Adolescent athletes are often held up as models of health: disciplined, motivated, and physically active. Clinically, that picture is incomplete. Young athletes, particularly those still in puberty, can be at elevated risk for eating disorders, and the very traits that make them successful in sport can conceal the illness for months or years. This post outlines why the risk is distinct, how these conditions present, and what the adults around a young athlete can do.

Why athletes under 18 are a distinct population

Adolescence is a period of rapid growth, hormonal change, and identity formation. Layer on top of that the demands of competitive sport, and several vulnerabilities converge:

Nutritional demand is high and non-negotiable. A growing body that is also training hard needs substantial energy. Inadequate intake in this window can affect bone accrual, pubertal progression, and growth, sometimes irreversibly.
Sport culture can normalize disordered patterns. Rigid food rules, "clean eating," compensatory exercise, and body comparison may be framed as commitment rather than symptoms.
Perfectionism and achievement orientation are well-documented risk factors for eating disorders and are also frequently rewarded in athletes.
Evaluation of the body is built into some sports, by judges, by weight classes, by uniforms, or by video review.

Research consistently suggests that eating disorders and disordered eating are more common in athletes in sports that emphasize leanness, aesthetics, or weight categories, such as gymnastics, figure skating, diving, distance running, wrestling, dance, rowing (lightweight classes), and swimming. Risk is not limited to those sports, and it is not limited to girls. Male athletes are underdiagnosed, in part because screening tools and public awareness have historically centered on female presentations.

The clinical picture

Athletes can meet criteria for any of the recognized eating disorders. Common presentations include:

Anorexia nervosa, characterized by restriction of energy intake, intense fear of weight gain, and disturbance in how body weight or shape is experienced. In youth, clinicians watch for failure to make expected developmental gains, not only weight loss.
Bulimia nervosa, involving recurrent binge eating followed by compensatory behaviors. In athletes, compensation may include excessive exercise, which can be harder for others to recognize as a symptom.
Binge-eating disorder, which is often overlooked in sport settings where larger bodies or irregular eating may be wrongly attributed to "training appetite."
Avoidant/restrictive food intake disorder (ARFID), in which restriction is driven by sensory sensitivity, fear of aversive consequences like choking or vomiting, or low interest in food, rather than body image concerns.
Other specified feeding or eating disorders (OSFED), a common category that includes atypical anorexia nervosa, where the person has the cognitive and behavioral features of anorexia but may not appear underweight. Medical complications can be just as serious in this group.

Relative Energy Deficiency in Sport (RED-S)

RED-S describes the health and performance consequences of low energy availability: when intake does not match the energy demands of training and basic bodily function. It can occur with or without an eating disorder, and it can be unintentional, for example when a young athlete simply does not realize how much fuel their training requires. RED-S can affect menstrual function, bone health, cardiovascular function, immunity, mood, and performance. It supersedes the older "female athlete triad" framework by recognizing that effects extend beyond the triad and occur in male athletes too.

Why it is so often missed

In the general population, a teenager who suddenly restricts food and exercises compulsively might prompt concern. In sport, the same behavior can earn praise. Common reasons for delayed recognition include:

Performance can initially improve, or at least hold steady, which reinforces the behavior.
Weight loss and leanness are sometimes complimented by teammates, coaches, or family.
Training provides cover for extra exercise, skipped meals, and social withdrawal.
Athletes may fear losing playing time, so they hide symptoms and minimize injuries.
Normal growth can be masked. A young person who has stopped growing along their expected trajectory may not look "sick."

Warning signs

No single sign is diagnostic, and many occur in healthy adolescents. Patterns, clusters, and change from baseline matter most.

Behavioral

Rigid food rules, eliminating whole food groups, or increasing anxiety around meals
Avoiding team meals, travel meals, or eating in front of others
Exercise beyond what the training plan requires, or distress when unable to train
Frequent bathroom trips after eating
Ritualized eating, cutting food into small pieces, or prolonged mealtimes
Heightened focus on body checking, weighing, or comparing

Physical

Changes in or loss of menstrual periods, or delayed puberty
Recurrent injuries, particularly stress fractures
Fatigue, dizziness, fainting, cold intolerance
Changes in heart rate or blood pressure noted at a sports physical
Stalled growth or a drop across growth-chart percentiles

Psychological

Irritability, mood changes, perfectionism that is intensifying
Withdrawal from friends and activities outside sport
Self-worth tied almost entirely to performance or appearance
Difficulty concentrating

Illustrative case examples

Case 1: The distance runner

"Maya," 15, is a high school cross-country runner. Over a season she becomes noticeably more rigid about food, begins preparing her own meals, and adds solo runs on rest days. Her times improve early on. Her coach praises her dedication. By spring she has had two stress fractures, her periods have stopped, and she is exhausted and irritable. At a pediatric visit, her heart rate is low and her growth has flattened. Clinical note: This presentation is consistent with restrictive eating with RED-S features. The early performance gains and praise delayed help-seeking. Treatment would involve medical stabilization and monitoring, nutritional rehabilitation, and a period of modified or suspended training.

Case 2: The wrestler

"Jordan," 16, competes in a weight class and cycles between severe restriction before weigh-ins and episodes of loss of control eating afterward. He feels intense shame and has begun compensating through excessive exercise. His teammates see this as normal "cutting." He has not told anyone about the binge episodes. Clinical note: Sport-sanctioned weight manipulation can mask bulimia-spectrum symptoms. Male athletes in weight-class sports are a high-risk group who are less likely to be screened. A clinician would assess for the full pattern of restriction, binge eating, and compensatory behavior, along with mood and medical status.

Case 3: The gymnast

"Priya," 13, has always been a high achiever. After a comment from a judge about her "lines," she begins skipping snacks and becomes preoccupied with how she looks in the leotard. She remains at a typical weight for her age, so family members are not concerned. She has become withdrawn and tearful. Clinical note: A person can have serious eating disorder cognitions and behaviors without being underweight. Weight alone is not a reliable indicator of severity. The influence of a single evaluative comment on a vulnerable adolescent is also worth noting.

Case 4: The swimmer with ARFID

"Eli," 14, has always been a selective eater but has recently narrowed his diet further after choking on a piece of food. He is not concerned about weight or shape, but he is eating too little for his training load, is losing weight, and feels weak in the pool. Clinical note: ARFID is easily overlooked because it lacks the body image focus most people associate with eating disorders. It still carries medical risk and requires specific treatment.

Assessment and treatment

Any concern should be taken to a medical professional promptly. Early intervention is associated with better outcomes.

Assessment typically includes a thorough medical evaluation (vital signs, growth trajectory, labs and other tests as indicated), a developmental and menstrual history where relevant, and a mental health evaluation that screens for co-occurring anxiety, depression, and obsessive-compulsive features. Sport-specific screening tools exist, and a clinician with experience in athletes is ideal.

Treatment is generally multidisciplinary, involving physicians, mental health clinicians, and dietitians, with level of care matched to medical and psychological severity.

For adolescents with anorexia nervosa, family-based treatment (FBT) has among the strongest evidence, positioning parents as active partners in restoring nutrition.
Cognitive-behavioral approaches are commonly used for bulimia nervosa and binge-eating disorder, and specialized CBT variants exist for ARFID.
Medical clearance for sport is a clinical decision, not a negotiation. Training may need to be reduced or paused until the young person is medically stable, and return-to-play is usually graded and monitored.
Treatment of the family and sport environment matters. Coaches, athletic trainers, and parents benefit from guidance on how to support recovery rather than unintentionally undermining it.

What parents and coaches can do

Do:

Express concern privately, specifically, and without blame, focusing on observed behaviors and wellbeing rather than weight or appearance.
Encourage a medical evaluation and follow the clinical team's guidance on participation.
Model a balanced, non-judgmental relationship with food and exercise, and make fueling a normal part of team culture.
Prioritize athletes' health over performance when the two conflict.

Avoid:

Commenting on any athlete's body, weight, or "ideal" physique, positively or negatively
Public weigh-ins or body composition testing without clinical oversight and a clear health rationale
Framing food as "good" or "bad," or as something to be earned or burned off
Trying to resolve the problem through willpower or ultimatums, which rarely works and often increases shame and secrecy

When to seek urgent care

Fainting, chest pain, a very slow or irregular heartbeat, confusion, severe weakness, refusal of all food or fluids, or any talk of self-harm or suicide warrants immediate medical attention.

Final thoughts

Eating disorders in young athletes are serious, treatable illnesses that thrive in environments where thinness and discipline are rewarded and where speaking up feels risky. The most protective factors are often cultural: coaches and families who value the whole person, medical teams who screen routinely, and athletes who know they can ask for help without losing their place on the team. Recovery is possible, and many athletes return to sport healthier and stronger.

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