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Nutrition and Performance in Sport

Christophe Hausswirth

Chapter 2. Nutrition, sport and health

Topic 7. Eating disorders

Christophe Hausswirth, Amélie Fosse, Eve Tiollier, Axel Heulin, Yann Le Meur, Véronique Rousseau et École Lenôtre

Texte intégral

Questions and answers

Key points
Some characteristics of sports are veritable risk factors for the appearance of eating disorders.
In sports where aesthetics are important it is important to consider the pressure related to physical appearance exerted by the athlete’s immediate environment (judges, coaches, managers, parents).
Self-esteem, perfectionism and social pressure are all factors that can contribute to the appearance of eating disorders in girls, whereas only perfectionism and social pressure contribute in boys.
Anorexic behaviour can cause energy, macronutritional and micronutritional deficiencies.
A symptom of bulimia is feeling hungry in a stressful context characterized by excitation and absence of control over food.

What are eating disorders?

1Eating disorders are a group of severe and complex diseases; they are particularly prevalent in Western society. Two major disorders in particular are very well known in the sports environment: anorexia and bulimia. It is difficult to treat these disorders, which have serious consequences for athlete’s health and career. Warning signs of these disorders are exacerbated by certain risk factors which must be taken into account in prevention. Female athletes are more exposed to these eating disorders (15 women for one man). These disorders involve restricted eating leading to deficiencies, but also to menstrual alterations and reductions in bone mass.

What are the vulnerability factors for female athletes?

2Some characteristics of sports appear to be veritable risk factors for the appearance of eating disorders:

  • Weight constraints play an important role, especially in disciplines where certain morphological types are required, such as thinness in aesthetic or artistic sports (gymnastics, ballet, synchronized swimming), or strict classification based on body weight (wrestling, boxing, judo, etc.). These constraints generate excessive concern about weight or body image. Rapid variations in body weight, fluctuating between periods of restricted energy intake and periods of abundance, destabilize the athlete’s diet and behaviour.

  • Poor control over emotions is another cause of fragility. Various phenomena combining dissatisfaction and compensation are thus observed when competition-related stress is experienced; mood swings may also be observed after defeat or injury. Finally, other situations linked to private life or to relationships with the coach or team can also cause fragility.

  • The athletic model shown in a sports environment (and even more so outside this environment), regardless of weight constraints linked to certain disciplines, maintains the cult of the athletic body, which is thus perceived as a required norm.

  • Excessive media coverage of some athletes or personalities, presented as models, can sometimes encourage athletes to mimic them, which only serves to reinforce the feeling of frustration relating to body image.

3Outside the context of sports, athletes can also have personality traits which make them more vulnerable:

  • Dissatisfaction with their body due to the contrast between their shape and the athletic norm shown in a sports environment.

  • Perfectionism is a great quality to have when seeking to optimize physical and technical preparation, however, when it extends to food and body image, it can lead to extreme behaviour.

  • Young people may fear maturity and physical transformations (including modifications caused by practising sports). Therefore, it is recommended that prepubescent female athletes practising a sport involving intense training (gymnastics, swimming, tennis, etc.) be closely monitored.

Do sport and context combine to make anorexic athletes?

4Many studies have tried to define high-risk sports. A recent American study investigated the relationship between “aesthetic” sports (ballet, gymnastics, artistic and rhythmic gymnastics, synchronized swimming, aerobics, etc.) and body weight in about 200 girls. The mothers of these athletes were also interviewed. Women competing in aesthetic sports are more concerned by their weight than those competing in “non-aesthetic” sports (volleyball, football, baseball, softball, hockey, tennis, martial arts), and this dichotomy is observed from age 7. Among them, the athletes with the highest risk are dancers, regardless of their body mass index (BMI) and of mothers’ concerns regarding weight. The hypothesis proposed is that the type of sport performed can influence the health and psychological future of these children who focus their attention on weight from a young age.

  • Another recent study assessed the link between eating disorders in women and a general tendency to addictive behaviours, especially addiction to running. The group of intense runners revealed:

  • a greater prevalence for eating disorders;

  • a greater addiction to running;

  • a lower BMI.

5The main result of the study was that 25% of women running more than 30 miles (about 50 km) per week score high in the “Eating Attitude Test” (EAT26) for a risk of mental anorexia. In addition, it seems that the earlier the practice is started the greater the risk, especially in judged disciplines such as ice-skating, synchronized swimming or gymnastics (compared to disciplines which are objectively measured). However, no approved questionnaire for the general population is completely appropriate for use with high-level athletes.

6Strict eating behaviour, going as far as adopting extremely restrictive diets, not only meet the discipline’s constraints, but also the search for control over their bodies by these pre-teens. This is fertile ground for developing eating disorders. Thus, during this period of life, sport allows the body to be drastically transformed through intense training.

7In sports where aesthetics are important, it is also important to take into account the pressure exerted by the athlete’s immediate environment (judges, coaches, managers, parents) relating to physical appearance. These actors can facilitate the appearance of eating disorders, by adhering to the discipline’s culture (athletics, boxing, etc.), driven by their desire for performance, or by Munchausen syndrome by proxy.

8In a more global way, a very recent meta-analysis counted 34 studies on the subject, involving 40% high-level athletes. The initial hypothesis, whereby female athletes are more prone to eating disorders than non-athletes, was confirmed, but with only a slight statistical difference (albeit significant), and results were very heterogeneous. The populations most at risk are university students (more than school-children), dancers and high-level athletes. Strangely enough, the analysis does not return these results in the case of gymnastics, swimming and running (compared to test groups) for eating disorders. According to the authors, this is due, on the one hand, to more attention being paid to this question in these sports, which are already identified as high risk, and, on the other hand, to the implementation of programmes to prevent eating disorders specific to these disciplines. Finally, factors protecting against eating disorders are underlined in two groups: sportswomen who do not practise at a high level (compared to non-athletes) and those who practise sports that do not impose a slim ideal. Eating habits in these populations are healthier, and these groups also tend to be more satisfied with their body image.

Is there any difference between men and women when it comes to eating disorders?

9Little data is available with regard to eating disorders in male athletes. A study comparing a female population and a male population shows that disorders appear later in men (age 20.56 versus 17.15 in women), even if they are more committed in sports where weight control influences performance. There are no other differences between men and women for the characteristics evaluated. The ratio of 15 women to each man suffering from eating disorders is around 15. Self-esteem, perfectionism and social pressure are factors contributing to the appearance of eating disorders in girls, whereas only perfectionism and social pressure affect boys.

Do eating disorders lead to menstrual problems?

10A certain number of studies have indicated that menstrual deregulation affects between 6 and 7% of female athletes, with the highest percentages measured in dancers and long-distance runners and the lowest in racing cyclists and swimmers. Athletes who present a risk of developing eating disorders and who suffer from menstrual disorders are also more prone to repeated injuries. Given that the association of eating disorders, menstrual disorders and osteoporosis (known as “female athlete triad”) can have serious health consequences, it appears important that athletes suffering from eating and menstrual disorders be given a complete medical check-up.

What are the risks associated with eating disorders?

11Anorexia is associated with many risks as it causes numerous deficiencies: energy, macro-and micronutritional deficiencies. Because calorie intake is insufficient, weight loss ensues. Very often, carbohydrates and lipids are completely omitted from the diet, even though they are essential. Most of the time, people with anorexia suffer from vitamin, mineral and trace element deficiencies. The consequences of this are serious, including hormone deficiencies, osteoporosis, immune problems, and an increased risk of infection.

12Bulimia also presents risks, this disease corresponds to feeling hungry in a context of anxiety characterized by excitation and absence of control over food intake. The need to eat becomes unpredictable and is no longer under control. This bulimic episode, which is rapid and uncontrolled, often centres around very high-calorie foods and most of the time, the voracity with which food is eaten generates digestive problems due to insufficient chewing. The bulimic episode stops when it triggers abdominal pain, when there is no more food available, or when an external event occurs to terminate it. These episodes of food frenzy lead to abdominal pains and digestive problems, nausea and vomiting, as well as to unpleasant feelings of discomfort and deformity. Bulimia can also cause menstrual disorders and mood swings (in the form of periods of depression). Violent feelings of guilt, disgust and shame may also be associated with this pathological behaviour. Indeed, eating disorders are often associated with comorbidities: periods of depression and anxiety.

13These diseases may evolve as follows:

  • 44% of cases recover fully;

  • % mortality due to undernourishment after ten years of restrictive anorexia;

  • 10% of bulimic patients die due to aggravated undernourishment and hypokalaemia after ten years with the disease.

How can eating disorders be prevented in athletes?

14To prevent anorexia, it must be detected as early as possible, thus athletes (especially those in high risk populations) must be offered medical and psychological follow-up. Risk factors should be identified, and any rapid and unexplained weight variation should attract attention. Validated questionnaires can be used to support diagnosis, such as the “EAT26” questionnaire, which contains 26 questions to detect anorexic eating habits. However, these questionnaires are not always completely relevant for high-level athletes. Regular medical and psychological follow-up of athletes also helps to prevent bulimia. Adhering to a balanced daily diet (see pyramid opposite), with specific adaptations for the sport practised, is also an essential factor in prevention.

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Photo credit: Fotolia

Practical applications

15Eating disorders (ED) are complex and do not necessarily have clearly defined symptoms. Nevertheless, they can be classified.

1. Definition of eating disorders

Main eating disorders


17Extremely restricted eating due to excessive focus on thinness and fear of gaining weight

18All the symptoms listed below must be found at the same time:

19■ Weight below minimum normal weight for age and height (< 85%)

20■ Intense fear of gaining weight

21■ Distorted body image

22■ Amenorrhea for at least three consecutive months


24Recurrent and frequent episodes of restricted eating followed by binge-eating and purges

25All the symptoms listed below must be found together:

26■ Recurrent episodes of uncontrolled binge-eating

27■ Recurrent use of inapproriate methods to avoid gaining weight

28■ Frequency of the restriction/purge cycle: at least twice a week for three months

29■ Self-esteem influenced by perceived body-image shape and weight

Other eating disorders

30Anorexia athletica

31Variant of anorexia specific to athletes

32■ Reduced energy intake and loss of weight, in spite of a good performance level

33■ Use of at least one method to control weight which is harmful to health (fasting, vomiting, appetite suppressant pills, laxatives or diuretics)

34■ Excessive and compulsive exercise

35■ Menstrual disorders

36■ Gastrointestinal problems

37Eating disorders not otherwise specified (EDNOS)

38Eating disorders that do not meet all the criteria for anorexia or bulimia

39For example:

40■ All the symptoms of anorexia, except amenorrhea, and normal weight

41■ All the symptoms of bulimia, but less frequently

42■ People with normal weight using purges on a regular basis

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2. Preventing eating disorders

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Risk factors


44■ Statistically: 15 women for 1 man

45■ In some disciplines, a higher proportion of men is affected

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46Type of sport

47■ Aesthetic sports

48■ Weight-category sports

49■ Sports for which weight is an important factor in performance

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51■ Recurrent injuries

52■ Lifestyle

53■ High-level competition

54■ Stressful environment (sport, home life)

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Some prevention measures

55 Promote nutritional education for athletes

56 Promote nutritional education underlining the importance of adhering to a diet compatible with practising sport based on health and performance

57 Do not weigh athletes in public (even men)

58 Any weight-loss programmes should be supervised by a dietician

59 Remember that the link between weight and performance is complex, and that losing weight does not necessarily improve performance

60 Be attentive to athletes’ reactions to comments about their weight and shape

61 In particular, pay attention to certain types of behaviour (agressiveness, refusal to talk, elusive behaviour) that these comments can trigger

62 Remember that optimal weight and fat mass are specific to each individual

3. Detecting eating disorders

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4. Treating eating disorders

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5. The female athlete triad: a dangerous combination


63 The female athlete triad is a symptom that combines these three elements which, alone or combined, are likely to affect the female athlete’s performance and health

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64 By a health professional

65 Should be looked for during the annual medical examination

66 If one of the elements is identified, check for the other two


67 From a nutritional point of view: increase energy availability

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68Objective: energy availability > 30 kcal/kg of lean mass/day


Increase Image 100000000000000A0000000ADD5E9616.jpg calorie intake

Decrease Image 100000000000000F0000000FB82F767B.jpg energy expenditure linked to exercise

70 Make sure you are getting enough calcium and vitamin D (See Factsheet no 6 Bone health, p. 295)

71 Seek advice from a nutritional expert


Fresh fruit salad with lemongrass and cardamom

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Photo credit: Thibaut Ruggeri.

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72Serves 4

73Preparation time: 30 minutes

74Cooking time: 15 minutes

Difficulty: Image 10000000000000290000001C76E69E20.jpg


76 1 lemongrass stalk

77 4 cardamom pods

78 1 star anise

79Peel the orange and make supremes*, keep the juice.

80Peel the other fruit and dice them. Hull the strawberries, keep a few blueberries and raspberries for decoration, and mix all the fruit together.

81Add the orange juice.

82Decorate with the blueberries and raspberries. Serve chilled.

83* Supreme: orange segment without skin or pith


851 mango

86 2 kiwi fruits

87 150 g melon

88 150 g pineapple

89 100 g raspberries

90 100 g strawberries

91 60 g blueberries

92 1 orange

93 100 ml orange juice

94Chef’s note

95This fruit salad is a real antioxidant cocktail. In addition to the polyphenols contained in the berries, it is rich in vitamin C (one portion provides almost 150% of the Dietary Reference Intake), in β-carotene, and it covers more than 20% of the DRI for vitamin E. It is also a good source of potassium and vitamin B9.

96Nutritional analysis per person

Energy (Cal)

Carbs (g)



Lipids (g)

Protein (g)




PhD, Research Department – French Institute of Sport, Expertise and Performance (INSEP), Paris

© INSEP-Éditions, 2015

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