Eating disorders in elite athletes pose 'unique complexities' in care

Elite-level athletes face special risks and risk factors for eating disorders—posing unique challenges at every level of care, according to a review in the March issue of Current Sports Medicine Reports, official journal of the American College of Sports Medicine (ACSM).

"In terms of eating pathology, treatment and support teams must be thoughtful about the appropriateness of physical activity and training depending on the severity of illness and medical stability," write Rachael E. Flatt, MA, and colleagues of University of North Carolina at Chapel Hill. Their paper is among the first to focus on eating disorders and their treatment in elite athletes, including the broader sport context and the role of the sport support team.

Focus on levels of care for athletes with eating disorders

Elite-level athletes are at increased risk of eating disorders. Up to 45 percent of female athletes and 19 percent of male athletes have positive screening results for eating disorders and disordered eating behaviors, compared to a population prevalence of 5 percent.

Athletes may also face "sport-specific" risk factors, such as an emphasis on leanness or weight categories, comments on body weight and shape, and revealing uniforms. It may be difficult to distinguish the high-calorie intake of athletes in training from binge eating, or intensive training regimens from the compulsive exercise seen in some patients with eating disorders.

Given their severe health impact and high medical costs, "it is important that eating disorder treatments at all levels of care are tailored for athletes given their unique risk factors and presentations," Ms. Flatt and coauthors write. They address the "unique complexities" of eating disorders, at every level of care:

• Inpatient/residential treatment is needed for athletes with severe eating disorders. These patients may have very low body weight or rapid weight loss, suicidal thoughts, and potential medical complications.
• Intensive outpatient/partial hospitalization is appropriate for athletes transitioning out of inpatient/residential care, or who need more than outpatient care. Although not hospitalized, patients are in treatment several days per week, several hours per day.
• Outpatient care is indicated for athletes with mild to moderate eating disorders, or those stepping down from a higher level of care. These patients are in "fairly stable" medical condition, but still need close monitoring to address disordered eating behaviors and thoughts and to monitor their progress.

A critical consideration at every level of care for athletes with eating disorders is navigating exercise and physical activity: "a major part of their lifestyle and identity." Patients in inpatient or residential care may be allowed little or no physical activity, as treatment focuses on addressing malnutrition and regaining body weight.

As athletes proceed through treatment, prescribed activity levels are gradually increased. Patients "might be surprised (and potentially triggered) by the caloric intake required to continue weight restoration with increased physical activity," Ms. Flatt and coauthors write. For many athletes, returning to sports participation is "a primary motivator" for progressing through treatment.

The review addresses the "broader sport context" at each level of care. This includes a coordinated approach to re-engaging with the athlete's sport support team—such as coaches, sports psychologists or dietitians, and teammates—and is an important aspect of care. "Support teams may also have the opportunity to be more involved in ensuring a smooth transition back into sport and/or creating a safe and healthy environment around the athletes," according to the authors.

The article includes a series of case scenarios, illustrating the complex factors involved at every level of care for eating disorders in elite athletes. Although their review is "not exhaustive," Ms. Flatt and colleagues hope it will spur further interest and research into the unique characteristics and management of eating disorders in athletes. They write, "Future research may consider longitudinal studies of athlete-specific treatment considerations outlined in this paper and the implementation of athlete-specific eating disorder assessment tools at various stages throughout treatment."