Intervention Strategies for Managing Athletes with Disordered Eating

By Terry Zeigler, EdD, ATC 

Female athletes with eating disorders are fairly common in sports especially in “thin-build” sports in which athletes are judged by their appearance. Identifying athletes with possible disordered eating is difficult because of the secrecy and hidden world of disordered eating. Even more challenging is successfully approaching the athlete in hopes of referral and medical intervention.

All those working in and around female athletes need to understand the challenges in approaching an athlete with a possible eating disorder. First, athletes with anorexia nervosa may not perceive that they have a problem because denial is one of the primary characteristic of this eating disorder. Even if she may believe that she has an eating problem, the athlete will most often deny that a problem exists.

Athletes with bulimia nervosa may acknowledge that they struggle with disordered eating, but may deny the problem due to embarrassment or fear of rejection from their peers (Ray, T. & Wiese-Bjornstal, D.M., 1999). Admitting to an eating disorder is admitting a loss of control or weakness. This is difficulty when strong facades are the norm in sports.

Even if the athlete will admit to disordered eating, the athlete may fear treatment because she may be afraid to put on weight. This is especially so in the athlete with anorexia nervosa who may believe that her performance will deteriorate if she puts on any weight. Because of this belief, compliance is a challenging component when designing strategies to help athletes with disordered eating.

Last, an athlete may believe that admitting that she has an eating disorder may affect her practice and playing time. Some higher level athletes may be fearful of losing a starting position or even loss of scholarship money.

Acknowledging that approaching an athlete with a possible eating disorder is a complex challenge is the first point of understanding how to approach this athlete. Approaching an athlete for the first time should be done with care and much preparation.

Intervention Strategies

Experts recommend that approaching an athlete with an eating disorder should be done with careful thought as to who will approach the athlete and when, where, and how the discussion will take place. Ideally, the person with the best rapport with the athlete and someone who has developed a personal relationship with the individual should be the one approaching the athlete.

The time should be selected for an opportunity in which neither the athlete nor sports medicine professional have any time conflicts. Adequate time should be set aside to talk to the athlete without distractions or interruptions.

The location should also be carefully selected to ensure that the discussion is done in private and in a place that ensures the confidentiality of the athlete. If a secure room is not available, a walk around the track or school could also work. Walking may also make the athlete more comfortable to engage in conversation as compared to sitting still and possibly feeling cornered in an office.

Suggestions for the individual guiding the conversation include the following:

• Utilize an open space with two chairs rather than sitting behind a desk. The desk creates a barrier between the two people.
• Utilize an open body position with both feet on the ground and arms open and resting on the chair rather than crossed.
• Sit with a slight forward lean. This position translates to an interest in what the other person is saying.
• Focused attention on eye contact. Eye contact is an important aspect of good communication.
• All distractive devices should be placed on hold to assure that the athlete is receiving the individual’s full attention.
• The individual’s voice should be at a lower volume and at a pace that is relaxing and comfortable for the athlete.

The National Association of Anorexia Nervosa and Associated Disorders created the mnemonic CONFRONT to provide guidance for approaching an individual with an eating disorder (Beals, K., 2004). This plan includes the following suggestions:

1. Express Concern for the athlete by saying that you care about his or her mental, physical, and nutritional needs.
2. Get Organized: plan where to confront the individual and determine a convenient time.
3. Having support groups and eating disorder resources available with an immediate Need after confrontation.
4. Face the athlete empathetically but directly. Remember to expect denial when you confront him or her.
5. Be sure to Respond to the athlete by listening to his or her concerns in an athlete-centered manner.
6. Offer help and suggestions for how the athlete should proceed, and be willing to support the athlete in the recovery process to ensure that the athlete follows through.
7. Negotiate another time to talk with the athlete once he or she has sought professional help.
8. Finally, recognize that recovery is Time-intensive and that the athlete faces many challenges in the treatment process.

Other helpful suggestions in the Ohio State University’s athletic department issued eating disorder policy (2001) include:

• Choose “I” statements over “you” statements to avoid placing the athlete on the defensive. For example, “I’ve noticed that you’ve been fatigued lately, and I’m concerned about you” is preferable to “you need to eat and everything will be fine”.
• Avoid giving simple solutions (i.e., “just eat something”) to a complex problem. This will only encourage the student athlete to hide the behavior from you in the future.
• Avoid discussing implications for team participation and instead affirm that the student athlete’s role on the team will not be jeopardized by an admission to a problem. The team may be the athlete’s only diversion from his or her disordered eating. By eliminating this opportunity for social support and the supervision of a coach or athletic trainer, the athlete may dive into further pathology.
• Regardless of whether the athlete responds with denial or hostility, it is important to encourage him or her to meet with a professional for assessment. Acknowledge that seeking outside help is often beneficial and is not a sign of weakness.

If the individual doing the confronting does not have a good rapport or established relationship with the athlete, it is suggested that the first conversation be focused on the overall health of the individual and not on any specific eating behaviors. The conversation can also include areas of general stress for the athlete including academic progress or challenges, athletic issues surrounding her team, and family or friend conflicts. This also allows the confronting individual to get to know the personality of the athlete and may provide important clues as to how to handle future conversations specific to the eating disorder.

Providing Referrals

Prior to the confrontation with the athlete, it is important to have already researched possible options for referral. Different options will be available depending on the age and environment of the athlete.

Athletes who are under 18 are legally under their parent’s authority in medical decision making. The parents are the legal surrogates and are responsible to make decisions for those under 18. This may or may not be a problem depending on the dynamics of the family. If the parents are part of the mitigating factors in causing the eating disorder in a young athlete, working with the parents to get the athlete the proper medical attention may be a challenge.

For those athletes over 18, there are a number of options that may be available to the athlete especially if she is a college athlete. Many universities have mental health professionals on campus free to students. For these athletes, help may only be a short phone call away.

For others who do not have access to university or college mental health services, the athlete may be covered under her parent’s medical insurance. Depending on whether the athlete is covered under a health maintenance organization (HMO) or a primary insurance, the athlete may be able to contact a psychologist directly if the service is available. If that is not an option, the athlete may need to see her primary care physician first and then be referred to a psychologist.

Preferably, the ideal psychologist is one who has experience treating individuals with eating disorders. If a psychologist can be found who also has experience in treating athletes with disordered eating, that is even better.

What needs to be understood is that an experienced psychologist is just one member of a comprehensive team that needs to be formed to treat someone with an eating disorder. The other medical team should include a dietician, physician, physical therapist (if needed), and certified athletic trainer. Each specialty is needed to provide the comprehensive care and management needed to bring an athlete with an eating disorder back to full health.

Treatment and Competition

In an ideal situation, the athlete will agree to seek treatment and will be compliant with the physician and medical team’s recommendations. Because the athlete’s health and mental well-being are at stake, it is also important to ensure that specific criteria are met before allowing the athlete to compete.

The criteria to compete during treatment are decided by the medical team and include (Thompson, R.A. & Trattner Sherman, R., 1993):

• Completing of extensive medical and psychological evaluations
• Determining that the athlete is not at risk medically and that competition will not increase her risk either medically or psychologically
• Determining that sport participation will not play a role in maintaining the disorder or make it more difficult for the athlete to successfully complete treatment.
• Ensuring that the athlete meets standards regarding health maintenance including: a). maintain 90% of ideal body weight; b). eat a minimum of three balanced meals a day with enough calories as determined by dietician; c) possible hormone replacement therapy for athletes without menstrual cycles for at least 6 months; and d) monitor and evaluate bone density levels.

While the above lists the medical criteria for allowing an athlete to continue to compete, the athlete needs to also agree to a list of compliance criteria monitored by sports medicine personnel that may include the following (Thompson, R.A. & Trattner Sherman, R., 1993):

• The athlete must agree to comply with all of the treatment strategies as recommended by her medical team;
• The athlete must want to genuinely compete
• The athlete must agree to be continuously monitored by her medical team
• The athlete (and coach) must agree that treatment must always take precedence over sport
• If the athlete is non-compliant with the above, then the privilege to compete can be taken away.

The coach plays a critical role in the compliance of an athlete towards her treatment. Because the athlete’s sport is usually very important for the athlete, the medical team may use the ability to continue to play sport as an incentive towards motivating the athlete towards treatment compliance. As long as the athlete complies with all of the medical, nutritional, and counseling treatment and recommendations, the athlete may be able to continue to compete as long as the medical team states that the athlete is healthy enough for activity.

However, for the good of the athlete, a coach may be asked by the medical team to hold the athlete out of practice and/or competition for a period of time during treatment or if the athlete becomes non-compliant to treatment. In this case, the good of the athlete needs to come before the sport.

Specifically, if an athlete is diagnosed with anorexia nervosa, the athlete should “not train or compete before successfully completing treatment” because the risk to the athlete’s health is too great (Thompson, R.A. & Trattner Sherman, R., 1993). However, because there is a wide continuum of disordered eating, if the athlete’s disordered eating is not severe, the athlete’s physician may allow her to compete.

The judgment to compete is solely under the control of the athlete’s primary physician. Because of this, an athlete with a suspected eating disorder should not be allowed to participate in sports unless the sports medicine staff or coach receives a verified written medical release from the athlete’s physician stating that the athlete is healthy enough to compete.

Even with treatment, an athlete’s health may suddenly worsen. It is for this reason that the coach needs to be in regular communication with the athlete’s medical team. Just as the medical team can provide important information to the coach, the coach can also provide important information to the medical team because of the amount of time that the coach spends with the athlete.

Because of the complex nature of eating disorders and disordered eating and the nature of the secrecy behind the disorders and behaviors, confronting an athlete with a possible eating disorder is a delicate task. However, if a coach or other personnel follow the guidelines suggested including careful preparation of the location, time, and content of the meeting, the individual will be better able to place the athlete at ease and provide the support, advice, and encouragement that the athlete needs to take the first steps towards healing.

References

Beals, K.A. (2004). Disordered Eating Among Athletes: A Comprehensive Guide for Health Professionals. Human Kinetics: Champaign, IL.

Kettles, M., Cole, C.L., & Wright, B.S. (2006). Women’s Health and Fitness Guide. Human Kinetics: Champaign, IL.

Ray, R. & Wiese-Bjornstal, D.M. (1999). Counseling in Sports Medicine. Human Kinetics: Champaign, IL.

Thompson, R.A & Trattner Sherman, R. (1993). Helping Athletes with Eating Disorders. Human Kinetics: Champaign, IL.