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3/7/2015
Outline
Athletes and Eating Disorders: Special Treatment Considerations
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Ron A. Thompson, PhD, FAED, CEDS
Consulting Psychologist, The Victory Program at McCallum Place
Email: [email protected]
Introduction
Athletes: Special Subpopulation
Treatment Staff/Philosophy
Special Treatment Components
Special Treatment Issues
Be humble in victory; be gracious in defeat.
Athletes and Eating Disorders:
The Facts NCAA Mental Health Task Force
• An NCAA Mental Health Task Force met in November, 2013. From that meeting, the handbook Mind, Body and Sport: Understanding and Supporting Student‐
Athlete Mental Wellness was developed.
• In addition to emphasizing early identification and treatment and decreasing the stigma associated with mental health problems and treatment, specific mental health problems targeted included: Depression, anxiety, disordered eating/eating disorders, disordered sleeping, substance abuse, and sexual abuse.
Why Specialized Treatment for Athletes with Eating Disorders?
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Athletes are more at risk than non‐athletes because they not only have the same risk factors as non‐athletes, they also have additional risk factors that are unique to the sport environment or to a particular sport. Because of their increased/special risk factors, athletes need specialized approaches to identification, management, prevention, and especially treatment.
The same personality factors that are related to good sport performance may increase the risk of an eating disorder in an athlete but also can be used to facilitate treatment.
Relapse prevention for athletes returning to training and competition is different than for their non‐athlete counterparts.
They have additional reasons to resist treatment.
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EDs occur in all sports but not at the same rate.
Sports do not cause EDs but may play a role.
Coaches do not cause EDs but may play a role.
EDs are more prevalent in athletes than non‐
athletes.
• EDs are more prevalent in aesthetic, endurance/gravitational, and weight‐class sports.
• Having an ED does not mean an athlete has to give up his/her sport.
Why Specialized Treatment for High Performance Athletes with ED?
• Research suggests that the prevalence of ED in athletes increases with competition level. • Training loads tend to increase with competition level. • Prevalence is probably higher due to different/greater pressures regarding performance.
• Differences in performance at high level competitions may be as small as a fraction of a second in timed sports or a fraction of a point in judged sports. • High level athletes are looking for an “edge.” Many are willing to do whatever is necessary to attain that “edge,” such as restrictive dieting, excessive training, and the use of pathogenic weight loss methods.
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Why Athletes with Eating Disorders Must be in Treatment
Athlete’s Resistance to Treatment • Same as non‐athletes plus...
• Assumes weight will increase and competitive edge will decrease
• Fears loss of status or playing time
• Fears time away from sport will result in a loss of conditioning/competitiveness
• Fears displeasing others involved in sport (i.e., coach, teammates), as well as, significant others outside of sport (i.e., family)
• Fears treatment providers will not value sport
• Recovery without treatment is unlikely.
• The athlete can become isolated from the team.
• The athlete deteriorates physically and
psychologically over time.
• Performance is eventually negatively affected.
• Poorer performance increases pressure.
• Pressure increases the need for the disorder.
Treatment of the Athlete with an Eating Disorder • Treatment per se is not different for an athlete, but treatment can be facilitated by:
– A treatment team with experience and expertise in treating athletes
– A treatment team that understands and appreciates the importance of sport in the life of the serious athlete
– A therapist who uses sport participation as a way to motivate the athlete in treatment
– A therapist who uses the athlete’s “sport family” (i.e., coach, teammates, etc.) in treatment
– A therapist who uses the athlete’s “good athlete” traits in treatment Treatment Staff Recommendations: Necessary and Ideal
• Treatment staff members should have experience and expertise in treating eating disorders and athletes, and also understand and appreciate the role of sport in the life of a serious athlete.
• Necessary: Physician, Dietitian, and Mental Health Practitioner.
• Ideal: Physical Medicine Doc, Psychiatrist, Eating Disorder Specialist, Sport Psychologist, and Sport Dietitian. Ideally, a Certified Athletic Trainer would assist in management.
Relationship Between Sport Participation and Eating Disorders
Treatment Components: Special Issues
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Relationship Between Sport and Eating Disorder Body Image/Competitive Thinness/Revealing Uniforms
Sport Nutrition
“Good Athlete” Traits
Sport Family
Physical Training
Sport Psychology/Mental Training
Medications
Sexual Abuse/Harassment
Relapse Prevention for Sport Environment
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Direct: Sport plays an integral role in the ED; sport participation precipitates and/or maintains ED; choice of sport may have resulted from ED; athlete feels pressure to decrease body fat, lose weight, maintain a suboptimal weight, or attain a small body, size, or shape based on a sport body ideal and/or demands of a coach.
Indirect: Sport plays a minor role in ED; sport participation may play a role in maintaining the ED; athlete would likely have an ED without sport; may use ED to relieve pressure, anxiety, or frustration associated with sport performance. Sport participation may be used by the athlete as a rationalization for needing to lose weight/maintain a suboptimal weight.
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Body Image Issues
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The relationship between body image and eating disorders in athletes appears to be different than in the general population. It is more conflicted and confused.
Sportswomen have more than one body image—one within sport and one outside of sport (de Bruin et al., 2011; Krane et al., 2001; Loland, 1999; Russell, 2004; Steinfeldt et al., 2012). DE/ED can occur in either.
Some female athletes are conflicted about having a strong, muscular body that facilitates sport performance that not only does not conform to the socially desired body type (Cole, 1993; Greenleaf, 2002; Krane et al., 2001; 2004), but which may also be perceived as being too muscular and violating societal norms of femininity (Cole, 1993; Krane et al., 2001; 2004; Greenleaf, 2002; Steinfeldt et al., 2010). Women are more negative about themselves in situations where their bodies have greater exposure or when in body focused situations (Haimovitz et al., 1992; Tiggeman, 2001). Many athletes wear revealing sport attire.
Research Related to Revealing Sport Attire (Female Athletes)
• Objectification theory: Culture socializes females to adopt observers’ perspectives on their physical selves—females are socialized to treat themselves as objects to be evaluated based on appearance (Fredrickson & Roberts, 1997).
• Self‐objectification increased body shame and decreased math performance while in a swimsuit (Fredrickson et al., 1998)
• 58% of cheerleaders surveyed indicated revealing uniforms as the highest pressure related to weight (Reel & Gill, 1996).
• Feather et al. (1996): Body satisfaction was related to uniform satisfaction in female basketball players.
• Dancers reported costumes and comparison with other dancers as sources of pressure (Reel, 1998; Reel et al., 2005).
Revealing Sport Attire for Women (cont’d)
• Ballet students reported lower self/body‐perception ratings wearing a leotard and tights versus wearing looser fitting clothing (Price & Pettijohn, 2006).
• 45% of swimmers surveyed reported a revealing swimsuit as a stressor (Reel & Gill, 2001).
• Toro et al. (2005): Highest prevalence of induced vomiting occurred in swimmers who had the greatest concerns regarding “public body exposure” (revealing swimsuit).
• Uniforms made athletes more aware of their shape and physique and influenced feelings of body dissatisfaction (Greenleaf, 2002).
• Revealing volleyball uniforms contributed to decreased body esteem and distracted players/impacted performance (Steinfeldt et al. 2012).
Risk Factors for Competitive Thinness
in the Sport Environment
Revealing Sport Attire for Male Athletes
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Uniform pressure involves the extent to which athletic apparel draws undesired attention and accentuates aesthetic flaws (Galli et al., 2013).
Of athletes in 16 sports, athletes in endurance sports reported the highest degree of uniform pressure (Galli et al., 2013).
As one former college wrestler said, “a wrestling singlet shows everything you have and maybe what you don’t have.” Pressures to look good in their uniforms may increase male athletes’ risk of body dissatisfaction and use of pathogenic body change behaviors (Petrie & Greenleaf, 2012).
Nutrition and Sport
• Belief that the leaner athlete will perform better (and look better?)
• Aesthetic sports in which appearance (athlete’s body) is “judged” (i.e., diving, figure skating, gymnastics, synchronized swimming etc.)
• Revealing sport attire
– May create unhealthy body consciousness, discomfort, and/or dissatisfaction
– Facilitates unhealthy body comparisons for the purpose of appearance and/or sport performance
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Similarities Between “Good Athlete” Traits and Anorexic Characteristics*
“Good Athlete”
Anorexic Patient
Mental toughness
Asceticism
Commitment to training
Excessive exercise
Pursuit of excellence Perfectionism
Coachability
Overcompliance
Unselfishness Selflessness
Performance despite pain Denial of discomfort
*Thompson & Sherman (1999)
Using the Athlete’s “Sport Family”
in Treatment
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The “sport family” can include coaches, teammates, and athletic trainers.
The sport family can be just as important to the athlete‐patient as his/her family of origin. Thus, it can play a positive role in identification, management, and treatment.
The sport family can be a primary source of support. The sport family can play a role in precipitating and perpetuating the disorder. Inclusion of sport family members in treatment occurs only after explanation of the rationale to the athlete and only with his/her full agreement.
The appropriate release of information to members of the sport family can also facilitate treatment and elicit more cooperation from the sport family.
“Fat Talk,” Body Dissatisfaction,
and Eating Problems
• “Fat talk” involves interactions between females in which they talk about body dissatisfaction and need to lose weight (Stice et al., 2003). It can also involve talking about others’ appearance and be related to eating pathology (Ousley et al., 2008).
• It occurs among female athletes in the locker room, and sport personnel need to stop it when they hear it.
Using “Good Athlete” Traits in Treatment
• Mental Toughness/Performance Despite Pain or Discomfort: The “toughness” the “good athlete” uses to perform well despite difficult circumstances can be used in treatment; that is, she/he is more apt to do what is necessary in treatment despite the fear and anxiety often associated with change in treatment.
• Commitment to Training/Treatment: Ask the “good athlete” to make the same commitment to treatment that she/he makes to training/sport.
• Pursuit of Excellence: The “good athlete” can be expected to pursue excellence in treatment just as in sport.
• Coachability: The “good athlete” is used to doing what her/his coach tells her to do. The therapist is the new “head” coach (with an important exception or two).
Weight Pressures Related to Teammates
• Recent research by Petrie and colleagues (Anderson, Petrie, & Neumann, 2011, 2012; Reel, SooHoo , Petrie, Greenleaf, & Carter, 2010) suggests that teammates are a source of weight pressure for athletes. In fact, Reel et al. found that teammates noticing weight‐
gain represented the strongest weight pressure for female athletes. It appears that not only female athletes are affected by teammate weight‐related issues. Engle et al.. (2003) found that an athlete’s restrictive eating was associated with her or his perception that team members were excessively dieting to control their weight. That male athletes are also affected by weight pressures from teammates has been suggested by Filaire et al., (2007) and Galli and Reel (2009). Body Comparisons, Body Dissatisfaction, and Disordered Eating
• Women compare to other women to determine weight status, and such comparisons may result in a woman feeling “fat,” which can in turn increase the tendency to engage in body comparisons (Striegel‐Moore et al., 1986).
• “Body‐related social comparisons” (Hamel et al., 2012) or “upward appearance comparisons” (Arigo et al., 2013) are related to body dissatisfaction and disordered eating.
• When women compare themselves to a “fit” (thin) peer, body dissatisfaction tends to increase (Krones et al., 2005; Lin & Kulik, 2002; Stice, 2002).
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Body Comparisons Among Sportswomen
• “I definitely feel like we’re a lot bigger because we’re working out so much and lifting weights all the time. I definitely feel like we have bigger bodies compared to women who don’t…comparing, I feel like a man sometimes…then you see little petite women who are, a lot smaller” (Steinfeldt et al., 2012).
• “Everyone walks around in their swimsuits and everyone’s wearing next to nothing—you can’t hide…I felt like everyone was comparing me to the next person” (Greenleaf, 2002).
• “Due to body comparisons with other athletes, I did not feel good enough…everyone was thinner, stronger, and more beautiful than me. I was always occupied with the others, watching how thin they were” (de Bruin et al., 2007).
Special Risks for Male Athletes:
Gender Bias
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Most people (i.e., healthcare professionals, sport personnel, lay public, males, etc.) are less apt to consider an eating disorder with males. Thus, males are probably identified later. We presume good health with good performance.
We are less apt to look for bone loss in males. Most ED assessments were standardized on females.
We are probably less apt to view extra training as excessive and/or symptomatic. Males are less apt to report symptoms because they don’t want to have a “female” problem.
Males with any psychological problem are less apt to seek treatment than females.
Coach‐Related Issues
Coaches: Why Have Them Involved?
• Weight pressures related to coaches:
• Coaches have significant power and influence with their athletes.
• Coaches’ power and influence with their athletes can either be used to promote or prevent eating disorders.
• Having them involved increases the likelihood that their power and influence will be used to prevent.
• Coaches can assist in identification because they are in a good position to identify a problem.
• Coaches can facilitate treatment with their encouragement and support.
• Prevention programs cannot succeed without their support.
– Athletes sometimes feel weight pressures from coaches (Anderson et al., 2011, 2012; Reel et al., 2013) that increase the risk of disordered eating (Arthur‐Cameselle & Baltzell, 2012; Kerr et al., 2006; Muskat & Long, 2008. • Coaching/training climate:
– An ego/performance‐centered motivational climate (vs. a skills‐mastery climate) has been associated with an increased risk of disordered eating (De Bruin et al., 2009).
• Relationship issues with coaches: – A relationship between coach and athlete characterized by high conflict and low support has been associated indirectly with an increased risk of eating pathology in athletes through low self‐esteem, increased self‐critical perfectionism, and depression (Shanmugam et al., 2011, 2012, 2013a, 2013b). • Coaches and eating disorder prevention: – Program was developed to provide coaches with knowledge/strategies regarding identification, management and prevention of ED (Martinsen et al., in press).
Research Related to Exercise
in Eating Disorder Treatment
Physical/Sport Training in Treatment
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Physical/sport training can begin when treatment staff agree that such training will not increase the medical or psychological risk to the athlete‐
patient.
Type of training, as well as its frequency, intensity, and duration are prescribed by the program exercise/performance specialist in consultation with treatment staff. It is typically sport related.
Physical/sport training is related to treatment progress and is implemented gradually. Initial training is usually monitored by the program exercise/performance specialist or the athletic trainer. Athletes report their “experience” of training (i.e., how they felt physically and emotionally); that information is made available to the treatment team. Physical training is used to motivate the athlete‐patient and can be withdrawn at any time at the recommendation of treatment staff.
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Studies related to exercise in ED treatment: Blinder et al., 1970, Beumont et al., 1994; Calogero & Pedrotty, 2004; Carraro et al., 1988; Chantler et al., 2006; Cook et al., 2011; Fernandez et al., 2014; Sabo & Green, 2002; Sundgot‐Borgen et al., 2002; Takumura et al., 2003, and Thein et al., 2000.
Reviews and meta‐analyses related to exercise in ED treatment: Campbell & Hausenblas, 2009; Hausenblas et al., 2008; Moola et al., 2013; Ng et al., 2013; Vancompfort et al., 2013: Zschuckle et al., 2013; and Zunker et al., 2011.
None of the aforementioned studies, reviews, or meta‐analyses reported any adverse effects. When nutritional needs are met, exercise in ED treatment appears to be a safe option.
Conclusion: Aerobic and/or resistance exercises have resulted in improvements in body satisfaction, mood, and quality of life, as well as physiological improvements in body mass in AN, BN, and BED patients.
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Rationales for Including Physical Training in Treating Athletes with Eating Disorders* Rationales for Including Sport in Treating Athletes with Eating Disorders*
• It can facilitate the eating changes that may be necessary.
• It can be used to motivate the athlete in treatment by withholding it and allowing it when appropriate.
• It can be used to determine if the athlete wants to continue in his/her sport.
• It provides the athlete with reasonable preparation for the training loads she/he will encounter on the return to sport participation.
• It allows the athlete to continue to be part of a team (provides a sense of attachment).
• Remaining in the sport may make it easier to monitor the athlete’s symptoms and condition.
• It allows the athlete to continue in an activity that may be his/her primary or only source of self‐esteem.
• It allows the athlete to maintain an important sense of identity (as an athlete).
*Those training and/or competing must meet health maintenance criteria, which vary on a case by case basis.
Athletes with Eating Disorders: Additional Criteria for Training*
• Following the treatment team’s determination that sport participation will not increase the risk to the athlete medically or psychologically, additional criteria necessary for training include:
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Athlete is in treatment and progressing
Athlete wants to return to sport
Athlete’s exercise/training is not symptomatic
Athlete agrees to increase caloric intake to balance training
Athlete agrees to comply with health maintenance criteria
*Decisions regarding training and should be viewed as tentative; they can be changed at anytime based on the athlete’s progress. Relative Energy Deficiency in Sport (RED‐S)
• The term ‘Relative Energy Deficiency in Sport’ (RED‐S), points to the complexity involved and the fact that male athletes are also affected. The syndrome of RED‐
S refers to impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular health caused by relative energy deficiency (Mountjoy et al., 2014.)
*Those training and/or competing must meet health maintenance criteria, which vary on a case by case basis.
Recent Consensus Statements Regarding When to (Return to) Play
• De Sousa et al. (2014). 2014 Female Athlete Triad Consensus Statement on Treatment and Return to Play of the Female Athlete Triad. British Journal of Sports Medicine, 48, 289‐308.
• Mountjoy et al. (2014). The IOC Consensus Statement: Beyond the Female Athlete Triad—Relative Energy Deficiency in Sport. British Journal of Sports Medicine, 48, 491‐497. (This article includes issues related to male athletes.)
Athletes, Sexual Abuse, and Eating Disorders
• Child sexual abuse is a nonspecific risk factor for eating disorders.
• Canadian, Danish, Norwegian, and Australian studies have reported high rates of sexual abuse/harassment in athletes.
• Sherwood et al. (2002) found that 7th, 9th, and 11th grade girls with eating disorders in weight‐related sports had experienced more physical and sexual abuse than their counterparts without eating disorders. • 4% of Norwegian sportswomen reported that sexual abuse or harassment was a reason for the development of their eating disorder (Sundgot‐
Borgen, 1994).
• A higher percentage (66%) of elite sportswomen with eating disorders than those without eating disorders reported experiencing sexual harassment/abuse, inside sport and outside of sport (Sundgot‐Borgen, et al., 2003).
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Relapse Prevention for Athletes with Eating Disorders
• Same relapse prevention as for non‐athletes, plus…
• Relapse prevention regarding risk factors unique to sport environment:
Questions
Questions
– Emphasis on weight/body fat and sport performance
• Good nutrition/good health contribute to good sport performance
– Contextual body image/competitive thinness/revealing uniforms
• Focus on sport competition rather than body comparisons/competitions
– Excessive training loads/overtraining
• Increased training requires increased energy intake
– Relationships with coaches
• Be assertive, especially as the issue relates to health
Be humble in victory; be gracious in defeat.
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