The Signs We Miss: Disordered Eating and Orthorexia in Athletes

Sport and eating disorders have a complicated relationship and most of the time, we are not talking about it clearly enough. The image of an eating disorder in sport tends to be a narrow one: the visibly underweight gymnast, the wrestler cutting weight dangerously before a weigh-in.

But the reality of disordered eating in sport is far broader, more subtle, and more common than these stereotypes suggest. And one of the fastest-growing yet least recognised patterns is orthorexia nervosa - an obsessive preoccupation with healthy or ‘clean’ eating that can cause significant physical and psychological harm while looking, from the outside, like exemplary self-discipline.

What Is Orthorexia?

Orthorexia nervosa is characterised by an obsessive preoccupation with eating what is perceived as ‘pure,’ ‘clean,’ or ‘right’ foods. Unlike anorexia or bulimia, orthorexia is not primarily driven by a desire to lose weight or change body shape. It is driven by a rigid belief that the right food choices will ensure health, performance, and self-discipline and that any deviation from those standards is catastrophic.

People with orthorexia spend excessive amounts of time researching, planning, and preparing food. They experience significant anxiety when their dietary rules are disrupted. They may restrict their diet to an increasingly narrow list of ‘acceptable’ foods, limiting social eating, travel, and spontaneity. And they feel a sense of identity, control, and superiority associated with their eating choices that makes the pattern feel positive, right up until it isn’t (Bratman & Knight, 2000).

Orthorexia is not yet formally recognised in the DSM-5, but research consistently identifies it at elevated rates in athletic populations, particularly in sports that emphasise weight management, body composition, or ‘performance nutrition.’ A study using orthorexia assessment tools found orthorexic tendencies significantly more common in athletes than non-athletes, and particularly in endurance, aesthetic, and combat sports (Giel et al., 2012).

Rates in Athletes — and What the Research Actually Shows

Disordered eating in athletes is far more common than most sporting environments acknowledge. A major systematic review and meta-analysis of 177 studies involving over 70,000 athletes found a mean prevalence of self-reported disordered eating of nearly 20%, with rates as high as 45% in some female athletic populations and certain sport categories (Ghazzawi et al., 2024).

Female athletes experience clinical eating disorders at rates dramatically higher than the general population: some estimates suggest 42% of elite female athletes experience clinically significant disordered eating, compared to approximately 1.6% of the general female population. In weight-dependent and aesthetic sports like gymnastics, diving, rowing, wrestling, ballet, the rates are higher still. For male athletes, the picture is different but equally concerning: disordered eating in male athletes is consistently underdiagnosed, partly because the stereotype of eating disorders as ‘women’s problems’ means warning signs are more likely to be missed or minimised.

The Problem with Online Fitness Influencers

We need to talk about social media. The online fitness influencer space has become one of the most significant vectors for the spread of disordered eating norms — and it is reaching athletes at exactly the ages when eating patterns are most vulnerable to disruption.

Research published in 2024 found that following nutrition or fitness accounts on Instagram positively predicts eating disorder symptoms. A sub-sample of fitness influencer followers scored significantly higher on measures of dieting, bulimia, and food preoccupation than control groups (Bocci Benucci et al., 2024). ‘What I eat in a day’ content, elimination diet trends, and the conflation of body aesthetics with health and athletic performance create an environment in which orthorexic and restrictive behaviours are normalised , even celebrated.

The challenge for athletes is that this content often mimics the language of evidence-based sport nutrition: ‘eating for performance,’ ‘fuelling clean,’ ‘optimising your diet.’ Without a critical lens and good nutritional support, it is very difficult to distinguish evidence-based advice from aesthetically-driven restriction dressed in performance language.

The Cognitive Dimension We Are Missing

One of the most important and least discussed aspects of eating disorders is the cognitive dimension. Most awareness campaigns focus on behaviours: restricting food intake, skipping meals, excessive weigh-ins. These are observable signs, and they matter. But the cognitive patterns that drive and maintain disordered eating are often invisible and treating only the behaviour without addressing the underlying thinking leaves the condition intact.

The core cognitive pathology across eating disorders includes overevaluation of shape, weight, and eating - meaning the person’s sense of self-worth is fundamentally tied to how they eat and how their body looks. This is accompanied by rigid, black-and-white thinking, perfectionism, and intolerance of uncertainty (Fairburn, 2008). For athletes, these cognitive patterns can be particularly hard to disentangle from sporting culture, which often reinforces perfectionism, discipline, and body scrutiny as virtues.

Fuelling the Body — and Avoiding Diagnosis

The difference between evidence-based performance nutrition and disordered eating is not always obvious, but it is important. Some markers of a healthy relationship with food in sport: eating enough to fuel training and competition with no prolonged periods of low energy availability; flexibility - the ability to eat a variety of foods including those that are not ‘optimal’ without significant anxiety; eating in social contexts without distress; no persistent preoccupation with food, weight, or body composition; and responding to hunger cues and fuelling around training rather than restricting.

Relative Energy Deficiency in Sport (RED-S) - the condition that results from chronic low energy availability - has significant consequences for athlete health, including impaired bone density, hormonal disruption, immune function, and performance (Mountjoy et al., 2023). It is preventable when athletes, coaches, and support staff are educated about adequate fuelling.

Getting the Conversation Right

Talking about eating in sport requires care. Well-intentioned comments about weight, body composition, and food choices (from coaches, parents, or peers) can plant seeds of disordered thinking in athletes who are already susceptible. The research is clear that body-focused feedback from coaches significantly increases eating disorder risk (Greenleaf et al., 2009).

If you are concerned about an athlete, the most useful first step is not to comment on their food or their body. It is to express concern about how they seem (their energy, their mood, their enjoyment of sport) and to connect them with a professional who can assess what is actually going on. Early intervention matters enormously. The longer disordered eating patterns are present, the more entrenched they become.

References

• Bocci Benucci, S., Fioravanti, G., Silvestro, V., Spinelli, M. C., Brogioni, G., Casalini, A., Allegrini, L., Altomare, A. I., Castellini, G., Ricca, V., & Rotella, F. (2024). The Impact of Following Instagram Influencers on Women’s Body Dissatisfaction and Eating Disorder Symptoms. Nutrients, 16(16), 2730. https://doi.org/10.3390/nu16162730

• Bratman, S., & Knight, D. (2000). Health Food Junkies: Orthorexia Nervosa — Overcoming the Obsession with Healthful Eating. Broadway Books.

• Fairburn, C. G. (2008). Cognitive Behavior Therapy and Eating Disorders. Guilford Press.

• Ghazzawi, H. A., et al. (2024). A systematic review, meta-analysis, and meta-regression of the prevalence of self-reported disordered eating among athletes worldwide. Journal of Eating Disorders, 12. https://doi.org/10.1186/s40337-024-00982-5

• Giel, K. E., et al. (2012). Eating disorder pathology in elite adolescent athletes. International Journal of Eating Disorders, 45(1), 11–18. https://doi.org/10.1002/eat.20903

• Greenleaf, C., Petrie, T. A., Carter, J., & Reel, J. J. (2009). Female collegiate athletes: Prevalence of eating disorders and disordered eating behaviours. Journal of American College Health, 57(5), 489–495.

• Mountjoy, M., et al. (2023). 2023 IOC consensus statement on Relative Energy Deficiency in Sport (REDs). British Journal of Sports Medicine, 57, 1073–1097. https://doi.org/10.1136/bjsports-2023-10699

This blog was drafted with assistance from Claude, an AI assistant. All content has been reviewed, edited, and approved by the author.