The latest research indicates that athletes with eating disorders should not be treated the same as the general population. In response, a clinic in Massachusetts has developed a unique, athlete-specific program.
This article first appeared in the March 2017 issue of Training & Conditioning.
By Matt Stranberg and Dr. Paula Quatromoni
Matt Stranberg, MS, RDN, LDN, CSCS, is the Nutritionist and Exercise Science Advisor for the Walden GOALS program at Walden Behavioral Care in Waltham, Mass. He can be reached at: firstname.lastname@example.org.
Paula Quatromoni, DSc, RD, LDN, is a Senior Consultant for Walden Behavioral Care, as well as Department Chair of Health Sciences and Associate Professor of Nutrition and Epidemiology at Boston University. She has a dozen years of clinical experience in eating disorders and sports nutrition that have informed several publications in the peer-reviewed literature. She can be reached at: email@example.com.
Studies show that athletes are two to three times more likely to develop an eating disorder than the general public. While professional help for eating disorders is available, there are few prevention programs, many barriers to treatment, and recovery can be elusive. As a result, athletes continue to struggle, and many experience devastating consequences to health and performance.
In the Walden GOALS Program at Walden Behavioral Care in Waltham, Mass., a team of experts created an innovative way to address this problem—by treating athlete-specific eating disorders with athlete-specific programming. Although this concept is novel, the need for athlete-specific services has been demonstrated by research that identifies risk factors for eating disorders unique to the sport environment, as well as obstacles to treatment that prevent athletes from getting the help they need.
GOALS was specifically built on this foundation of research, while also incorporating more than a decade of clinical practice experience. Comprised of counselors, sport psychologists, dietitians, and exercise science professionals with formal training and experience in sport, our team understands the elements that contribute to disordered eating in athletes and the accompanying warning signs. We provide athletes with sport-specific advice, tailored therapeutic interventions, and individualized plans to equip them with the mental and nutritional skills to achieve their full athletic potential and sustain a positive mindset.
OVERVIEW OF THE ISSUE
An important aim of our program is to increase recognition of risk factors by sports professionals. Strength coaches and athletic trainers can be the first line of defense in eating disorder prevention and are instrumental in early detection. As such, they need basic education on nutrition for athletes and recognizing risk for eating disorders in sport.
There are many obstacles that threaten to derail even the most disciplined athletes and put them on the slippery slope to disordered eating. For starters, nutrition for sport is an ominous landscape to navigate. Many athletes do not understand how much food and fluids they need for their sport, position, and body type. They may also lack the skills or resources to plan, shop, cook, and feed themselves adequately. Furthermore, they do not always have access to reliable, valid nutrition information and are often targeted consumers in a multibillion-dollar marketplace that promotes quick-fix bars, shakes, powders, and pills rather than wholesome, nutritious foods.
Another obstacle stems from the high expectations of sport and the pressure athletes face to meet them. Athletes are expected to strive for perfection and be driven, committed, hard-working, and focused. Mantras such as “No pain, no gain” and “You’ve got to be thin to win” reinforce a mindset that can push athletes to take drastic nutritional measures without any awareness of the detrimental consequences. In some cases, this can lead to skipping meals, under-fueling and under-hydrating, removing specific foods or entire food groups from their diets, or sacrificing post-workout recovery nutrition for the sake of calorie cutting.
Given these realities, it’s not difficult to imagine how an athlete adopting a well-intentioned diet, a strict commitment to popular fads like “clean eating,” and a high level of training could slip into the realm of disordered eating. Although increased risk has been documented in “weight-sensitive” sports like running, swimming, wrestling, gymnastics, or figure skating, athletes in ball sports (soccer, volleyball, lacrosse, basketball, etc.) also experience eating disorders. In addition, both male and female athletes are affected, and rates among males are climbing.
Armed with this knowledge, coaches and athletic trainers have a responsibility to identify athletes who are taking an unhealthy approach to fueling. Early detection and appropriate confrontation are often keys to intervention, treatment, and restoration of wellness. Here are a number of warning signs to watch out for:
Under-fueling/overtraining: A classic red flag is an athlete who eats too little and/or trains excessively. Behaviors like calorie counting, restricting specific foods, or following strict diets contribute to nutritional risk. Similarly, excessive exercise without rest and proper nourishment increases the risk for injury and could be a sign of compulsion.
Emphasis on weight, body shape, or size: An obsessive focus on weight or appearance tends to drive dieting behavior, food restriction, binge eating, purging, laxative abuse, or excessive exercise. In males, an obsession with increasing muscle mass may represent a form of body image discontent.
Substantial weight loss or appearing underweight: This outcome is one of the more visible warning signs of an eating disorder. Although some shifts in bodyweight are expected when athletes move in and out of their competitive seasons, rapid shifts in weight or prolonged periods of remaining underweight reflect inadequate food intake. Not all athletes with eating disorders are underweight, though. Those who suffer from bulimia or binge-eating disorder may be at a healthy weight or overweight.
Disrupted sex hormone cycles: Over time, the body will perceive limited nutritional intake as a threat to survival and will sacrifice vitality and reproduction for short-term energy. For males, abnormal sex hormone cycles typically manifest in low testosterone. Symptoms include fatigue, lack of energy, reduced muscle mass and strength, decreased bone mass, mood changes, disrupted sleep, low sex drive, and hair loss. For females, abnormal sex hormone cycles result in missed, irregular, or shorter menstrual periods that can have long-term implications, such as infertility and compromised bone health. Birth control pills can mask symptoms of an eating disorder in females by restoring hormonal balance and menses, contributing to a false sense of well-being for the affected athlete.
Injuries and other health issues: The combination of insufficient food and nutrient intake, high intensity training, and low bodyweight reduces the strength of bones over time, which naturally increases the risk for stress fractures and other injuries. Chronic fatigue, dehydration, fainting, weakness, anemia, and low immunity are additional causes for concern.
HOW TO INTERVENE
If an athlete is showing some or all of these warning signs, strength coaches and athletic trainers should be prepared to take action. Athletic trainers can start by screening the athlete for an eating disorder, using tools such as the Relative Energy Deficiency in Sport (RED-S) clinical assessment. This tool evaluates the presence or absence of eating disorder symptoms to determine if an athlete is at low, medium, or high risk of relative energy deficiency. The RED-S tool can also help identify when an athlete should be restricted from sport participation or requires a therapeutic contract that specifies an intervention plan.
When it comes time to confront the athlete, it is recommended that strength coaches and/or athletic trainers approach the athlete in a private conversation to express care and concern. Research shows that athletes who have recovered from eating disorders report intervention by people they respected often sparked a turning point that allowed them to accept help. Denial is a typical feature of an eating disorder, so athletes may have a dismissive or angry response when approached. For this reason, it is a good idea to ask a guidance counselor, residential life expert, or sport psychologist to join the discussion.
Keep in mind when speaking with the athlete that there are many barriers to eating disorder treatment, and affected individuals often suffer in silence, isolate themselves from support, and expend tremendous energy to keep their eating disorder a secret. Athletes in particular may fear asking for or accepting help if they believe their scholarship or playing time would be in jeopardy or that their coaches or teammates would judge them. Furthermore, beliefs that eating disorders only affect women may prevent male athletes from seeking treatment.
Once an eating disorder has been detected and the athlete has agreed to get help, evidence-based best practices recommend referral to eating disorder experts who understand the demands, culture, and environment of sport. Treatment should consist of a multidisciplinary team, including a physician, therapist, and registered dietitian who are each trained, licensed, and credentialed to treat eating disorders in athletes.
AN INNOVATIVE SOLUTION
Beyond educating coaches and athletic trainers on sports nutrition and eating disorders, the centerpiece of our athlete-specific programming is treatment in the GOALS program. Catering to high school, collegiate, and adult athletes, we help our clients develop self-care life skills, self-reliant fueling strategies, and healthier coping skills to deal with the stress of being a competitive athlete.
GOALS is an intensive outpatient program that runs three hours a night, three nights a week, for six weeks. Athletes are referred to us from many sources, including physicians, athletic trainers, outpatient therapists, nutritionists, friends, or self-referral. Typically, there are three to six athletes in GOALS at any given time, allowing for individualized attention and interactive participation.
When athletes begin GOALS, they undergo an in-depth, individualized assessment and complete surveys to help us evaluate their behaviors related to exercise, training, and feeding. Treatment strategies and goal setting are client-driven and tailored to each individual’s readiness to change their identified personal behaviors.
Each night of programming entails two group sessions—one with a therapist and one with a nutritionist—designed to target coping and life skills around athlete-specific topics. Group meals are prepared and shared at every meeting, allowing athletes supported opportunities to develop essential coping skills through food exposure. Weekly, each athlete meets one-on-one with a therapist and a nutritionist to discuss private topics, fine-tune his or her individualized treatment plan, and engage family members in treatment, if desired.
The GOALS curriculum is based on research involving onset, treatment, and recovery from eating disorders in athletes, informed by our collective years of clinical experience. Built upon “Five Pillars of Strength,” it provides athletes with the building blocks to achieve and maintain wellness. The Pillars include:
1. Fueling for sport and life: This program component defines the athlete’s nutritional needs for wellness, training, injury prevention, and performance. Our program uses a variety of strategies to interrupt disordered eating behaviors, educate athletes, and encourage normalized meal and snack patterns.
2. Eating competence: This pillar gives athletes the tools to become competent eaters. Adapted from the work of Ellyn Satter, MS, RDN, MSSW, a renowned feeding expert, eating-competent athletes will feel good about consuming food and will fuel themselves according to their mental and physical needs. This requires athletes to be reliable in feeding themselves, choose foods that give them pleasure, eat as much as they are hungry for while respecting fullness cues, and dispel notions of “forbidden foods” at meals and snacks. Through lessons, practice, and exposure therapy, each athlete learns how to become a more flexible, intuitive eater. Over time, they are challenged to increase the variety of daily food choices and experience joy in eating.
3. Body esteem: This intervention addresses one of the greatest obstacles to eating disorder recovery by countering the socio-cultural belief that thinner is better. To do this, we utilize a variety of evidence-based eating disorder treatments, including cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), motivational interviewing, and acceptance and commitment therapy (ACT). Each lesson helps explore body image in the context of sport and society. As athletes progress, they practice developing respect and admiration for the strength, power, and capabilities of their bodies.
4. Recovery skills: This component forms the foundation for the coping mechanisms needed to manage the conflicts of life. Through these lessons, athletes learn to apply the skills of CBT, DBT, ACT, and mindfulness to difficult life situations that require interpersonal communication, stress management, emotion regulation, distress tolerance, and conflict resolution. Athletes also learn how to cope with and manage injury, disappointment, anxiety, depression, and obsessive-compulsive thoughts.
5. Resiliency: This final pillar helps athletes develop tenacity by learning how to refocus and reengage when setbacks or relapses occur. These skills help our clients anticipate and navigate difficult situations that may trigger disordered thoughts or behaviors, learn how to effectively engage support systems, and develop a variety of skills for long-term self-care.
While enrolled in GOALS, athletes may be allowed to continue training and participating in their sport depending on their health status and compliance with treatment recommendations. However, this is highly individualized. Some athletes are given guidance to taper their workouts or refrain from exercise until measurable recovery goals are achieved.
GOALS providers collaborate with families, outside clinicians, and members of the athlete’s sport community, as appropriate for each individual. For instance, with the athlete’s permission, the GOALS team can help athletic trainers apply the RED-S assessment model and interpret the health-related data to guide decisions about sport participation. Similarly, the GOALS staff can collaborate with the athlete’s strength coach to set appropriate training guidelines and advance exercise plans as progress is made in weight restoration and fueling goals.
STORY OF RECOVERY
With the GOALS model of care, we’ve seen great results. One of our most inspiring cases involved a female collegiate ice hockey player. She came to us commited to dedicate her summer break to recovering from her eating disorder.
Despite taking the positive step of getting into treatment, the athlete stated a firm belief that she could “never imagine being happy” with her weight, and she expressed strong feelings of helplessness and hopelessness. Her score on the eating competence assessment was nine, where competent eaters are expected to score above 32.
On entry to GOALS, the athlete was exercising excessively, restricting her food intake well below her nutritional needs, exhibiting substantially entrenched food fears, and allowing herself only a narrow range of foods in her daily diet. Additionally, she admitted to struggling with weekly purging and laxative abuse.
She began the program weighing close to her ideal bodyweight and did not appear underweight. However, when her body composition was evaluated, it revealed that her high muscle mass was masking a relatively low body fat percentage, an imbalance that had resulted in years of irregular menstrual periods.
Prior to coming to GOALS, the athlete had been evaluated for treatment several times but had never followed through. Being athlete-specific, the GOALS program appealed to her in ways that other treatment options had not. In GOALS, she was able to work with expert providers who saw her as an athlete, as well as a young woman. Our staff understood her sport environment, and their insight was as helpful to her recovery as was being in treatment alongside other athletes who “got her.”
In addition, this athlete had no idea of her nutritional needs as a collegiate hockey player before coming to GOALS. The knowledge she gained from our group and individualized sessions helped her to stop drastically under-fueling her body and pushing it to the limits physically.
After several months of solid commitment to therapy, education, food exposure, and support from the GOALS team, the athlete experienced a shift in her mindset that allowed her to reduce her exercise to appropriate levels and adopt more flexible eating behaviors. The majority of her sport-specific eating disorder risk behaviors were extinguished, and her eating competence score rose well into the desired range to 45 (out of a maximum score of 48).
During the course of the program, the athlete gained 16 pounds. Most notably, she reported being happy at her new weight. She proudly told stories that reflected her newly mastered abilities to go out to dinner and socialize with friends, choose to eat whatever she wanted from the menu, tune into her own body’s cues about hunger and fullness, and trust herself to properly fuel for sport.
By the end of her treatment, the athlete was tearfully smiling and thanking the GOALS team for helping her reclaim her life. When she was discharged from the program, she confided in her sport coach, strength coach, and athletic trainer about her diagnosis and treatment so that they could support her ongoing progress. She transitioned to an outpatient team of providers near her college campus to continue her recovery work, while resuming school and returning to hockey.
This case description of an eating disorder in sport reminds us that even those who appear to be functioning well in sport may struggle with body image issues and need help. In GOALS, we believe that the unique experience of being understood as an athlete and allowed to recover alongside other athletes who are similarly affected provides patients with an important sense of universality that aids recovery.
IN HER OWN WORDS
Athletes who have eating disorders often feel isolated and suffer in silence. The poem below was written by an athlete who fit this description. As a soccer goalie on a full scholarship to an NCAA Division I school, she was elite, capable, talented, and full of promise. Yet, her career was overshadowed by an eating disorder driven by the perception that she was overweight for her position. A therapeutic way of coping during treatment for her eating disorder included expressing herself through poetry.
Why can’t I be small?
Skinny enough to not exist at all.
All my teammates, they don’t look like me.
I want to break the stereotype, be fit as can be ...
When I look in the mirror, I cry.
Did you eat? Yes, I did … but really, that’s a lie.
All I want to do is start.
And I know my weight is a contributing part.
My weight problem has inflicted SO MUCH PAIN.
Diet after diet, it’s driving me insane.
The bottom of my shower is filled with tears.
This is a problem I’ve been facing for years.
It’s just mind over matter, right?
I’ve tried it all and I still can’t stand my sight.
People may think I’m fine ‘cuz I’m not model thin.
But every time I eat, I feel like it’s a sin ...
DO’S AND DON’TS
Key players in addressing the issue of eating disorders among athletes are sport coaches, strength coaches, and athletic trainers. They should strive to promote a culture where team norms and messages support healthy eating and training habits. Here are some additional do’s and don’ts to guide you:
• Become educated on eating disorders in sport.
• Practice positive psychology to motivate players.
• Focus on sport skills, not bodyweight, as a means of achieving performance goals and when giving athletes feedback.
• Emphasize the importance of proper nutrition, hydration, sleep, and rest days.
• Promote healthy eating habits by ensuring access to nutritious foods at team meals, when traveling to away games, and for recovery nutrition.
• Facilitate access to licensed, credentialed nutrition experts who can provide accurate and appropriate nutritional advice to athletes.
• Recognize warning signs, intervene early by making referrals to qualified professionals, know when to limit participation in sport, and provide emotional support.
• Engage in prevention programming with teams. Provide educational resources and connect athletes with nutrition and mental health experts to raise awareness, increase knowledge, and teach athletes skills for self-care and stress management.
• Enforce team weigh-ins or closely monitor athletes’ weights.
• Comment on an athlete’s weight, body size, or food choices, especially in public.
• Put athletes on diets or endorse nutritional fads.
• Condone or turn a blind eye to restrictive eating or excessive exercise behaviors.
• Ignore an athlete who exhibits warning signs. Allowing an athlete to train and compete in an undernourished state condones a behavior that has severe consequences on health and conveys a message to teammates about team norms and acceptable training strategies. In addition, ignoring the warning signs may cause further distress to the affected athlete if they perceive they are not worthy of the coach’s care and concern.