Eating Disorders in Female Athletes: Anorexia, Bulimia, and Exercise-Related Amenorrhea

Why Are Female Athletes a High-Risk Group?

The myth in sports culture that “thin = fast” and “light = strong,” combined with societal pressures on women, produces startling statistics:

• Lifetime prevalence of eating disorders in the general female population: 8–13%
• Women in aesthetic sports (gymnastics, ballet, bodybuilding): 30–60%
• Women in endurance sports (marathon, triathlon, cycling): 25–35%
• Recreational athletes are not necessarily at lower risk than elites

Three Main Types of Eating Disorders

1. Anorexia Nervosa

• Severe calorie restriction, body weight below a healthy range (BMI < 17.5)
• Distorted perception of weight / body shape
• Intense fear of “gaining weight”
• Athlete characteristics: persists with training, denies the problem, compulsive tracking

2. Bulimia Nervosa

• Recurrent binge eating + inappropriate compensatory behaviors (vomiting, laxatives, excessive exercise)
• Weight may be normal or slightly elevated
• Severe mood swings and shame
• Athlete characteristics: excessive compensation after training, highly secretive

3. Binge Eating Disorder (BED)

• Loss-of-control eating without compensatory behaviors
• Often accompanied by guilt and isolation
• Weight is usually higher

Athlete-Specific: The Gray Zone of DE-OSFED and RED-S

Many female athletes do not meet clinical diagnostic criteria but already exhibit:

• Restrictive eating patterns
• Strict food classification (good vs. bad)
• Compulsive calorie tracking
• Excessive exercise to “burn off” meals
• Hiding food, eating alone
• Refusing to eat at restaurants

This is called “DE” (Disordered Eating) and is a pre-disease state. Identification and intervention are critical.

Red Flag Checklist

Behavioral Signs

• Continuously reducing food variety
• Compulsive pursuit of “clean eating”
• Refusing refueling after training
• Excessive anxiety before meals
• Overly frequent food-related conversations
• Weighing multiple times per day

Physiological Signs

• Menstrual irregularities or amenorrhea
• Continuous weight loss
• Feeling cold, low resting heart rate (< 40 bpm)
• Thinning hair, increased lanugo
• Tooth erosion, bad breath (clues to vomiting)
• Arrhythmia
• Stress fractures
• Plateau or decline in performance

Psychological Signs

• Excessive preoccupation with weight / food
• Intense perfectionism
• Social withdrawal
• Low mood, irritability
• Insomnia

Exercise-Related Amenorrhea: Don’t Treat It as “Normal”

“I train a lot, so not having my period is normal” — Wrong.

• Menstruation is a health indicator, equivalent to a vital sign
• Missing your period for 3 consecutive months warrants a medical visit
• It’s not simply “low body fat”; it’s the shutdown of the pituitary–ovarian axis
• Long-term effects: bone density, cardiovascular health, metabolism, fertility

Multifaceted Treatment

Medical Team

• Sports medicine / internal medicine physician: assess physiological status, fluid management, training cessation decisions
• Sports dietitian: establish eating plans, educate on energy needs
• Psychotherapist (CBT, FBT): cognitive-behavioral therapy, family-based treatment
• Gynecologist: hormonal assessment, menstrual recovery

Treatment Phases

What Coaches / Teammates Should Do

Do

• Express concern privately: “I’ve noticed you seem different lately; I want to understand”
• Emphasize health rather than appearance
• Connect to professional resources
• Provide ongoing support

Don’t

• Publicly comment on weight / appearance
• Offer dietary advice
• Compare with other athletes
• Ask “Are you okay?”-style questions
• Ignore warning signs

A Culture of Prevention

What the sports community can do:

1. Coach education: at least one eating disorder workshop per year
2. Scale policy: no scales at training camps, no public weigh-ins
3. Apparel policy: no training attire that exposes the body
4. Language correction: avoid focusing on “body fat percentage,” “abs,” “thin”
5. Health marker monitoring: menstruation, bone density, HRV, training load

Resources for Help

• Taiwan: Ministry of Health and Welfare’s Department of Mental and Oral Health, sports medicine clinics at major hospitals
• National Suicide Prevention Center: 1925
• International: NEDA (National Eating Disorders Association)

In One Sentence

An athlete’s worth is not in her appearance, but in what she can do with her body. When you are well-fed, menstruating regularly, and have strong bones, you will discover what true progress feels like.

Related Reading

• The Female Athlete Triad: A Health Warning Every Endurance Woman Should Know
• Disordered Eating Risk in Female Runners: The Warning Sign of Low Energy Availability
• The Iron Crisis: The Most Common Yet Most Overlooked Nutritional Issue for Female Endurance Athletes
• Iron in Female Athletes: The Double Drain of Menstrual Blood Loss and Endurance Training