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Eating disorders, disordered eating, and relative energy deficiency in sport (RED-S, formerly known as the female athlete triad) are all too common in endurance sports, yet not talked about enough. This week, during National Eating Disorder Awareness Week, we want to share some insights about the prevalence and dangers of eating disorders and how to decrease stigma, increase awareness and education, and foster a positive culture around having a healthy relationship with food and body image in endurance sports.

Among female high school athletes in aesthetic sports, 42% reported disordered eating and they were 8x more likely to incur injury than athletes who did not report disordered eating (1). Likely there are similar or higher rates (mental health issues are often underreported in surveys) in collegiate, post-collegiate, and recreational female athletes of all ages. While eating disorders are commonly associated with females, male athletes are also at risk- one study reported that 33% of male athletes in aesthetic and weight-class sports are affected by eating disorders (2). RED-S (formerly known as female athlete triad, but now known to affect men too) is a syndrome of impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health caused by relative energy deficiency (insufficient caloric intake and/or excessive energy expenditure), and can affect female and male athletes of all ages, especially those in endurance sports (3). Relative energy deficiency can lead to increased risk of injury (particularly stress fractures), decreased training response, decreased endurance performance, decreased muscle strength, decreased glycogen stores, decreased coordination, decreased concentration, impaired judgment, irritability, and depression (3).

Why are these so common in endurance athletes? More research is needed to study this, but likely some of the same qualities that draw people to and make people great at endurance sports can be double-edged swords that can also predispose people to disordered eating. Bringing awareness to these predispositions can allow one to look at their own personalities and behaviors and evaluate if they are helping them or hindering them and seek support and help if needed. We can all work on challenging these stereotypes to contribute to a positive and healthy endurance sports culture.

Competitive drive: the do whatever it takes mentality to train hard, achieve success, and be better than the competition can lead to disordered eating behaviors and an obsession with training that in reality does not allow the body to be fueled properly or rest adequately.

• Instead try to foster a competitive drive with an evidence-based approach rather than a do-whatever-it-takes approach to proper fueling, adequate rest, and effective training to achieve long-term success and health.
  

Striving for perfectionism: being an overachiever with perfect form and perfect training, can be a slippery slope to striving for the perfect diet and perfect body, which does not exist.

• Dismantle perfectionism and emphasize that we are all imperfectly perfect in our own unique ways.
  

Ability to fight through pain: the often applauded quality of being able to push through and not listen to the body in workouts or races can quickly cross the line into not acknowledging warning signs of injury or not listening to hunger signals.

• Learn to listen to and honor the body and allow it to work with you instead of against you.
  

Identity attached to only being an athlete: it can be fun and powerful to identify as an athlete, but tying too much identical to that can cause one to rely only on success, PRs, and external sources of validation rather than having a true inner and inherent sense of self-worth.

• You are inherently worthy, you are enough just as you are, and you do not need any external validation to prove so.
  

Emphasis on data: numbers and tracking can be a helpful part of the training, but can also quickly spiral into obsessing over tracking miles, steps, calories, food intake, etc for the sake of achieving a number rather than looking at the whole picture.

• Numbers don’t tell the whole story. There are so many variables that affect training, nutrition, health, etc and the beautifully complex body cannot be defined by mere numbers alone.
  

Using running (or endurance activity of choice) as a release: running and endurance activities can provide stress reduction, peace, and a sense of freedom from the endorphins and “runner’s high” of moving the body and being outside. During challenging times, the same “runner’s high” can quickly become an unhealthy coping mechanism that numbs other feelings, struggles, or issues instead of addressing them directly.

• Normalize feeling the feelings, speaking up about struggles, having numerous tools in the self-care toolbox, and asking for help when needed.
  

In addition to these predispositions in athletes, diet culture has also spilled over into the running and endurance sports community, leading to dangerous misconceptions about nutrition, body image, and performance. Proper nutrition education and body image support for athletes, teams, and coaches are extremely lacking and desperately needed. There are several resources linked at the end of the article to learn more, but we will clear the air about some of the most important ones.

❌ Leaner is better, lighter is faster

• We do not need to be thin to be fast. Fast times come from consistent training, proper fueling, and adequate rest.
  

❌ Needing to have a “runner’s body”

• We do not need a six-pack or need to look like the pros, the competition on the starting line or our teammates to be a runner/endurance athlete. Fast times can happen in any shape or sized body. Comparison is not healthy or helpful.
• It is never okay for anyone (teammates, coaches, competitors, sports commentators, family, friends, even you) to comment on one’s body.

❌ The body shouldn’t change

• The body is designed to grow and change with each season of life, puberty, hormones, age, etc and that is normal and okay. Learn how to work with these changes rather than fight them.

❌ How much and what one should eat like an endurance athlete

• Endurance sports require a lot of fuel from all the macronutrients (carbohydrates, fat, and protein) and micronutrients (vitamins, minerals, antioxidants, phytonutrients, etc), but those fuel requirements and preferences vary from individual to individual. Other than ensuring you get enough fuel from varied food sources that you have access to, there is no one thing you should or should not consume. Focus on your needs rather than comparing your portion sizes and food choices to others (especially to a non-endurance athlete whose needs are likely much less than yours).
• It is never okay for anyone to comment on one’s food portions or choices.

❌ Good vs bad food

• Food does not have inherent moral value (good vs bad), yet diet culture has instilled this in our brains and makes us fear certain foods. Yes, some foods have more nutrients than others, but that does not make them good or bad. Additionally, we are allowed to have food provide us more than just nutrition- food can provide us celebration, pleasure, comfort, cultural experiences, and more.
  

❌ Personal self-worth is defined by appearance, athletic ability, diet, exercise regimen

• Everyone is inherently worthy and enough just as they are. We do not need to earn our food based on how we look, how much we trained, what we ate the meal/day/weekend before, and/or how we performed. We also do not need to punish ourselves with exercise for our food choices.

❌ Irregular or skipped periods are a normal part of the training

• The absence or irregularity of menstruating in a previously menstruating human can be a sign of underfueling and/or overtraining and can lead to injury. This needs to be taken seriously and brought to the attention of a trained medical professional.

❌ Only skinny, white girls have eating disorders

• Eating disorders can affect all genders, ages, races, and body sizes. One doesn’t have to look a certain way or be performing poorly to be struggling and deserving of help.

❌ Asking for help is a sign of weakness

• Asking for help is a sign of self-awareness, courage, and strength. It is okay to need and ask for help if you are struggling with anything. It is also okay and important to set boundaries and speak up when someone is contributing negativity or triggering you.
  

If we all work to challenge these misconceptions and foster a positive, supportive endurance sports community culture, we can help to decrease and prevent the occurrence of eating disorders, disordered eating, and RED-S in endurance athletes and in the world at large.

Resources:

• NEDA https://www.nationaleatingdisorders.org/
• The Female and Male Triad Coalition https://www.femaleandmaleathletetriad.org/
• Women are Not Small Men (Dr. Stacy Sims) https://www.drstacysims.com/
• Lane 9 Project https://lane9project.org/
• Running in Silence https://runninginsilence.org/
  

Citations:

1. Jankowski, C. (2012). Associations Between Disordered Eating, Menstrual Dysfunction, and Musculoskeletal Injury Among High School Athletes. Yearbook of Sports Medicine, 2012, 394-395. doi:10.1016/j.yspm.2011.08.003.

2. Sports Nutrition for Coaches by Leslie Bonci, MPH, RD, CSSD, 2009.

3. Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S) British Journal of Sports Medicine 2014;48:491-497.

Author’s note: As a competitive high school runner, Jenna struggled with an eating disorder, amenorrhea, RED-S, and suffered three stress fractures within a one and a half year time frame, even though she didn’t understand or admit it at the time. Through the support of professionals, coaches, family, and friends, she has done the challenging, yet important, inner work to heal her relationship with food and body image, restore her period, improve her bone health (stress fracture free since 2012!), and release (most of) her perfectionistic tendencies. As a physician assistant and coach, she aims to provide hope and support to those struggling, to increase awareness and education, and decrease stigma in the running and medical communities.