J Obstet Gynecol, (1982): 98-102, available at
http://www.ncbi.nlm.nih.gov/pubmed/7114117 (last accessed March 2016); Dusek T,
Influence of high intensity training on menstrual cycle disorders in athletes, Croat Med
J., (2001): 79-82, available at http://www.ncbi.nlm.nih.gov/pubmed/11172662 (last
accessed March 2016); Pettersson F, Fries H, Nillius SJ, Epidemiology of secondary

10 | P a g e

amenorrhea: I Inciddnce and prevalence rates, Am J Obstet Gynecol, (1973): 80-86,

available at http://www.ncbi.nlm.nih.gov/pubmed/4722382 (last accessed March 2016);
Singh KB, Menstrual disorders in college students, Am J Obstet Gynecol, (1981): 299302, available at http://www.ncbi.nlm.nih.gov/pubmed/7246632 (last accessed March
2016)
6. Nazem and Kathry E. Ackerman, The Female Athlete Triad.; Byrne S, McLean N.,
Elite athletes: effects of the pressure to be thin, J Sci Med Sport (2002): 80-94,
available at http://www.ncbi.nlm.nih.gov/pubmed/12188089 (last accessed March 2016);
Elite athlete, according to the medical dictionary in sports medicine, refers to An
athlete with potential for competing in the Olympics or as a professional athlete; Elite
Athletes are at increased risk for injuries, given the amount of training, for psychological
abuse by coaches and parents, and self-abuse, or a person who currently or has
previously competed as a varsity player (individual or team), a professional player or a
national or international level player, available at http://medicaldictionary.thefreedictionary.com/elite+athlete; Sundgot-Borgen J, Torstveit MK, Aspects
of disordered eating continuum in elite high-intensity sports.; Sundgot-Borgen J,
Torstveit MK, Prevalence of eating disorders in elite athletes is higher than in the
general population, Clin J Sport Med, (2004): 25-32, available at
http://www.ncbi.nlm.nih.gov/pubmed/14712163 (last accessed March 2016); Torstveit
MK, Rosenvinge JH, Sundgot-Borgen J., Prevalence of eating disorders and the
predictive power of risk models in female elite athletes: a controlled study, Scand J Med
Sci Sports (2008): 108-118, available at http://www.ncbi.nlm.nih.gov/pubmed/17490455
(last accessed March 2016)

11 | P a g e

7. Nazem and Kathryn E. Ackerman, The Female Athlete Triad.; Sundgot-Borgen J,

Torstveit MK, Aspects of disordered eating continuum in elite high-intensity sports,
Scand J Med Sci Sports (2010): 112-121, available at
http://www.ncbi.nlm.nih.gov/pubmed/20840569 (last accessed March 2016); Byrne S,
McLean N., Elite athletes: effects of the pressure to be thin, J Sci Med Sport (2002):
80-94, available at http://www.ncbi.nlm.nih.gov/pubmed/12188089 (last accessed March
2016); Sundgot-Borgen J, Torstveit MK, Prevalence of eating disorders in elite athletes
is higher than in the general population.
8. Nazem and Kathryn E. Ackerman, The Female Athlete Triad.; Khan KM, Liu-Ambrose
T, Sran MM, Ashe MC, Donaldson MG, Wark JD, New criteria for female athlete
syndrome? As osteoporosis is rare, should osteopenia be among the criteria for defining
the female athlete triad syndrome? Br J Sports Med (2002): 10-13, available at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1724456/ (last access March 2016)
9. Nazem and Kathryn E. Ackerman, The Female Athlete Triad.; Nattiv A, Loucks AB,
Manore MM, Sanborn CF, Sundgot-Borgen J, Warren MP, American College of Sports
Medicine position stand: the female athlete triad, Med Sci Sports Exerc. (2007): 18671882, available at http://www.ncbi.nlm.nih.gov/pubmed/17909417 (last accessed March
2016)
10. Nazem and Kathryn E. Ackerman, The Female Athlete Triad.
11. National Eating Disorder Association, Health Consequences of Eating Disorders,
available at https://www.nationaleatingdisorders.org/health-consequences-eatingdisorders (last accessed March 2016)
12. R. Douglas Fields, The Deadliest Disorder: There is nothing wrong with me.
13. National Eating Disorder Association, Athletes and Eating Disorders.
14. R. Douglas Fields, The Deadliest Disorder: There is nothing wrong with me.
15. Mary Jane De Souza, Aurelia Nattiv, Elizabeth Joy, Madhusmita Misra, Nancy I
Williams, Rebecca J Mallinson, Jenna C Gibbs, Marion Olmsted, Marci Goolsby, Gordon

12 | P a g e

Matheson, Expert Panel, 2014 Female Athlete Triad Coalition Consensus Statement of
Treatment and Return to Play of the Female Athlete Triad: 1st International Conference
held in San Francisco, California, May 2012 and 2nd International Conference held in
Indianapolis, Indiana, May 2013, available at http://www.femaleathletetriad.org/wpcontent/uploads/2014/02/De-Souza-et-al.-2014_FAT-Consensus-Paper.pdf (last accessed
April 2016)
16. Nazem and Kathryn E. Ackerman, The Female Athlete Triad.
17. Ibid.
18. American College of Sports Medicine, The Female Athlete Triad, (2011), available at
https://www.acsm.org/docs/brochures/the-female-athlete-triad.pdf (last accessed April
2016)
19. National Eating Disorder Association, Athletes and Eating Disorders.
20. Ibid.
21. Dying to be Barbie: Eating Disorders in Pursuit of the Impossible, An Epidemic of Body
Hatred, available at http://www.rehabs.com/explore/dying-to-be-barbie/#.VwfVtvkrLIU
(last accessed April 2016)
22. National Eating Disorder Association, Educator Toolkit, available at
https://www.nationaleatingdisorders.org/sites/default/files/Toolkits/EducatorToolkit.pdf
(last accessed April 2016)
23. C. J. Weibell, Principles of learning: 7 principles to guide personalized, student-centered
learning in the technology-enhanced, blended learning environment, (2011), available at
https://principlesoflearning.wordpress.com (last access April 2016)

13 | P a g e