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We frequently mention that family-based treatment (FBT) is the only evidence-based eating disorder treatment for young people. But, as we all know, families vary drastically from one to the next, and no two eating disorders are the same. So do certain demographic or diagnostic factors determine whether FBT will work for a patient? According to new research, no.

Predictors of family-based treatment for adolescent eating disorders: Do family or diagnostic factors matter?

”, was co-authored by Equip’s VP of Clinical Programs, Cara Bohon, and appeared in the December 2022 issue of the 

International Journal of Eating Disorders.

Researchers analyzed data from six clinical trials in both the U.S. and Canada, which included a combined 724 patients ages 12-18 with a diagnosis of either anorexia or bulimia who were receiving some form of treatment, either FBT or other approaches. Using this data, they compared outcomes with a variety of different familial and diagnostic factors, including socioeconomic status, feelings of self-efficacy (caregivers’ belief about their ability to take care of their loved one successfully), family configuration (i.e., married vs divorced), prior treatment, illness duration, and more.

Their findings showed that the only factor that directly predicted the success of FBT was whether or not a patient had received prior eating disorder treatment (those with no prior treatment had better outcomes). No other demographic or clinical variables affected the outcome of FBT.

These results have significant implications for future treatment. While providers may hesitate to refer certain patients and families to FBT because of misconceptions around who it works for, this initial analysis suggests that factors commonly assumed to impede FBT actually have no impact. Rather, FBT can be an equally effective approach for all families and patients.

“Overall, it feels good to confirm what my clinical experience had suggested to be true,” says Bohon, who has almost 20 years of experience in clinical eating disorder research. “FBT is adaptable and can meet family and patient needs, whatever they may be.”

New Research: What Family Factors Determine Success with FBT? 

If you've made it this far through the holidays, take a moment to celebrate. This time of year can be hard for anyone, and especially so for people navigating 

. But just as the major December festivities pass, it’s time to get ready for the bombardment of “new year, new you” messaging on TV, social media, subway ads, and more.

Although setting goals to improve yourself isn't a bad thing, per se, New Year's resolutions often have two problems: First, people don't tend to follow through on them. According to one recent study, about 

 of people abandon their commitments within a month—and failure to reach your resolution may make you feel worse about yourself. Second, the vast majority of year-end goals are centered around diets, weight loss, and fitness, which makes the whole resolution business particularly problematic for those in eating disorder recovery. If you or a loved one are working toward recovery (or in recovery), this might be triggering, or even cause a slide back into disordered eating and 

If you feel tempted to “improve” yourself this January with diet or fitness-related resolutions, we encourage you to keep reading. Learning why so many resolutions are rooted in physical appearance—and how to successfully strive for something more meaningful—can help you create resolutions that are aligned with your values and put you on track to follow through with those goals.

Why diet-focused New Year’s resolutions are harmful

“It’s totally understandable in our current culture why, when we think about a time of change and transformation, we think about changing our bodies to be more ‘acceptable’ and ‘healthy,’” says Equip therapist Kirstin Quinn Siegel, LMFT. “We have so many messages—constantly, every day—bombarding us with false ideas about health, body size, and what will make us happy.”

The desire to be accepted is completely natural. The problem, Siegel says, is that 

 has co-opted and capitalized upon these very fundamental and basic human needs. “Diet culture tells us that thinner bodies are better in every way and larger bodies are potential projects to be changed and ‘transformed’ by any means necessary,” she says. This mindset is damaging for anyone with a body, and particularly for people living with an eating disorder or 

.See, whether a resolution is about a particular weight, a fitness goal, or simply being “healthier”, many of these ambitions are associated with achieving a specific number, following certain “rules” about eating or exercise, and other rigid practices. These things are common 

 and, in turn, may fuel unhealthy habits that people in recovery are working so hard to let go of.

On top of all that, body-centric resolutions are often unsustainable. As many of us have experienced, 

 can often lead to bingeing and an unhealthy relationship with food; and your body can handle only so much exercise before it starts causing injury, messing with your sleep, or leaving you tired all the time, 

. Adding insult to injury, failing to reach a goal can 

trigger or increase anxiety and depression

If “new year, new you” messaging is so harmful...why is it everywhere? Because it sells, and the timing couldn’t be more perfect for those looking to profit.

At the end of the year, we celebrate Thanksgiving, Hanukkah, Kwanzaa, Christmas, New Years, and often more. For most people, 

 are not only a time to gather with loved ones, they're also a time to connect over food. And the message we tend to hear about this eating centers around guilt and “overindulging.”

No matter how little or much we actually eat, companies know we may 

 we “overdid it”—so they take advantage of that opportunity to sell us their weight-loss program, cleanse, workout plan, detoxification, or other “quick fix.” And since January 1 is approaching, they promote their product as a way to kick off the new year with a bang and “improve” yourself.

focusing on external changes like weight loss

 detracts from holistic health goals. When you fixate on a number, it not only casts a lot of gray area into black and white, it’s also arbitrary and fleeting: no specific weight or size makes you “healthy” or “unhealthy,” and all too often, the target for these goals keeps moving (you continue to want to lose more and more).

On the other hand, resolutions that promote positive 

, a healthy relationship with food, and simply feeling good support both your physical and your mental health, and help you listen to and trust your inner voice. These are the types of changes that ultimately lead to confidence, fulfillment, and real well-being.

In a world where “clean” eating (whatever that means) and a “more-is-more” attitude about exercise are so widely considered to be good things—despite evidence otherwise—it can be tough to know what a “healthy” resolution actually entails.

For starters, it helps to remember that “health” is not about a number on the scale or arbitrary body-based goals. It’s about doing things that positively impact your mental, physical, and emotional well-being. With that in mind, here are some tips to help guide you toward resolutions that promote 

“A key aspect of a supportive resolution is that it comes from an intrinsic desire and is aligned with your values,” says Equip Peer Mentor Stacy Jones. “Having resolutions that are intrinsically driven means they aren't about others seeing you a certain way, or about what you ‘should’ do. It is something truly for you that will support your most expansive and aligned life.”

As Equip co-founder and Chief Clinical Officer Dr. Erin Parks, PhD puts it, no one should be “should”-ing themselves when setting their resolutions: “A healthy resolution is one that makes you happy when you think about doing it—and doesn't make you feel guilty when you think about not doing it.” To her point, Parks picks a resolution each year that's based around learning a new skill or engaging in an activity she’s always wanted to try. One year it was knitting, another year it was surfing. “It’s not about changing myself—I certainly am not becoming a knitter or a surfer. Instead, I wanted to have the experience of learning how to do something,” she says. “And if I hadn't followed through and didn’t actually learn to surf, I wouldn't have felt guilty about it.”

To prevent slipping into the “should” mentality (even when setting non-body-based goals) Siegel suggests finding the reason behind the resolution and asking yourself what purpose it serves. Park agrees, adding that you may have to ask yourself several times to help you set the right intention. “When making a resolution, ask yourself why you're resolving to do it, and when you think you've answered it, ask ‘why’ again,” she says. “So if your answer is ‘to be healthy’, what does healthy mean to you? Why do you want to be healthy? Maybe it’s, ‘I want to be healthy so that I can have the energy to play with my grandkids.’ If it’s, ‘I want to drink more water,’ and you say it’s because you want to ‘be healthy’, maybe what you really want is to feel in control of your health. So maybe that means trying to have a regular sleep schedule, and it's not actually about drinking more water. Figure out what you're really saying and be honest with yourself.”

Resolutions don’t have to be about physical health; your mental health matters just as much. “Characteristics of a ‘healthy’ resolution might include practicing daily acceptance of where you are, just as you are, and turning focus inward to the state of your nervous system and mental well-being first,” says Equip Family Mentor Inga Yanoski. “‘Healthy’ goals might include gratitude, intentional rest, and achievable resolutions that don’t have anything to do with physical transformation or diets. Like focusing on 

 rather than movement that is coming from a place of ‘I should,’or a resolution of giving oneself permission to say ‘no’ instead of always saying ‘yes.’”

 or an eating disorder or have in the past, be honest with yourself about whether it’s you or the eating disorder setting goals. Take the time to have a heart-to-heart with yourself (and any professionals or loved ones who are part of your support team). You'll know in your gut who's controlling the steering wheel.

If you're in treatment for an eating disorder, loop your therapist and other healthcare providers in on your resolution-making process. They can work with you to help you determine whether setting resolutions could be helpful or harmful in supporting recovery. And if it could help, together you can brainstorm ideas of resolutions that promote your physical and mental health.

If we can agree that weight loss- and appearance-focused resolutions are more likely than not to result in disappointment at best—and trigger or exacerbate disordered behaviors at worst—how can people (both in recovery and otherwise) go about setting end-of-year goals that will help them feel happier and healthier?

Jones believes it may help to initially switch up the language that describes New Year ambitions. “What I really like to do is set ‘intentions’ for the New Year instead of ‘resolutions,’” she says. “This allows me to view my life in a holistic way and consider how I want to feel in it.”

Yanoski agrees that the semantics can make a big psychological impact: “Setting an intention takes the pressure off of ‘resolving’ to do something. It softens the rigidity and the rules that come along with a resolution,” she says. (This is particularly important for those in recovery, as 

rigidity is often characteristic of an eating disorder mentality

Only you know which intentions are best for you. To help you, here are some goals to inspire your brainstorming:

Develop hobbies, like gardening or learning a new skill

Take a cooking class with a friend or partner

Setting resolutions is one thing. Sticking to them so you reach your goals is another. While you should allow yourself grace to not “achieve” everything on your list, these tips can help you continue moving toward your intentions for the year:

 Sometimes, an end goal can seem far away. But if you record your progress daily or weekly, you'll see the small improvements that you're making, and that will eventually lead you to achieving your big goal. As a bonus, this process helps you stay motivated, because success inspires success.

 It's easy to ditch a resolution when nobody else knows about it. But when you tell one person (or more), suddenly you're accountable for your goal. You could schedule regular check-ins with your accountability buddy or reach out when you need support. Either way, just by them being aware of your intention, they’ll help keep you on track.

 If you find yourself struggling to stick with a resolution, pause for a moment and have another honest conversation with yourself. Do you truly want this intention, or have your desires shifted? It's perfectly acceptable to change your mind and drop or adjust a resolution at any time of the year, especially if doing so aligns with your inner values.

Tips for dismantling diet culture in January and beyond

Let's face it: Although the new year is one time when diet culture is particularly rampant, it can make an appearance in our lives any day of the year. The tips below can help you stay strong and avoid its influence.

Instagram, TikTok, and other platforms can be sources of knowledge and connection, but there's also a lot of misinformation and deception. Unfollow any accounts that make you feel worse about yourself, promote unhealthy behaviors, or produce weight-centric content.

 is a mindset where you appreciate and respect your body for what it can do, rather than focusing on how it looks. This can help you better value yourself based on your internal worth, not your external appearance.

This practice helps many people develop a more positive relationship with food. With 

, you give up any “food rules” and instead listen and respond to your body's cues about what and when to eat. This practice embraces all the reasons we eat: for nourishment, pleasure, socialization, and more. If you’re in eating disorder treatment or recovery, talk with your care team or a dietitian about whether intuitive eating is a good choice for you. It can be a very supportive and empowering practice, but it’s not for everyone at every stage of recovery.

If friends or family engage in diet or weight talk, you can let them know you don't want to be part of that discussion. Simply say, “I'd rather not talk about food. Let's talk about [other topic].” Or you could try something like, “I'm trying to keep a positive outlook about my body. Can we change the topic?” If they ask questions, you can explain your feelings—but you don't have to.

How to support loved ones in avoiding diet-centered resolutions

If New Year's resolutions are triggering for a loved one (and especially if they struggle with body image or eating) you can be a source of solace this time of year. By being more mindful of resolution-related triggers, you can help them set intentions that align with their true selves.

Foster positive conversations about goals

Making resolutions can cause us to focus on what's “wrong” with us and what “needs” to change. This doesn't make anyone feel good. Instead, center these discussions around how your loved one can feel even better than they do today. It may help to begin their resolution brainstorm by having them think of all the awesome things about them, then considering how they might build upon those things.

Remember, we want to avoid diet or weight talk. If your loved one brings up a resolution that's even somewhat related to these things, help them off the slippery slope. You can ask them why they want to set their suggested resolution. Once you get at the real underlying intention, you can suggest a body-neutral goal. Such resolutions may be about starting a new hobby, practicing self-compassion, or doing something each day that makes them happy.

The Equip takeaway: Embrace intentions over resolutions

While experts advise avoiding any “shoulds” in resolution-setting, there’s one exception: at the end of the day (or year!), your resolution “should” be rooted in your true values and inspire feelings of joy, excitement, and inspiration. Body-focused goals don’t take these feelings into consideration, stemming instead from a diet culture mentality that often evokes feelings of shame and unworthiness—feelings that are awful for everyone, and possibly dangerous to those affected by eating disorders.

Instead, lean into activities, hobbies, and behaviors that enrich your life, your relationships, and your sense of self, goals that are much more likely to stick and that help you evolve into the person you’re striving to be. “Clean slates can be really exciting,” Parks says. “I think the new year is an opportunity for us to be introspective, to be reflective, and to look back on the previous year. And it's an opportunity to celebrate, give ourselves grace, and then think about what we want to do next.”

Sign up for the Equip newsletter to get more expert guidance and resources. 

Get Expert Resources Delivered To Your Inbox

1. Dickson, JM et al. “Self-Regulatory Goal Motivational Processes in Sustained New Year Resolution Pursuit and Mental Wellbeing.” International Journal of Environmental Research and Public Health vol. 18,6 (2021):3084. 

2. “Are you getting too much exercise?” MedlinePlus [Internet] (updated 2022). Available from:

 https://medlineplus.gov/ency/patientinstructions/000807.htm

3. Johnson, Judith et al. “Resilience to emotional distress in response to failure, error or mistakes: A systematic review.” Clinical Psychology Review vol. 52 (2017):19-42

4. Wang, Shirley B. et al. “Cognitive rigidity and heightened attention to detail occur transdiagnostically in adolescents with eating disorders.” Eating Disorders vol. 29,4 (2021): 408-420. 

New Year’s Resolutions Around Diet Can Be Harmful — Here’s What to Do Instead

When Equip Peer Mentor Jamie Drago began treatment for her eating disorder, she Googled the phrase, “how to want to recover.” At the time, Drago couldn’t find a way to make herself feel enthusiastic about the changes she was making and the goals she was setting in treatment. “‘Ambivalent’ was how I felt about recovery for probably the majority of my journey,” Drago says. “I would feel motivated and ready to dedicate myself to moving forward, and then end the night telling myself, ‘I am going to walk in there tomorrow and tell them I quit! And slam the door on my way out!’ Instead, I would show up the next day and do it all over again. And I think that’s okay.”

Drago is describing an experience that Equip Therapist Lead Jonathan Levine, LCSW, says is not only common but somewhat expected. “There are so many reasons why someone might feel ambivalent about recovery,” he says. “Change—any change—is hard, even if we know it's something ‘good’ for us or something we actively want, so I see ambivalence as just a key part of the human condition.”

Read on to learn more about why ambivalence is so common in eating disorder recovery, and how to overcome it.

Why you might feel ambivalent about recovery

As Levine points out, it’s natural for humans to have mixed feelings about transitions and changes of any kind—and this becomes even more intense when a complex mental health issue is involved. “When you add an eating disorder to the mix, that ambivalence is amplified because, for many diagnoses, the behaviors that keep the eating disorder active are serving a purpose,” Levine says. “If you take away these behaviors, you lose access to a safety net of sorts, and that is a scary thing to undertake because it's new, it's uncertain.”

—meaning that they feel aligned with a person’s self-image and values—and so those affected by one might not want to recover at all. Of course, this sense of alignment is a symptom of the eating disorder itself, but to the person struggling, it feels very real. As Levine explains, some people with eating disorders might want to get better in theory, but feel compelled to retain at least some aspect of their eating disorder (

) while letting go of others (for example, obsessive thoughts). “Realistically, those two things are intertwined and you can’t really change one without changing both,” he says.

There’s another major reason people might feel ambivalent about recovery, and it’s pretty straightforward: “Plain and simple: recovery is hard,” Drago says. “Challenging long-held beliefs or fears is scary and uncertain. For a lot of people, eating disorders are serving a very real function, whatever that may be, and it would be hard to feel 100% sure about giving it up if you don’t know what the outcome will be.”

There are also environmental factors that can contribute to ambivalence. Trying to contend with a society immersed in 

 can be incredibly confusing and disorienting for anyone considering recovery. Unfortunately, we exist in a world that conflates thinness with health and deems 

certain foods “good” and others “bad”

—and since so many of the principles of recovery directly oppose these diet culture beliefs, it can make it hard to choose that path, even if you know it’s the right one. Surrounded by all these contradictory messages, even someone who truly wants to recover may experience a fair amount of internal conflict and ambivalence.

This can be particularly true for people whose bodies don’t match society’s (harmful and unrealistic) ideals. “Something I have also heard from a lot of people in large bodies is that living in our society constantly being faced with weight stigma, it is really hard to challenge an eating disorder when people—even healthcare professionals—are actually encouraging things that reinforce eating disorder thoughts and behaviors,” says Drago.

“Ambivalence is that sticky middle ground where you think about changing and get stuck in inaction,” Levine says. “But if you don't take action, nothing will change; if you don't try to reach towards a place of recovery, then you will not be able to get there. It's a feedback loop, a nonstarter. You can't keep on doing the same thing and expect a different outcome, and that fear of change will keep the eating disorder active and in control, which will make recovery out of reach.”

Drago says that in her case, ambivalence kept her stuck for a long time because she felt she needed to be completely “ready” or “sure” before embarking on a healing journey. “Ambivalence can be really tricky,” she says. “Ambivalence can sound a lot like, ‘well, I don’t even want to recover anyway,’ ‘I can’t recover if I don’t agree with XYZ parts of it,’ or ‘I will recover but 

No matter how ambivalence shows up, it can be a hurdle on the path to recovery. In many cases, recovery from an eating disorder is a self-driven exercise: the person with the eating disorder is the one who needs to actually stick to the 

, stop compensatory behaviors, and turn to healthy coping skills when urges come up. When the person in the driver’s seat isn’t sure of where they want to go, it makes it much less certain that they’ll reach the right destination.

How to overcome ambivalence and commit to recovery

Ambivalence can be difficult to navigate in any context, but it’s particularly tough to handle on your own—that’s why it’s so essential to seek out expert guidance if you or a loved one is struggling with any form of 

. “Ask for help!” Levine says. “Find a therapist, a dietitian, a team, someone who can support you so that you have people in your corner on the days you feel motivated, and especially the days you do not.”

It’s also important to acknowledge that in many ways, some level of ambivalence is to be expected—but it doesn’t have to be a dealbreaker in the recovery process. “Ambivalence is a part of life, of eating disorders, of change; expect to not want to do the hard work of recovery some days, and don't let that dictate your actions,” Levine says. “Discipline and follow-through beats motivation every day, so having people that can help you on the darker days is critical.”

Levine also advises anyone struggling with ambivalence to make a list of pros and cons of recovery, which may help clarify the real motivation driving the desire for change. “And give yourself grace to be imperfect and don't let one bad meal, day, or week lead to a decision to drop recovery actions entirely,” he says. “It's 

 all or nothing, even when your brain tells you it is. Keep showing up to the work.”

For Drago, a pivotal moment came when her dietitian asked her to identify one thing about recovery that sounded appealing or that might improve her quality of life. “I might not have wanted the things that scared me about recovery, but I knew I wanted to have more energy,” Drago says. “I might not have wanted to challenge my anxieties, but I knew I wanted to be able to go out with my friends. Sometimes the entire mountain of recovery just looks way too big to climb, so maybe you don’t agree to the whole mountain at first. Maybe you make it up the most climbable hill and then go from there.”

While ambivalence may be uncomfortable to navigate, it doesn’t have to stall or stop progress. The path to recovery can start at any time—even when the conditions don’t feel quite right or the journey seems messy and uncertain. “I waited for so long to feel ‘ready’ to recover, and I tried for so long to find a way to keep the parts of my eating disorder that I ‘wanted’ at the time but not have the parts I didn’t want,” Drago says. “If I had kept waiting to feel ready or to feel fully on board, I would still be waiting.”

If you or a loved one is dealing with an eating disorder, don’t wait to feel fully “ready” to get help. You can get started on the road to recovery even if just one little voice inside you knows it’s the right choice. Talk with your doctor or a trusted mental health professional, or 

schedule a call with an Equip team member

It’s Common to Feel Ambivalent About Recovery. Here’s How to Handle It.

Athletes are often very disciplined. In addition to practicing for hours every week (or even every day), many spend additional time training or doing other workouts to prepare for the big game or competition. They may also be mindful about what they're eating, particularly before and after their sport, to ensure they can perform and recover properly.

This is all healthy—until it isn't. There's a fine line between being disciplined and adopting a regimen that actually harms health and performance. All too often, 

Camilla Blanton, RD, Lead Registered Dietitian at Equip, explains that undereating is when “there's a mismatch where the energy demands of the sport or activity are not being matched by the athlete's energy intake.” Essentially, it occurs when you're not giving your body the nutrients it needs to function, let alone perform at its best for the sport.

Studies show this tends to be pretty common: according to one meta-analysis, about 

 of athletes have “low energy availability” (another term for undereating). Making things more concerning, although not everyone who underfuels has an eating disorder, athletes in general have 

 of developing an eating disorder compared to their non-athlete peers.

Everyone needs a certain amount of calories and the right balance of nutrients for their body to function day in and day out—and athletes need even more because of all the energy they expend. When athletes undereat, it not only has a negative impact on their physical (and mental) health, but also hurts their athletic performance.

Whether you're an athlete, parent of an athlete, coach, or trainer, it’s important to understand the causes, risks, and solutions to undereating in athletes. Read on to learn why athletes may not realize they're not eating enough, signs and risks of undereating, and how athletes can ensure they're getting balanced nutrition for peak performance.

Why athletes may be undereating without realizing it

In some instances—like in the case of an eating disorder—an athlete might know that they’re not eating enough. But in many cases, athletes are completely unaware that they’re underfueling. There can be a number of reasons for this, including the factors below.

Pressure to maintain a certain body image

No matter the sport, “a lot of the time, the reason for undereating might be cultural messaging from coaches, trainers, and other people of influence,” Blanton says. We know all too well how the media loves to talk when an athlete (or other celebrity) loses or gains weight, and this can cause younger athletes in the same sport to think they need to look a certain way to succeed. Additionally, coaches and trainers might make comments about an athlete's weight, body shape, or something they see them eating. It doesn't matter if the comment is directed at the athlete or one of their peers, if it’s critical or complimentary, or if it’s well-intentioned: the message to look a certain way or eat or not eat certain foods can affect everyone who hears.

Social media and the recent change in name, image, and likeness (NIL) rights for college athletes has heightened body dissatisfaction, Blanton adds. “There's an 

emphasis on leanness and athletic aesthetic

, and you see that image through social media, as far as who's getting deals. And that means you need to have a social presence, which means you constantly need to see images of yourself, which is not helpful.”

“There's a lot of messaging in the athlete world about pushing through. A lot of people hear, 'No pain no gain,'” Blanton says. “It can teach athletes of any age to ignore their body cues.” This may lead them to ignore 

, when their body is trying to say, “We're not getting enough nutrition,” she adds.

Nutrition is highly individualized. Each of us has different needs. Many athletes may simply underestimate how much they need to eat to support their activity level. Part of this may be due to 

 and misinformation from social media, where anyone can claim to be an expert and recommend their eating plan. Additionally, not all trainers are well educated about nutrition, and they may share unhelpful tips.

Appetite suppression after intense workouts

Some athletes may undereat simply because they don't feel hungry after training. Various hormones play a role in hunger and fullness, and research shows that these hormones change after exercise. For example, 

 cause levels of ghrelin (the hormone that causes hunger) to fall and levels of peptide YY and glucagon-like peptide-1 (two hormones that increase fullness) to increase. 

 may have an even greater effect at reducing ghrelin levels, leaving athletes less hungry after harder workouts.

So how can you tell if you, your child, or an athlete you work with may not be getting proper nutrition? “It doesn't take a lot for the body to show physical signs and symptoms of low energy availability,” Blanton says. Watch for the below symptoms of under-fueling in sports—if you notice more than one, it's probably time to talk to a healthcare professional.

Frequent injuries, such as stress fractures

Missing practice or training due to illness

 (in power, endurance, strength, speed, coordination, agility, etc.)

Social withdrawal or avoiding meals with others

Risks of chronic undereating for athletes

Underfueling in athletes can lead to serious long-term risks, which include physical, psychological, and athletic consequences. This is true for athletes who underfuel consistently as well as those who only do it intermittently, like skipping snacks or nutrition after a workout.

 RED-S occurs when someone doesn't eat enough to support their level of everyday and physical activity. In 

 of elite and pre-elite female athletes, 80 percent showed signs of RED-S. These symptoms include a decline in performance, fatigue, injuries, GI problems, and trouble sleeping and concentrating. RED-S can lead to bone loss, delayed growth, dizziness, slowed metabolism, and loss of menstruation.

suppresses the release of gonadotropin-releasing hormone 

(GnRH). This causes the body to produce less luteinizing hormone (LH) and follicle-stimulating hormone (FSH), hormones that regulate reproduction and menstruation.

boosts production of reactive oxygen species

, unstable molecules that can damage cells and impair immune response.

 Constipation and abdominal pain can occur if an athlete is underfueling, due to 

, the process where the body repairs and builds muscle. Since working out damages muscle, this can cause you to lose muscle. You need muscle for athlete performance as well as to support bone health.

 For one, athletes who undereat may not be consuming sufficient calcium, vitamin D, and other nutrients to support bone health. And second, if an athlete loses their period, their body is producing less LH and FSH. These hormones regulate estrogen production, which we need for bone growth. Decreased levels can lead to 

 Because of the effects on muscle and bone, athletes who undereat are 

 of all kinds. They often keep having the same injury, Blanton adds.

 in positive and negative ways. So if you're not eating a varied diet or enough of certain nutrients, it may increase the risk of depression and anxiety.

 “Sports participation doesn't cause eating disorders, but it can be a contributing factor to maintaining eating disorders,” Blanton says. “We see a lot of problematic eating behaviors in athletes.” For example, having strict rules about food and exercise might eventually develop into 

 may set someone up to later binge. At the same time, “athletes are less likely to receive a diagnosis and treatment, even though we know they have a 

,” Blanton adds. This is at least in part because many disordered behaviors—like controlling food intake and exercising obsessively—can seem normal or even “good” in the context of sports.

Practical nutrition and recovery tips for athletes

In a world where we're often being told what not to eat, it can be difficult to figure out what

 eat—especially what to eat more of if you're an athlete. Although each person's needs are unique to their body and their sport, below are some starting guidelines for athletes to avoid underfueling.

You may need to eat more than you think. “A lot of times, athletes are eating three meals plus snacks throughout the day, but their nutritional needs are so high, that's not enough,” says sports dietitian and eating disorder expert 

, MS, RD, CSSD. If you increase exercise duration, frequency, or intensity, you also need additional energy, Blanton adds. Lastly, if you notice any of the symptoms of underfueling listed above, there's a good chance your body is saying it needs more food, she says.

Build a balanced plate for peak performance

Most “diets” advise reducing our intake of certain nutrients, especially carbohydrates. But “we should never cut out food groups, because all of them combined gives our body exactly what it needs to support performance,” Blanton says. “In particular, carbs provide energy, protein supports recovery, and fats help unlock vitamins in certain foods.” So athletes 

 (carbohydrates, proteins, fiber, and healthy fats), ideally at every meal, she says. Also, don't neglect fruits and vegetables, which provide micronutrients that play a role in muscle growth, 

“A lot of athletes think they need supplements, but we want to take a food-first approach because food is synergistic. Different macronutrients work together to help your body unlock other nutrients at times,” Blanton explains. If you find it challenging to get all the nutrition you need from food, see a registered sports dietitian. They can help you see if you could make any changes to your diet first, and if there are still gaps, discuss supplements. “Even if it's just a one-session assessment to get an idea or framework of what your body needs and what that looks like,” it helps, Ostrowe says.

Most athletes require pre- and post-workout nutrition to properly fuel and recover. “In terms of performance and feeling your best regarding endurance and energy for your workout, pre-workout nutrition is important. You'll notice you get a better workout and reduce the risk of injury,” Ostrowe says. “And post-workout nutrition will help your body recover so you're able to perform at your best day after day and prevent injury.”

Understand that recovery is part of training

Recovery is part of training. Rest days help your body recover and tend to 

. In turn, sleep is essential for both physical and mental health. Too little sleep 

increases stress hormones, negatively affects muscle repair, and leads to fatigue

What to do if you’re struggling with undereating as an athlete

Given all the mixed messages athletes can receive about body shape, weight, exercise, and nutrition, it's understandable that so many athletes grapple with undereating at times. If you think or know you're not consuming enough to fuel your activity, consider the following tips to help you give your body and mind the fuel you need to thrive.

It's not always easy to determine if you're undereating. Blanton suggests asking yourself questions about your performance and habits like:

Am I running out of steam or power during my training or workouts?

Do I feel frustrated with my athletic performance?

How am I doing now versus the start of the season?

Do I feel low energy, weak, or tired all the time?