Treating Athletes with Eating Disorders

Bridging the Gap between Sport and Clinical Worlds

Kate Bennett

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000468410
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

This book provides readers with concrete, tangible tools for treating athletes with eating disorders by discussing issues that are unique to this population and introducing specific ideas to help facilitate recovery among this population.

Dr. Bennett integrates her experiences in sport and mental health to provide a comprehensive resource for all healthcare providers who support athletes with eating disorders. Traditional sport psychology interventions are translated into clinical action to help therapists align with the athletic identities of individuals recovering from eating disorders. From diagnosis and neurobiology to athletic identity and excellence, this book covers a range of topics to help readers build their own toolboxes of creative and clinically sound psychological interventions.

This comprehensive guide provides professionals who are new to the field with essential knowledge pertaining to the treatment of eating disorders and offers experienced healthcare providers insight on treatment aspects that are unique to working with athletes.

Part I
Foundations for the Treatment of Eating Disorders

DOI: 10.4324/9781003138426-1

My goal in writing this book is to provide healthcare professionals with the essentials for treating athletes with eating disorders. I would be remiss if I did not devote a section of the book to eating disorder basics such as assessment, treatment considerations, neurobiology, and medical complications. For seasoned eating disorder specialists: Please feel free to skim or skip this section. Part I is dedicated to individuals who do not have formal education or supervised training related to the treatment of eating disorders. If you are a healthcare professional new to this field, I urge you to obtain formal supervision within your profession as you prepare to treat athletes with eating disorders. For athletic support staff who are not involved directly with treatment yet play pivotal roles in the lives of athletes, I encourage you to take time to review both the medical complications and the neurobiology of eating disorders. These are complex disorders with seemingly simple solutions (“just eat normally”) that challenge even the most resilient athletes because recovery is far from simple.

1
Diagnostically Speaking

DOI: 10.4324/9781003138426-2

People often assume that they can tell whether athletes have eating disorders based on how they look. This is a faulty assumption. Eating disorders are masters of disguise. Some individuals may appear malnourished but are, in fact, psychologically and physically healthy. Others may look physically strong and healthy but are actually suffering psychologically and medically. Judgments are rarely helpful and more often hurtful. It is essential that healthcare providers not only understand the various diagnoses of eating disorders, but more importantly, learn to assess thoughts and behaviors related to food, body image, and movement to determine whether athletes are psychologically (and medically) healthy. Athletes rely on healthcare providers to discern whether their relationship with food, body, and exercise supports their values, goals, and well-being.

Clinical Diagnoses

Anorexia Nervosa

Most people think of anorexia nervosa (AN) when they think of an eating disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) defines AN as insufficient fueling, which leads to significantly low body weight (including delayed development during childhood and adolescence), intense fear of gaining weight or becoming fat, persistent behaviors that interfere with weight restoration, and distortions in how the body is experienced.¹ AN carries one of the highest mortality rates of all mental illnesses, second only to opiate use disorders.²

Athletes struggling with AN are convinced that the distorted perceptions of their bodies that they see are accurate. Many athletes are acutely aware of their bodies and describe an ability to “feel” extra weight (from a sensory perspective). I conceptualize these experiences as looking through “anorexic goggles.” When we put on a pair of sunglasses to dim the bright sunlight, our perception of the world in front of us changes. On the basis of the lens, we might see a darker or rosier version of the scene in front of us. Anorexic goggles are similar. Athletes with body image disturbance appraise their bodies through a different (distorted) lens. Our appraisal of their shape and size is comparable to us viewing their bodies without a lens filtering the image. They are looking through the distorted lens, unable to witness the reality that we see.

Anorexia nervosa has two subtypes: restricting and binge-eating/purging.¹ The former, restricting AN, is characterized by weight loss due to restricting caloric intake through dieting or fasting. Binge-eating/purging AN refers to individuals who restrict their intake, maintain significantly low body weights, and engage in binge eating and/or purging behaviors.

Bulimia Nervosa

Bulimia nervosa (BN) describes a pattern of binge eating and purging behaviors. Binge eating (bingeing) is defined as eating more food in a discrete period of time than most individuals would eat under normal circumstances and feeling out of control while eating.¹ Purging follows bingeing as a way to rid oneself of the calories consumed and associated guilt through self-induced vomiting, laxatives, diuretics, fasting, exercise, or other medications. Notably, this is not an effective weight-loss strategy. Individuals who struggle with BN often base their self-worth on distorted perceptions of their bodies.

Binge Eating Disorder

Binge eating disorder (BED) was first recognized as a stand-alone clinical disorder with the publication of the DSM 5 in 2013. BED is characterized by bingeing (as described under BN) but goes into more detail regarding the experiences of this behavior, including eating more quickly than normal; eating until uncomfortably full; consuming large amounts of food when not physically hungry; eating in privacy because of embarrassment; and feeling disgust, guilt, depression, and shame as a result of the binge.¹ It is important to note that people stereotype BED as only occurring in larger-bodied individuals. But athletes who appear healthy, fit, and strong also struggle with BED. This is another example challenging the notion that eating disorders look a certain way. Lastly, it is important to note that athletes may develop BED after struggling with another eating disorder such as AN or BN. Likewise, athletes may develop AN or BN following an initial diagnosis of BED. Eating disorders are fluid and may evolve into new disordered eating behaviors throughout the course of treatment and recovery.

Case Study: Binge Eating Disorder

Brad is a 28-year-old Caucasian cisgender male triathlete. He does not compete professionally but receives some compensation through sponsorship and race earnings. Brad takes his performance very seriously and spends most of his free time researching the newest information on optimizing performance. He developed his knowledge base of nutrition through podcasts and online articles.

Brad is 6-feet 2-inches tall and weighs 165 pounds. His weight fluctuates between 150 and 180 pounds depending on where he is within his competitive season. During competitive months, Brad restricts his intake to “lean down” (reduce his body fat percentage) and achieve optimal performance through an improved power to weight ratio to support his climbing on the bike in races. His identified race weight is 154 pounds. Brad described a complete shift in his behaviors once the competition season ended and reported that daily binge episodes start almost immediately after his final race of the season (frequently the evening of his last race if he is not traveling).

Brad receives praise from his teammates, who frequently ask Brad how he leans down for the season. Conversations about power to weight ratio and strategies for losing weight are rampant within his sport community. Brad described immense shame as he answered their questions while anticipating his next binge episode, which looms in the not-too-distant future. He said that he socially isolates during the off-season because of embarrassment about how much weight he gains as a result of bingeing.

After several years of this seasonal restrict–binge cycle, Brad contacted an eating disorder therapist to address his behaviors. He reported feeling out of control and hopeless, citing countless efforts to address his bingeing through self-help books, podcasts, sports nutritionists, and “cold turkey” attempts. Not understanding that some nutritionists are not licensed or credentialed and may not have training on the treatment of eating disorders, Brad did not check to ensure that the sports nutritionists that he previously worked with had the necessary training and experience to treat BED. Disappointingly, these professionals affirmed him, telling him that his eating habits supported his performance goals. They offered minor suggestions, such as adding more protein to his meal plan while supporting his intermittent fasting habits.

Brad stated that his typical in-season intake is 1,500 calories per day, with most of his nutrition coming from plant-based sources. He practiced intermittent fasting and frequently completed morning work-outs during his fasting period. Brad understood the importance of protein and consumed animal products occasionally throughout the week to support his performance. He considered carbohydrates such as breads, grains, and pastas to be poor sources of nutrition. Brad admitted that he feels hungry throughout the day and relies on large quantities of vegetables to keep himself feeling full. In addition to training two to four hours per day, Brad is a landscaper and spends six to eight hours a day installing yard renovations. Aside from his embarrassment after bingeing, Brad denied body image concerns and stated that his restrictive behaviors were purely for performance gains. He said that he genuinely enjoys food and looks forward to preparing his meals.

Brad described the binges as 6,000- to 8,000-calorie episodes in the evening after dinner. He said that he does not feel satisfied after dinner and goes back for a second portion of dinner to satisfy his hunger. Being back in the kitchen triggers an instant sense of needing more food and feeling out of control. Brad purposefully keeps binge foods out of his home and typically uses a food delivery app to gather more food despite dreading his next bite. Brad said that his binges stop because of utter exhaustion and physical discomfort. He indicated that he occasionally takes time off work because of discomfort the day after bingeing and frequently skips his morning workouts for the same reason. Brad said that he does not eat breakfast or lunch the following day because he is not hungry again until late afternoon. Purging via exercise is never an option because he is so physically uncomfortable after the binges.

In the early stages of recovery, Brad’s therapist provided education about binge eating and worked on behavioral modification to interrupt the restrict–binge cycles. The therapist challenged many of Brad’s food rules that supported intermittent fasting and clean eating. Despite agreeing to eat regularly throughout the day and working to integrate some of his off-limit foods, Brad continued to struggle with bingeing. His therapist regularly discussed the need to bring a registered dietitian nutritionist (RDN) onto the treatment team but Brad resisted the idea of working with an RDN because of his extensive nutrition knowledge and previous poor experiences with unlicensed and uncredentialed sports nutritionists.

Brad felt defeated. He was eating more calories more often as well as consuming more carbohydrates. However, the bingeing continued. Brad’s therapist recommended that he have body composition and metabolic testing to determine whether his body composition was healthy as well as to better understand his body’s daily energy expenditure and metabolic needs. Desperate, Brad agreed to ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication Page
• Contents
• List of Tables
• Foreword
• Preface
• Acknowledgments
• List of Abbreviations
• Part I Foundations for the Treatment of Eating Disorders
• Part II Bridging the Gap
• Part III Leveraging Past Success
• Conclusion
• Mental Skills Summary
• Index