Case study: Treatment of RED-S with eating disorder with a multidisciplinary approach
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Clinical eating disorders in elite athletes can be devastating, leading to a ruined career. This clinical case study focuses on the teamwork that finally lead to return to play for a 20-year-old, female elite tennis player.
The athlete had been competing at elite level for several years. She presented with: primary amenorrhea, she had multiple bone stress injuries, (hip fracture of the femur neck, sternum), frequent upper respiratory tract infections, and gastrointestinal dysfunction. She claimed that her self-defined eating disorder was triggered by nutrition counseling that focused on reducing carbohydrate intake.
She was convinced that her amenorrhea was due to genetics and was nothing to worry about. She had tried hard to eat “right”, but she was confused and also worried about gaining weight. She wasn’t sure that she wanted to be a competitive athlete anymore. She was diagnosed with Relative Energy Deficiency in Sports (RED-S), as well as the DSM 5 diagnoses of anorexia nervosa, major depression, and insomnia.
Table 1. Client characteristics at baseline
| Variables | Value | Normal Range Value |
| Body mass (kg) | 56.7 | |
| Height (m) | 1.79 | |
| BMI (kg/m2 | 17.9 | |
| Percent body fat | 8.9 | |
| Fat mass (kg) | 5.2 | |
| Fat-free mass (kg) | 52.6 | |
| Bone mineral density whole body (Z-score) | 1.3 | |
| Bone mineral density L1L4 (Z – Score) | 0.6 | |
| Bone mineral density whole body (Z-score) | 1.1 | |
| Resting metabolic rate* measured (kcal) | 1100 | -1657 |
| Resting metabolic rate (kcal/kg FFM) | 20.9 | 30 |
| Resting metabolic rate ratio | 0.66 | >0.9-1.1 |
| Energy deficiency – 2595-1945 (kcal) | 659 | |
| Energy intake (kcal/day) | 1945 | |
| Carbohydrate intake (g/kg/day) | 3.7 | |
| Protein intake (g/kg/day) | 1.7 | |
| Fat intake (g/kg/day) | 1.9 | |
| Cortisol | 747 | 200-800 |
| T3 (pmol/L) | 3 | 3.1-6.8 |
| Hemoglobin | 112 | 117-153 |
| Zn | 10 | (11-18) |
*Resting metabolic rate was measured after an overnight fast, using a ventilated open hood system (Oxycon Pro 4, Jeager, Germany).
The initial treatment was a complete absence from training due to medical reasons. This was followed by a gradual increase in her training, in parallel with an increased energy intake, particularly her carbohydrate intake. She also was supplemented with zinc and iron.
After six months of intervention, the athlete had her first menstrual period. Her biochemical markers had normalized, as well as her eating behaviors and sleeping patterns. She was training 2-3 h/day and returned to competitive play in March 2018. The athlete was full of enthusiasm and energy; she was eager to compete again.
Table 2. Characteristics after 3 years of treatment
| Variables | Value | Normal Range Value | Baseline |
| Body mass (kg) | 67 | 56.7 | |
| Height (m) | 1.79 | 1.79 | |
| BMI (kg/m2 | 20.7 | 17.9 | |
| Percent body fat | 10.2 | 8.9 | |
| Fat mass (kg) | 6.9 | 5.2 | |
| Fat-free mass (kg) | 60.1 | 52.6 | |
| Resting metabolic rate* measured [(1657) (kcal)] | 1398 | -1657 | 1100 |
| Resting metabolic rate (kcal/kg FFM) | 23.3 | 30 | 20.9 |
| Resting metabolic rate (ratio) | 0.76 | >0.9-1.1 | 0.66 |
*RMR was measured after an overnight fast, using a ventilated open hood system (Oxycon Pro 4, Jeager, Germany).
The first year was characterized by primarily psychological counselling, where nutrition counselling and medical support played a smaller role. The second year focused more on nutrition counseling aimed at optimizing performance. At this stage, the coach became involved with the treatment team. Finally, during the third year the team focused on performance where the major part was nutrition counselling with support from the psychologist and the physician.
The psychological treatment was complex and involved several years. There were in total 27 sessions with enhanced cognitive behavior (CBT-E: 27 sessions). The sessions involved how to stop dieting and start refeeding, emotional regulation, body image, self-esteem, depression, behavior activation, ways to get back on track, exposure to competitive environments, and mindfulness.
Conclusions
Providing nutritional, psychology, and medical consultations to elite athletes is complex, time consuming, and requires teamwork. Athletes present with multifaceted nutritional, medical, psychological, and performance issues that can be of severe character. Working with this population includes being flexible about timing of sessions as well as involving trainers and/or family members. It is important to avoid compromising on delivering the appropriate treatment, including all above mentioned support.
Author
Petra Lundström is from Sweden. She has earned a Ph. Lic. in Medicine and IOC Dip Sp Nut, International Olympic Committee, MSc in Medical Physiology, and MSc in Nutrition.
