1. Chapter 8 Education and Intervention Programs for Disordered Eating in the Active Female Jacalyn J. Robert-McComb, PhD, FACSM

2. Learning Objectives After viewing this presentation, you should have an understanding of: The importance of self-esteem in the prevention and treatment of disordered eating The importance of self-esteem in the prevention and treatment of disordered eating The transtheoretical model used to explain the process of health behavior change The transtheoretical model used to explain the process of health behavior change Athletes@Risk Prevention program Athletes@Risk Prevention program General treatment principles General treatment principles Medical criteria for hospitalization Medical criteria for hospitalization Eating disorder organizations and resources Eating disorder organizations and resources

3. Introduction Low self-esteem, accompanied with perfectionism, is a well-recognized trait of those with disordered eating and could be a precipitating factor in the development of eating disorders. The terms self-concept, self-worth, and self-image are often used interchangeably with self-esteem and are all based on self- perception. Low self-esteem, accompanied with perfectionism, is a well-recognized trait of those with disordered eating and could be a precipitating factor in the development of eating disorders. The terms self-concept, self-worth, and self-image are often used interchangeably with self-esteem and are all based on self- perception.

4. Definition of Self-esteem Self-esteem – extent to which a person feels positive about himself or herself Self-esteem – extent to which a person feels positive about himself or herself Self-esteem has 3 major components: Self-esteem has 3 major components: 1) Social identities - how individual defines him/herself in society 2) Personal dispositions – perceptions of traits, preferences, response tendencies 3) Physical characteristics – height, weight, body fat distribution, attractiveness, etc.

5. Introduction Cont’ Education to prevent disordered eating is only effective if the individual understands and accepts herself, even her limitations Education to prevent disordered eating is only effective if the individual understands and accepts herself, even her limitations Physically active women are more aware of their body and its limitations, which can lead to low self-esteem (losing a race, finishing last, etc.) Physically active women are more aware of their body and its limitations, which can lead to low self-esteem (losing a race, finishing last, etc.)

6. The Transtheoretical Model used to Explain the Process of Health Behavior Change Transtheoretical Model (TTM) – model of intentional behavior change Transtheoretical Model (TTM) – model of intentional behavior change Four concepts considered central to health behavior change: Four concepts considered central to health behavior change: 1) Stage of change 2) Self-efficacy 3) Decisional balance 4) Processes of change

7. Stages of Change Five stages of change: Five stages of change: Precontemplation – no intention to change health behaviors within next 6 months Precontemplation – no intention to change health behaviors within next 6 months Contemplation – seriously considering behavioral change within next 6 months Contemplation – seriously considering behavioral change within next 6 months Preparation – still lack commitment to change, but investigating the possibility of change within next 30 days Preparation – still lack commitment to change, but investigating the possibility of change within next 30 days Action - actively modifying problematic behavior within last 6 months Action - actively modifying problematic behavior within last 6 months Maintenance – self-control of behavior established more than 6 months ago Maintenance – self-control of behavior established more than 6 months ago

8. Self-efficacy Refers to an individual’s confidence in his/her ability to perform specific behavior, which can increase as individual moves through stages Refers to an individual’s confidence in his/her ability to perform specific behavior, which can increase as individual moves through stages

9. Decisional Balance Relates to the benefits and costs of behavior Relates to the benefits and costs of behavior Example: Eating gives me more energy, yet it might make me fat (individual might change behavior because benefit outweighs cost) Example: Eating gives me more energy, yet it might make me fat (individual might change behavior because benefit outweighs cost) Individuals who change their behaviors have positive decisional balance because the positive beliefs about the behavior outweigh the negative ones. Individuals who change their behaviors have positive decisional balance because the positive beliefs about the behavior outweigh the negative ones. The benefits increase while the cons decrease as one moves through the stages of change. The benefits increase while the cons decrease as one moves through the stages of change.

10. Process of Change Defined as a “type of activity that is initiated or experienced by an individual in modifying affect, behavior, cognition or relationships” Defined as a “type of activity that is initiated or experienced by an individual in modifying affect, behavior, cognition or relationships” Health professionals can help with process of change and the maintenance of the new behavior with follow-up support. Health professionals can help with process of change and the maintenance of the new behavior with follow-up support.

11. Athletes at Risk Program Preventative educational program for female athletes in recreational and competitive sport who are at risk for developing disordered eating, amenorrhea, and osteoporosis Preventative educational program for female athletes in recreational and competitive sport who are at risk for developing disordered eating, amenorrhea, and osteoporosis

12. General Treatment Principles Recovery unlikely without fundamental change in attitudes such as: Recovery unlikely without fundamental change in attitudes such as: Perfectionist attitudes Perfectionist attitudes Low self-esteem Low self-esteem Unrelenting pursuit of thinness Unrelenting pursuit of thinness Intolerance of mood fluctuations Intolerance of mood fluctuations Poor coping skills Poor coping skills All lead toward anorexia nervosa (AN) and bulimia nervosa (BN) All lead toward anorexia nervosa (AN) and bulimia nervosa (BN)

13. General Treatment Principles Cont’ Therapists and their personality are major therapeutic parts of treatment of patients with AN Therapists and their personality are major therapeutic parts of treatment of patients with AN Family therapy effective in younger patients Family therapy effective in younger patients

14. General Treatment Principles Cont’ Most BN patients are treated in outpatient setting Most BN patients are treated in outpatient setting Inpatient treatment recommended for patients: Inpatient treatment recommended for patients: Less than 75% of average weight, severe metabolic disturbances, suicidal feelings, or no improvement after outpatient or partial program treatment Less than 75% of average weight, severe metabolic disturbances, suicidal feelings, or no improvement after outpatient or partial program treatment Inpatient treatment continued until patient reaches healthy body weight Inpatient treatment continued until patient reaches healthy body weight

15. General Treatment Principles Cont’ Outpatient treatment: Outpatient treatment: Cognitive behavioral therapy (CBT) choice treatment Cognitive behavioral therapy (CBT) choice treatment Fairburn developed most used CBT over 18 weeks: Fairburn developed most used CBT over 18 weeks: First Stage: behavioral techniques replace binge eating with regular eating First Stage: behavioral techniques replace binge eating with regular eating Second Stage: eliminate dieting, focus on thoughts, beliefs, and values that reinforce dieting Second Stage: eliminate dieting, focus on thoughts, beliefs, and values that reinforce dieting Third Stage: maintenance of new healthy behaviors and thought patterns Third Stage: maintenance of new healthy behaviors and thought patterns

16. General Treatment Principles Cont’ Self-help (SH) Self-help (SH) Written based manual based on principles of CBT Written based manual based on principles of CBT More accessible than CBT (use without therapist) More accessible than CBT (use without therapist) 7 sessions over 12 weeks 7 sessions over 12 weeks

17. Web Resources for Treatment of Eating Disorders Targeted for Physicians The Academy for Eating Disorders (AED) The Academy for Eating Disorders (AED) Web Site: http://www.aedweb.org Web Site: http://www.aedweb.orghttp://www.aedweb.org American Psychiatric Association (APA) American Psychiatric Association (APA) Web site: http://www.psych.org Web site: http://www.psych.orghttp://www.psych.org Internet Mental Health (IMH) Internet Mental Health (IMH) Web site: http://www.mentalhealth.com Web site: http://www.mentalhealth.comhttp://www.mentalhealth.com National Association of Anorexia and Associated Disorders (ANAD) National Association of Anorexia and Associated Disorders (ANAD) Website: http://www.anad.org Website: http://www.anad.orghttp://www.anad.org

18. For additional Eating Disorder Organizations and Resources National Mental Health Association or additional resources: 1-800-969-NMHA (6642) or http://www.nmha.org/infoctr/index.cfm National Mental Health Association or additional resources: 1-800-969-NMHA (6642) or http://www.nmha.org/infoctr/index.cfmhttp://www.nmha.org/infoctr/index.cfm

19. Summary Practice guidelines for the treatment of patients with eating disorders have been developed by psychiatrists who are in active clinical practice and are available on the web at http://www.psych.org/psych_pract/treatg/pg/eating_revisebook index.cfm?pf=y. Practice guidelines for the treatment of patients with eating disorders have been developed by psychiatrists who are in active clinical practice and are available on the web at http://www.psych.org/psych_pract/treatg/pg/eating_revisebook index.cfm?pf=y. http://www.psych.org/psych_pract/treatg/pg/eating_revisebook index.cfm?pf=y http://www.psych.org/psych_pract/treatg/pg/eating_revisebook index.cfm?pf=y These guidelines were approved by the American Psychiatric Association in 1999 and published in 2000. These guidelines were approved by the American Psychiatric Association in 1999 and published in 2000. These guidelines are not intended to serve as a standard of medical care but rather provide recommendations for treating patients with eating disorders. These guidelines are not intended to serve as a standard of medical care but rather provide recommendations for treating patients with eating disorders.