Return to Training for Athletes with Anorexia Nervosa
Athletes with anorexia nervosa should be categorically restricted from training and competition until they achieve a BMI ≥18.5 kg/m², demonstrate cessation of disordered eating behaviors, and receive clearance from a multidisciplinary team. 1
Risk Assessment and Medical Clearance
The decision to allow an athlete with anorexia nervosa to resume training requires careful medical evaluation and risk stratification:
Absolute Restrictions from Training
- BMI <16 kg/m² - categorically restricted from all training and competition 1
- Moderate-to-severe bulimia nervosa (purging >4 times/week) 1
- Medical instability (cardiac arrhythmias, severe electrolyte abnormalities)
- Acute psychiatric risk (suicidal ideation, severe depression)
Minimum Requirements for Return Consideration
- BMI ≥18.5 kg/m² 1
- Cessation of disordered eating behaviors (restriction, bingeing, purging)
- Normalized laboratory values and vital signs
- Engagement with treatment team
Multidisciplinary Team Approach
Return to play decisions must involve a core multidisciplinary team (CMT) consisting of:
- Team physician (ultimate decision-maker) 1
- Sports dietitian
- Mental health professional (psychologist/psychiatrist)
- Athletic trainer/coach (as appropriate)
Phased Return Protocol
Once minimum requirements are met, implement a graduated return to training:
Phase 1: Limited Clearance (Moderate Risk)
- Low-intensity, supervised exercise only
- Reduced training volume (50-70% of normal)
- Regular weight monitoring
- Weekly team check-ins
- No competition permitted
Phase 2: Provisional Clearance
- Gradual increase in training intensity and volume
- Continued monitoring of weight stability
- Bi-weekly team check-ins
- Limited competition may be considered
Phase 3: Full Clearance
- Return to full training load
- Continued engagement with treatment team
- Regular nutritional assessment
- Ongoing psychological support
Special Considerations
Sport-Specific Risk Factors
- Higher risk in weight-sensitive and aesthetic sports (gymnastics, figure skating, distance running)
- Leanness-focused sports require more cautious return protocols 1
- Consider timing of season and competitive pressure
Bone Health Monitoring
- Athletes with history of amenorrhea require DXA scanning
- Low bone mineral density (Z-score <-1.0) requires modification of high-impact activities 1
- Bone stress injuries require longer restriction from weight-bearing activities
Menstrual Function (Female Athletes)
- Return of menses is a positive prognostic indicator 1
- Weight gain of approximately 2-5 kg is typically required for menstrual recovery 1
- Resumption of menses correlates with improved bone health outcomes
Treatment Contract
For moderate and high-risk athletes, implement a written contract that specifies:
- Required medical parameters (weight, labs, vital signs)
- Behavioral expectations (compliance with meal plan, therapy attendance)
- Training limitations and progression criteria
- Consequences of non-adherence
- Regular reassessment schedule
Common Pitfalls to Avoid
- Premature return: Allowing return based solely on weight without addressing psychological factors
- Inadequate monitoring: Failing to maintain regular medical and psychological follow-up
- Overemphasis on performance: Prioritizing athletic goals over health recovery
- Ignoring warning signs: Missing early indicators of relapse (subtle weight loss, increased exercise compulsivity)
- Coach pressure: Yielding to external pressure for early return from coaches or the athlete
Long-Term Management
Recovery from anorexia nervosa is often prolonged, requiring ongoing vigilance:
- Regular reassessment of eating behaviors and weight stability
- Continued psychological support focusing on body image and performance anxiety
- Education for coaches and teammates about supportive environments
- Monitoring for signs of relapse, particularly during high-stress periods
Remember that health must always be prioritized over performance, and the team physician has ultimate authority in return-to-play decisions 1.