Warning Signs of Eating Disorders and Relative Energy Deficiency in Athletes: How to Recognize It in Yourself, Support Others, and Know When to Seek Help

An Issue That Deserves Serious Attention but Is Often Overlooked

In the world of endurance sports, traits like “self-discipline,” “commitment,” and “control” are highly prized—controlling diet, controlling training volume, and controlling body weight are all seen as necessary conditions for achieving卓越 performance. This culture itself is not the problem; the problem is that when the line of “control” is crossed, becoming a pattern of behavior that cannot be voluntarily stopped and even harms physical and mental health, many athletes, coaches, and family members struggle to recognize it in time. This is because the outward behavior looks almost identical to that of a “seriously disciplined athlete”: eating less, training more, having a lean physique, and holding oneself to strict standards. This is precisely the root reason why eating disorders and relative energy deficiency issues in the endurance sports community are so easily overlooked, or even unintentionally encouraged.

This article is the one in this series that needs to be handled with the most care, because eating disorders involve real health risks and can even be life-threatening. The purpose of this article is to provide a checklist of warning signs and a guide for action that is as complete and practical as possible, helping readers with self-awareness, supporting those around them, and knowing when to seek professional help. This article does not provide a diagnosis and cannot replace professional medical and psychological evaluation. If you or someone around you is experiencing what is described in this article, please treat this article as a starting point, not an endpoint—proper evaluation and assistance require the involvement of qualified professionals.

Understanding Relative Energy Deficiency: More Than Just “Not Eating Enough”

Previous articles in this series introduced the concept of “Relative Energy Deficiency in Sport” (RED-S): a state where long-term energy intake is insufficient to support training expenditure and basic physiological functions, leading to impacts on multiple systems including bone health, immunity, hormones, and metabolism. The causes of this condition are not necessarily deliberate dietary restriction; it can also result from unintentional inadequate energy intake—for example, a sudden significant increase in training volume without a corresponding adjustment in diet, overly strict food choices leading to insufficient caloric density, or irregular eating patterns due to a busy lifestyle. This means the at-risk population for RED-S includes not only those consciously trying to lose weight, but also serious trainees who simply “don’t realize they aren’t eating enough.”

However, in some cases, long-term energy deficiency is indeed related to disordered eating tendencies or clinical eating disorders, and the boundary between the two is sometimes unclear, with both potentially coexisting. Understanding this is important because it means that when facing energy deficiency or weight issues, in addition to “numerical” adjustments like calculating calories and training volume, it is sometimes also necessary to pay attention to psychological and behavioral factors.

Concepts of Common Eating Disorder Types

This section is only a conceptual introduction, intended to help readers understand possible presentations. It is not a basis for self-diagnosis; an actual diagnosis requires evaluation by a qualified psychiatrist or clinical psychologist.

Behavioral patterns with anorexic tendencies: Pursuing continuous weight loss through strict restriction of food intake or types of food, continuing to restrict even when body weight is already clearly low, holding an intense fear of weight gain, and having a distorted body image (clearly underweight, yet still feeling “too fat”).

Patterns of binge eating followed by compensatory behaviors: Recurrent episodes of uncontrolled excessive eating, followed by compensatory behaviors such as self-induced vomiting, excessive exercise, or misuse of laxatives or diuretics, in an attempt to offset the calories consumed.

Binge eating patterns (without compensatory behaviors): Recurrent episodes of uncontrolled excessive eating without compensatory behaviors like vomiting or medication misuse, often accompanied by intense guilt and self-loathing.

The hidden pattern unique to athletes: This is the pattern that requires special attention in the endurance sports community. The behavior may not fully conform to the typical categories above, but instead uses “overtraining” as the primary means of energy expenditure and emotional regulation. Dietary restriction is often packaged as “for performance” or “for healthy eating,” making it harder for both the individual and those around them to recognize this as a behavioral pattern requiring attention. This pattern is sometimes referred to under the related concept of “athletic anorexia,” with the core characteristic being the use of exercise itself as a tool for controlling weight and emotions, to the point where the individual cannot allow themselves to rest even when injured, ill, or extremely fatigued.

Why the Risk in the Endurance Sports Community Deserves Particular Attention

Not all sports carry the same level of exposure to eating disorder risk. In sports science and clinical observation, it is generally recognized that sports emphasizing low body weight and a lean physique as beneficial to performance (such as long-distance running, road cycling climbing, and triathlon) have a higher level of exposure for at-risk individuals compared to sports emphasizing absolute strength or physical mass (such as weightlifting or American football offensive linemen). There are several understandable reasons behind this that deserve to be acknowledged by coaches and athletes in the endurance sports community, rather than ignored.

The intuitive link between performance and body weight: As mentioned in the first article of this series, climbing and long-distance pacing do have a physical relationship with body weight, which makes “lighter” easily simplified as the only means to “faster,” overlooking the potential physiological costs behind weight loss.

Training culture emphasizes discipline and pain tolerance: Endurance training itself requires a considerable ability to tolerate discomfort and delay gratification. Without healthy boundaries, this trait can easily extend to dietary control, treating “resisting the urge to eat” and “enduring a brutal interval session” through the same psychological mechanism, blurring the line between healthy discipline and harmful restriction.

Clothing and visibility: Cycling and running race kits are typically form-fitting, making changes in body shape easily noticeable to oneself and others. This high visibility can increase self-awareness of physique and exposure to external commentary, which may be an additional source of stress for those already prone to body image concerns.

The comparison culture of social media: Training logs, race results, and physique photos are highly publicly shared and compared on social platforms. This environment can amplify attention on body shape and weight, and may unintentionally reinforce pre-existing disordered eating tendencies through social interactions (such as likes or comments praising someone for “looking thinner”).

The purpose of recognizing these risk factors is not to create panic or to imply that all endurance athletes are at risk of eating disorders, but to help coaches, parents, and athletes themselves understand that this issue does have its own specific cultural and contextual factors within the endurance sports community. It deserves to be discussed more proactively and without prejudice, rather than being treated as a taboo subject to be avoided.

A Complete Warning Sign Checklist: Divided into Behavioral, Psychological, and Physiological Aspects

Behavioral Warning Signs

• Developing rigid, almost non-negotiable rules about food types, portions, and eating times
• Avoiding social situations where food is present, or attending but finding various reasons not to eat
• Deliberately eating more in front of others than when alone (or vice versa), with eating behavior clearly inconsistent depending on whether others are present
• Beginning to frequently use language like “clean eating” or “zero guilt” to describe food choices, dividing food into “good” and “bad”
• Insisting on completing planned training volume even when injured, ill, or extremely fatigued, unable to accept rest
• Repeatedly weighing oneself, measuring body fat, and taking photos to compare physique, with a frequency clearly beyond reasonable limits
• Engaging in binge eating followed by self-induced vomiting, misuse of laxatives or diuretics, or using excessive exercise to “compensate” for eating
• Beginning to collect large amounts of information related to diet, weight, and calories, with clearly excessive time and energy invested

Psychological Warning Signs

• Self-worth being highly tied to whether weight, physique, and diet meet “targets”
• Holding a disproportionately intense fear of weight gain, even when current weight is within a healthy or even low range
• Distorted body image: clearly lean or even underweight, yet still subjectively feeling certain body parts are “too fat”
• Mood swings highly correlated with diet or exercise performance, with “eating too much” or “not training” triggering intense self-criticism
• Showing strong defensiveness or denial in response to others’ concerns about diet or physique
• Persistent anxiety and low mood, especially around themes of food and body image

Physiological Warning Signs

• Unplanned, rapid weight loss
• Irregular menstruation or amenorrhea for three or more consecutive months in women
• Recurrent colds, slow wound healing, and overall decreased immunity
• Recurrent pain in specific areas, potentially related to bone loss or stress fractures
• Unusual fatigue, dizziness, palpitations, or abnormal resting heart rate
• Feeling cold easily, cold hands and feet, and diminished thermoregulation
• Thinning or shedding hair, dry skin, and brittle nails
• Digestive dysfunction, long-term bloating, or changes in bowel habits

If three or more warning signs appear across different categories simultaneously, this is a clear signal. It is recommended to seek professional assessment as soon as possible, rather than delaying with a “let’s wait and see” attitude.

If three or more warning signs appear across different categories simultaneously, it is recommended to seek professional assessment as soon as possible, rather than delaying with a “let’s wait and see” attitude.

How to Self-Detect: Honestly Facing the Psychology of Denial

A core feature of eating disorders is that those affected often lack insight into their own condition—that is, even when outward behavior already shows the aforementioned warning signs, they subjectively feel “I’m just being disciplined” or “I’m just pursuing better performance.” This denial is not a moral failing; it is a common part of this type of psychological state. Understanding this can reduce the shame involved in the process of self-awareness.

Several concrete practices to help with self-detection: Keep a food and training diary, and after a period of time, look back to see whether behavioral patterns are becoming increasingly rigid or extreme; honestly answer the question, “If I don’t eat or train according to plan today, how strong would my emotional reaction be?” — if the answer is “very strong, almost out of control,” this in itself is a signal worth paying attention to; pay attention to whether close people around you have ever expressed concern, and even if you feel offended or disagree in the moment, it is recommended to write down this feedback and reconsider it calmly later; regularly use the RED-S warning sign checklist provided in the previous article, cross-referencing it with the three-category warning sign checklist in this article to review your own condition.

How to Support Someone Around You Showing Warning Signs

If you are a coach, teammate, family member, or friend who observes someone around you showing the aforementioned warning signs, this is a situation that requires caution but cannot be avoided. Here are some principle-based recommendations:

Choose an appropriate time and manner to express concern: Do it privately, one-on-one, in a non-public setting, using a calm and non-judgmental tone. Focus on specific observed behaviors and changes (for example, “I’ve noticed you often say you’re really tired after training lately, and it seems like you rarely eat with the group anymore”), rather than directly commenting on weight or physique (for example, language like “aren’t you too thin” can easily trigger defensiveness, even if the intention is caring).

Avoid giving specific dietary or training advice: Unless you are a professional in the relevant field, it is not recommended to directly give the person dietary plans or training adjustment advice. This could unintentionally reinforce their tendency toward excessive control over food and training, and could also backfire if the advice is not professional enough. Your role is to express concern, listen, and encourage seeking professional help, not to play the role of a therapist.

Anticipate that the person may deny or become defensive: This is a common reaction and does not mean your concern is wrong or meaningless. You can explain that you will continue to care and that the door is always open, without needing to convince the person to admit the problem or take immediate action in a single conversation.

If the situation is urgent (for example, fainting, signs of arrhythmia, or obvious self-harming behavior), do not hesitate—assist in seeking immediate medical care. In such cases, physiological safety takes priority over waiting for the person to be “ready” to talk about it.

The role of coaches and sports organizations: It is recommended to establish a team culture that does not use weight or physique as evaluation criteria. Training plans and feedback should focus on performance indicators rather than body shape. For athletes showing warning signs, refer them early and privately to resources with relevant professional backgrounds, rather than handling it publicly or ignoring the problem until the athlete’s body breaks down.

When to Seek Help: No Need to Wait Until It’s “Serious Enough”

Many people hold a mistaken threshold for “whether to seek help”—feeling that they should wait until the situation is “really serious” before it warrants using professional resources. This is a myth that needs to be broken: with professional assistance related to eating disorders, the earlier the intervention, the smoother the recovery process typically is. There is no need to wait for serious physiological complications before seeking help. The following situations are all appropriate for proactively seeking professional assistance:

• Experiencing any of the physiological warning signs mentioned in this article, especially menstrual abnormalities, recurrent bone pain, or unusual fatigue
• Anxiety about food and physique has begun to affect daily functioning (social life, academics, work, emotional stability)
• You or those around you have already noticed abnormalities in behavioral patterns but don’t know how to handle them
• Having tried to adjust on your own but repeatedly failed, feeling unable to control these behaviors through willpower alone
• Simply wanting to “confirm whether your condition is normal”—this in itself is a legitimate reason to seek help; there is no need to wait until the problem becomes clearly defined

Recovery Is a Process: What Reasonable Expectations Look Like

If you or someone around you has begun seeking professional help, it is important to understand that “recovery is a process that takes time,” to avoid giving up midway due to overly high expectations or seemingly slow progress. The following are some general concepts to help establish reasonable psychological expectations. Actual recovery journeys vary from person to person and require close collaboration with a professional team.

Physiological recovery usually precedes psychological recovery, or it may be the reverse—it varies by individual: Some people, after restoring normal energy intake, will see gradual improvement in physiological indicators (such as the return of menstruation, bone density scan values, or blood test results), but psychological anxiety about food and physique may take longer to resolve. Others may show significant psychological progress first, with physiological indicators taking more time to catch up. These two types of recovery progressing at different rates is a common phenomenon and does not mean recovery is “failing” or “not working.”

Changes in weight or physique during recovery are not necessarily linear: This process may involve a staged increase in weight, which is usually a necessary part of the body re-establishing normal metabolic and hormonal function, not a sign of being “out of control.” This stage can be psychologically very difficult for the individual, and continuous support from the professional team is particularly important during this period.

Training and competition participation may need temporary adjustment: Depending on the individual situation, the professional team may recommend temporarily reducing training volume or even pausing specific training or competition plans, prioritizing allowing the physiological systems to repair. For those who strongly identify with their identity as athletes, this is often one of the most difficult parts of the recovery process, because training and competition are often important sources of self-worth and life meaning. During this stage, it is recommended to seek a medical team that understands both athlete psychology and clinical expertise. A simple “rest” recommendation without accompanying psychological support typically has poor success rates.

Relapse is a possible part of the recovery process and does not mean total failure: The recovery journey from an eating disorder is rarely a straight line. Experiencing setbacks or short-term regression is common. What matters is maintaining contact with the professional team rather than abandoning the entire recovery plan because of a single setback.

Conceptual Directions for Seeking Help in Taiwan

The following provides conceptual directions for seeking help. Please search for specific institutions and resources based on current circumstances or consult your family physician for referrals. This article does not list specific organization names to avoid outdated or inaccurate information:

Medical system: You can use a family physician or sports medicine outpatient clinic as a first step, describing the full range of symptoms (including both physiological and psychological aspects). The physician can assess and refer you to psychiatry, psychosomatic medicine, or nutrition for further evaluation. Some medical centers have integrated eating disorder or sports medicine clinics; please inquire about relevant hospital outpatient information.

Psychological counseling resources: Schools (if you are still a student) typically have free or subsidized counseling centers. Some city and county health bureaus offer subsidized psychological counseling programs. You can also seek a counseling psychologist with expertise in eating issues or sports psychology on a private-pay basis.

Nutrition professionals: Seek a qualified sports dietitian, particularly one with experience handling energy intake and eating behavior issues in athletes, who can provide recommendations more suited to individual circumstances than general online information.

Peer and organizational resources: If your team, school club team, running or cycling club has athletic trainers, team physicians, or counseling teachers, these are also first-line resources you can approach. They typically have channels for referral to professional resources.

Emergency situations: If life-threatening signs appear (such as severe dehydration, arrhythmia, loss of consciousness, or suicidal ideation), seek immediate medical care or call the local emergency medical hotline. Do not wait for the normal outpatient appointment process.

Special Populations Requiring Extra Attention: Adolescent Athletes and Adult Beginners

Adolescence is a critical stage for bone development and reproductive system maturation. If long-term energy deficiency or disordered eating tendencies develop during this stage, the impact on long-term health can be more profound than if it occurs in adulthood—for example, affecting peak bone mass accumulation during skeletal development, and affecting secondary sexual characteristic development and long-term reproductive health. Parents and coaches of adolescent athletes need to pay special attention to whether training intensity and dietary intake are reasonably matched, avoiding the pursuit of short-term competition results at the expense of long-term developmental needs. They should also be aware that adolescents may be more sensitive to body image under peer and social media pressure than adults, requiring more proactive and nuanced forms of care.

For adult beginners just starting structured training, another common scenario is: due to lack of training experience, they easily underestimate the increased energy requirements that come with increased training volume, unknowingly falling into a state where energy intake cannot keep up with training expenditure, while mistakenly believing this is “the wall every beginner must hit” without realizing the root cause may be inadequate energy intake. The way to address this situation is typically to have a sports dietitian help assess actual energy needs and increase intake in tandem with training volume adjustments, rather than passively pushing through and waiting for the body to “adapt on its own.”

Conclusion: This Is Courage, Not Weakness

The endurance sports community easily and incorrectly links “seeking help” with “not being disciplined enough” or “lacking willpower.” This is a myth that needs to be actively broken. Eating disorders and relative energy deficiency are the result of complex physiological and psychological interactions, not problems that can be solved through personal willpower alone. Seeking professional help is a responsible and wise act, not a symbol of failure. What truly benefits performance and health in the long run is a sustainable training and dietary pattern that the body can support—not a state that looks disciplined in the short term but is actually overdrawing physical and mental health.

Action Checklist:

1. Regularly use the three-category warning sign checklist in this article for self-assessment; if three or more warning signs appear simultaneously, seek professional help promptly.
2. Honestly keep a food and training diary, and pay attention to whether rules are becoming increasingly rigid and extreme.
3. When observing warning signs in someone around you, express concern privately and non-judgmentally, avoiding direct dietary or training advice.
4. Do not use “it’s not serious enough yet” as a reason to delay seeking help; the earlier the intervention, the smoother recovery typically is.
5. Coaches and organizations should establish a team culture that does not evaluate athletes based on physique.
6. Emergency physiological signs (fainting, arrhythmia, loss of consciousness) require immediate medical attention; do not wait for the regular appointment process.
7. Remember: seeking help is an act of courage and responsibility, not proof of insufficient discipline.

Related Reading

• When “Eating Clean” Becomes a Disease: Eating Disorder Risks and Recognition in Athletes
• Eating Disorders in Cycling: Recognizing Warning Signs and Seeking Help
• Relative Energy Deficiency in Sport (RED-S): Causes, Warning Signs, Effects on Bone and Endocrine Health, and How to Seek Help
• The Real Cost of Weight Loss for Endurance Athletes: How Energy Deficiency Undermines Performance, Bone Health, Immunity, and Hormones