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Eating Disorders

Lessons from a Marathon Runner in Recovery

For athletes with eating disorders, using your grit is the key.

Key points

  • In a recent study, more than 86 percent of athletes met criteria for either a subclinical eating disorder or an eating disorder.
  • For athletes with an eating disorder, their goal-orientation, persistence, and mental toughness can be used to return to full health.
  • A multidisciplinary team that includes a therapist, physician, and dietitian can offer expert mental, physical, and nutritional guidance.
Joel Papalini/istockphoto
Source: Joel Papalini/istockphoto

This post was written by Gia Marson, Ed.D.

We often see athletes as being the embodiment of good health. After all, they appear to exercise a lot, eat well, and take good care of their bodies. A deeper look, however, shows that a large number may be harboring serious health conditions and illnesses. Most studies suggest that athletes in sports that require leanness (such as long-distance running) have a higher percentage of subthreshold eating disorders and clinical eating disorders compared to other athletes and non-athletes.

Research sheds light on eating disorders and athletes

According to recent research, when asked about disordered eating and weight-control behaviors, more than one-third of female athletes reported attitudes and symptoms that placed them at risk for anorexia nervosa—and male athletes also bore risk.

This aligns with other research from the past three decades, including a 2004 study of Norwegian male and female elite athletes who had a higher prevalence of eating disorders compared to those from a control group; the female athletes had higher rates than the male athletes, and eating disorders were more common among those competing in lean and weight-dependent sports.

Another study, conducted during 2018’s National Eating Disorders Awareness Week, surveyed more than 23,000 people. More than 14 percent of respondents identified themselves as competitive athletes. Here is a snapshot of what the surveyed athletes reported compared to non-athletes:

  • More than 86 percent met the criteria for either a subclinical eating disorder or an eating disorder.
  • Less than 3 percent were in treatment at the time.
  • They were more likely to report excessive exercise.
  • They were less likely to reach out for help because of the specific issues in their sport, the stigma associated with mental health difficulties, or the barriers they experienced when trying to access care.
  • Equally alarming, more than half of all study participants—athletes and non-athletes—reported suicidal ideation.

As if that isn’t concerning enough, a study published this year revealed troubling findings after surveying more than 200 adult runners who participated in the 26th European Cross-Country Championships:

  • Cross-country athletes are at high risk of low-energy availability (LEA), a state of energy deficiency with potentially negative health consequences.
  • Nearly 80 percent of the female runners and more than 50 percent of the male runners reported a high prevalence of gastrointestinal impairments.
  • Nearly half of female athletes did not report normal menstruation, a symptom that may be linked to the female athlete triad (characterized by low energy availability, low bone mineral density, and amenorrhea).

Unfortunately, it’s not only adult athletes who are at risk. Eating disorders are also more common in adolescent elite athletes across genders, sports, and levels of competitiveness.

The symptoms of eating disorders

Specific behaviors and symptoms associated with eating disorders vary by type, but here are some of the most common that might be prevalent in athletes:

  • Fear of weight gain and overvaluing of weight and shape.
  • Not admitting the severity of the problem.
  • Eating an unusually large amount of food in a short period of time while feeling out of control.
  • Using laxatives, enemas, or diuretics, or regularly engaging in severe dieting or self-induced vomiting.
  • Low bone mineral density.
  • Mood swings.
  • Stress fractures or overuse injuries.
  • Gastrointestinal problems.
  • Hormonal dysregulation.
  • Withdrawing from friends or social activities.
  • Low heart rate.
  • Hiding food or throwing it away.
  • Over-exercising or over-training.
  • Following rigid food rules or rituals.

What else puts athletes at risk?

These symptoms can be present in anyone with an eating disorder; some are more common in athletes with eating disorders. However, high-performing athletes have some additional traits. Because they are expected to be physically superior and mentally tough, and to excel at their sport, this extra pressure can lead them to want to win at all costs—and that cost may manifest in an exhausted, dysregulated, and nutritionally starved body due to restrictive eating or cycling between nutritional deprivation and binge eating.

An eating disorder can also be driven by extreme perfectionism—the unrelenting commitment to be the perfect weight, body shape, and muscle tone for their sport. Beliefs about reaching a performance goal or achieving a personal record or personal best may be linked to maintaining an 'ideal' weight. The problem is that living at a low weight can be risky—and being perfect is an impossible goal. Yet, athletes will train with grueling schedules and closely monitor what they eat, putting their health in danger.

The good news

The same traits that athletes have honed to create greatness in their sports can be turned toward reaching health goals. The bottom line: Once you fully heal, you may be able to run marathons in recovery. Erin Knipe recently wrote about what happened after she fell in love with competitive running. Over the years, the presence of an eating disorder, along with compulsive exercise, put a dangerous strain on her body—so much so that she was diagnosed with numerous stress fractures, amenorrhea, and LEA, leading her to fear that having a child might not be possible. After dealing with bulimia nervosa for more 20 years, Knipe is now in her sixth year of active recovery and has given birth to a healthy baby girl.

Running brings Erin strength and clarity. The marathon is her distance of choice, and she feels unfinished business there. Her goal is to achieve the Olympic Trials marathon qualifying time standard when her body has been at health for a couple more years. She also craves the mental and physical toughness of ultra distances, a world she has not yet dabbled in:

As runners, we thrive in putting ourselves in difficult, painful situations. We do this by choice. We take pride in this decision. We often crave steeper hills, faster splits, and seek out races with the toughest competition; constantly pursuing a new threshold for pain. We enjoy the suffering, feel alive in it, get to know ourselves intimately while there. Confronting and deciding to recover from an eating disorder and/or exercise addiction will be one of the most painful and challenging decisions that we make in our life. Full recovery is possible. —Erin Knipe

Do’s and don’ts for athletes in eating disorder recovery

Despite the complex nature of recovery for athletes and non-athletes alike, full recovery is absolutely possible.

  1. Do seek out a multidisciplinary treatment team that includes a licensed mental health therapist, a registered dietitian, a sports medicine physician or another specialized medical doctor who understands the physical rigor of your sport, and possibly an athletic trainer and psychiatrist. Once you have gathered your team, be transparent about your mental and physical struggles. Even the best clinical team cannot help you if you are not honest with them. Keep in mind that you are expected to be imperfect as you navigate recovery.
  2. Don’t trust a treatment protocol just because someone else is following it. Recovery approaches are not one-size-fits-all. Your recovery plan should be tailored to your unique situation.
  3. Do stop excessive exercising. Your health must stabilize first, which often means reducing or temporarily halting exercise. This break will not last forever. You are probably highly goal-oriented. Use that expertise to restore your health. Check in with a doctor to identify specific health goals for restarting training. Knowing your recovery targets can help with motivation.
  4. Don’t restrict foods. You will need vital vitamins, minerals, and other nutrients to restore your energy to healthy levels and to repair tissue throughout your body. Remind yourself that food is fuel, and that it’s also your medicine. Give up the rules and question the myths that got you into this crisis. When it comes to what, when, and how much to eat, follow the advice of the licensed dietitian on your team.
  5. Don’t listen to the voice of the eating disorder. Your hard-driving inner voice may try to trick you into believing that you’re a failure when you take days off training and eat more than you used to. Recognize that all-or-nothing narrative as the voice of the eating disorder that’s far from honest. Ask your therapist for tips to help you tolerate the inevitable distress that comes from eating more and moving less.
  6. Do treat yourself with kindness. Write out the advice you would give to an athlete in your situation who was 10 years younger than you are now. Say those same supportive, optimistic things to yourself.

The grit we have gathered through running is a secret weapon in eating disorder recovery. When we run, we set up moments that bring us face to face with the feelings of addiction, and in these moments, our sport instantly becomes a tool that we can use to battle the disorders. We will be forced, in that single moment, to choose recovery or our eating disorder.

Eating disorders are sneaky. Strict parameters around running are necessary so that we can observe how both our head and body react, allowing us to make a decision in order to confront our instincts.

When we run through recovery, we continuously put ourselves in “single moment decision” situations. This forces us to rewire the old patterns of our brain. This new skill can be equally applied to our actions around food—restricting, bingeing, purging—as it is to running. It’s all the same feeling, so it’s really about learning how to sit in it, and trust that it will shift. If we repeat these actions consistently, the five minutes or five hours of excruciating pain will eventually become barely noticeable. It was a battle for me to accept that, even in the abstinence of the eating disorder habits, exercise addiction continued to control my life. It took a year before I started to embrace and trust the process. —Erin Knipe

You deserve support

If you’re trying to recover from an eating disorder while simultaneously trying to balance the risks and rewards of participating in the sport you love, you may not have the clarity to decide on your energy needs, exercise limits, or potential psychological and medical risks.

Reach out for help as soon as possible. As a competitive athlete, you may be at greater risk, but you have even stronger protective factors that make recovery possible. Access the grit and resilience that’s gotten you this far, and use it to change your thinking and how you relate to food, one bite at a time.

There are days when the eating disorder and exercise addiction win; I can’t deny that. I constantly remind myself about the power that comes from stillness and the growth that can only happen there. It’s easy to outsmart something you know well, you just have to be willing to face all of it with complete awareness, honesty, and a slight desire to seek out and overcome the pain. —Erin Knipe


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