Returning to Sport After an Eating Disorder: A Safe, Gradual Path Back for Athletes
For many athletes, sport is more than exercise. It can be a source of identity, friendship, structure, confidence, and belonging. When an eating disorder requires an athlete to reduce or temporarily stop training, the loss can feel overwhelming.
Athletes and families often ask:
When can I return to my sport?
Do I have to be completely recovered first?
How do we know whether exercise is medically safe?
What if returning to practice triggers eating-disorder thoughts?
Who should make the final decision?
There is no single timeline that applies to every athlete. Returning to sport after an eating disorder should be an individualized, gradual process based on medical stability, nutritional recovery, psychological readiness, injury risk, and the demands of the athlete’s specific sport.
The goal is not simply to get an athlete back into competition as quickly as possible. The goal is to help the athlete return in a way that protects long-term health, supports recovery, and allows sport to become sustainable again.
Why Can an Eating Disorder Make Sport Unsafe?
Athletes need adequate nutrition not only for training, but also for growth, brain function, cardiovascular health, hormone production, immune function, bone development, and recovery from exercise.
When an athlete’s energy intake does not adequately meet the combined demands of exercise and basic physiological functioning, the athlete may experience low energy availability. Prolonged or severe low energy availability may contribute to Relative Energy Deficiency in Sport, commonly called REDs.
REDs can affect athletes of any sex, gender, body size, age, or level of competition. It may impair:
Bone health
Menstrual and reproductive function
Cardiovascular functioning
Metabolism
Immune functioning
Muscle growth and recovery
Concentration and judgment
Mood and psychological well-being
Training response and athletic performance
Importantly, an athlete does not need to appear underweight to be medically compromised. Eating disorders and REDs can occur across the weight spectrum, including among athletes with atypical anorexia nervosa or other restrictive eating disorders.
The International Olympic Committee emphasizes that REDs is a multifactorial syndrome involving impaired physiological or psychological functioning caused by problematic low energy availability. It can increase injury risk and reduce performance even when the athlete initially believes that weight loss or additional training is helping (Mountjoy et al., 2023).
Is Returning to Sport the Same as Being Fully Recovered?
Not necessarily.
Return to sport is often better understood as a continuum rather than a single moment when an athlete is suddenly “cleared.” Depending on the athlete’s condition, the process may move through stages such as:
Rest from structured training
Medically supervised light movement
Limited or modified practice
Increased sport-specific training
Full practice
Return to competition
Continued recovery while maintaining participation
An athlete may be able to begin limited activity before every eating-disorder symptom has resolved. However, participation should not advance faster than the athlete’s medical, nutritional, and psychological recovery.
In some cases, continued sport participation may be possible with modifications and close monitoring. In other cases, temporary removal from training and competition is necessary to prevent serious medical complications or further entrenchment of the eating disorder.
Who Decides When an Athlete Can Return?
Return-to-sport decisions should not be made by the athlete, therapist, parent, or coach alone.
Ideally, the decision is coordinated by a multidisciplinary eating-disorder treatment team that may include:
A physician or advanced-practice medical clinician
An eating-disorder therapist
A registered dietitian experienced in eating disorders and sports nutrition
Parents or caregivers, especially for children and adolescents
An athletic trainer
A coach or sports administrator, when appropriate and authorized by the athlete
Other specialists, such as a physical therapist, endocrinologist, cardiologist, or exercise physiologist
Consensus recommendations for athletes with disordered eating emphasize care from a core multidisciplinary team that includes medical, nutritional, and psychological professionals (Wells et al., 2020).
The physician or qualified medical clinician is typically responsible for determining whether the athlete is medically safe to participate. The therapist helps evaluate whether exercise is functioning as healthy sport participation or as an eating-disorder behavior. The dietitian assesses whether the athlete can meet the increased energy and nutritional demands created by training.
For minors, parents generally play a central role in implementing meals, monitoring symptoms, communicating with the treatment team, and maintaining boundaries around activity.
What Does Medical Clearance for Sport Consider?
Medical clearance should involve more than checking an athlete’s weight or asking whether the athlete feels ready.
A clinician may consider:
Heart rate and blood pressure
Orthostatic changes in heart rate or blood pressure
Electrocardiogram findings, when indicated
Laboratory abnormalities
Hydration status
Weight trajectory and growth history
Nutritional intake
Menstrual or hormonal functioning
History of fainting, dizziness, chest pain, or palpitations
Bone density and bone-stress injuries
Muscle weakness and physical deconditioning
Frequency of bingeing, vomiting, laxative use, or other compensatory behaviors
Injury history
Medication use
The intensity and physical risks of the athlete’s sport
The IOC REDs Clinical Assessment Tool, Version 2, uses a physician-led process involving screening, severity and risk assessment, and an individualized diagnosis and treatment plan. It categorizes risk along a continuum and connects that risk level with recommendations about training and competition (Stellingwerff et al., 2023).
These tools support clinical judgment; they are not self-assessment checklists and should not be used by athletes, coaches, or families to independently approve participation.
Signs an Athlete May Not Be Ready to Return
An athlete may need continued restriction or modification when there is ongoing medical instability or when sport participation is likely to reinforce the eating disorder.
Concerning signs may include:
Fainting, dizziness, chest pain, palpitations, or shortness of breath
Significant weakness or inability to complete ordinary daily activities
Abnormal vital signs, laboratory results, or electrocardiogram findings
Continued weight loss or failure to follow an expected growth trajectory
Inability to consistently complete the prescribed nutrition plan
Active restriction, bingeing, vomiting, laxative use, or other compensatory behavior
Recurrent stress fractures or an unresolved bone-stress injury
Training secretly or exercising beyond the treatment plan
Severe distress when required to rest
Exercise driven primarily by guilt, fear, body dissatisfaction, or a need to compensate for eating
Refusal to fuel before or after activity
Increasing eating-disorder symptoms after practices
Dishonesty with parents, clinicians, or coaches about food or exercise
Suicidal thoughts, severe depression, or another acute mental-health concern
A formal eating-disorder diagnosis is not required before training modifications become appropriate. Disordered eating alone may create enough medical or psychological risk to justify limiting participation (Wells et al., 2020).
Psychological Readiness Matters Too
Medical stability is essential, but it is not the only part of readiness.
An athlete may have reassuring medical findings while continuing to experience compulsive exercise, intense body dissatisfaction, rigid food rules, fear of weight gain, or an overwhelming need to earn food through movement.
Before advancing activity, the treatment team may consider whether the athlete can:
Take prescribed rest days without secretly exercising
Stop when asked by a parent, coach, athletic trainer, or clinician
Eat adequately before and after training
Adjust nutrition when training demands increase
Tolerate changes in body shape, weight, strength, or performance
Recognize pain, fatigue, hunger, and other body signals
Distinguish athletic goals from eating-disorder goals
Respond flexibly when a practice is canceled or changed
Discuss exercise urges honestly
Participate without using movement to compensate for food
Prioritize recovery over a race, meet, game, weigh-in, or season
Compulsive exercise is a common eating-disorder symptom and may contribute to a more prolonged illness or poorer treatment outcomes. Addressing it directly is therefore an important part of treatment rather than an issue to postpone until later in recovery (Gorrell et al., 2026).
What Does a Gradual Return to Sport Look Like?
There is no universal return-to-sport protocol for eating disorders. The progression must account for the athlete’s age, diagnosis, medical history, nutritional status, treatment engagement, injury risk, and sport.
A treatment team may use a staged approach.
Stage 1: Establish Medical and Nutritional Stability
Early goals may include:
Completing the nutrition plan consistently
Interrupting bingeing, purging, restriction, or compensatory exercise
Stabilizing medical concerns
Restoring hydration and electrolyte balance
Establishing an appropriate weight or growth trajectory
Treating injuries
Improving sleep and daily functioning
Beginning work on exercise-related beliefs and urges
Structured exercise may need to stop during this stage. This is not a punishment. It is a medical and therapeutic intervention intended to give the body enough energy to repair itself.
Stage 2: Introduce Supported Movement When Appropriate
After medical approval, movement may begin in a limited and purposeful form.
The initial plan may specify:
Type of movement
Duration
Frequency
Intensity
Required supervision
Pre-activity and post-activity nutrition
Symptoms that require stopping
Criteria for advancing or reducing activity
The first activity is not necessarily the athlete’s preferred sport. Lower-intensity, supervised, or noncompetitive movement may offer a safer opportunity to assess the athlete’s physical response and psychological flexibility.
Stage 3: Add Modified Sport-Specific Participation
The athlete may begin selected aspects of practice while avoiding high-risk components.
Examples include:
Attending only part of practice
Participating in skill drills but not conditioning
Eliminating extra workouts
Avoiding unsupervised training
Reducing impact or contact
Limiting repetitions, mileage, or training volume
Postponing competition
Requiring rest between sessions
Prohibiting weight cutting or body-composition manipulation
Progression should be based on sustained recovery behaviors, not simply the passage of time.
Stage 4: Return to Full Practice
Before full practice, the team should confirm that the athlete is tolerating the current activity level without deterioration in:
Medical status
Nutritional intake
Weight or growth trajectory
Mood
Sleep
Eating-disorder symptoms
Exercise compulsivity
Injury status
Academic or daily functioning
An athlete who can physically complete a workout is not automatically ready for unrestricted participation.
Stage 5: Return to Competition
Competition adds intensity, pressure, comparison, travel, schedule disruption, and performance evaluation. These factors may increase relapse risk.
Before competition, the plan should address:
Meals and snacks on competition days
Travel nutrition
Locker-room and team triggers
Uniform or body-image concerns
Weigh-ins or body-composition testing
Post-event recovery nutrition
Managing disappointment or reduced performance
Communication with coaches or athletic trainers
What happens if symptoms return
Return to competition should be viewed as another treatment transition—not the end of treatment.
Why Fueling Must Increase as Training Increases
A frequent recovery mistake is adding training without increasing nutrition.
As exercise volume or intensity rises, the athlete’s energy, carbohydrate, protein, fluid, and micronutrient needs may also rise. Without corresponding nutritional changes, an athlete can return to low energy availability even if eating has improved compared with the beginning of treatment.
A return-to-sport plan should therefore connect each increase in activity with a review of:
Meal and snack adequacy
Pre-training nutrition
Fueling during longer training sessions, when applicable
Post-training recovery nutrition
Hydration
Changes in hunger and fullness cues
Weight or growth trajectory
Fatigue, soreness, injury, and recovery time
Restoring adequate energy availability through changes in nutrition and exercise is a cornerstone of REDs treatment (Mountjoy et al., 2023).
Special Considerations for Children and Teen Athletes
Adolescents are not simply smaller adults.
Children and teens need energy for training as well as puberty, brain development, height gain, organ function, and bone-mass accumulation. Adolescence is a critical period for bone development, and prolonged energy deficiency or hormonal disruption may have lasting consequences (De Souza et al., 2025a).
Parents may need to temporarily take greater control over:
Meals and snacks
Transportation to practices
Communication with coaches
Access to gyms or exercise equipment
Activity-monitoring devices
Training outside organized practice
Decisions about competition
A teen may sincerely want recovery and still be unable to resist eating-disorder urges without firm external support. Appropriate parental supervision is not a failure of independence. It is part of treatment.
How Coaches Can Support a Safe Return
Coaches can strongly influence whether returning to sport supports recovery or undermines it.
Helpful coaching practices include:
Following the clinical return-to-sport plan
Avoiding comments about weight, shape, appearance, or food
Avoiding public weigh-ins or body-composition discussions
Not praising weight loss, leanness, or extra training
Supporting rest and modified participation
Keeping health information private
Avoiding pressure to return for an important competition
Asking what accommodations are needed
Reinforcing effort, teamwork, skill, and character rather than appearance
Reporting concerning changes through the agreed communication process
Sport organizations should avoid establishing arbitrary “ideal” body weights or body-fat percentages. There are no universally accepted sport-specific minimum or optimal body-weight or body-fat values, and inappropriate body-composition practices can increase harm (Wells et al., 2020).
What If the Athlete’s Performance Is Worse at First?
It is common for athletes to fear that rest, weight restoration, or body changes will permanently reduce performance.
During early return, the athlete may experience:
Reduced conditioning
Changes in speed or endurance
Temporary loss of strength
Coordination changes
Increased soreness
Anxiety about being observed
Frustration about being behind teammates
Grief over a missed season or altered role
These experiences do not mean that recovery has failed.
The body may need time to rebuild muscle, restore glycogen, repair bone, normalize hormones, and regain training capacity. Sustainable performance depends on adequate fuel and recovery. Returning too quickly may prolong illness, worsen injury risk, or lead to another period away from sport.
What Happens if Eating-Disorder Symptoms Return?
A return-to-sport plan should include clear criteria for pausing, reducing, or stopping activity.
The athlete may need to step back when there is:
Renewed restriction, bingeing, purging, or compensatory behavior
A medically concerning change
Failure to complete increased nutrition
Secret or unauthorized exercise
Escalating distress around rest
New dizziness, fainting, chest pain, palpitations, or unusual shortness of breath
A new injury or stress-fracture concern
Significant worsening of anxiety, depression, or body-image distress
Dishonesty that prevents the team from assessing safety
Needing to step back does not erase previous progress. Recovery is rarely perfectly linear. Early intervention can prevent a lapse from becoming a more significant relapse.
Eating-Disorder Treatment for Athletes at Ezer Psychotherapy
Ezer Psychotherapy provides specialized eating-disorder therapy for children, adolescents, young adults, and families, including athletes who are navigating the emotional and behavioral challenges of stepping away from or returning to sport.
Treatment may address:
Restrictive eating and rigid food rules
Bingeing or compensatory behaviors
Compulsive or driven exercise
Fear of rest, recovery, or reduced training
Body-image distress
Perfectionism and performance pressure
Identity concerns related to being an athlete
Anxiety about weight restoration or body changes
Communication between athletes, parents, and treatment providers
Coping with injury, missed seasons, or changes in performance
Relapse prevention during return to practice and competition
Depending on the client’s age and clinical needs, treatment at Ezer Psychotherapy may incorporate evidence-based approaches such as:
Family-Based Treatment: A family-centered treatment frequently used with children and adolescents with eating disorders. Parents are supported in interrupting eating-disorder behaviors, restoring adequate nutrition, and helping their child gradually return to developmentally appropriate independence.
Enhanced Cognitive Behavioral Therapy: An individualized approach that addresses the thoughts, emotions, and behaviors maintaining an eating disorder.
Adolescent-Focused Therapy: A developmentally informed approach that helps adolescents strengthen identity, emotional awareness, coping skills, and autonomy outside the eating disorder.
For athletes, therapy may also focus specifically on rebuilding a flexible relationship with movement. This can include examining the difference between committed training and compulsive exercise, tolerating rest, responding to performance setbacks, and developing an identity that is not dependent solely on sport, weight, or achievement.
Ezer Psychotherapy coordinates with outside physicians, dietitians, athletic trainers, schools, and other members of the treatment team when appropriate and when proper authorization is in place. Medical clearance and nutritional management must be provided by qualified medical and nutrition professionals.
Returning Safely Is More Important Than Returning Quickly
Temporarily stepping away from sport can be painful, especially when the athlete feels that participation is central to identity, relationships, or future goals.
However, an early return is not always a successful return.
A safe return means the athlete has adequate medical stability, sufficient nutrition, meaningful psychological progress, and a clear monitoring plan. It also means that the adults and professionals around the athlete are willing to prioritize long-term health over a single season, competition, scholarship opportunity, or performance goal.
With coordinated treatment and a gradual plan, many athletes can work toward returning to the sport they value while developing a healthier and more sustainable relationship with food, movement, performance, and their bodies.
When to Seek Immediate Medical Help
Seek urgent medical evaluation for an athlete experiencing symptoms such as:
Fainting or near-fainting
Chest pain
A very slow, irregular, or racing heartbeat
Severe weakness or confusion
Difficulty breathing
Repeated vomiting
Signs of severe dehydration
Seizure activity
Inability to eat or drink
Suicidal thoughts or an inability to remain safe
Call 911 or go to the nearest emergency department when symptoms appear life-threatening.
Frequently Asked Questions
Can an athlete continue playing while receiving eating-disorder treatment?
Sometimes, but not always. The decision depends on medical stability, nutritional adequacy, eating-disorder behaviors, psychological readiness, injury risk, and the demands of the sport. Some athletes may continue with modifications; others need temporary removal from training and competition.
Does an athlete need to reach a certain weight before returning?
Weight may be one factor, but there is no single weight that establishes readiness for every athlete. Clinicians should consider the athlete’s growth history, weight trajectory, medical findings, nutrition, hormonal and bone health, behaviors, and overall clinical context.
Can someone have REDs without having an eating disorder?
Yes. Low energy availability may occur intentionally or unintentionally. An athlete may underfuel because of an eating disorder, poor sports-nutrition knowledge, a demanding schedule, food insecurity, gastrointestinal symptoms, increased training, or failure to adjust intake when exercise demands rise.
Can male athletes develop eating disorders or REDs?
Yes. Male athletes can experience eating disorders, low energy availability, hormonal disruption, impaired bone health, injuries, and performance consequences. Symptoms may be overlooked when they involve muscularity, “clean eating,” excessive training, or attempts to become leaner rather than an expressed desire to lose weight (Fredericson et al., 2021).
Should a therapist provide medical clearance?
No. A therapist can assess eating-disorder symptoms, exercise compulsivity, motivation, and psychological readiness, but medical clearance should come from an appropriately qualified medical clinician. Return-to-sport decisions are strongest when made collaboratively by the full treatment team.
How can I begin eating-disorder therapy at Ezer Psychotherapy?
Contact Ezer Psychotherapy to ask about current availability, insurance participation, telehealth eligibility, and whether its services are appropriate for the athlete’s needs. Because eating disorders can cause serious medical complications at any body size, therapy should be coordinated with medical and nutritional care rather than used as a substitute for those services.
References
De Souza, M. J., Nattiv, A., Joy, E., et al. (2014). 2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the Female Athlete Triad. British Journal of Sports Medicine, 48(4), 289. https://doi.org/10.1136/bjsports-2013-093218
De Souza, M. J., Williams, N. I., Misra, M., et al. (2025a). 2025 update to the Female Athlete Triad Coalition consensus statement, Part 1: State of the science and introduction of a new adolescent model. Sports Medicine. Advance online publication.
Fredericson, M., Kussman, A., Misra, M., et al. (2021). The Male Athlete Triad—A consensus statement from the Female and Male Athlete Triad Coalition, Part II: Diagnosis, treatment, and return-to-play. Clinical Journal of Sport Medicine, 31(4), 349–366. https://doi.org/10.1097/JSM.0000000000000948
Gorrell, S., Drury, C., & Schaumberg, K. (2026). Managing exercise in eating disorder treatment and adapting treatment for athletes. Psychiatric Clinics of North America, 49(1), 97–114. https://doi.org/10.1016/j.psc.2025.08.008
Mathisen, T. F., Sundgot-Borgen, J., Bulik, C. M., & Bratland-Sanda, S. (2023). How to address physical activity and exercise during treatment from eating disorders: A scoping review. Current Opinion in Psychiatry, 36, 419–427.
Mountjoy, M., Ackerman, K. E., Bailey, D. M., et al. (2023). 2023 International Olympic Committee’s consensus statement on Relative Energy Deficiency in Sport (REDs). British Journal of Sports Medicine, 57(17), 1073–1097. https://doi.org/10.1136/bjsports-2023-106994
Pensgaard, A. M., Sundgot-Borgen, J., Edwards, C., et al. (2023). Intersection of mental health issues and Relative Energy Deficiency in Sport: A narrative review by a subgroup of the IOC consensus on REDs. British Journal of Sports Medicine.
Stellingwerff, T., Mountjoy, M., McCluskey, W. T. P., et al. (2023). Review of the scientific rationale, development and validation of the International Olympic Committee Relative Energy Deficiency in Sport Clinical Assessment Tool: Version 2. British Journal of Sports Medicine, 57(17), 1109–1121.
Wells, K. R., Jeacocke, N. A., Appaneal, R., et al. (2020). The Australian Institute of Sport and National Eating Disorders Collaboration position statement on disordered eating in high performance sport. British Journal of Sports Medicine, 54(21), 1247–1258. https://doi.org/10.1136/bjsports-2019-101813
Medical Disclaimer: This article is for educational purposes and is not a substitute for individualized medical advice, diagnosis, or treatment. Return-to-sport decisions should be made by qualified healthcare professionals familiar with the athlete’s complete medical and psychological history.
