Eating Disorders and Adolescent Athletes
By Dani Gonzales, Psy.D., Sarah Archer, L.M.F.T., and Sammi Montag R.D.
Conflicting and Concurrent Literature
Whether rooting for elite athletes in the Olympics, getting fantasy football roster line-ups, or watching little league sports on weekends, it is clear that sports and athletes surround our daily lives. The topic of eating disorders within athlete populations has received increased attention over the past several decades. What is confusing about this topic is that prevalence rates of eating disorders in athlete populations ranges from as low as 1% to 62% across a variety of sports (Byrne & McClean, 2001). Even more confusing is the fact that studies indicate a variety of risks for developing eating disorders and treatment recommendations. This article aims to discuss three topics: 1.) the conflicting literature in regards to athletes at risk or struggling with eating disorders, 2.) specialized dietary approach for athletes, 3.) treatment recommendations and family-based interventions for athletes.
A comprehensive review of current literature suggests that as a field full of effective treatment providers, we largely disagree on our recommendations for this specific demographic population especially in regards to return to play. One camp of the argument suggests that athletes are at greater risk for developing eating disorders when compared to nonathletes (Hausenblaus & Carron, 1999; Sundogt-Borgen, 1994; Zucker, Womble, Williamson, & Perrin, 1999). The other camp defends that sport serves to protect athletes from developing eating disorders (DiBartolo & Shaffer, 2002; Gutgesell, Moreau, & Thompson, 2003; Hausenblaus & McNally, 2004; Reinking & Alexander, 2005). What is agreed upon is that the qualities which make an athlete desirable are also traits found in individuals with eating disorders, such as excessive exercise, (over) compliance, perfectionism, denial of discomfort, working through the pain, commitment, and high achievement (Thompson and Sherman, 1999).
One of the most important areas of concern and motivation for athletes and their caregivers is the decision and clearance to return to play. Currently, there is no clear consensus regarding recovery criteria for athletes with eating disorders. For female athletes with eating disorders, the Female Athlete Triad and openness to fuel for additional exercise can generally be a good guideline to follow (Joy, Kussman, & Nattiv, 2016). Clinicians and their treatment team providers should also incorporate dietary recommendations, BMI, bone mineral density labs, medication compliance, and therapeutic feedback from the families involved, as well as coaches before a decision is reached. It is recommended that families and coaches also form a written agreement to implement before return to play is initiated. These return to play contracts have demonstrated specific guidelines in which the athlete is to meet with the appropriate treatment team providers, follow daily meal plan, agreement to weigh-in, and limitation of workout/play time.
Specialized Dietary Approach
An adolescent athlete entering treatment for an eating disorder is set apart by their desire to return to their sport for the enjoyment rather than a means of weight loss. We see many teens that identify as athletes, however, who began their sport in the context of the eating disorder as a way to facilitate weight loss. The primary target, upon entering treatment, for any of our athletes is medical stabilization and movement towards weight restoration (if applicable). Once medically cleared, the treatment team is able to develop a reintegration plan which ideally includes feedback and buy in from the coach. A primary distinguisher that the dietary staff at UC San Diego-Eating Disorder Center for Treatment and Research (UCSD-EDC) looks for in regard to the athlete’s readiness to transition back into their sport, is an understanding of increased caloric needs and the willingness to fuel nutritionally to meet the physical demands of their sport. In addition, it is imperative for the athlete to have a mentality orientated toward recovery in order to slowly rehabilitate from their metabolic injury. Transition back into their sport requires close observation by a primary care physician to oversee vitals and a registered dietitian to monitor weight trends and the quality and quantity of intake.
In an attempt to prevent relapse, many aspects of recovery must be taken into consideration with the treatment discharge of an adolescent athlete. Key components that need to be addressed include the continued growth of adolescents requiring a moving goal weight range, the necessity for continued nutritional fueling for the energy requirements of their sport, and identifying essential adjustments to nutritional intake with an increase in training and/or intensity. Each of these components is vital for continued recovery as well as optimal athletic performance.
Application of Treatment via Family-Based Interventions
As treatment providers for pediatric and adolescent programs, challenging patients with fear foods, restaurant outings, and coping ahead for the return to school is both commonplace and necessary to challenge the eating disorder and promote recovery. At the same time, due to the fears surrounding exercise and the impact on weight gain, medical and mental stability, many treatment programs are cautious about the right time to return patients to their sport or allow exercise as an integral treatment component. However, following the current data that indicates exercise can not only promote our patient’s mental well-being but also increase recovery rates (Arthur-Cameselle & Quatromoni, 2014), we now recognize the importance of sport in our patient’s lives and when medically appropriate encourage its return.
While we know from research that athletes in lean sports are more at risk for developing an eating disorder (Cameselle & Quatromoni, 2014; Joy, Kussman, & Nattiv, 2016), it is evident that more and more athletes are at risk for developing an eating disorder. At UCSD-EDC we have also seen an increase in our overall student athlete admissions across multiple sports. These athletes range from water polo players, swimmers, runners, soccer players to dancers and with support from the parents, our athletes plan on returning to sport. Rather than being hesitant to have these middle and high school aged athletes return to their sport, the treatment team, comprised of parents and clinicians, now use it both as a motivator and goal at the onset of treatment.
To lay the ground work, we provide psychoeducation to the real experts on these patients: their parents. We discuss the impact of sport on the eating disorder, risk factors such as signs of overtraining and following the evidence based Family Based Treatment model, and allow the parents to decide if and when they feel their child is ready to return to their sport. With feedback from our medical, dietary, and therapeutic members of the treatment team, parents create a plan for return to sport and slowly increase their child’s participation while our team closely monitors their medical and psychiatric stability.
As our adolescent athletes are still in school and live at home with their parents, parent psychoeducation of Sport and Eating Disorders is paramount, in that they are the primary source of supervision of meals and exercise for these athletes. At UCSD-EDC, we firmly believe the parents are the key to not only the re-feeding process, supervision, and reduction of eating disorder behaviors, but additionally, the ones to oversee the return to exercise. While the treatment team provides expertise and focuses on medical stability, our goal is to continue to empower and charge the parents in the task of supervising their child’s healthy return to sport.
Similar to the model laid out at the Victory Program within McCallum Place, we also look to coaches, trainers, and athletes as having a role within the FBT “family” as they have direct access to the patient and are often highly respected by the student athlete. Whether it’s speaking to coaches directly or providing trainings to athletic directors and trainers, our aim is to provide our patient’s athletic “family” with knowledge and skills to effectively manage the athlete’s return to sport.
At the UCSD-EDC we take a unique approach. While we aim to empower parents and educate coaches, we also provide a curriculum for our athletes that is focused on the areas of psychoeducation, Body Image, Cognitive Behavior Therapy and Dialectical Behavior Therapy. Our primary goals include, challenging myths related to eating disorders and sports, openly discussing the athlete’s specific concerns related to body image while having our patient develop and utilize skills that help them more effectively regulate mood and anxiety. While medical stability is always the number one priority, we firmly believe both the physical and mental health benefits of our patient’s returning to their sport can outweigh the risks if carefully executed with the goal of maintaining the athlete’s health. While the return to sports can play a positive role in an adolescent’s life, we also know that building leadership skills, mastery, and increasing self-esteem assist in one’s long-term recovery. At UCSD-EDC we are dedicated to developing quality based programs founded on empirically supported research that help guide parents and the adolescent athlete by expanding their knowledge of healthy nutrition and positive sport performance.
About the Authors:
Dani Gonzales, Psy.D. obtained her undergraduate degree in both Psychology and Women’s Studies from California State University San Marcos in 2010. She was awarded her Master of Arts in Clinical Psychology at the California School of Professional Psychology San Diego in 2012, and in 2016 was awarded her Doctorate of Clinical Psychology (PsyD). She began her work with eating disorders in 2011 at the University of California San Diego Dept. of Psychiatry Treatment and Research for Eating Disorders where she was trained in DBT and CBT therapeutic modalities. In 2014, Dani joined ERC-San Antonio as part of her residency in completing her Doctorate in Clinical Psychology and completed rotations at San Antonio’s Methodist Children’s Hospital and St. Mary’s University. While completing her residency she developed and implemented ERC-SA’s Substance Use Track. Currently, Dani Gonzales in a Postdoctoral Fellow at UCSD-EDC and her clinical interests include BED, Post Bariatric eating disorders, Borderline Personality Disorder, collegiate athletes, and individuals struggling with Substance Use. In addition to her work with individuals and families, Dani also conducts research regarding personality disorders and comorbidity issues for those struggling with a variety of Eating Disorders. Her research has been accepted and presented at national and international forums.
Sarah Archer, LMFT, is a licensed Marriage and Family Therapist who has been working with adolescents, teens, and their families for over 15 years. Sarah began as a Therapeutic Behavioral Coach providing in-home behavioral modification services for at-risk youth. Upon graduating from University of San Diego with her Masters in Marriage and Family Therapy, Sarah transitioned to Children’s Hospital providing treatment for children ages 3-18 and their families. There, she worked with a variety of diagnoses such as Depression, Anxiety, ADHD, ASD, as well as co-occurring disorders such as Substance Abuse and Eating Disorders. Sarah joined our team in May 2011 and currently acts as Adolescent Program Manager, Director of Athlete Programming, as well as primary clinician and family therapist.
Sammi Montag, RD, is a Registered Dietitian working with the adolescent and pediatric programs at UCSD Eating Disorder Treatment and Research Center. Sammi earned her Bachelor of Science in dietetics from Point Loma Nazarene University and went on to complete a dietetic internship at UCSD Medical Center. With a clinical background, Sammi has gained experience working with various patient populations including oncology, cardiology, renal, intensive care, diabetes, and eating disorders. Sammi has been working with the Family Based Therapy (FBT) modality with the adolescent/pediatric eating disorder population since 2014.
Arthur-Cameselle, J., & Quatromoni, P. (2014). Eating Disorders in Collegiate Female Athletes: Factors that Assist Recovery. Eating Disorders, 22, 50-61.
Byrne, S., & McClean, N. (2001). Eating disorders in athletes: A review of literature. Journal of Science and Medicine in Sport, 4(2), 149-159.
DiBartolo, P.M., & Shaffer, C. (2002). A comparison of female college athletes and nonathletes; Eating disorder symptomatology and psychological well being. Journal of Sport & Exercise Psychology, 24, 33-41.
Gutgesell, M.E., Moreau, K.L., & Thompson, D.L. (2003). Weight concerns, problem eating behaviors, and problem drinking behaviors in female college athletes. Journal of Athletic Training, 38(1), 62–66
Hausenblaus, H.A., & Carron, A.V. (1999). Eating disorder indices in athletes: An integration. Journal of Sport & Exercise Psychology, 21, 230–258.
Hausenblaus, H.A., & McNally, K.D. (2004). Eating disorder prevalence and symptoms for track and field athletes and nonathletes. Journal of Applied Sport Psychology, 16, 274–286.
Sundgot-Borgen, J. (1994). Risk and trigger factors for the development of eating disorders in female elite athletes. Medicine and Science in Sports and Exercise, 26, 414–419.
Thompson, R.A., & Sherman, R.T. (1999). Athletes, athletic performance, and eating disorders: Healthier alternatives. The Journal of Social Issues, 55(2), 317–337.
Zucker, N.L., Womble, L.G., Williamson, D.A., & Perrin, L.A. (1999). Protective factors for eating disorders in female college athletes. The Journal of Treatment and Prevention, 7(3), 207–218.