We present the 2-year case study of a 23-year-old female orienteer who has been involved in the sport since the age of 13 and has been following an ovo-lacto vegetarian diet for 3 years. She is a talented athlete; in the year prior to the intervention, she competed in 45 events and won medals in 20 of them. We aim to illustrate how her symptoms transitioned from DE to ED. This case study was approved by the Human Ethics Committee of ELTE Eötvös Loránd University, Faculty of Pedagogy and Psychology (license number: 2023/104). The athlete gave written permission to publish the results. Detailed first-year information is available from a previous study (Kovács and Boros, 2024). We sought special permission to disclose the data in the medical documentation from the institution where the treatments were conducted.

The starting point was in February 2022, when she visited the ambulatory dietetic care. She sought support from her coach and was also motivated by her own determination. Her current goal was to focus on achieving her best performance; however, her coach was rather worried about her health. According to her food diary, she consumed an average of 1,200 kcal/day (25.9 kcal/fat-free kgs) and trained 6 days per week. She was 1.73 meters tall, weighed 50.1 kg, had a BMI of 16.9 kg/m², and a body fat percentage (PBF) of 7.5%. She had not had her menstrual period and had not undergone a gynecological examination since 2020. The laboratory results confirmed low levels of serum iron. Before she became vegetarian, she weighed 57–58 kgs, and her periods were regular.

Following the nutritional assessment, she underwent consultations with an internist, psychologist, and psychiatrist, after which a common therapeutic assessment commenced in May 2022. According to the DSM-V, she did not meet the criteria of an ED, but she exhibited several DE symptoms. She counted calories but was not afraid of gaining weight; rather, she worried about not consuming a sufficient amount of energy. Moreover, she declined restaurant invitations because she believed that there would not be suitable dishes for vegetarians. Based on the medical team’s decision, it was not necessary to revoke her competition license or reduce her training volume. Psychiatric medicine prescription and hospitalization were also deemed unnecessary. She started working with a sports psychologist, who also worked with the athlete’s teammates. To help regulate her serum iron levels, Krauterblut syrup was recommended by the nutritionist (OGYI-NYTSZ-337/92).

Throughout the treatment process, monthly dietary assessments, biweekly psychological evaluations, and semiannual internal medicine examinations, including blood test analysis, were conducted. During the dietary consultations, body composition measurements [performed with an (InBody Co., Ltd., Seoul, Korea) device; Brewer et al., 2021] and food diary analysis (with Nutricomp DietCAD software) were conducted. The athlete did not want to follow a structured diet prepared by the specialist, but she agreed to discuss and review her meals during each meeting. The therapeutic goals were defined as follows: a minimum BMI of 18.5 kg/m² (~ 55 kg), a minimum of 12% body fat, and the maintenance of regular menstrual cycles. The medical team never convened a joint meeting to discuss the athlete’s condition and further treatment recommendations, so the practitioners were informed by the athlete about the progress she was making in each of the respective fields. The internist and the dietitian were at the same institute, so they accessed each other’s documentation regarding the athlete; however, there was no information about the psychological consultations.

In her first year, she achieved initial success. Her body weight slightly reached the therapeutic goal (54.8 kg), so her body fat percentage (11%), and in July 2022, she had her menstrual period. The body composition results started to deteriorate after the suspension of the psychological consultations (August 2022). By the end of the first year (February 2023), the orienteer was diagnosed with an ED [anorexia nervosa (AN)]. The events of the upcoming year are summarized in Figure 1. Psychological consultations were recommended to be restarted urgently, but this time weekly instead of biweekly. Concerning the competition license, she was still not banned from sport. The most important thing for the athlete was to be still able to compete, but she was not aware of her serious health condition. In April 2023, the athlete’s body weight dropped below 50 kgs (BMI 16.7 kg/m²). Her serum iron levels remained low, as did the red blood cell and hemoglobin concentrations. By July, the body fat percentage dropped to 4.5% when a cardiology examination was performed with no abnormalities. The medical team determined that AN clearly presented her medical history and current physical condition, which required the immediate revocation of her competition license. Hospitalization and psychiatric prescriptions were not recommended. At this point, the coach radically reduced the training volume rather than eliminating it entirely (as would have been necessary, but the athlete strongly opposed it). For the next 6 months, contact was made more difficult by an Erasmus scholarship program, which meant that the athlete was abroad. We overcame this by having her body composition checked at a foreign university, which was evaluated online by the dietitian. She also participated in individual online therapies with the sports psychologist. After returning home in February 2024, the athlete reported severe abdominal pain and spasms, especially after meals. An abdominal ultrasound was conducted, which revealed no abnormalities. However, the laboratory results indicated concerning findings for liver function (GOT-glutamate-oxalacetate-transaminase, GPT- glutamate-piruvate-transaminase, gamma GT- gamma-glutamil-transferase, LDH-lactate dehydrogenase), and no further investigation was conducted. It was recommended to start psychotherapy with a clinical psychiatrist specialized in eating disorders instead of a sports psychologist. From then on, therapy included weekly psychiatric consultations (now with the ED specialist), monthly dietary counseling, and quarterly internal medicine check-ups.

Since then, the athlete’s condition had improved. However, similar to the previous 2 years, there had been minor setbacks in body weight and body composition due to personal life problems. Her current weight was 54 kg, her body fat percentage was 10.8%, and her abdominal pain had disappeared. Although these values did not yet reach the target set at the beginning of the therapy, she had maintained them steadily in recent months. The frequency of psychiatric consultations had been reduced to once every 2 weeks. Psychiatric prescription was still not recommended.

In October 2024, after a joint decision by the medical team, the athlete was issued a 1-month competition license. Her training load had increased, but she had not yet returned to her preintervention level. The competition permit was renewed each month, with the consent of the dietitian and psychiatrist.

Regarding her eating habits, she continued to follow an ovo-lacto vegetarian diet. The blood test results indicated a slight increase in serum iron levels, hemoglobin, and red blood cells; however, these levels still remained low. Cholesterol and liver function markers had normalized. She has had her menstrual period once since then, marking the second occurrence since 2020. Consequently, the sports physician referred her for a dual-energy X-ray absorptiometry (DXA or DEXA) bone density test that revealed early-stage osteoporosis in the spine. Further endocrinological testing is ongoing.

The most serious issue in this case is the low body weight and body fat percentage, which was accompanied by amenorrhea. Low body weight, inadequate nutrition, and excessive physical activity can collectively disrupt the production of sex hormones (such as estrogen and luteinizing hormone), leading to menstrual irregularities or even the complete cessation of menstruation (Berz and McCambridge, 2016; Klein and Poth, 2013; Winston, 2012). This is particularly critical among female athletes, as amenorrhea not only threatens reproductive health but also raises risks, such as decreased bone density and stress fractures (Costa et al., 2022). Therefore, restoring energy balance and maintaining adequate body fat levels are essential (Melin et al., 2019; De Bruin, 2017; Mountjoy et al., 2014).

Throughout the observed period, the athlete’s cholesterol levels remained consistently elevated. Previous studies indicate that in cases of AN, endogenous cholesterol production increases, likely triggered by the body’s energy-deficient state (Hussain et al., 2019; Winston, 2012). This may arise from the liver’s compensatory mechanism trying to maintain the necessary lipid levels necessary for cellular function. This increase in cholesterol poses long-term cardiovascular risks, especially if other metabolic issues are present. A thorough review of the diet and addressing nutritional deficiencies are essential for managing the condition (Neglia, 2021; Melin et al., 2015).

Although the abdominal ultrasound report was negative, the symptoms indicated the possibility of superior mesenteric artery syndrome (SMAS). This condition typically occurs in cases of significant weight loss, where the reduction of abdominal fat causes the artery to compress the duodenum, resulting in digestive issues and severe pain (Bloomberg et al., 2023; Singh and Contrucci, 2023). SMAS is often associated with EDs and can serve as a warning sign of AN (Recio-Barbero et al., 2019; Sato and Fukudo, 2015). Nevertheless, SMAS is a relatively rare condition; however, its incidence is higher in patients with EDs, especially AN, than in the general population (Farina et al., 2017; Oliva-Fonte et al., 2017).

The athlete followed a vegetarian diet, which may be a challenge in restoring energy balance and adequate nutrient intake. However, numerous professional guidelines exist for the nutrition of vegetarian athletes, emphasizing that both health and performance enhancement can be achieved through proper planning (Craddock et al., 2016; Barr and Rideout, 2004). Nevertheless, these diets require careful attention, especially regarding adequate intake of essential proteins, iron, calcium, vitamin D, and vitamin B12 (Nebl et al., 2019; West et al., 2023). Collaborating with a sports dietitian is essential to ensure that the athlete’s diet meets the requirements for recovery and hormonal balance restoration (Kussman and Choo, 2024).

By the end of the first year, the athlete’s condition further deteriorated, necessitating the revocation of the competition license. This decision aligns with other case studies that indicate better long-term outcomes when competition is suspended, allowing for a focus on rehabilitation (Quatromoni, 2017).

A multidisciplinary approach is essential for effective treatment as recommended by the IOC (Mountjoy et al., 2023). Collaborating with a psychologist or psychiatrist who specializes in ED is crucial, as psychotherapy assists in uncovering and addressing the underlying psychological causes (Grilo, 2024; Eichstadt et al., 2020; Hay, 2020; Petisco-Rodríguez et al., 2020; Murphy et al., 2010). Furthermore, a controlled and gradually increased nutritional intake, along with a temporary halt to physical activity, is vital for the body’s recovery (Neglia, 2021).

This athlete’s situation shows that improvement is possible with appropriate treatment. The condition can be reversed when physical, nutritional, and psychological aspects are thoughtfully considered and addressed in an integrated approach.

The case study presents a detailed overview of an athlete’s journey. However, several limitations must be considered. This is a single case study, which means that the findings are specific to one individual. While it can provide valuable insights into the athlete’s experience, these results cannot necessarily be generalized to all athletes, particularly those with varying eating habits, training routines, or backgrounds. Although psychological treatments and interventions were part of the athlete’s care, we were unable to provide detailed information on the types of therapies used. Furthermore, an eating disorder specialist was involved only after a year and a half. The specific impact of these therapies on her recovery remains unclear. The athlete’s progress was monitored by various specialists (internist, dietitian, psychologist, and psychiatrist) who did not always collaborate directly. This lack of coordinated care may have influenced the outcomes and indicates that a more integrated, multidisciplinary approach might have been more beneficial.