Art by Alexandra Ma

Eating Away at Athletes

After months of disciplined eating and fitness habits and a successful cross-country season, Duke sophomore and Menlo School alumni Charlotte Tomkinson was diagnosed with a grade-four stress fracture — the most severe type — in her sacrum — the bone connecting the spine to the hips.

In her article “Running Dangerously” for The Oval, Tomkinson discusses her journey with compulsive exercise disorder and orthorexia as a collegiate runner. 

“Often, injuries can feel as though the body has betrayed the athlete, but this time around I finally admitted that by underfueling and overexercising, I was the one who had betrayed my body,” Tomkinson wrote. “I had run until my bones literally broke.”

While orthorexia is not formally recognized by the Diagnostic and Statistical Manual, the National Eating Disorder Association characterizes it as an obsession with proper and healthy eating. 

“I insisted on doing most of my own cooking, kept a daily mental inventory of everything I ate and routinely held back tears as I watched my mom put olive oil in a pan,” Tomkinson wrote. “I’m ashamed to recall one specific night when I involuntarily broke down over bread. Yes, literal bread.” 

Tomkinson is not alone in combating orthorexia. Stanford sports medicine physician Andrea Kussman said there’s evidence that eating disorders in general are more common in athletes than non-athletes.

“Part of it is the pressures from sport,” Kussman said. “There are also studies that look at various personality traits that might be related to disordered eating and some of those traits are the same traits that make an athlete highly successful, such as a trend towards perfectionism.”

In particular, Kussman said these pressures stem from needing to have a lean body physique because it’s perceived to have a competitive advantage — running faster if you’re lighter — or it’s needed to meet weight class restrictions — wrestlers or lightweight rowers — or it’s part of a sport’s aesthetic component.

To achieve this desired physique, Stanford Psychologist and Clinical Professor Kristine Luce said athletes commonly alter their eating habits due to prescribed plans by trainers, nutritionists and dieticians.

“These athletes aren’t losing weight just to lose weight, they are trying to eat healthy and do the right things,” Luce said. “But they (instead) find themselves undernourished.”

This lack of nutrition and resulting energy deficiency is ultimately detrimental to every aspect of the body, Kussman said, which explains why Tomkinson’s stress fracture was a result of her disordered eating. 

“It can cause liver issues, kidney issues and reproductive issues,” Kussman said. “It can also cause issues with cognitive function, bone health which increases risk of fractures, reductions in muscle mass and increased rates of cardiac arrhythmias.”

Despite the damaging effects of eating disorders, athletes often go undiagnosed because they naturally have lower heart rates — a typical sign of an eating disorder. Luce said this is especially pertinent because low heart rates coupled with eating disorders can be dangerous.

“Sometimes physicians don’t realize an athlete has an eating disorder because they attribute their low heart rate to them being fit, but sometimes it’s just because they’re undernourished,” Luce said. 

In addition to heart rate, Luce said amenorrhea — loss of menstruation — is a sign of being unhealthy and a potential eating disorder, but this diagnosis wasn’t commonly used until recently. 

“We used to think that being really physically fit caused people not to menstruate, but we didn’t realize it’s because they don’t have enough body fat to sustain menstruation,” Luce said. “It’s an important biological process because if you’re not menstruating, then you’re not getting enough nutrients to your heart and other organs.”

However, Luce said it’s harder to diagnose men with orthorexia and other eating disorders because there’s no sign like amenorrhea, even though eating disorders are equally common among male and female athletes. 

“Failure to identify biological men with malnourishment or anorexia delays the onset of treatment and increases the risk of death,” Luce said. “Early identification and treatment are vital because, next to opiate overdose, anorexia has the highest mortality in mental health disorders.” 

To combat eating disorders on his teams, Paly wrestling coach Jonathan Kessler said he has worked to create an environment where his athletes have a positive relationship with food.

Kessler said he understands athletes who participate in sports like wrestling that require weigh-ins are more at risk of developing a bad relationship with food, so he has implemented visual nutrition reminders and expectations. Laminated sheets of paper cover an entire door in the wrestling room and display different meal options depending on the level of intensity that day — hard training/race day, moderate training and easy training. 

“This is what we expect (wrestlers) to put into their bodies,” Kessler said. “We always tell them to put in a vegetable, a grain, a carbohydrate and a protein.”

Despite participating in a sport where weight matters, Kessler said he believes in properly fueling the body no matter food’s impact on weight. 

“If you’re not putting enough food into your body, then you’re not going to have enough energy to practice,” Kessler said. “We’re all about working hard and eating food so that you have the fuel to practice.”

On top of properly fueling the body, Kussman said that discussing eating disorders more frequently can also help prevent the occurrence of one by reducing the secrecy and stigma that are associated with eating disorders. 

Thus, by sharing her story, Tomkinson hopes to create more discussions around orthorexia to help others avoid it altogether. 

“By sharing what I’ve gone through, I can help even one person salvage their relationship with food and sports — and avoid the physical and emotional pain that comes with disorder, and ultimately, injury,” Tomkinson wrote. “After all, it doesn’t matter how your uniform fits — or even how fast you might race — if you can’t run at all.”