Eating disorder treatment programs for athletes

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Many athletes believe disordered eating behaviors will enhance their athletic performance. However, evidence shows that eating disorders both inhibit performance and increase the risks of injury. (5) Eating disorders and also disordered eating are common in athletes, particularly among those who participate in sports that emphasize body image. (9)

Without treatment, eating disorders can cause serious physical and psychological health consequences for athletes and in some cases, may even cause death. 

This article provides an overview of eating disorder treatment programs for athletes and how you can help athletes who struggle with disordered eating.

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Understanding athletes with eating disorders

Perfectionism is a common trait of competitive athletes. Additionally, athletes are often inundated with the concept of “no pain, no gain” and are expected to forgo their needs in lieu of the need of their sport or their team.  In pursuit of excellence, athletes may engage in grueling training schedules to improve their competitive edge. Athletes who experience high levels of stress related to competitive sports are at an increased risk for eating disorders. (10) 

The seriousness of this is oftentimes overlooked as the appeal of being “athletic” is enormous, and the idea that an athlete is healthy is a basic assumption. All of this only adds to the complexity of the circumstances. In addition, taking the time off from a sport is often seen as implausible, as athletes make so many sacrifices to position themselves for competition. To forgo opportunities for the sport activity instead of tending to the needs of the individual human being inside the athlete, can feel to the person (and family, team, and others) to be non-optional.

Athletes may prioritize performance over personal health and adopt strict eating and exercise rules that leave them vulnerable to malnutrition and injury. In sports that have weight-related restrictions, athletes may drastically increase or decrease calorie intake to conform to the standards of their sport.

Overtraining is often seen as a commitment to a team or sport, and unhealthy eating or exercise practices in the pursuit of “greatness” can therefore go unnoticed. Athletes who show high levels of dedication to their training regimens receive praise, recognition, and positive feedback from their coaches and teammates. 

The concern is that this type of reinforcement may actually prevent athletes from seeking treatment for their eating disorders. If this is the main area in their life where they are successful, or receiving praise, it can lead to a “win at any cost” mentality, even if the cost is a healthy relationship to food, body, and movement.

Stats & trends in athletes with eating disorders

Studies have repeatedly shown that athletes have a higher incidence of eating disorders than their non-athletic peers. The lifetime prevalence of eating disorders in athletes is 13.5%, compared to 4.6% in non-athletes. (1)

The use of diet pills, diuretics, and laxatives are less common in athletes with eating disorders, which may be due to rigid drug testing requirements in some sports. (2) Instead, athletes with eating disorders are more likely to use extreme exercise as their preferred compensatory behavior, however assumptions should never be made regarding an athlete and their form of eating disorder.

All genders experience eating disorders, but the incidence is higher among individuals who identify as women, particularly athletes. One study found that 25.5% of female college athletes had subclinical eating disorder symptoms. (3)

Another study that examined college-aged female athletes found that more than 25% were at high risk for developing an eating disorder. (4)

Athlete eating disorder signs & symptoms

Sports that emphasize body image, such as those which prefer a specific physique, add pressure to an athlete’s body image, and can create an environment for disordered eating. 

Eating disorders are more common in the following sports: (9) 

  • Gymnastics
  • Cheerleading
  • Bodybuilding
  • Diving 
  • Figure skating
  • Swimming
  • Wrestling
  • Dance
  • Boxing
  • Equestrian
  • Ballet

Athletes outside of these sports can also struggle with eating disorders. The following characteristics place athletes at a higher risk for developing an eating disorder:

  • Involvement in sports that value and encourage a specific body size, shape, appearance, or weight
  • Perfectionism
  • Self-imposed high expectations
  • Competitiveness
  • Rigorous and repetitive exercise routines
  • Misperceptions about body image
  • Preoccupation with weight 
  • Performance-related anxiety
  • Social reinforcement of no-pain no gain
  • Authoritarian dynamics within teams where the needs of the individual (vs the team) is seen in a negative light 

Many athletes go to great lengths to conceal their behaviors, for example, athletes who engage in disordered eating behaviors also have a twofold risk of struggling from a sports-related injury. (5) This can make eating disorders in athletes particularly difficult to diagnose, if the individual is in denial or hiding symptoms due to shame. 

Some of the most common signs and symptoms of eating disorders include the following: 

  • A fixation on weight and body image
  • Visiting the restroom frequently, especially after meals
  • Unexplained weight loss or extreme thinness
  • Frequent injuries 
  • Irregular or halted menstruation in women (amenorrhea) 
  • Low performance 
  • Frequent muscle cramps
  • Stress fractures
  • Fear of gaining weight
  • Loss of muscle mass
  • Choosing if and how much to eat based on weight
  • Avoiding social gatherings where food is available 
  • Fasting, purging, or excessive exercise to meet weight requirements for certain sports

The female triad

This phenomenon is common among young athletes participating in girls’ sports and is characterized by low energy, reduced bone density, and menstrual dysfunction. This condition can be potentially dangerous without treatment, which frequently requires an interdisciplinary team consisting of a sports physician, nutritional counselor, therapist, family members, and team coach. (11) 

It’s important to keep in mind that the term “female triad” is out of date and not inclusive, as many athletes who were assigned female at birth do not identify as a female.

Treating athletes with eating disorders

Convincing athletes to enter a treatment program can be challenging. Studies have shown that 66% of athletes with eating disorders have no plans to seek treatment. (2) 

The most common barriers include the following: 

  • Failure to recognize treatment is needed 
  • High cost of treatment programs
  • Lack of insurance coverage 
  • Social stigma 
  • Fear that seeking treatment is viewed as weakness 
  • Lack of time due to training schedule
  • Lack of support from family, teammates, or coaching staff 

Overcoming resistance to treatment is vital to avoid further health damage.  

Multidisciplinary teams

The best eating disorder treatment programs for athletes will be tailored to each patient’s unique needs. 

A multidisciplinary team approach is a preferred method for treating eating disorders. Comprehensive treatment programs use a stepped-care approach, allowing patients to quickly step up or down to different levels of care, depending on their needs. 

Interdisciplinary care teams typically include a physician, mental health professional, and a registered dietitian, and other supportive providers such as mentors or peer counselors, each of whom has specialized knowledge and training in treating eating disorders. Group experiences in which the athlete can be a part of a group while still having their own individual needs met can be particularly meaningful to the athlete impacted by an eating disorder. 

Medical care

Physicians provide ongoing medical care and monitoring for patients who are undergoing treatment for eating disorders. 

In addition to addressing medical conditions that are both, directly and indirectly, related to eating disorders, they also coordinate referrals to specialists as needed.

To determine which treatment approach is best suited for a patient, a thorough medical evaluation may be completed by a physician familiar with eating disorders. 

It is absolutely vital that the medical provider understand eating disorders, understand that malnutrition can occur in “normal weight” individuals, understand weight stigma and realize that their voice may be the one voice that can be put forth to speak up for the client’s needs. 

Nutritional care

Registered dietitians provide individualized nutrition therapy for patients with eating disorders. (7) The primary goals of treatment generally include:

  • Correcting nutritional deficiencies
  • Reducing or eliminating compensatory behaviors
  • Modifying eating patterns to meet calorie and micronutrient requirements
  • Educating patients on how to achieve adequate nutrition
  • Reestablishing a healthy relationship with food 
  • Helping patients begin to recognize hunger and the need for joy in their relationship with food
  • Addressing rigid thoughts about food, weight, and nutritional needs 

Mental Health Care  

Psychotherapy is a core component of successful eating disorder treatment programs. 

  • Dialectical Behavior Therapy (DBT): A type of therapy that was originally created to treat patients with borderline personality disorder, DBT has proven successful in treating eating disorders as well. Patients learn a set of DBT skills that enable them to better regulate their emotions, tolerate negative thoughts and emotions, and communicate with others.
  • Exposure Therapy: Exposure therapy helps alleviate anxiety surrounding various fears a patient may have, such as looking in the mirror or eating a certain food. Patients are exposed to their fear, repeatedly, over time, and eventually they experience a reduction in anxiety.
  • Group Therapy; Group therapy is a general term for many types of counseling groups offered at eating disorder treatment. Each group may utilize a different treatment modality, such as a CBT group or DBT group. Group counseling has countless benefits, including helping to improve trust and vulnerability, social skills, and conflict resolution.
  • Cognitive Behavioral Therapy (CBT): CBT is considered one of the most effective treatments for patients with eating disorders.8 Therapists who use this methodology focus on helping patients understand the links between their thoughts and behaviors.

The primary goals of psychotherapy are to help patients recognize their behavioral patterns, understand the links between their thoughts and behaviors, modify existing behaviors, and replace unhealthy coping strategies with healthy ones.

Hospitalization 

In some cases, hospitalization may become necessary. Athletes with medically unstable conditions, such as cardiac arrhythmias or severe malnutrition require ongoing medical care and monitoring. 

Regardless of the approach, the goals of an eating disorder treatment program focus on prioritizing and treating each patient’s unique challenges. 

Coping strategies for athletes with eating disorders

Athletes who struggle with eating disorders often use them to cope with the high demands associated with their sport. Developing healthy coping strategies, such as establishing strong support systems, is critical for individuals undergoing treatment. For athletes with eating disorders, this extends beyond their immediate families and includes their teammates and coaching staff as well.

It is highly recommended that the athlete speak with a psychotherapist who specializes in eating disorders to help identify any underlying contributing factors to the disordered eating behavior. It is not necessary for anyone to “cope” or try and navigate a potentially deadly eating disorder alone. Help is always available.


How to help athletes with eating disorders

Families, coaches, and teammates are often the first to notice concerning changes in behavior or that the person may be struggling. Note that overtly rigid eating is not to be mistaken for “healthy eating” even when done for a specific sport or event. Learning how to recognize the warning signs of eating disorders can help athletes connect with treatment resources sooner. 

If you suspect an athlete may have an eating disorder, address your concerns as soon as possible.9 Early treatment can prevent permanent damage to an athlete’s health, and in some cases, it can even be lifesaving. 

Consider the following guidelines when addressing a suspected eating disorder with an athlete: 

  • Act quickly: If you observe signs or symptoms of an eating disorder in an athlete, consider timing and the best approach to intervening. Speaking with a professional can be critical to developing a plan to provide support 
  • Be transparent and compassionate: Express genuine concern for the athlete’s health and well-being and address your concerns clearly. 
  • Meet privately: Meet with the athlete privately and assure them the conversation will be kept confidential. 
  • Make a referral: Refer the athlete to a provider or program with expertise in treating eating disorders.
  • Do your best to be  supportive. Reassure the athlete that seeking treatment for the disorder is not a sign of weakness or failure, rather an opportunity to take the brave step toward authenticity, and true healing 

If you or an athlete close to you are looking for help in healing disordered eating behaviors, we are here for you. Call Within Health’s clinical care team to learn more about our virtual treatment program for eating disorders. 

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Resources

  1. Fewell, L. K., Nickols, R., Schlitzer Tierney, A., & Levinson, C. A. (2018). Eating Disorders in Sport: Comparing Eating Disorder Symptomatology in Athletes and Non-Athletes During Intensive Eating Disorder Treatment, Journal of Clinical Sport Psychology, 12(4), 578-594. 
  2. Flatt, R. E., Thornton, L. M., Fitzsimmons-Craft, E. E., Balantekin, K. N., Smolar, L., Mysko, C., Wilfley, D. E., Taylor, C. B., DeFreese, J. D., Bardone-Cone, A. M., & Bulik, C. M. (2021). Comparing eating disorder characteristics and treatment in self-identified competitive athletes and non-athletes from the National Eating Disorders Association online screening tool. The International Journal of Eating Disorders, 54(3), 365–375. 
  3. Greenleaf, C., Petrie, T. A., Carter, J., & Reel, J. J. (2009). Female collegiate athletes: prevalence of eating disorders and disordered eating behaviors. Journal of American College Health: J of ACH, 57(5), 489–495. 
  4. Thein-Nissenbaum, J. M., Rauh, M. J., Carr, K. E., Loud, K. J., & McGuine, T. A. (2011). Associations between disordered eating, menstrual dysfunction, and musculoskeletal injury among high school athletes. The Journal of Orthopaedic and Sports Physical Therapy, 41(2), 60–69. 
  5. Bello, N. T., & Yeomans, B. L. (2018). Safety of pharmacotherapy options for bulimia nervosa and binge eating disorder. Expert opinion on drug safety, 17(1), 17–23.
  6. Academy of Nutrition and Dietetics. (2006) Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa, and Other Eating Disorders
  7. de Jong, M., Schoorl, M., & Hoek, H. W. (2018). Enhanced cognitive behavioural therapy for patients with eating disorders: a systematic review. Current opinion in psychiatry, 31(6), 436–444. 
  8. Garner, David & Rosen, Lionel. (1991). Eating Disorders among Athletes: Research and Recommendations. Journal of Applied Sport Science Research. 5. 100-107. 
  9. National Eating Disorders Association (NEDA). (Accessed 9/29/2021). Eating Disorders & Athletes.
  10. Nazem, T. G., & Ackerman, K. E. (2012). The female athlete triad. Sports health, 4(4), 302–311. https://doi.org/10.1177/1941738112439685

FAQs

How common are eating disorders in athletes?

The lifetime prevalence of eating disorders for athletes is 13.5%, compared to non-athletes who have a lifetime risk of 4.6%.

How can you tell if an athlete has an eating disorder?

Prominent signs of eating disorders in athletes include a fixation on weight and body image, unexplained weight loss or extreme thinness, frequent injuries, poor athletic performance, frequent muscle cramps, and stress fractures.

How can you help an athlete when you suspect they have an eating disorder?

WIthin Health offers comprehensive eating disorder programs to support athletes. Contact us to learn more about resources available in your area.

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