Eating Disorder Recovery Programs for Athletes: A Global Perspective

Eating Disorder Recovery Programs for Athletes: A Global Perspective

Too many athletes struggle with dysfunctional eating, putting them at risk for relative energy deficiency in sport (RED-S) and eating disorders (EDs). While highly developed countries like the U.S. have a few well-established athlete-specific treatment programs, many other countries lack treatment options.

As a profession, we need to develop sports dietitians who have the skills needed to effectively prevent, identify, and treat EDs in sports. By building the workforce, sports dietitians can competently provide specialized treatment services.

One way to attack this global shortage of sports dietitians with skills in ED management is via international collaboration. Just recently, the University of Pavia (Italy) brought together two sports dietitians from different continents: Paula Quatromoni, DSc, RD, of Boston University (Boston, USA), and Cinzia Ferraris, PhD, RD, of the University of Pavia, teamed up to share their knowledge, expertise, and research ideas. Each spent two months at the other’s university, establishing a collaborative infrastructure and outlining a research agenda. Here’s what they learned and are aspiring to do—

Dr. Quatromoni, what is available for U.S. athletes who suffer from an eating disorder?
Only a small handful of athlete-specific ED treatment programs exist in the U.S., most notably:
• the Victory Program at McCallum Place (St. Louis, MO)
• Athlete Edge at EDCare (Denver, CO)
• the GOALS Program at Walden Behavioral Care (Boston, MA)

Here, athletes receive individual and group treatment alongside other athletes, creating a “team” environment within the ED recovery program. Athletes support one another in their recovery efforts, just like their teammates support them in sport.

Counseling, nutrition interventions, and therapeutic activities are specifically designed to help athletes build skills to confront, address, and cope with the pressures, people, and stressors in the sports environment including body image, compulsive exercise, and/or overtraining. The multidisciplinary treatment team includes providers trained in sport psychology, sport nutrition, and exercise science, allowing comprehensive and integrated care tailored to the athletes’ life circumstances. The commonality of the athlete experience draws athletes into these specialized treatment programs in ways that traditional programming may not, potentially increasing access to care.

Is there any research on best practices or treatment outcomes from athlete ED treatment programs?

Only two journal articles show outcomes of athlete-specific ED treatment programs (1,2) and one other article outlines best practices for treating eating disorders in sport (3). I co-authored a book chapter on best practices for assessment and treatment of athletes with EDs in the Handbook of Clinical Sport Psychology (4).

• Treatment outcomes from the Victory Program demonstrated improvements in muscular strength and power as a consequence of ED treatment for 21 athletes treated in their residential and partial hospitalization programs (PHP) (1).

• Data from the GOALS intensive outpatient program (IOP) showed its ability to attract female athletes who otherwise might have gone untreated. In treatment, these athletes increased their eating competence, decreased behavioral ED risk factors, and decreased pathological eating (2). More, and more rigorous, research is urgently needed on this topic.

What is your role in the GOALS program?

I am a full-time faculty member at Boston University (BU), where we equip aspiring dietitians with skills in medical nutrition therapy, sports nutrition, eating disorders care, and interprofessional practice. In 2004, I built BU’s sports nutrition counseling service for student-athletes. In 2015, I used my experience to help develop the GOALS program at Walden Behavioral Care. We built admission and discharge assessments into the GOALS program to systematically track the types of athletes who seek treatment and to evaluate treatment outcomes. This activity informs research while identifying and addressing the barriers that hinder help-seeking, treatment, and recovery among athletes.

Dr. Ferraris, how are athletes with eating disorders treated in Italy?

Throughout Italy, ED treatment services are lacking, particularly at the higher levels of inpatient or residential care. Currently in Italy, there are no national ED treatment centers that offer a specialized program for athletes. Some of these ED treatment centers are accessible through the National Health Service, others are private. In our Laboratory of Food Education and Sports Nutrition at the University of Pavia, we use a multidisciplinary approach to treat athletes with eating disorders in our outpatient clinic. Dietitians trained in sports nutrition and eating disorders collaborate with psychologists, coaches, and family members to enhance the success of our treatment.

What are you and your colleagues doing to address the lack of nutrition professionals trained to treat athletes with eating disorders in Italy?

In 2022, at the University of Pavia, we established Italy’s first specialist postgraduate Master’s degree for dietitians, Nutritional Counseling for Lifestyle Modification: From Sedentary to Sportive. In this program, we built a specific module on the treatment of eating disorders in athletes. Our innovative specialist program allows the dietitian to acquire new skills and knowledge on the prevention and treatment of eating disorders in athletes (amateur or elite), applying advanced nutritional counseling techniques.

With great pleasure, we hosted Prof. Quatromoni as a visiting professor to teach in Pavia this year. She shared with our students her extensive experiences and the rich resources that she provides to aspiring dietitians in her graduate course on eating disorders prevention and treatment at Boston University. She also helped us establish a partnership with Walden Behavioral Care to provide a post-graduate fellowship opportunity for Italian dietitians to train in eating disorders care in the U.S.

We are aware that the training of registered dietitians in Italy differs across universities. This reality highlights the importance of specialized post-graduate training so that nutrition professionals can deepen their skillset targeting these important topics. Athletes have unique risk factors, distinctive needs, and heightened barriers to treatment and recovery. Global collaboration can enhance education, training, and research in service to athlete wellbeing.

Any final thoughts?
PINES members, we would love to know about recovery programs (or lack thereof) in your country! Please feel free to email us at cinzia.ferraris@unipv.it and paulaq@bu.edu.

References:

1. Fewell LK, Nickols R, Tierney AS, Levinson CA. (2018). Strength and power improvements in athlete and non-athletes during intensive eating disorder treatment. J Clin Sport Psychol, 12:562-577.
2. Stranberg M, Slager E, Coia C, Spital D, Quatromoni PA. (2020). Athlete-specific treatment for eating disorders in sport yields measurable outcomes: Initial findings from the Walden GOALS program inform practice and research. J Academy Nutr Diet, 120(2):183-192.
3. Conviser JH, Tierney AS, Nickols R. (2018). Essentials of best practice: Treatment approaches for athletes with eating disorders. J Clin Sport Psychol, 12:495-507.
4. Arthur-Cameselle J and Quatromoni PA. (2021). Best Practices for Assessment and Treatment of Eating Disorders in Sport and Performance Contexts. In, The Handbook of Clinical Sport Psychology, (Kendahl Shortway, editor), Milton Park, UK: Routledge.

Additional articles that might be of interest:

• Arthur-Cameselle J, Quatromoni PA. (2011). Factors related to the onset of eating disorders reported by female collegiate athletes. Sport Psychologist, 25:1-17. https://doi.org/10.1123/tsp.25.1.1.
• Arthur-Cameselle J, Quatromoni PA. (2014). Eating disorders in collegiate female athletes: factors that assist recovery. Eat Disord, 22(1):50-61. PMID: 24365527.
• Arthur-Cameselle J, Quatromoni PA. (2014). A qualitative analysis of female collegiate athletes’ eating disorder recovery experiences. Sport Psychologist, 28:334-346. https://doi.org/10.1123/tsp.2013-0079
• Arthur-Cameselle J, Sossin K, Quatromoni PA. (2017). A qualitative analysis of factors related to eating disorder onset in female athletes and non-athletes. Eat Disord, 25(3):199-215. PMID: 27897463.
• Freedman J, Hage S, Quatromoni PA. (2021). Eating disorders in male athletes: Factors associated with onset and maintenance. J Clin Sport Psychol, online ahead of print. doi:10.1123/jcsp.2020-0039.