Eating Disorders in Athletes: Top 10 Tips for Collaborative Care in the Community

Dr. Michelle Mathias, MD, MA (Sport Psychology), FRCPC, Psychiatrist

It is funny what a shared roof can do. There is no doubt that treatment of eating disorders requires a cohesive multi-disciplinary approach, with various experts coming together in a collaborative fashion.  But that can be much more challenging when they are not all under the same roof. This is the case when providing care to athletes in the community, where professionals work from different centres, with different schedules, different resources and different levels of experience and expertise.  This, compared to inpatient or hospital-based care teams who share offices, cross paths in the hallway, have shared document drives and medical records, consistent scheduled team meetings and even… eat lunch together. It heightens the communication and consistency that is greatly needed for optimizing effective care.  So how does one navigate that when the athlete’s eating disorder is not so severe as to need hospital-based care, but rather treatment in the community?

This article will summarize the Top 10 Tips for optimizing community collaborative care.  It will not review diagnostic differences between RED-S and DSM-5 eating disorders. Nor will it compare the validity and metrics of assessment methods or treatment paradigms. It focuses on the daily practicalities of treating the complex illnesses of eating disorders.

Let’s start with a case example, with identifying details modified for confidentiality purposes.

Case:

Jessie was 14 years old when she was first diagnosed with anorexia nervosa and admitted to a hospital eating disorder unit for treatment.  At the time, she was an avid ballerina and her physical appearance was key to her success and ability to acquire roles in her dance company. While things improved after hospitalization, eating and her mental health again became a challenge when she went to university and lived on her own.  The stressors of independent living were notable when living out from the structure and support of her parents, who she described as being often over-bearing, rigid and intrusive. This did not seem to be the opinion of her sister, with whom Jessie struggled to connect, always feeling in her shadow. Without a dance company in the town of her university, Jessie turned to her long-time love of running and joined a track & field club. Her drive to perform compounded her restrictive eating and led to a fracture and a 2-year physical recovery and ongoing mental health struggles.  When she returned to sport, she chose a different track & field event, hoping she could gain greater success. She chose hurdling. Focused on details and with a strong history of perfectionism, she excelled quickly, until she suffered another fracture.  Her coach urged her to seek help, specifically a sport medicine doctor who could properly supervise recovery and return to sport safely.  Knowing a multi-disciplinary team would be needed, that SEM consulted a sport psychiatrist and a registered dietician from the community.

Tip #1:  Diagnosis Consistency

This may seem like an evident point, but it is a vital starting point.  Experts of the collaborative care team (CCT), should understand the current identified diagnosis and the factors determining that diagnosis vs another. In the world of sport, we face RED-S (red, orange, yellow zones), disordered eating and eating disorders.  The diagnosis determines the treatment modalities and methods as well as risk assessment.  Consistency in diagnosis also ensures messaging is clear to the athlete so they may take ownership of their illness, a key first step in embarking on treatment.  It can be confusing if one member of the CCT uses one diagnosis and another uses a different term. It can leave the athlete feeling, “What do I actually have?”  A diagnostic discrepancy also opens the door for an illness affected brain to minimize their illness with thoughts like: “Well, my other health expert says I only have X diagnosis, not Y diagnosis, so it must not be that bad and I can continue on.” Admittedly diagnoses may change over time, at which point this also ought to be revisited and re-discussed with the CCT and athlete.

Tip #2: A Clear Target or End-Goal

There are many ways to measure improvement, each with its benefits and possible challenges. From the old-school scale, to BMI, to DEXA scans, to the return of a menstrual cycle, etc. … they vary quite a bit in accuracy, value and accessibility. Beyond the quantifiable, there are also behavioural, cognitive and emotional changes to observe. While multiple measures can be used, there should be a clear identified target for the person being treated. Remember that from the athlete’s perspective, they might not know what a lot of these terms mean or represent and getting into the details of them may cause confusion, increased perfectionism and even stress. It is a delicate balance between providing education and potentially feeding pathology. The members of the CCT may discuss various methods in their team meetings, but when with the individual seeking treatment, chose one consistent measure that is easily understood so that it can be used to highlight their gains, or struggles, for the purposes of motivating improvement in health.

Tip #3: Tracking Progress… Old School

Similar to tip #2 there are various methods for assessing changes in weight and body composition. In the context of eating disorders, however, the end-goal is to have a marker that can be easily and objectively tracked. Week by week, the athlete will encounter different situations and stressors that will impact their mental health and ultimately their eating, which they have been using as a coping strategy. It is key there be a visible and temporal link between  stressors, eating and exercise habits (healthy and unhealthy), and the use of alternative coping mechanisms changes in weight .  For this, weighing the individual regularly and consistently is required.  Given weight varies across the days of a week and over the course of a day, weight is ideally taken on the same day of the week and same time for consistency. The practicality of this is, admittedly, challenging.  Scale variability also requires the same scale be used.  As such, the CCT should identify which member will perform the weight assessments and how this will be communicated to all members so they are aware and can adapt their next appointments  relative to nutrition, exercise and therapy.

Tip #4: The Big C… for Communication

This comes back to the lack of a single roof. With communication complexity, establishing a consistent method and schedule for communication ensures all members of the CCT are in agreement and messaging is consistent to the athlete.  Regular CCT meetings are recommended to ensure that the athlete learns about their illness from different sources who echo the consistent messaging around their improvements, their ongoing challenges, strategies and the ultimate goal they have identified as the motivation for getting better.   If possible, monthly meetings can assist CCT members in ensuring gains are continuing to be made and, if not, brainstorming alternative strategies or approaches.  Monthly meetings may be difficult to organize due to varying schedules, but virtual means have definitely improved their feasibility with advanced planning.

Tip #5: Mind the Complexity of Over-lapping Boundaries

Frequent and regularly schedule CCT meetings also ensure each health professional is not only echoing the messaging of their colleagues, but also being mindful and respectful of each discipline’s expertise.  There is inevitably overlap between each discipline’s knowledge and expertise.  Comfort with the overlap can assist professionals in feeling confident their role is valued, respected and that all CCT members have a shared goal of assisting the individual at the centre of the care circle.

All place-settings at the table take up the same amount of space, with the athlete at the head of the table, while we pass dishes in a sharing fashion… family-style.

Tip #6: The CCT… A Balance between Consistency and Adaptability

With the importance of regular CCT meetings and the scheduling challenge it may pose, consider keeping a consistent CCT for multiple patients.  That way, when you meet to review patient progress, you can review multiple patients at a time.  The consistency of your CCT will also provide increased opportunity for learning how you each work, typical methods for managing cases and being able to echo that more easily. Past cases you have shared can also inform current or potential future ones.

In the same sense that a consistent CCT may be helpful from case to case, optimizing care of the athlete may require the inclusion of different individuals over the course of treatment.  These individuals may be health professionals such as physiotherapists, RMTs, athletic therapists, etc.  Or they may be other people that the athlete feels play an important and supportive role in their life such as a coach, teammate, parent or friend.  Separate meetings may be held with them, alongside the athlete, to identify how they can optimize the support they provide to the athlete in the process of overcoming their eating disorder. For example, the involvement of a coach may be particularly helpful and important in ensuring that energy expenditure is being managed relative to energy intake (nutrition). The selection of non-health care professionals should be based on the athlete’s comfort and ensuring they are a positive support.

Throughout the course of an athlete’s treatment and recovery, different health care professionals or other supports may be involved  (or not), depending on what is required at that time.  This means that, similar to the need for athlete consent when individuals are added to the CCT, sharing of confidential information should cease when the role is no longer active. CCT membership has its privileges… and responsibilities.

Tip #7: Eating Disorder as a Coping Mechanism

Recognizing the origin of the eating disorder, as well as its sustaining factors, is key to determining how to unbuild it.  Individuals develop eating disorders as a method of coping.  It is important to understand what stressors the athlete was experiencing when they began their impaired eating habits and what benefits the athlete is continuing to experience from the eating disorder. Given the athlete has, in an unhealthy way, gained benefit from their eating disorder (as a coping mechanism), expect that there will be resistance in efforts to try and move away from those behaviours.  Resistance may come in the form of inability to carry out change, refusal to accomplish behavioural homework, minimizing and downplaying severity of symptoms, etc.

As stressors and daily challenges arise, therapy is key in aiding the athlete to develop alternative, healthy methods for coping.  It is also in the efforts to dismantle the eating disorder that other unhealthy coping mechanisms may develop, worsen or return. These can include self-harm or suicide attempts. Accurate assessment of risk is important. Some of these may be more or less harmful than the eating disorder itself.  Their duration may vary from brief to longer-lasting. Ideally healthy coping mechanisms can be developed as soon as possible to minimize comfort with unhealthy means and thus decrease their durability.

Tip #8: Resistance to Change in the Form of Deception

The CCT should be mindful that as part of the efforts to maintain eating disorder habits and resistance to change, athletes may also resort to frank withholding of information or even deception.  With this in mind, an accurate understanding of their exercise and eating behaviours may be challenging, particularly in a community setting.  Inpatient or day hospital programs can have the advantage of observing athletes during meals and preventing post-meal trips to the washroom for vomiting.  An accurate picture of energy intake may be more difficult in the community.  Having the athlete track their nutritional intake provides valuable information to the CCT, but must also be done in delicate balance with ensuring it does not foster or feed the pathology of perfectionism or anxiety.  It is for this reason there are many creative methods for tracking nutrition and the properly chosen strategy can make a great difference in the success of moving forward through the discomfort of increased food intake. Without an effective method for understanding and monitoring intake challenges, the CCT may be left feeling in the dark and struggle to problem-solve impaired progress.

Knowing that deception and information with-holding may be present is another reason why the  CCT should meet regularly – to share gathered information. If incongruencies are present, it is important to discuss these with the athlete so they understand this as an additional symptom, which is trying to resist overcoming their eating disorder behaviours.

Tip #9:  You Get Further with Honey than a Stick

From the start of treatment or care, it is important to know what the athlete’s main motivation or goal is in getting better from their eating disorder.  Is it to feel more energy during competition? Is it to feel stronger in their sport? Is it to be able to concentrate better and feel more awake in class? Messaging from all CCT members should regularly return to the athlete’s primary motivation so that it echoes their internal drive.   In doing so, any small gains should be recognized in the light of the ultimate goal. Increases in weight can lead to safe increases in sport and training.  For example, “Great job consistently getting that chocolate milk snack in daily.  This means we can add 10 minutes to your cardio workout.” While setbacks and challenges may be present, progress will be greater with positive reinforcement of success, versus imposed restrictions.  The former fosters self-confidence and positivity, whereas the later may foster resistance and a sense of feeling controlled.

Evidently there may be times when restrictions need to be placed for safety reasons, such as preventing further fractures.  For this, clear communication about safety limits needs to be provided to the athlete ahead of time.  For example, “Below a weight of X, we will need to cut back on how many hours of intense training you can carry out, to protect your health.”  Knowing this ahead of time ensures the athlete maintains their autonomy for decision-making around their intake and exercise in recognition of possible negative outcomes. In other words, the athlete will reflect, “Well, I know that if I do not meet my energy intake needs, I won’t be able to have two intensity workouts this week.  Is it worth it?”

Tip #10:  Know When to Tap Out

Similar to team sports and games where some athletes are less performing than others, treatment of eating disorders is a long path that at times may require consulting more experienced colleagues or even transfer of care to other service providers with greater  resources.  Knowing when this is the case involves understanding acceptance criteria for certain programs and accurate assessment of the athlete’s eating disorder severity.  Within this, however, is also the need to evaluate what gains have been made, if any.

In providing treatment and support to an athlete with a complex, chronic mental health challenge, gains can be slow and limited… but there still should be some gains, even if among setbacks. If progress or forward movement is not being seen, it is important that each of the CCT members ask themselves a few important questions:

• Should we, as a CCT, be doing anything differently?
• Are there other resources or strategies we should be using?
• Should I be doing anything differently?
• Do I have the skill, knowledge and training needed to help this individual?

Yes, therapeutic rapport is key to making gains.  One must ensure, however, it is not present in the absence of objective improvement.  Should that arise, ask yourself, “Is this athlete simply gaining from the supportive environment I provide, without making actual progress towards their goal?”  In that sense, a gentle balance between “good cop, bad cop” in your sessions could motivate staying on task while saying, “I am still here to support you.”  After all, while a supportive, listening ear can feel good for the athlete, only a healthy weight prevents fractures.