Treating Athletes with Eating Disorders: Tips from a dietitian and a therapist
Written by: Nancy Clark MS RD CSSD
At the October 2022 Food and Nutrition Expo and Conference of the Academy of Nutrition and Dietetics, two eating disorders specialists addressed the topic of Athletes with Eating Disorders: Unique Nutrition Assessment and Treatment Parameters.
Below are some of their therapeutic approaches that might help PINES clinicians effectively counsel these challenging clients.
Counseling tips from a sports dietitian
Sports dietitian Page Love MS RD CSSD (https://www.nutrifitga.com) has years of experience working with athletes with eating disorders. She currently has a private practice in the Atlanta area. She shared these words of wisdom:
• Some common reasons athletes seek help from a sports dietitian include fatigue, low energy, low iron status, dehydration, frequent injury, amenorrhea, stress fractures, and disordered eating. Be sure you feel confident addressing those topics!
• Revealing questions to include in your initial assessment:
–Do you have any food allergies and intolerances?
–Can you tell me about your food rules and nutrition beliefs?
–Do you enjoy eating socially?
–Do you currently have regular menstrual periods? What has been your menstrual history?
–Do you have any gastro-intestinal complaints?
–Does your family have a history of eating issues, dieting practices, and/or mental health concerns?
–What percent of your time do you spend thinking about food and weight? (Thinking about food includes shopping for food, preparing food for self and others, reading cookbooks or other food/diet related publications, binge-eating, purging, thinking about how much you ate at your last meal, etc.).
• When recommending treatment for athletes with Low Energy Availability, set a minimum of 2,000 kcals per day (generally more) — or increase intake to 20% to 30% over what the athlete had been consuming prior to meeting with you.
• Refer to food as fuel and to shift the athlete’s mindset from a diet mentality to an all foods fit mentality.
• Encourage athletes to consume more than 20% of calories from fat, given a fat intake less than that increases the risk of inadequate energy intake.
• To increase food variety, ask your eating disordered (ED) clients about their fear-foods (foods they are afraid to eat because they lack nutrient-density or are “fattening”). Make a Top Ten Fear Food Hierarchy and challenge the athlete to include fear foods into meals and snacks, starting with the easiest and saving the hardest to last.
Thoughts from a therapist
Psychologist Ron Thompson PhD of Bloomington, Indiana (rthomps2@att.net) has treated athletes with eating disorders for more than 35 years. He shared these pearls of wisdom.
• Athletes with eating disorders often have more reasons to keep the eating disorder than they do to give it up. Eating disorders—
— provide the athlete with distraction from difficult emotions.
–offer a source of power and control.
–give a sense of security.
–provide an excuse for anything and everything.
–sustain an identity.
–offer a way to be angry, self-abusive, special, rebellious, competitive inside and/or outside of sport.
• A therapist can figure out if the athlete would have had the eating disorder without sports, how the ED is helpful to the athlete, and how the athlete sees the future with and without the ED.
• Motivating the athlete to give up the eating disorder is difficult. Reasons, why athletes resist treatment, include:
–fear they will gain weight—and the added weight will impair their performance.
–fear they will not be able to participate in training or competitions, hence lose status on the team.
–fear they will displease their coaches, teammates, family, fans etc. (They prefer to be “people pleasers.”)
• To assess an athlete’s level of denial about the seriousness of the ED, Dr. Thompson might ask his clients, “Do you realize that people with your disorder sometimes die?”
• Athletes are often motivated to fuel better and comply with the protocols when they hear threats to reduce or stop participation in sports. Athletes in ED treatment programs really want to be healthy enough to participate in sport.
• Athletes with EDs are at high risk for injuries. The ED healthcare team can motivate recovery by educating athletes about the possibility they will reduce their risk of getting injured, be able to perform better, and be better able to sustain longevity as an athlete.
• When athletes obsessively weigh themselves, they learn not just their weight but also what they perceive to be a measure of their self-worth and if they are “good enough.” Unfortunately, the scale does not weigh one’s self-worth or self-esteem.
• A medical professional (sport dietitian, nurse, MD) should be the ones who weighs athletes with EDs, doing so within the scheduled appointment time. Whether or not athletes in recovery should know their weights depends on many factors personal to each individual athlete. Many athletes with EDs prefer to not know how much their weight changes during recovery.
• Ideally, a treatment team includes a (sport medicine) physician, psychiatrist, sport psychologist, sport dietitian, athletic trainer/physical therapist, and exercise specialist/coach.
Around the globe, help is scarce for athletes with EDs. As many PINES members know, some countries have few or no specialized treatment programs for competitive athletes with eating disorders.
If you are interested in learning how eating disorder programs specifically for athletes can be structured, here are three examples of programs in the US:
GOALS Program at Walden Behavioral Care in the Boston area: This virtual eating disorder treatment program meets three nights a week for three hours (5:30 to 8:30 pm) and includes meal support at dinnertime.
Athlete EDGE at EDCare in Denver: This treatment program meets for 10 hours a day, 7 days a week, with affordable housing options for out-of-town athletes.
Victory Program at McCallum Place in St. Louis: This program offers a spectrum of treatment options, from 24-hour inpatient care to day-treatment programs, to transitional apartment living.
Author
Sports nutritionist Nancy Clark MS RD CSSD has a private practice in the Boston-area, where she helps many athletes with dysfunctional eating. She is author of the best-selling Nancy Clark’s Sports Nutrition Guidebook. For more information, visit www.NancyClarkRD.com
