What is anorexia athletica?

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You may not have ever heard of “anorexia athletica,” because it goes by a number of names, including “sports anorexia” and “hypergymnasia”. This disorder is characterized by excessive exercise in order to restrict or control the body. Eating and working out become an obsession with anorexia athletica, and can lead to unhealthy mental and physical consequences.

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What is anorexia athletica?

Anorexia athletica is where someone exercises excessively to restrict or control their body. They may also cut calories and restrict their diet to an extreme. They use the exercise to lose weight or prevent weight gain. This behavior can end up causing health issues. 

Anorexia athletica isn’t an “official” eating disorder. The American Psychiatric Association, the group that determines what is an eating disorder and what isn’t, doesn’t currently list “anorexia athletica” in their diagnostic textbook called DSM-6. Other eating disorders however are included in their latest version of the DSM.

Anorexia athletica may be seen in those who are already diagnosed with anorexia nervosa (AN) or bulimia. Instead of using a laxative or vomiting, someone with this disorder instead uses excessive exercise to control their weight. Instead of the goal of the exercise being health or enjoyment, the goal is weight loss and restriction.

The athletic mindset

Many athletes understandably are taught to strive for perfection. To achieve this, the athlete has to be strict about weight, eating behavior and performance. In some sports, there’s a lot of pressure on the athlete due to weight limits, judging criteria, and uniforms that show every inch of the body. (1) 

The extreme culture of athleticism in our society can end up causing athletes to feel as if they can’t meet the standards for an “ideal” body. This is a big problem if the athlete is involved in a sport where the best body type for that sport doesn’t conform to society’s image of an athlete’s body. Athletes in lean body sports had higher body shape concern scores than those of non-lean sports, according to one study. (2)

This body dissatisfaction isn’t restricted to women who are athletes. In one study of 576 German athletes, 59% of the men reported dissatisfaction with their body. (3) Even 46% of elite rugby players were found to have dissatisfaction with their body. (4)

The prevalence of eating disorders varies from 6-45% in female athletes and 0 to 19% in male athletes. (5) In one study of 755 elite Icelandic athletes in their 20s, 17.9% of the athletes had severe or moderate body image dissatisfaction. (1) Women’s scores were higher than men’s, pointing to the existence of a real problem for athletes. This body image dissatisfaction can progress to a true eating disorder. (1)

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Prevalence of anorexia athletica

Estimates of anorexia athletica vary. In one German study of 52 pre-professional ballet dancers between the ages of 13 and 20, anorexia athletica was diagnosed in 6% of the dancers compared to 2% of regular high school students. (6) In a study of 1620 Norwegian athletes, the overall presence of eating disorders among female athletes was higher in aesthetic sports (42%) than in endurance (24%) sports and ball game sports (16%). (7) Aesthetic sports are sports where leanness is encouraged such as dance, cheerleading, swimming, aerobics, gymnastics, baton twirling, and figure skating. Non-aesthetic sports are ones such as soccer, volleyball, softball, basketball, hockey, tennis, martial arts and track. (8)

Causes of anorexia athletica

Causes vary depending on the individual. However, most experts agree that the following characteristics predispose to anorexia athletica:

  • Perfectionism
  • Difficulty in communicating negative emotions
  • Substance misuse
  • Past trauma or abuse
  • Poor family relationships
  • Difficulty in resolving conflict
  • Poor self-esteem
  • Bullying behavior
  • Non-suicidal self-injury disorder
  • Dieting at a young age

Signs and symptoms of anorexia athletica

Since anorexia athletica still isn’t considered an “official” eating disorder, there aren’t any official signs and symptoms yet that have been clinically determined. However, the two main types of signs and symptoms seen are ones that relate to body image obsession, weight obsession and excessive desire to exercise. Some of these signs and symptoms are similar to the ones for anorexia and bulimia. 

These signs and symptoms include:

  • Obsessive thoughts and behaviors around weight, calories, fat, and body image
  • Fearful of eating out at restaurants with friends because of possible weight gain
  • Eating secretly
  • Unwilling to eat with other people
  • Drinking water or diet soda constantly
  • Limiting the 
  • Swollen glands under the jaw
  • Bathroom smells like vomit
  • Eating a large meal and then disappearing
  • Eating excessive amounts of food that aren’t consistent with bodyweight
  • Excessively exercising
  • Not enjoying exercise
  • Denying that you exercise too much
  • Self-worth is based on physical performance in one’s sport
  • Feeling fat even though weight is normal or below average
  • Wearing baggy clothes
  • Large fluctuations in weight over a short period of time
  • Dissatisfied about your appearance 
  • Feelings of guilt when you ‘cheat’ on your diet 
  • Irregular menstrual cycle or periods have stopped

Medical complications of anorexia athletica

Medical complications of anorexia athletica are similar to those of anorexia nervosa (GI problems, weight loss, low body weight, menstrual difficulties, heart problems) or bulimia (teeth and esophagus problems, GI disturbances) and malnourishment (liver failure, kidney failure). Also, exercising excessively can result in the breakdown of muscles, torn ligaments and tendons, and bone problems such as arthritis. The long term outcomes of anorexia athletica has not yet been thoroughly studied and we still have a lot to learn about how best to identify and treat this condition among athletes. (8)

Treatment for anorexia athletica

Psychotherapy with cognitive behavioral therapy is the main treatment for anorexia athletica. The patient may also receive interpersonal psychotherapy. The goal of therapy is to improve body image. Once this improves, disordered eating behavior decreases, and this may be followed by changes in the excessive exercise. (9)

Nutritional counseling is imperative when treating anorexia athletica. Treatment with psychotherapy or nutrition may be either inpatient or outpatient. 

Part of the treatment for anorexia athletica is addressing the societal norms that impose these high standards for what athletic bodies should and shouldn’t look like. There is an urgent need for reform in how we address body weight and performance in sports. (10)

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Resources

  1. Kristjansdottir H, Siguroardottir P, Jonsdottir S, Porsteinsdottir G, Saavedra J. Body Image Concern and Eating Disorder Symptoms Among Elite Icelandic Athletes. Int J Environ Res Public Health. 2019 Aug; 16(15):2728. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6696614/
  2. Wells E, Chin AD, Tacke JA, Bunn JA. Risk of disordered eating among division I female college athletes. Int J Exerc Sci. 2015;8:256-264. 
  3. Rosendahl J, Bormann B, Ascenbrenner K, Asxhenbrenner F, Strauss B. Dieting and disordered eating in German high school athletes and non-athletes. Scand J Med Sci Sports. 2009;19:731-739.
  4. Gibson C, Hindle C, et al. Body image amongst elite rugby union players. J Strength Cond Res 2019 Aug; 33(8):2217-2222. https://pubmed.ncbi.nlm.nih.gov/31343602/ 
  5. Bratland-Sanda S, Sundgot-Borgen J. Eating disorders in athletes: Overview of prevalence, risk factors and recommendations for prevention and treatment. Eur J Sport Sci. 2013;13:499-508. 
  6. Herbrich L, Pfeiffer E, Lehmkuhl U, Schneider N. Anorexia athletica in pre-professional ballet dancers. J Sports Sci. 2011 Aug;29(11):1115-23. https://pubmed.ncbi.nlm.nih.gov/21774749/
  7. Sundgot-Borgen J, Klungland Torstveit M. Prevalence of eating disorders in elite athletes is higher than in the general population. Clin J Sport Med. 2004 Jan;14(1):25-32. https://pubmed.ncbi.nlm.nih.gov/14712163/
  8. Krahnstoever Davison K, Earnest MB, Birch LL. Participation in aesthetic sports and girls’ weight concerns at ages 5 and 7 years. Int J Eat Disord. 2002 Apr31(3):312-7.
  9. De Oliveira Coelho GM, da Silva Gomes AI, Ribeiro BG, deAbreu Soares E. Prevention of eating disorders in female athletes. Open Access J Sports Med. 2014; 5:105-113. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4026548/ 
  10. Sudi K, Ottl K, et al. Anorexia athletica. Nutrition. Jul-Aug 2004; 20 (7-8): 657-61.

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