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Avoidant/Restrictive Food Intake Disorder: The New Kid on the Block

By Rebecca Bernard, Ph.D.

A New Home for an Old Problem

Juliet is a 16-year-old female who was admitted to the hospital due to chronic abdominal pain, nausea, early satiety, and significant weight loss/malnutrition. She has a long-standing history of intermittent abdominal pain and anxiety and more recently has developed a fear of nausea or vomiting after eating. She denies any concerns about weight gain and reports wishing she could eat like her peers and gain weight.

Jonathan is a 7-year-old male who had a recent traumatic experience where he choked on a chicken bone during dinner. Since that time he has become increasingly afraid of eating most solid foods which has led to rapid weight loss over the past two weeks. His parents report that he appears highly anxious before meals and will often cry and yell when presented with food.

Eating disorder treatment programs and hospitals have long encountered this subset of patients who present with food avoidance and low weight but lack fear of weight gain or becoming fat, a core diagnostic criterion of anorexia nervosa. Under the DSM-IV criteria, the types of patients mentioned above would likely have been diagnosed with eating disorder not otherwise specified (EDNOS). Unlike anorexia nervosa (AN) and bulimia nervosa (BN) which are better defined and understood by providers, EDNOS was often more of a “catch all” category for patients who did not fit neatly into the AN or BN diagnostic criteria. In fact, the majority of patients presenting with eating disorder symptoms were given a diagnosis of EDNOS (Fisher, Gonzalez, & Malizio, 2015; Peebles, Hardy, Wilson, & Lock, 2010).

The EDNOS category was made up of a myriad of patient presentations. For example, EDNOS was a frequent diagnosis for patients with less severe or less frequent symptoms of AN or BN and also for patients with significant medical sequelae related to malnutrition from symptoms such as severe selective eating habits or fear of nausea/vomiting. Due to this range in patient presentation and symptom severity, EDNOS was sometimes perceived as less serious than other eating disorders. For patients like Juliet and Jonathan, this was simply not the case. In fact, there is evidence to suggest that patients with EDNOS were more medically compromised than patients with BN (Peebles et al, 2010) and had similar types of medical complications, although less severe, than patients with AN (Peebles et al, 2010; Strandjord, Sieke, Richmond, & Rome,  2015). Moreover, in a retrospective study Norris et al. (2014) found that almost one third of patients who met criteria for ARFID required hospitalization due to medical instability. Clearly further diagnostic clarification within the EDNOS category was called for and the DSM-5 sought to remedy this in part by further defining this subset of patients.

What is ARFID?

Avoidant/restrictive food intake disorder (ARFID) is defined as an eating or feeding disturbance resulting in failure to meet nutritional needs. This disturbance is associated with one or more of the following: significant weight loss or failure to gain weight as expected, significant nutritional deficiency, reliance on some type of nutritional supplement or enteral feeding, or significant interference with psychological functioning. A key feature that differentiates ARFID from AN and BN, is that the patient with ARFID does not exhibit, and there is no evidence of, concern about weight or shape. The DSM-5 goes on to specify that the eating disturbance cannot be due to lack of food or cultural reasons and is not due to another mental or medical condition. ARFID can manifest in children, adolescents, or adults but is most common in children (American Psychiatric Association, 2013).

Although this is a new diagnosis and much is likely to be discovered about prevalence, associated features, and treatment of this disorder, there is initial evidence regarding characteristics of ARFID. Compared to other eating disorders, patients diagnosed with ARFID tend to be younger, have been ill for longer, have higher rates of comorbid anxiety and medical conditions, and have lower rates of depression (Fisher et al., 2014). Also, a higher proportion of patients with ARFID are males when compared with other eating disorders (Fisher et al., 2014; Nicely, Lane-Loney, Masciulli, Hollenbeak, & Ornstein, 2014). In a recent study, Fisher et al. (2104) identified several common ways ARFID presented in their sample, including: selective eating (28.7%), generalized anxiety (21.4%), gastrointestinal symptoms (19.4%), a past history of vomiting or choking (13.2%), and food allergies (4.1%). Kurz et al. (2016) categorized patients with ARFID in a different manner but also found a high percentage of patients presented with selective eating habits. This study also identified patients with poor food intake related to an emotional disturbance (e.g., anxiety) as well as patients who avoided food due to some specific fear (e.g., choking) (Kurz, van Dyck, Dremmel, Munsch, & Hilbert, 2016). To date there has been one study examining ARFID in adults and there were some differences found from pediatric patients. Specifically, in this study patients with ARFID were all female and most had poor food intake due to emotional difficulties with a smaller percentage due to gastrointestinal complaints (Nakai, Nin, Noma, Teramukai, & Wonderlich, 2016).

Picky Eating vs. ARFID

It is important to note that selective or picky eating is fairly common, especially among younger children (Nicely et al., 2014). Children may avoid foods due to taste, smell, or texture and numerous parents have experienced a phase when their child only ate a select number of foods or refused to eat entire food groups. For many children this will resolve or children will still be able to meet their nutritional needs in spite of low variety of foods consumed. However, when picky eating results in failure to gain weight, significant weight loss, nutritional deficiencies, or issues with psychological functioning, then a diagnosis of ARFID is likely appropriate.

How Can I Tell if My Child is At Risk: Tips for Parents

Some of the reasons for disrupted eating patterns may be more straightforward for parents to identify than others. For example, ARFID symptoms are easier to detect when the child experiences a specific incident such as a traumatic choking episode or a period of vomiting that results in food avoidance and significant anxiety related to eating. Knowing when picky eating or gastrointestinal complaints with food avoidance cross the line into ARFID may be more challenging. The most tangible warning sign for parents is weight loss or lack of weight gain. Many parents do not regularly weigh their child but may notice that their child’s clothing has become baggy, they appear thinner, or they are not growing at a similar rate as their peers. As mentioned above, many children go through a period of picky eating which may be worrisome for parents. Fortunately, picky eating is not necessarily a problem unless it results in health issues or interferes with the child’s functioning in a significant way. When gastrointestinal symptoms accompanied by significant weight loss have been evaluated by a physician and found not to be due to an underlying medical condition, ARFID may be considered. Other warning signs include increased parental frustration that eating has become a “battle” due to their child’s anxiety about consequences of eating (e.g., nausea), narrowing of food preferences, or apparent lack of interest in eating. Parents also may be shocked to find that their child is hiding/throwing away food instead of eating it or not being truthful about the amount of food eaten due to the child’s anxiety about eating.

How Can I Tell if My Patient is At Risk: Tips for Physicians

Given the weight loss and potential medical complications associated with ARFID, physicians may be the first point of contact for these patients and their parents. Physicians may notice that a child has a persistently low percentage median body weight, has “fallen off” of his or her typical weight/growth curve, or that his or her weight/growth curve is trending down (Bryant-Waugh, 2013; Fisher et al., 2014). More specifically, examination of the child’s body mass index (BMI) will help determine if there has been significant weight loss, failure to gain weight, or failure to grow in height at the expected growth trajectory. However, other times clues may be less obvious such as slowly becoming increasingly selective with foods, decreased interest in eating, eating smaller and smaller amounts of food, increased gastrointestinal complaints or general somatic complaints (e.g., headaches, not feeling well, etc.) related to eating, or increased anxiety around meal times. Thus, when physicians notice weight loss or failure to meet expected growth, it is important to inquire further about a child’s feeding patterns, any changes in eating habits, and what seems to be impeding eating such as somatic symptoms or anxiety. Asking parents to bring in a food log or describe their child’s typical food intake can help physicians determine if nutritional needs are being met. Physicians should also look out for medical indicators of nutritional deficiency or malnutrition (Bryant-Waugh, 2013). Signs that indicate the need for hospitalization for medical stabilization include severe malnutrition, bradycardia, hypotension, hypothermia, orthostatic changes in heart rate or blood pressure, or acute food refusal (American Academy of Pediatrics, 2003; Peebles et al., 2010).

How is ARFID Treated?

Like other eating disorders, ARFID has potentially serious medical consequences and early intervention is important. When a child experiences weight loss or failure to maintain expected growth rate, it is important to consult with a medical professional to rule out any medical issues that may be causing the weight loss. This is especially true for children with gastrointestinal complaints accompanied with significant weight loss. Once possible medical explanations for the weight loss/failure to maintain expected growth are ruled out, early referral to providers who specialize in the treatment of eating disorders is recommended. Treatment of ARFID typically involves a multidisciplinary team including a mental health professional who specializes in eating disorders, a physician, and often a dietitian. Children with significant weight loss should be closely monitored for nutritional deficiencies, electrolyte imbalances, cardiac sequelae, and orthostasis throughout treatment. Some may initially require nutritional rehabilitation in a hospital or intensive treatment program.

Since this is a new diagnosis, few treatment studies have been conducted on the treatment of ARFID specifically. Fortunately, early case reports (Bryant-Waugh, 2013; King, Urbach, & Steward, 2015; Norris, Spettigue, & Katzman, 2016) and a recent pilot study (Sharp et al., 2016) have demonstrated effectiveness in treating ARFID. It also is important to remember that clinicians have been treating patients with ARFID for years, even though it was called EDNOS. Thus, there is a much larger research base on the treatment of feeding/eating issues that treatment providers can utilize when developing a treatment plan for a patient with ARFID. These include but are not limited to family-based treatment for AN (the Maudsley approach), cognitive behavioral therapy for anxiety symptoms, and behavioral treatment for feeding issues. Now that the diagnostic criteria for ARFID has been laid out, researchers can focus on tailoring existing treatment techniques to this population as well as developing novel treatments specifically for patients with ARFID.

One factor that appears to be key is matching the type of treatment to the presenting features. An essential first step is accurately identifying the reasons for poor nutritional intake. For example, a patient who is primarily not eating due to fears of choking would likely benefit from methods that have proven to be effective in the treatment of anxiety/phobias (e.g., cognitive behavioral therapy). For patients who present with sensory issues related to eating, behavioral techniques may be beneficial. A child with significant anxiety about gastrointestinal pain or vomiting after eating may benefit from the family-based therapy approach of parents taking responsibility for weight restoration coupled with individual therapy focused on anxiety management.

Conclusions

With the addition of ARFID to the DSM-5, this subset of patients with significant eating disturbance who lack concern about weight or body shape has been formally recognized. However, symptom presentations within this category are broad and range from children with a long history of selective eating to acute food refusal due to a traumatic incident involving food or vomiting. Parents and physicians should be vigilant for changes in weight or eating habits as well as chronic low weight/lack of growth and selective eating. Treatment should include medical evaluation for nutritional deficiency and malnutrition and close follow-up by a multidisciplinary team. It also is important to match the treatment to the reason for the eating disturbance. With proper evaluation and follow-up, the prognosis for patients with ARFID improves.

Other Specified Feeding or Eating Disorders (OSFED): Your Symptoms Have a Name!

By Kathryn Coniglio

Mary is a 35 year old woman who is of normal weight. She frequently diets, going through bouts of restricting calories for a few days, and then binges on her “forbidden foods.” Mary constantly worries about food and calories, even when she is busy doing things she likes, like being in the company of friends or reading a book. Mary is worried she may have an eating disorder, so she tries to find more information online about what her diagnosis might be. She quickly realizes she does not meet criteria for anorexia nervosa (AN), bulimia nervosa (BN), or binge eating disorder (BED), which are the only eating disorders Mary has ever heard of. Mary feels confused and disheartened.

Does Mary’s experience sound familiar to you? If it does, you are not alone. Actually, Mary very likely does meet criteria for an eating disorder – OSFED. Other Specified Feeding or Eating Disorder (OSFED) is more common than the other, more commonly known eating disorder diagnoses, like AN, BN, or BED. In fact, in our outpatient eating disorders clinic in Boston, OSFED makes up about 25% of all diagnoses.  Clinicians and researchers used to think of OSFED as a kind of subthreshold eating disorder (ED), but in fact research shows that individuals with OSFED have similar levels of impairment and share similar genetic risk factors to individuals with full threshold EDs (Fairweather-Schmidt & Wade, 2014). Our clinic frequently receives calls on our intake phone line from people of all ages, races, and genders who seek an evaluation, but who qualify their symptoms by saying “I am not underweight so I don’t know if I really have an eating disorder” or “I don’t binge every single day, so I’m not sure if this is really the right place for me.”

AN and BN are extreme examples of eating disorders, but are relatively rare, with lifetime prevalence rates at only around 1.7% and 0.8%  respectively (Smink et al. 2014). Due to the media attention these disorders receive, some people with clinically significant eating problems (but who don’t meet criteria for AN or BN) may not realize that their symptoms, too, have a name. The often impairing and distressing symptoms that these individuals are experiencing are well deserving of clinical attention and we are always glad they called us for help.

Luckily, the newest (5th) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included an improved classification, featuring broader diagnostic criteria, for diagnosing eating disorders. For example, many individuals who normally would not have met criteria for AN or BN in the 4th edition (DSM-IV) would now receive such a diagnosis in DSM-5 (Quick et al. 2014). DSM-5 also improved on the criteria for OSFED. Where DSM-IV labeled eating disorders that did not fit into any category as eating disorders as “Eating Disorder Not Otherwise Specified (EDNOS)”, DSM-5 replaced this category with OSFED.

OSFED includes five specific example presentations. Atypical anorexia nervosa (OSFED-AA) is a type of OSFED that encompasses individuals who have a fear of weight gain and body image disturbance, but who are not underweight. OSFED – Purging disorder describes individuals who engage in purging but do not engage in bingeing, while OSFED – Night eating syndrome is likely appropriate for an individual who wakes up, after already having fallen asleep, and consumes a large amount of food. Two OSFED categories capture the symptoms of individuals who are both bingeing and purging (OSFED-BN) or just bingeing (OSFED-BED). But perhaps binge frequency isn’t as important in determining impairment; one study found that feeling a loss of control while eating, rather than binge frequency and size, is a better predictor of clinically significant binge eating (Vannucci et al. 2013).

Some individuals may be experiencing distressing eating symptoms or attitudes, but still might not fall into any of these categories. For these individuals, a diagnosis of OSFED-Other can be assigned. A 2014 study found that, among patients presenting for outpatient eating disorder treatment, two thirds would have been diagnosed with EDNOS in DSM-IV, whereas just over 1% had a diagnosis of Unspecified Feeding or Eating Disorder (UFED) in DSM-5, which is to be used when not enough information can be obtained in order to assign a more specific diagnosis. In our clinic, both OSFED-Other and UFED are becoming more rare, given the multiple broad examples of symptom presentations offered in the OSFED category.

So, overall, DSM-5 succeeded in adding specificity to various symptom pictures. Some medical professionals argue that OSFED categories may unnecessarily pathologize symptoms, like negative body image or dieting, that many individuals may experience to some degree over the course of their life. However, most patients are relieved when a clinician can assign a diagnosis to the suffering they are experiencing; it is often validating for an individual’s suffering to be recognized and named. Further, from a clinical standpoint, treatment can be formulated to address only the symptoms the patient is currently experiencing, rather than a “one size fits all” model.

A 2013 longitudinal study found that individuals with OSFED-BN and OSFED-BED eventually developed BN or BED over the course of the 8-year follow-up (Stice et al. 2013). Therefore, not only are these OSFED categories useful for patients, they may help clinicians identify who might be at risk for developing another eating disorder diagnosis later on.

The good news is that individuals with OSFED can benefit greatly from treatment. A popular evidence-based treatment for eating disorders is enhanced cognitive behavioral therapy (CBT-E; Fairburn 2008), which has been shown to alleviate symptoms in individuals with OSFED-BN as well (Waller et al. 2014). Researchers are also working on other ways to disseminate treatment to individuals who have OSFED. For instance, a randomized controlled trial of an Internet-based intervention showed that, among individuals with OSFED, both eating disorder attitudes and behaviors (like bingeing and purging) were significantly reduced (Jacobi et al. 2011) compared to the control group.

If you would like to learn more about OSFED, Almost Anorexic: Is My (Or My Loved One’s) Relationship with Food a Problem? is a helpful, reader-friendly guide written by Dr. Jennifer J. Thomas, the co-director of the Eating Disorders Clinical and Research Program at Massachusetts General Hospital. In sum, if you think you might have OSFED, please don’t hesitate to seek treatment. Your experiences and symptoms have a name and are valid and worthy of attention and because they are treatable. Instead, you could follow Mary’s example: she went to see a psychologist and was diagnosed with OSFED. He recommended she enroll in weekly sessions of CBT-E, after which Mary saw significant improvement in her binge frequency and her attitudes about food and eating in general.

Lose Hate Not Weight

By Virgie Tovar

It took me years to realize that the horrifying and vitriolic treatment I have received in this culture because I am a fat woman is a product of bigotry – not a product of my personal failure be thin.

It is very difficult in this cultural moment to imagine that anti-fat bias – in medical, personal, romantic, or professional settings – is morally inexcusable because it is maintained and substantiated through discourses of public health and personal wellness. I assure you, however, that marginalizing people because of their size is without a doubt a morally inexcusable act. The “demand for health” is made in a vacuum, willfully refusing to engage with the reality that stigma creates shortened lifespans and lowered quality of life.

For a very long time I believed that fatphobia was my fault. I believed that doctors and peers, strangers on the street, and advertisers had the right to shame, deride, and humiliate me because I had fundamentally failed at fulfilling an acceptable cultural expectation. I realize now that it is not acceptable to expect people of all genders, races, and cultural backgrounds to conform to one body type. Now I see the danger of a demand for homogeneity.

Currently, we believe that the solution to fatphobia is for all fat people to become thin people. This belief positions fatphobia as natural and inevitable, neither of which are true. Fatphobia is a learned ideology. Now that I am a fat activist who refuses to engage in weight-loss measures, I realize how absurd it is that the onus of bigotry be placed on the victims and not the perpetrators. It baffles me that the fatphobia apologists within the medical community hide behind empiricism, when the most obvious empirical truth is that it takes considerably fewer resources to stop being a bigot than to stop being a fat person.

I have firsthand experience with the ways in which gender and race compound fatphobia. Fatphobia maps onto preexisting inferiority ideologies taught to women and people of color. As the girl child of Mexican immigrants, I realize now that I saw dieting as both a behavior that was appropriate and desirable for my gender, as well as a behavior that indicated my desire to assimilate into mainstream (white) culture. I internalized the belief that my body was inferior because the boys at school told me it was, and they felt the right to control and police my size because of the misogyny they themselves had internalized. As Sander Gilman points out in his book Fat: A Cultural History of Obesity, “Dieting is a process by which the individual claims control over her body and thus shows her ability to understand her role.” 

Since creating Babecamp (www.virgietovar.com/babecamp.html) – a 4-week online course designed to help people who are ready to “break up” with diet culture – in Winter 2015, I have taught almost 200 people how to deconstruct the history and mechanisms of diet culture. I work primarily with women, and so many of them believe they have a problem with food. In actuality, for many of them, their relationship to food is a metaphor for their relationship to mainstream culture.

I recently wrote the following about my relationship to food and my periods of self-enforced starvation in an essay for art magazine, Art21 (http://blog.art21.org/2016/07/05/a-fat-brown-babes-guide-to-exposure-in-five-acts/):

“I came to realize that my starvation was a metaphor. My plate was the ring, the battlefield, a tiny physical space (my whole world) where I could live out all the unnecessary satisfaction I had inherited, that I sensed all around me, in real time. I was being starved emotionally and spiritually—no meat, just bones—and so of course I learned to accept it and do it and love it. Eating meant freedom, which I had no appetite for. Each bite represented the most unfeminine of acts to me. Bites were the units I used to measure the distance to my biggest dreams. Food was failure.”

In response to the current cultural paradigm around fatness, I have devised a campaign called #LoseHateNotWeight, which focuses on the idea that it is not weight that needs to be shed but rather the ideology that we are never good enough (self-hatred). I argue that fatphobia is maintained by the drive for homogeneity and its resulting hate-based systems like racism, classism, and sexism. And so, if self-acceptance and self-love are our goals, we cannot ever achieve them through self-hatred. Weight loss does not lead to the positive emotional outcomes we expect because there is no amount of weight we can shed in order to change an ideology. We must change our minds and our hearts, not our waistlines, to get what we want most from life.

Defining Energy Deficiency in Sport: Beyond the Female Athlete Trials

By: Laura J Moretti, MS RD CSSD LDN

Drive, passion, and determination are characteristics that enable athletes to push themselves both mentally and physically to excel in their respective sport. Athletes, especially elite athletes, are well akin to the notions of sacrifice in their lives and working hard to achieve their goals. In such a population, particularly adolescents and young adults, it is essential to ensure that these athletes are providing their bodies with the adequate nutrition to support their high levels of training and overall health. Energy availability is calculated as the energy intake (EI) less the energy cost of exercise relative to fat-free mass (FFM), in other words a failure to intake enough calories to support exercise expenditures.  A decrease in EI, increase in exercise expenditure, or a combination of the two, can have a negative impact on an athlete’s performance and overall health.

Relative Energy Deficiency in Sport, otherwise known as RED-S, was first introduced by the International Olympic Committee (IOC) in 2014. RED-S is a syndrome that encompasses the myriad negative impacts of energy deficiency on both male and female athletes. Energy Deficiency in sport has often been thought to be a “female athlete only” problem known as the Female Athlete Triad (menstrual function, bone health, and energy availability). Although the components of the Triad are included in the RED-s model there is also a much broader range of symptoms that may be caused by energy deficiency in sport that do not discriminate between the sexes (figure 1). The RED-s model includes the negative impact that energy deficiency may have on gastrointestinal, immunological, endocrine, metabolic, hematological, and cardiovascular systems. RED-S can also have a psychological impact as well as cause a delay in growth and development, particularly in adolescent athletes. The negative impact of energy deficiency on bone development can cause stress injuries and some may be irreversible, potentially leading to osteoporosis.  The negative performance effects of energy deficiency include decreased endurance, increased recovery time, irritability, difficulty concentrating, and a decreased training response (figure 2).

Although disordered eating and/or eating disorders are sometimes the cause of energy deficiency, it is important to note that it may also be a lack of knowledge on the athlete’s part for the number of calories they need to support their expenditures. A Registered Sports Dietitian (RD CSSD) plays a valuable role in estimating the needs of an athlete while considering resting metabolism and caloric expenditures from training.  These professionals can also educate the athlete on exercise metabolism as well as fueling strategies for before, during, and after competition to meet elevated energy needs.

If an athlete is found to have a clinical eating disorder or disordered eating, a multidisciplinary approach is recommended. The treatment team should consist of a physician, psychologist or psychotherapist, registered dietitian, and in the case of an athlete, may also include a physical therapist, athletic trainer, and/or coach.  Throughout treatment it can be helpful to closely involve the athlete’s coach so that the individual feels supported by not just his/her family, but also his/her athletic family, which can lead to a better prognosis and cooperation with treatment recommendations. It is also very helpful to have a treatment contract to be shared with the athlete, members of the coaching staff, and any other necessary individuals to eliminate confusion around level of activity, return to play, and other recommendations from the clinical team.

The signs and symptoms of RED-S vary athlete to athlete. However, some common symptoms for low energy availability may include: excessive fatigue, muscle loss, frequent illness or injury, stress fractures, menstrual dysfunction, inability to recover, and decrease in performance.  It is important for coaches, trainers, and parents to be aware of these signs and symptoms to be able to intervene early. Early intervention is especially important for adolescent athletes since they are in their peak growth years.  Education of young athletes around proper fueling practices can help prevent injury, promote growth, and boost overall performance.

About the author:

Laura Moretti, MS, RD, CSSD, LDN, completed a Master’s Degree in clinical nutrition as well as her didactic program in clinical dietetics at New York University’s Steinhardt School of Education, Department of Nutrition and Food Studies. She completed her dietetic internship at New York-Presbyterian Hospital including intensive training at the Weill Cornell Medical Center inpatient eating disorder treatment program. Laura recently moved to Boston from New York City to join the Sports Medicine Team at Boston Children’s Hospital where she is also the Dietitian for the Female Athlete Program. She previously worked as the Primary Nutrition Therapist at Columbus Park Collaborative and Appleman Nutrition in New York City. She possesses a specialty in sports performance based nutrition as well as treating low energy availability, disordered eating, and eating disorders in athletes.  Laura has an extensive amount of experience in consulting and collaborating with local colleges, universities, professional sport, and dance facilities. She also is the consulting RD for the Boston Ballet Company. Laura is an active member of the Academy of Nutrition and Dietetics, International Academy of Eating Disorders, Massachusetts Dietetic Association, Collegiate and Professional Sports Dietitian Association, Co-Chair of the AED Sport and Exercise SIG, and the Sports, Cardiovascular, and Wellness Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics.  On a personal note, Laura is a competitive triathlete as well as a Boston Marathon Qualifier.

References:

1. Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. The IOC consensus statement: beyond the Female Athlete Triad– Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014 Apr;48(7):491-7. doi: 10.1136/bjsports-2014- 093502. PubMed PMID: 24620037. http://www.ncbi.nlm.nih.gov/pubmed/?term=red-s+bjsm
2. Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A, Ackerman K. RED-S CAT. Relative Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT). Br J Sports Med. 2015 Apr;49(7):421-3. PubMed PMID: 25896450. http://www.ncbi.nlm.nih.gov/pubmed/?term=red-s+bjsm

Athletes and Eating Disorders: Redefining an Injury and Expanding Identity in Treatment

By Riley Nickols, Ph.D.

In the Victory Program at McCallum Place, athlete-patients are regularly reminded that an eating disorder is an injury – a metabolic injury.  Similar to most physical injuries, eating disorders require proper treatment, rest, and rehabilitation to facilitate healing before it is safe and appropriate to return to sport.  If an eating disorder is conceptualized as an injury, it can help to best inform treatment considerations (e.g., how and when to integrate training during treatment).  Additionally, it is important to recognize that an eating disorder is an injury so that expectations during treatment and upon return to training or sport can be discussed and modified if needed.

Upon return to sport, a false sense of health and wellness can inappropriately be attributed to an athlete-patient by coaches, teammates, and sports medicine personnel due to the athlete-patient’s seemingly improved physical appearance after obtaining treatment to address complications from an eating disorder. Unlike a visible representation that can be apparent after an athlete sustains certain injuries (e.g., needing crutches after ACL surgery), a metabolic injury that results from an eating disorder is not always visible by the naked eye and, as a result, an athlete-patient may not appear as though he or she is still injured.  Although metabolic injuries, such as eating disorders, can sometimes be more covert and the implications might be less observable compared to musculoskeletal injuries, individuals are in significant danger of relapse if treatment, support, and parameters upon returning to sport are not appropriate and consistent.  Therefore, it is essential that coaches, athletic trainers, and sports medicine personnel are thoroughly informed by the athlete-patient’s treatment team about specific recommendations on how to best support an athlete-patient’s return to sport.

Similar to musculoskeletal injuries in sport, there are significant risks when sport training is incorporated too aggressively during eating disorder treatment as the athlete-patient remains physically and psychologically vulnerable.  Additionally, a heightened risk for re-injury or relapse exists if sport training is introduced in an inappropriate or unsupported manner during the eating disorder treatment process.   As such, it is imperative that a treatment team is sensitive and informed of how to best facilitate and support sport training into an athlete-patient’s treatment.  Eating disorder treatment providers should remain current on recent research addressing recommendations for incorporating exercise into treatment and, if needed, obtain consultation from other experienced providers.

A serious injury can be both physically and psychologically traumatic for an athlete.  A multitude of challenges are likely to follow after an athlete experiences an injury.  For athletes who devote an immense amount of time, energy, and emotion to their sport and define their self-worth by their performance and success in athletics, a serious injury can be psychologically devastating.  An athlete can experience a loss of identity as a result of needing to halt participation in sport due to an injury or eating disorder.  An athlete is likely to encounter significant difficulties, especially if identity is largely, or entirely, comprised of “being an athlete” when participation in sport is abruptly stopped due to an injury (including an eating disorder).  Specifically, if perceived value and worth are largely contingent on sport participation and accomplishments, an individual’s identity can be threatened when sport participation is disrupted by injury or when sport participation ends (e.g., retirement).

The need to abstain from sport training or competition can sometimes be similar to the stages of grief (i.e., denial, anger, bargaining, depression and acceptance; Kubler-Ross, 1969), therefore, providers must demonstrate sensitivity to the challenges the athlete-patient is likely to experience during treatment.  Before identity is explored in treatment, it is critical the athlete-patient is able to mourn the temporary (or permanent) loss of sport.  If an athlete-patient is not allowed to grieve the loss of sport, efforts to address his or her identity in treatment can inadvertently be interpreted as being dismissive of a distressing experience.  Individuals who are either temporarily or permanently not able to participate in sport can perceive their identity as “an athlete” to no longer exist since they are not currently competing in sport.  The factors that characterize an athlete are well-established, enduring traits that persist in the midst of an injury or after competitive sport participation ends.  Recognizing that “being an athlete” is a trait, rather than a state, can be powerful in treatment, especially when an athlete-patient is unable to compete in sport or is not performing up to expectations.

A treatment team should be supportive and sensitive to the important role of sport in an athlete-patient’s life.  In conjunction with supporting an athlete-patient’s identity as an athlete, an athlete-patient has a unique and important opportunity to develop a more expansive identity during treatment.    With the help of an attuned clinician, an athlete-patient can recognize and develop other parts of his or her identity (e.g., sibling, son/daughter, cousin, student, friend, volunteer) that might have previously been superseded by an all-encompassing athlete identity.

The ability to develop a more robust identity and self-representation can help an individual securely answer questions such as, “Who am I without my sport?” when continued sport participation is in jeopardy or ends.  This process is not intended to decrease the importance of sport in one’s life, but rather to increase the other parts of oneself that have been neglected or minimized in proportion to an individual’s athlete identity.  When an individual is able to cultivate a broader sense of self, they are more likely to experience the setbacks and success in sport more easily than if their identity is solely as an athlete.

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.