Man Standing Near The Opened Fridge To Pick Some Food At Night At Home

Coaching Endurance Athletes with Eating Disorders

BY Dr. Jeff Sankoff

Unfortunately, disordered eating isn't uncommon among endurance athletes. If you believe your athlete is struggling, it's essential to tread carefully.

Weight loss is a tricky but often necessary topic for coaches to discuss with their athletes. It necessitates finesse, empathy and a steadfast adherence to their doctors’ recommendations. In cases where weight loss evolves into disordered eating, sometimes coaches have greater insight into their athletes’ progression than others, as they are so attuned to the athletes’ physical performance and general health. Disordered eating presents a coach with an even greater challenge as there are several key signs, considerations and methods that merit focused attention.

Two Common Cases for Disordered Eating Among Athletes 

When General Weight Loss Goes Too Far

One of the common stories of origin for disordered eating that I’ve witnessed, specifically among triathletes, starts with concerns over obesity and health. Obesity remains a common health issue in the western world, with many in public health considering it to be one of the major preventable contributors to long-term disability and shortened lifespan. Being overweight can contribute to the development of many chronic health conditions, an increased risk of cancer and heart attacks. As such it isn’t uncommon for overweight, beginner athletes, looking to change their lives with training to be weight-loss motivated. 

That being said, in many cases, setting weight-loss as a goal is great! However, when your athlete seems overly fixated on their weight and continues to drop large amounts of weight, these should trigger you to engage in a deeper conversation with them.

“Slimming Down” for Speed

Alternatively, in the case of more advanced athletes, as they progress in training and become more competitive, some look for weight loss-related ways to make gains. One sign to look out for is when this type of athlete makes comments comparing their body to those of fast, slim athletes (commonly at the professional level). Once they fixate on the body type of this idealized professional athlete, regardless of their own health and actual fitness progress, it’s time to intervene.

The Signs and Dangers of Disordered Eating

I spoke with Dr. Margherite Mascolo, a Certified Eating Disorder Specialist and the Chief Medical Officer of Alsana: An Eating Recovery Community in order to get her perspective on things to look out for. She told me that eating disorders such as anorexia nervosa and bulimia are more frequently seen in female athletes, although certainly not always. They are initially characterized by a very “restrictive diet in conjunction with eating very similar foods in small amounts. Coaches should always be watchful for athletes who become fixated on their looks and on losing weight, especially when their notion of the amount of weight loss needed exceeds what they need to achieve athletic success.”

In some cases, athletes won’t confide in their coach about their weight loss aspirations, but may still exhibit signs. According to Dr. Mascolo “If an athlete begins to develop injuries more frequently than would otherwise be expected and seems to be taking longer to recover from them, this suggests poor nutritional intake.” Other signs and symptoms to be on the lookout for include depression and anxiety related to weight, losing the ability to hit previously attainable training efforts and use of weight loss aids like laxatives or diuretics.

Coaches also need to be comfortable talking to their female athletes about their menstrual cycle and be watchful for any changes therein. Changes in the regularity or loss of a normal menstrual cycle is a sign that an athlete is not getting adequate caloric intake to sustain this vital endocrinologic and reproductive process. If left unchecked, it will lead to injuries and stress fractures.

An Empathetic, Fully Supported Approach

Disordered eating is unfortunately not easily remedied but the first step in helping a struggling athlete is recognizing it and having a non-judgmental conversation. “Always approach this issue from a place of concern for the athlete’s wellness and ability to perform their sport,” Mascolo says. “Tell them how worried you are about their ability to train if they remain under-fueled—in order for them to do that, they need to accept that they may be doing things in a way that is unproductive.”

Disordered eating is difficult to treat but it can be remedied. The highest rates of success are seen when a multidisciplinary team is involved. “At our centers and in many others across the country, we have seen the best results when athletes are treated by a team comprised of a dietician, physician and therapist,” Mascolo told me. In the most severe cases, athletes may have to reduce or cease training until they can get the situation under control, but for others, training can continue. To get a sense of whether or not an athlete needs to alter their training regimen, a medical professional should evaluate the athlete and make use of the Relative Energy Deficiency in Sport Clinical Assessment Tool (RED-S CAT)

The RED-S CAT assesses athlete behavior and either determines the severity of existing complications or evaluates the likelihood of the athlete developing complications. It assigns a level of risk to the athlete based on their age, sex, physical and laboratory attributes, eating behaviors and characteristics related to sport performance. Based on this level of risk, a recommendation can be made about whether or not the athlete can continue training.

If you are a coach and have concerns about an athlete manifesting signs of disordered eating or RED-S, then a good place to start is with the International Association of Eating Disorder Professionals. There you can find an eating disorder specialist local to you or your athlete and help them start the process of recovery.

Train hard, train healthy.


Br J Sports Med 2015;49:421–423. doi:10.1136/bjsports-2014-094559

Burke LM, Close GL, Lundy B, Mooses M, Morton JP, Tenforde AS. Relative Energy Deficiency in Sport in Male Athletes: A Commentary on Its Presentation Among Selected Groups of Male Athletes. 2018. doi:10.1123/ijsnem.2018-0182

Matzkin E, Curry EJ, Whitlock K. Female Athlete Triad. J Am Acad Orthop Surg. 2015;23(7):424-432. doi:10.5435/JAAOS-D-14-00168

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About Dr. Jeff Sankoff

Jeff Sankoff is an Emergency Physician, long time triathlete and USAT/IRONMAN University Certified coach. He has completed 6 IRONMAN races (including Kona) and more than fifty races at the 70.3 distance including 5 World Championships. He produces the TriDoc Podcast that can be found on most popular podcast platforms and iWork’s with LifeSport Coaching. You can learn more about him at his website: TriDoc Coaching.