Treatment Options for Athletes with Eating Disorders

By Terry Zeigler, EdD, ATC

When trying to help someone with an eating disorder, the most important thing you can do is to encourage the person to seek treatment. Because of the physiological and psychological complexities of disordered eating behaviors and clinical eating disorders, professional treatment is the only recommended option for a full recovery.

Unfortunately, for individuals with eating disorders, there are no “quick” fixes or miracle cures. Effective treatments take many months of hard work and effort from both the individual with the eating disorder and the family (for those under 18).

To be effective, a treatment plan needs to address both the physiological and psychological needs of the athlete. The general goals of treatment should include the following (Segal, J., Smith, M. & Barston, S., 2008):

1. Treat any medical or nutritional needs
2. Promote a healthy relationship with food
3. Teach constructive ways to cope with life and its challenges

Treatment Options for Athletes with Anorexia Nervosa

According to Lock, J. & Fitzpatrick, K.K. (2007), the mortality rates for individuals with anorexia nervosa are higher than any other psychiatric disorder. Because of the high mortality rate, early detection and treatment are essential.

The initial treatment should include a baseline medical and psychiatric assessment so that the disorder can be properly diagnosed. Because athletes with anorexia nervosa rarely self-report to a physician (Williams, P.M., Goodie, J. & Mossinger, C., 2008), it may take some coaxing from a trusted friend, coach, or family member to convince the athlete to make an appointment with her physician.

The athlete’s physician may be the first medical professional to diagnose the disorder and help the athlete to recognize the seriousness of the disorder. Often times, athletes with anorexia nervosa deny that they have an eating disorder. It may take objective data from a physician to convince the athlete that she does have a problem.

Along with providing an initial medical assessment of the patient, the role of the physician is to also monitor weight and nutrition status, assist in the management strategies of other team members, and serve as the care coordinator. Other important members of the team may include a nutritionist and a behavioral health care professional (Williams, P.M., Goodie, J. & Motsinger, C., 2008).

To understand the variety of treatment options available, the American Psychiatric Association established a set of guidelines or levels of care in 1999 to help health care professionals determine the most appropriate treatment setting for a patient with an eating disorder (Beals, K., 2004). The levels of care include:

• Level 1 (outpatient treatment)
• Level 2 (intensive outpatient treatment)
• Level 3 (partial hospitalization)
• Level 4 (residential health care facility)
• Level 5 (inpatient hospitalization)

The level of care required is dependent on a number of factors including medical complications, suicidal tendencies, body weight, environmental stress, other disorders present, and structure needed for eating and gaining weight. Inpatient hospitalization may be required if the individual is dangerously malnourished, severely depressed or suicidal, suffering from medical complications (i.e., electrolyte imbalances), or getting worse despite treatment (Segal, J., Smith, M. & Barston, S., 2008).

Inpatient hospitalization may also be recommended by the health care team if the individual’s family requests she be hospitalized or if the patient herself requests hospitalization. While some experts believe that most individuals suffering from anorexia nervosa require at least some inpatient treatment, there is research that supports the use of day-patient settings (Manzer, J., 2000).

A study was conducted at the Toronto General Hospital’s program for eating disorders to compare the effectiveness of inpatient hospital care versus day-patient care for treating individuals with anorexia nervosa. The study included 57 anorexic patients who were treated in the hospital and 42 day-stay patients.

After comparing the two programs, the results indicated that although the inpatient program admitted sicker patients and had marginally better outcomes, both programs had success in terms of restoring weight. A key factor for families may be the cost factor of each.

An inpatient hospitalization program may cost $20,000 for the patient as compared to a day program at $6,000 (Manzer, J., 2000). This research is encouraging because it provides evidence for the effectiveness of a day-patient setting. While this may not be effective for the sickest of patients, it may be a good option for others.

While various levels of care are available for treatment settings for individuals suffering from anorexia nervosa, the specific types of treatment are also varied and may include individual therapy, group therapy, family based therapy, nutritional counseling, and pharmacotherapy. The treatment format may also be based on the age of the patient.

A recent article published in the Journal of Contemporary Psychotherapy (Lock, J., & Fitzpatrick, K., 2007) reviewed evidenced-based treatments for children and adolescents with eating disorders specifically looking at out-patient family therapy and family-facilitated cognitive-behavioral therapy. According to their research, only family therapy based on parental re-feeding has been found to be effective in adolescents with anorexia nervosa.

The family-based therapy takes place over a 6-12 month period and includes three distinct phases. In the first phase, the goal is to help the parents find effective strategies to restore their child’s weight. The strategy is to “empower the parents to find their own specific strategies for weight restoration that work for their family while incorporating expert advice” from a knowledgeable therapist (Lock, J., Fitzpatrick, K., 2007).

The second phase begins when the patient has had a steady weight gain and is approaching normal weight. This phase focuses on gradually turning back control of eating to the patient and allowing more independence during eating.

Once the patient is eating normally and maintaining a normal weight without parent monitoring, the third phase of the program can begin. This phase focuses on encouraging age-appropriate behaviors and activities that may have been disrupted due to the disorder.

The benefit of this type of therapy is that the athlete may remain in her own environment while being carefully monitored while receiving care. Another benefit is that this type of therapy involves the entire family. All those who have been affected by the disorder can have a chance to share their feelings and have them addressed.

According to Williams, P.M., Goodie, J. & Motsinger, C. (2008), “individual psychotherapy may be ineffective in the starving patient”. These patients need to be stabilized first and then treated with efforts focused on “modifying thoughts and beliefs about food, weight, self-concept, and control, as well as developing relapse-prevention strategies”.

 

Treatment Options for Athletes with Bulimia Nervosa

According to Williams, P., Goodie, J., & Motsinger, C. (2008), the most effective treatment for individuals with bulimia nervosa is cognitive behavior therapy (CBT) and in particular, interpersonal therapy. A review of the research demonstrated that patients treated with behavioral interventions had greater decreases in binge and purge frequency as compared to control patients.

Adding further support to the effectiveness of CBT was the work undertaken by Lock, J. & Fitzpatrick, K. (2007). The underlying assumption is that the foundation of bulimia nervosa is dysfunctional attitudes toward body shape and weight. This extreme focus on body shape and size leads to attempts to reshape the body through extreme dieting strategies.

These extreme dieting strategies can lead to both physiological and psychological problems and may include depression, anxiety, and mood swings. As a result of the extreme dieting, the individual is in a state of constant hunger which may result in bingeing behavior. To alleviate the guilt from the bingeing, the athlete may then purge herself of the calories through a number of disordered eating behaviors including vomiting, the use of diuretics, and/or extreme bouts of exercise.

One successful CBT program focuses on changing the athlete’s attitudes about self and food. The program breaks the therapy into three phases lasting about 20 sessions over 6 months (Lock, J. & Fitzpatrick, K., 2007). The first phase is focused on educating the athlete about eating disorders, nutrition and healthy weight management, and the application of graded behavioral techniques for regular eating and reducing the frequency of overeating.

Parents may be asked to be involved as part of the therapy process by changing specific environmental factors at home that may lead to disordered eating behaviors. For example, parents may be asked to not purchase food items that are known to precipitate bingeing. This first phase takes approximately 10 sessions over three months.

The second phase consists of six sessions over a two-month period. The goals for therapy during this phase include teaching the effective coping strategies for situations which place the individual at high risk for binge-eating. Over time, additional cognitive procedures are used to “identify and modify thoughts and attitudes maintaining the eating problem” (Lock, J. & Fitzpatrick, K., 2007).

The last phase is focused on how to help the athlete maintain healthy eating behaviors after treatment is over including relapse prevention strategies. Because specific adolescent stressors may lead to relapses, possible scenarios are also discussed during this stage to anticipate and prevent possible future problems.

 

Pharmacology as Part of a Treatment Plan

The effectiveness of using pharmacotherapy to treat patients with anorexia nervosa is questionable. While some medications have been proven effective for decreasing some of the symptoms that may accompany disordered eating (i.e., anxiety, depression), there has been no research to show that medications are effective in treating clinical eating disorders.

Regardless of the type of medication used, it is important to note that while medications may alleviate some of the symptoms that accompany disordered eating, they should not be the sole form of treatment (Beals, K., 2004). If used, they need to be incorporated as part of a larger treatment plan.

For athletes, care must be taken when using medication because of the side effects that might affect athletic performance. For example, anti-depressant drugs may cause excessive sweating, gastrointestinal distress, nausea, drowsiness, and dizziness. Excessive sweating may leave an athlete prone to dehydration and heat illness. However, this can be prevented by the athlete taking extra care to stay hydrated before, during, and after activity.

Drowsiness and dizziness may also impair an athlete who needs to be alert in her sport. Drowsiness at inopportune times during sports with high velocity implements may place the athlete at risk for injury. These side effects can also be decreased by changing the time the medications are taken.

Nutritional Counseling

While there are a large range of disordered eating and clinical eating disorders, many are based on the fear of food or food phobias. The goal of the nutritionist is to educate the athlete about the facts of food in order to replace the misconceptions that may exist in the athlete’s mind. Information might include the following topics (Beals, K., 2004):

• Energy balance
• Functions and requirements of vitamins and minerals
• Fluid requirements
• Healthy meal plans
• Strategies to deal with irrational food thoughts and behaviors
• Physiological feelings of hunger and satiety

For the individual suffering from anorexia nervosa, the focus is on restoring and maintaining a healthy weight. For the individual suffering from bulimia, the focus is on reducing bingeing and purging behaviors.

Exercise Therapy

While there is some controversy in using exercise therapy for athletes with disordered eating (because excessive exercise is a pathological behavior some athletes use to decrease weight or eliminate excess calories), some research shows that it can be beneficial if incorporated carefully. A pilot study in 2000 looked at the effectiveness of a graded exercise program for the treatment of anorexia nervosa (Thien, V., Thomas, A., Markin, D. & Birmingham, C.).

Their study was based on the assumption that athletes could be motivated to comply with a treatment plan if part of the reward for the athlete is the ability to exercise. The program was based on the patient’s body weight and body fat composition and included seven levels.

For example, level one (patient is less than 75% of her ideal body weight and less than 19% body fat) includes stretching exercises three times per week in sitting or lying positions. As the patient’s weight and body fat increase, the types of exercise increase. When the athlete’s body weight is back to her ideal body weight or a body fat percentage of 25%, the athlete is allowed to stretch, participate in resistance training (2-3 sets), and participate in low-impact cardiovascular exercise three times per week.

Some researchers have found that physical exercise can help to alleviate body dissatisfaction more than nutritional counseling and cognitive-behavioral therapy (Beal, K., 2004). One of the reasons given is that exercise provides an outlet for the athlete. Athletes with eating disorders may be more compliant to treatment if they know they can exercise at the same time.

Helping Those Going Through Treatment

It is important to understand that the treatment time for recovery from an eating disorder can take months to years because the eating disorder most likely developed over a long period of time. Friends, family, and coaches need to be patient, compassionate, and understanding throughout the process.

With that in mind, there are some recommendations as to how to best help someone who is going through treatment. The recommendations include the following (Segal, J., Smith, M., & Barston, S., 2008):

• Set a good example by being a positive role model for healthy living and self-acceptance. Avoid dieting or making negative statements about your own body or eating habits.
• Learn about eating disorders so that you can better understand the complexities of the disorder and the healing process.
• Listen without lecturing. Show that you care by providing support and understanding.
• Avoid power struggles over food and do not make mealtimes a battleground.
• Do not be the “food police”. This will only create more stress and anxiety within the relationships.
• Avoid commenting about someone’s weight or appearance.

Last, provide hope and encouragement throughout the course of treatment. Be the friend that praises often, stays positive even through setbacks, and provides the unconditional love that the individual needs to make a full recovery.

References

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

Kent, H. (March 7, 2000). BC’s eating disorders program looks toward outpatient model. Canadian Medical Association Journal. 162 (5), 684.

Lock. J. & Fitzpatrick, K. (2007). Evidenced-based treatments for children and adolescents with eating disorders: Family therapy and family-facilitated cognitive-behavioral therapy. Journal of Contemporary Psychotherapy. 37: 145-155.

Manzer, J. (July 4, 2000). Eating disorders can be treated in day-patient setting. Medical Post Toronto. 36(25): 51.

National Eating Disorders Association (2004). Treatment of Eating Disorders. Accessed on www.NationalEatingdisorders.org on October 5, 2010.

Segal, J., Smith, M., & Barston, S. (February, 2008). Helping Someone With an Eating Disorder. Accessed on www.helpguide.org on October 7, 2010.

Thien, V., Thomas, A., Markin, D., & Birmingham, C. (2000). Pilot study of a graded exercise program for the treatment of anorexia nervosa. International Journal of Eating Disorder 28: 101-106.

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

Williams, P., Goodie, J., & Motsinger, C. (January 15, 2008). Treating eating disorders in primary care. American Family Practice. 77(2): 187-192.