Anorexia Nervosa in Male Athletes: Clinical Recognition and Diagnostic Challenges

In clinical practice, male athletes with anorexia nervosa often present with high levels of discipline, performance, and apparent psychological control. These features can obscure underlying pathology and contribute to delayed recognition. Although eating disorders have historically been conceptualized as predominantly affecting women, there is now substantial evidence that men, particularly athletes, represent a clinically significant and underdiagnosed population.^1,2

In male athletes, anorexia nervosa involves restricted intake leading to significantly low body weight, intense fear of weight gain or persistent behaviors preventing weight gain, and disturbed body image, self-worth overly tied to weight or shape, or persistent failure to recognize the seriousness of low weight.³ Male athletes occupy a unique intersection of risk, where performance demands, body composition pressures, and cultural norms converge. For clinicians, this creates diagnostic challenges that require heightened awareness of sex-specific presentations and sport-related risk factors.^4,5

Epidemiology and Underrecognition

Eating disorders in males have been historically underrecognized, in part due to earlier diagnostic frameworks and persistent gender stereotypes.^1,2 Epidemiologic data now suggest that men account for a meaningful proportion of eating disorder cases, with higher risk observed in athletic populations.^5,6

Prevalence of eating disorders in adult male elite athletes has been reported at up to 32.5%, with wide variation by definition and sport, though anorexia nervosa is specifically lower. Some adult male elite athlete populations demonstrate higher rates of eating pathology compared with nonathlete controls, particularly in weight-sensitive sports, highlighting the type of sport as a significant risk factor.⁵ Despite this, male athletes are less likely to be identified, referred, or treated. Delayed diagnosis is common and contributes to increased medical and psychiatric morbidity.^1,4

Clinical Presentation: Key Differences in Males

Male patients are more likely to:

• Emphasize leanness or muscularity rather than thinness²
• Have a history of higher premorbid body weight²
• Exhibit less overt verbalization of body dissatisfaction^1,2
• Present later in the course of illness¹

In athletes, these features may be further masked by sport-specific norms. Restrictive eating, excessive exercise, and rigid routines are often interpreted as discipline rather than pathology.^4,5 This can delay clinical recognition until medical complications or performance decline emerge.⁴

The Role of Sport-Specific Risk

Certain sports place athletes at increased risk, particularly those emphasizing weight, aesthetics, or endurance.^5,6 These include:

• Weight-class sports (eg, wrestling, boxing)^5,6
• Endurance sports (eg, distance running, cycling)⁵
• Aesthetic sports (eg, gymnastics, bodybuilding)⁵

In these contexts, body composition is often directly linked to performance or selection, reinforcing behaviors that may overlap with eating disorder pathology.^4,5,7

It is also critical to distinguish anorexia nervosa from relative energy deficiency in sport (REDs) and subthreshold disordered eating. Anorexia nervosa is defined by specific diagnostic criteria.³ REDs involves health impairments resulting from prolonged or severe low energy availability and can occur with or without an eating disorder, including through unintentional underfueling. Anorexia nervosa and REDs may coexist, and they are not distinguished simply by the degree of cognitive distortion or psychological impairment.⁸

Barriers to Diagnosis

Several factors contribute to the underdiagnosis of anorexia nervosa in male athletes:

1. Atypical Presentation

The focus on muscularity and performance may obscure classic signs of weight and shape concern.^1,2

2. Normalization Within Sport

Behaviors such as caloric restriction, dehydration, and overtraining may be reinforced by coaches, peers, or competitive demands.^4,5,7

3. Stigma and Gender Norms

Eating disorders remain widely perceived as a female condition, leading to reduced help-seeking and underreporting among males.^1,2

4. Limitations of Screening Tools

Common screening instruments may be less sensitive to male-specific concerns, particularly those related to muscularity.²

Clinical Red Flags

Early identification is critical. Clinicians should maintain a high index of suspicion in male athletes presenting with:

• Rapid or significant weight loss^1,4
• Rigid dietary rules or restrictive patterns^1,2
• Excessive or compulsive exercise beyond training requirements^4,5
• Preoccupation with body composition rather than weight alone²
• Fatigue, decreased performance, or impaired recovery⁴
• Recurrent injuries or stress fractures⁴
• Endocrine changes (eg, low testosterone, decreased libido)^1,2

Validated screening tools such as the SCOFF questionnaire and Eating Disorder Examination Questionnaire (EDE-Q) may be useful, although clinicians should interpret results with caution in the context of male-specific symptom patterns, asexisting instruments may underdetect male-specific presentations.²

Medical and Psychiatric Consequences

The consequences of anorexia nervosa in male athletes are substantial and often underappreciated.^1,2,4

Physiological Effects

• Hypogonadism and hormonal dysregulation^1,2
• Decreased bone mineral density^1,2
• Muscle catabolism^1,2
• Cardiovascular complications^1,2

Psychiatric Effects

• Anxiety and obsessive thinking^1,2
• Depressive symptoms^1,2
• Social withdrawal¹
• Overidentification with performance⁴

These complications may paradoxically impair athletic performance, despite initial attempts to enhance it.

Treatment Considerations

Treatment recommendations are extrapolated from the broader anorexia nervosa literature, as a 2020 scoping review identified no studies reporting an evidence-based approach to management specifically in male elite athletes.⁵

Management requires a multidisciplinary approach, typically involving^2,4:

• Psychiatry
• Sports medicine
• Nutrition
• Endocrinology (when indicated)

Treatment centers on medical stabilization, nutritional rehabilitation, and weight restoration, combined with eating disorder-focused psychotherapy (eg, CBT-E) in adults. Family-based treatment is recommended for adolescents and emerging adults with an involved caregiver.⁹

Treatment should address:

• Cognitive distortions related to body image and performance
• Maladaptive exercise patterns
• Comorbid psychiatric conditions²

Pharmacologic treatment may be indicated for comorbid depression, anxiety, or obsessive-compulsive symptoms, although there is no primary medication for anorexia nervosa itself.² Engagement can be challenging, particularly in athletes who perceive their behaviors as performance-enhancing. Framing treatment in terms of performance sustainability and injury prevention may improve adherence.⁴

Implications for Clinical Practice

For clinicians working with athletes, several principles are essential:

• Maintain vigilance for atypical presentations of eating disorders in males^1,2,4
• Differentiate between performance-driven behaviors and pathological patterns^4,5
• Incorporate routine screening in high-risk populations^5,6
• Collaborate with coaches, trainers, and sports organizations when appropriate⁶
• Address stigma directly to facilitate disclosure and treatment engagement^1,2

Concluding Thoughts

Anorexia nervosa in male athletes remains underrecognized despite increasing awareness and growing evidence. The overlap between athletic discipline and pathological behavior creates a unique diagnostic challenge, requiring clinicians to move beyond traditional assumptions about eating disorders.^1,2

Improved recognition, earlier intervention, and a nuanced understanding of male-specific presentations are essential to reducing morbidity and supporting both mental health and long-term performance.

Dr Paraskevas is a Research Fellow with Athletes for Hope.

Dr Mirhom is Chief Wellbeing Officer of Athletes for Hope and Team Psychiatrist of the Sacramento Kings.

References

1. Raevuori A, Keski-Rahkonen A, Hoek HW. A review of eating disorders in males. Curr Opin Psychiatry. 2014;27(6):426-430.

2. Murray SB, Nagata JM, Griffiths S, et al. The enigma of male eating disorders: a critical review and synthesis. Clin Psychol Rev. 2017;57:1-11.

3. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text rev. American Psychiatric Association Publishing; 2022.

4. Eichstadt M, Luzier J, Cho D, Weisenmuller C. Eating disorders in male athletes. Sports Health. 2020;12(4):327-333.

5. Karrer Y, Halioua R, Mötteli S, et al. Disordered eating and eating disorders in male elite athletes: a scoping review. BMJ Open Sport Exerc Med. 2020;6(1):e000801.

6. Sundgot-Borgen J, Torstveit MK. Prevalence of eating disorders in elite athletes is higher than in the general population. Clin J Sport Med. 2004;14(1):25-32.

7. Sudi K, Öttl K, Payerl D, et al. Anorexia athletica. Nutrition. 2004;20(7-8):657-661.

8. Mountjoy M, Ackerman KE, Bailey DM, et al. 2023 International Olympic Committee’s (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med. 2023;57(17):1073-1097.

9. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders. 4th ed. American Psychiatric Association Publishing; 2023.