Understanding Orthorexia, LEA, and RED-S in Athletes

By Karina Diaz (Undergraduate Intern at MEDA)

Being a student athlete means more than just playing a sport – it signifies belonging to a team; a select group of individuals united by shared commitment and passion. Athletes devote countless hours to training, pushing themselves physically and mentally in pursuit of growth and excellence.

Control and discipline are drilled into the minds of athletes from an early age. They learn that mastering their bodies and minds will lead to success, praise, and achievement. Along the way, athletes develop a heightened sense of awareness of their bodies – constantly evaluating what makes them leaner, quicker, or faster. Questions about food and performance often surface early: When is it best to eat before a sporting event? What should they eat the night before a long competition weekend?

Unfortunately, some young athletes think that restricting food will enhance performance. In reality, under-fueling does quite the opposite, and it can increase the risk for injury, illness, and disordered eating.

In many sports, performance becomes entangled with appearance. Athletes may feel the need to look a certain way or meet a specific number on the scale, whether they are 8 or 23 years old. Research shows that in sports with a strong and specific body-focused mindset, messaging – intentional or not – can contribute to harmful beliefs about food and bodies, especially for young, developing athletes.

As these children grow into teenagers and adults, the impact of this messaging may already be deeply ingrained. Coaches and instructors who are meant to build strong foundations for athletes, can, without realizing it, reinforce unhealthy behaviors – sometimes praising restriction and rigid control as signs of dedication.

There are three key factors that play into the damage caused when discussing eating disorders in athletes, their performance, and health:

Orthorexia

Orthorexia is characterized as an obsession with “healthy” eating, coupled with restrictive behaviors that can lead to malnourishment, poor energy, and loss of relationships. Orthorexia in sports has always been a cause for concern, but with increased access to media and the internet, it has skyrocketed.

Athletes are searching for quicker ways to get results, whether that means restrictive eating or eliminating entire foods and food groups. Food is often the one area where athletes believe they have control; they decide how to fuel their bodies, and what they believe is the best way to stay strong, healthy, and fit for their sport.

While it will not happen overnight, those who continue with irregular eating habits can find themselves unintentionally insufficient in many nutrients needed to fuel their bodies, altering their performance, behaviors, and psychological processes. Orthorexia is not a recognized eating disorder in the DSM-5, but can be used as a descriptor for several symptoms that involve restriction.

Symptoms of Orthorexia:

• Only eating foods considered “clean” or “healthy”
• Self-imposed diet rules that are “non-negotiable”
• Anxiety
• Weight loss
• Social isolation, avoids eating socially
• Critical views over other people’s diets

These symptoms are especially prevalent among athletes, fueled by pervasive social media trends, the glorification of “lean” body ideals, and coaching environments that may place heightened emphasis on specific body compositions. This can be seen as discipline, but in fact requires intervention. Over time, these symptoms can impact performance or energy reallocation to protect vital organs and lead to Low Energy Availability (LEA).

Low Energy Availability (LEA)

Low Energy Availability is the result of an athlete who does not have a high enough energy intake to support athletic events/demands as well as involuntary functions. This energy intake is a direct correlation to the amount of food being put into the body and the amount of energy being burned during sport and by non-essential functions. Symptoms of Low Energy Availability (LEA) can present in a variety of ways and including:

• Chronic Fatigue
• Irritability
• Poor Recovery
• Loss of menstrual cycle (in individuals assigned female at birth)
• Decreased testosterone (in individuals assigned male at birth)

Athletes do not need to have a diagnosed eating disorder to experience LEA or either of the two other key factors in relation to athletic performance and health. Many athletes can find themselves with a number of these symptoms by not fueling themselves properly.

Parents and coaches can monitor their athletes to see if any of these symptoms coincide with their athlete’s behavior. It is important to note that this does not mean they have an eating disorder, simply that they are not fueling their bodies properly for the amount of exertion.

Orthorexia, is a direct predecessor for LEA, and should be highlighted as a precursor to low energy in high performing athletes. It is important to have enough energy storage that the body is not looking into other functional systems in the body and pulling energy from those.

Those who exhibit LEA symptoms should look to reframe their workout and eating habits. Making sure athletes get proper rest and do not ignore hunger cues are the biggest changes that should be made over time. With no intervention, LEA symptoms, like hormonal disruption and bone density loss, can eventually lead into Relative Energy Deficiency in Sports (RED-S). This could be a sign that an athlete needs to or must stop playing their sport for a period of time for the benefit of their health.

Relative Energy Deficiency in Sport (RED-S)

RED-S syndrome is a result of an energy intake deficit that causes a wide range of body malfunctions like cardiovascular health, bone health, and impairment of metabolic rate. These non-essential functions are directly compromised to ensure the essential functions in the body are maintained. RED-S represents the most severe spectrum of eating disorder-related syndromes affecting athletic performance, as it can result in actual injuries and time away from sport.

Once an athlete develops RED-S, they are more prone to stress fractures, higher frequency of injuries, abnormal bruising, and a lengthier recovery process. These physical injuries that athletes can get do not mean that they have RED-S, but when it is partnered with other symptoms, there is a cause for concern. As stated above for orthorexia and LEA, these three fall into one another and are essentially more severe cases of the latter.

This is where coaches, teachers, and parents play a critical role in fostering healthy habits for athletes. Many athletes are highly driven to excel and fear being perceived as weak, which can lead to punishment or judgment. As a result, they may try to hide restrictive eating behaviors, believing that such practices are harmless. While some dietary restrictions are necessary for allergies, RED-S syndrome demonstrates that dieting to impress oneself or others can have serious consequences. MEDA, along with other eating disorders organizations, works closely with athletes and their support networks to provide both preventive and restorative care for those ready to address these symptoms directly.

This path to RED-S is just one of many, and athletes, like any other individual, can have a multitude of these symptoms while believing it is a normal or common practice to achieve peak performance and excellence in their sport.

When looking at orthorexia, LEA, and RED-S, there is a powerful message to all athletes: fueling should never come with anxiety or obsession. The need to take control is why early detection matters. There are professionals who can take on these supportive roles, like sports physicians, sports nutritionists, dieticians, and mental health professionals. Any of these individuals on their own, or in hand with another, can give individualized care or strategies to athletes on how to best fuel their bodies.

Being proactive in prevention ensures athletes have a strong foundation to excel in their sport, health, and future endeavors whether it be individually or on a team.

References

Ashley, Smith. “Orthorexia & Kids: How to Identify When “Healthy” Eating in Children Goes Too Far – the Renfrew Center.” The Renfrew Center, 18 Aug. 2021, renfrewcenter.com/orthorexia-kids-how-to-identify-when-healthy-eating-in-children-goes-too-far/.

Logue, Danielle M., et al. “Low Energy Availability in Athletes 2020: An Updated Narrative Review of Prevalence, Risk, Within-Day Energy Balance, Knowledge, and Impact on Sports Performance.” Nutrients, vol. 12, no. 3, 20 Mar. 2020, p. 835, https://doi.org/10.3390/nu12030835. Accessed 22 Mar. 2020.

“Relative Energy Deficiency in Sport (REDs).” Childrenshospital.org, 2025, www.childrenshospital.org/conditions-treatments/reds.

Sundgot-Borgen, Jorunn, and Monica Klungland Torstveit. “Prevalence of Eating Disorders in Elite Athletes Is Higher than in the General Population.” Clinical Journal of Sport Medicine, vol. 14, no. 1, Jan. 2004, pp. 25–32, pubmed.ncbi.nlm.nih.gov/14712163/, https://doi.org/10.1097/00042752-200401000-00005.