How should an individual with anorexia nervosa (AN) be managed while engaging in sports training?

Management of Anorexia Nervosa in Athletes Engaging in Sports Training

Athletes with anorexia nervosa should be categorically restricted from training and competition until they achieve a BMI >18.5 kg/m², receive appropriate treatment for their eating disorder, and undergo comprehensive evaluation by a multidisciplinary team. 1

Initial Assessment and Risk Stratification

When an athlete with anorexia nervosa (AN) presents in a sports context, immediate comprehensive evaluation is required:

Medical Assessment

• Vital signs (heart rate, blood pressure, temperature)
• BMI calculation (critical threshold: <16 kg/m² requires immediate restriction from sport) 1
• Bone health evaluation (DXA scan for bone mineral density)
• Laboratory tests: CBC, electrolytes, thyroid function, 25-OH vitamin D 1
• Menstrual function assessment in females (amenorrhea indicates higher risk)
• Screening for relative energy deficiency in sport (RED-S) 1

Psychological Assessment

• Comprehensive mental health evaluation
• Assessment of eating disorder severity and duration
• Evaluation of co-occurring conditions (depression, anxiety, OCD)
• Assessment of social adjustment 1

Management Protocol

Step 1: Immediate Intervention

• BMI <16 kg/m²: Categorical restriction from all training and competition 1
• Moderate-to-severe bulimia behaviors (purging >4 times/week): Categorical restriction 1
• Referral to specialized eating disorder treatment service 1
• If specialized services are unavailable, the core multidisciplinary team assumes responsibility 1

Step 2: Core Multidisciplinary Team Formation

The cornerstone of management is a multidisciplinary team consisting of:

• Sports physician/doctor
• Sports dietitian
• Psychologist/psychiatrist 1

Each team member has specific responsibilities:

• Physician: Medical stability assessment, clearance decisions, treatment coordination
• Dietitian: Nutritional assessment, energy availability evaluation, meal planning
• Psychologist: Mental health treatment, cognitive-behavioral therapy, monitoring psychological readiness 1

Step 3: Treatment Implementation

• Prioritize health over performance in all decisions 1
• Establish clear treatment contract with specific behavioral objectives
• Focus on weight restoration (target BMI >18.5 kg/m²) 1
• Address disordered eating behaviors and underlying psychological factors
• Implement nutritional rehabilitation with safe, supported, and individualized nutrition plan 1
• Regular monitoring of physical and psychological parameters

Return to Play Protocol

Return to sports training should follow a structured approach:

Minimum Requirements for Consideration:

• BMI ≥18.5 kg/m² 1
• Cessation of purging behaviors
• Demonstrated adherence to treatment plan
• Medical stability (normal vital signs, electrolytes)
• Psychological readiness as determined by mental health provider

Graduated Return Process:

1. Limited non-competitive activity under close supervision
2. Structured training with regular monitoring of weight, vital signs, and psychological state
3. Gradual increase in training load with continued multidisciplinary oversight
4. Return to competition only after sustained stability and with ongoing support

Decision Authority:

• The team physician has ultimate authority in return-to-play decisions 1
• Decisions should be made in consultation with the multidisciplinary team
• Athlete's health and safety must supersede all other considerations 1

Special Considerations

Sport-Specific Risk Factors

• Higher risk in "lean" sports (distance running, gymnastics, figure skating)
• Sports with subjective judging or aesthetic components require additional vigilance 1
• Weight-class sports (wrestling, boxing) require careful monitoring 2, 3

Male Athletes

• Eating disorders in male athletes may be overlooked or missed 3
• Male athletes may present differently, often with muscle dysmorphia concerns
• Similar multidisciplinary approach is required regardless of gender 4

Prevention Strategies

• Education for athletes, coaches, and support staff about eating disorders 1
• Creating sport environments that deemphasize weight or body image 2
• Regular screening for early identification of disordered eating 1
• Promotion of optimized nutrition that is safe, supported, and individualized 1

Common Pitfalls to Avoid

• Premature return to sport: Allowing return before adequate weight restoration and psychological stability
• Overlooking severity: Eating disorders have one of the highest mortality rates of any mental illness 1
• Yielding to pressure: External pressure from coaches, family, or the athlete should not override medical decisions 1
• Focusing solely on weight: Energy availability may be compromised even with stable weight 1
• Inadequate follow-up: Continued monitoring is essential even after return to sport

In some cases, participation in sport becomes so integrated with the eating disorder that resuming sports participation may not be realistic in the short or medium term 1. The health and wellbeing of the athlete must always take precedence over athletic performance.