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Behavioral Contracting in the Treatment of Eating Disorders

David A. Brubaker, MD; John J. Leddy, MD


In Brief: Team physicians frequently encounter athletes who have eating disorders. Behavioral contracting may be an effective tool for motivating these patients to implement nutritional changes. An effective contract must be built on five important principles: a collaborative physician-athlete relationship developed over time, patient involvement in setting the terms, appropriate outcome and process goals, a system for monitoring progress, and clearly defined consequences that will be carried out consistently if the contract is broken. As we show, failing to apply basic contracting principles can render treatment ineffective.

Disordered eating is a common problem among athletes.1-3 While the exact prevalence is unknown, studies suggest that 15% to 62% of female athletes may struggle with disordered eating,2 and male athletes are also affected (eg, wrestlers trying to make a lighter weight class, runners who think extra weight will slow them down). Because of the complex etiologic picture, including sociocultural, psychological and physiologic factors, management of eating disorders is best carried out by a multidisciplinary team of care providers who can address medical, nutritional, and psychological components of the illness.1,3,4

Team physicians should be skilled in recognizing (table 1) and treating eating disorders in athletes.1 As part of a comprehensive treatment plan, contracting may be an effective tool for motivating patients to implement behavioral change.3,5,6 Behavioral or nutritional contracting may best be done by a mental healthcare provider or nutritional counselor. In certain circumstances, these resources may not be readily accessible (eg, in a rural setting), and team physicians, many of whom may not have had adequate training in contracting, may find themselves in the position of applying this technique themselves. Although behavioral contracts alone are not adequate treatment for patients who have eating disorders, a full review of eating disorder management is beyond the scope of this brief report. Behavioral contracting is one aspect of care that can undermine the rest of the treatment program if not done properly (see "An Illustrative Case," below).

TABLE 1. Common Signs and Symptoms of Eating
Disorders in Athletes3-5

Warning Signs
Compulsive exercise outside one's prescribed training program
Frequent criticism of one's body
Frequent trips to the bathroom
Rapid weight loss
Secretive behavior
Social isolation
Wearing baggy clothing

Common Symptoms
Cold intolerance
Decreased concentration
Hair loss
Lightheadedness or dizziness

Common Clinical Signs
Dry skin
Lanugo hair
Parotid gland enlargement
Peripheral edema
Stress fractures
Tooth enamel erosion

Weighing the Options

Clearance for sports participation is often the source of much anxiety for both athletes and team physicians. Although participating in sports adds pressures that may perpetuate or exacerbate existing disordered eating behaviors, it is important to remember that sports do not cause eating disorders and to recognize the potential threat to athletes' self-esteem if they are prohibited from participating.7 On the other hand, participating in sports will increase energy requirements that, if not met by adequate caloric intake, can have potentially dangerous medical consequences.1-4

Behavioral contracts may be a useful tool to determine clearance for sports participation. Although the overall goal of treatment is to change underlying behavior and to restore healthy body image, contracts based on weight gain have been suggested as a means to keep athletes participating in sports while holding them accountable for meeting energy requirements.3,5,6

Difficulties can arise from a poorly negotiated contract, and the following five principles must be applied in order to make this technique effective.

Principle 1: Allow time for the development of a therapeutic relationship. An initial commitment to change is the foundation of a successful behavioral contract.8 In this case on page 17, it was apparent at the first encounter that this patient lacked insight into her problem and felt little need to change. The contract established on this visit was unlikely to be effective. Though the patient was obviously struggling with a restrictive eating disorder, physical exam and lab data indicated that she was clinically stable and was in no immediate medical danger. Because of these findings, delaying the written contract by several weeks, while continuing to meet with the patient, would have been appropriate. More time for discussion and education would have allowed a stronger therapeutic relationship to develop7,9 and might have increased her understanding of her illness and how it might impair performance. Helping her develop insight into her illness prior to developing a written agreement would have helped to increase her commitment to the contract.

Principle 2: Involve the patient in the development of the contract. The agreement must be as much the patient's contract as it is the physician's.9 If the patient feels imposed upon, the agreement may exacerbate an underlying sense of being out of control and alienate the patient from the physician. Again, time is required to establish a relationship of cooperation and trust. In the end, however, if this patient felt that she had collaborated in establishing the terms of the contract, compliance may have been improved.

Principle 3: Include appropriate outcome and process goals in the contract. The weight goals in this case are the outcome goals. Although the rate of weight gain outlined in this contract is consistent with recommendations from the American Psychiatric Association,4 it would have been more appropriate to emphasize weight maintenance rather than weight gain. For patients whose weight is within 10% of ideal body weight (ideal body weight [IBW] for women = 100 lb + 4 lb/in. for each inch over 5 ft; IBW for men = 110 lb + 5 lb/in. for each inch over 5 ft), no limitation of activity is indicated.4 Body mass index tables may also be used to calculate a healthy weight. If weight is more than 20% below IBW, patients should be restricted from all practice and competitive activities.10 Because she was less than 5% below IBW and medically stable, there was no need to insist on weight gain for participation in sports.

Process goals are specific behavioral or nutritional goals that help patients achieve overall outcome goals.8 No process goals were included in this contract, but there are several important reasons for including them in a contract with a patient who has disordered eating. First, giving specific incremental behavioral or nutritional goals (eg, add 1 tbsp peanut butter to lunch each day) will help the patient, in a practical way, attain the outcome goals that have been set. In addition, including process goals reinforces educational messages9 (table 2). This helps the patient understand that weight, though followed as an objective measure of energy intake, is not the underlying issue. When accessible, an experienced nutritionist or mental healthcare provider should negotiate nutritional and behavioral goals.

TABLE 2. Some Important Educational Messages for Athletes Who Have Disordered Eating4,9
Food should be viewed as the body's fuel that is necessary for optimal performance.

"Fat" is not a feeling. "Inadequate," "out of control," and "imperfect"—these are feelings that are often expressed through criticism of one's body.

Disordered eating reflects a lack of other more appropriate coping mechanisms. This is an area that can be explored during counseling sessions.

Amenorrhea is not "normal."

Lighter body weight does not necessarily translate into faster times or better performance; in fact, too much weight loss can lead to loss of stamina, strength, and concentration, all of which can decrease performance.

Principle 4: Provide a mechanism for monitoring progress toward contracted goals. Monitoring provides accountability and promotes ongoing discussion.10 In this case, monitoring was done through weekly follow-up visits with the physician for weight checks, serial examinations, symptom review, and discussion of dietary habits. When monitoring weight, it is important to maintain as much consistency as possible with time (same day each week or month), place, clothing, and scales. Clinicians must also be aware that athletes have creative ways of manipulating weight, such as drinking a great deal of water just before being weighed.

One mistake made with our patient was that counseling was not mandated as part of the contract. Despite good intentions, it sent the wrong message—that counseling was not as important as monitoring her weight. The cause of disordered eating is usually psychosocial. Without addressing psychosocial issues, contracts based on weight gain alone are unlikely to succeed. Weekly follow-up in the counseling center should have been an integral part of this contract.

Principle 5: Carry out consequences with consistency. In this case, the consequence for not meeting weight goals (restriction from participation) was implemented inconsistently. On reflection, it is clear that the patient was receiving mixed messages from the beginning. She had been sent to college with permission from her previous treatment team to participate even though she was below the designated weight at which they had agreed restriction would occur. This necessitated an immediate change in the "original" contract and set the stage for a pattern of frequent renegotiation that allowed the patient to continue participating (with intermittent periods of restriction) while continuing to lose weight—the exact opposite of what the contract was intended to accomplish. This underscores the importance of setting firm limits with clearly defined and understood consequences that will be carried out consistently if the contract is broken10; otherwise, the contract is useless. In implementing consequences, the physician must have the support of the athletic administration and coaching staff.

Take-Home Message

An effective behavioral contract must be built on sound principles. Keeping these principles in mind may enable team physicians—who sometimes must work without the help of the usual multidisciplinary team members—to successfully use the tool of contracting to elicit behavioral change and to prevent undermining a successful treatment program. Lessons learned from difficult experiences, like this one, can become the building blocks for more effective care in the future.


  1. Otis CL, Drinkwater B, Johnson M, et al: American College of Sports Medicine position stand: the female athlete triad. Med Sci Sports Exer 1997;29(5):i-ix
  2. Wilmore JH: Eating and weight disorders in the female athlete. Int J Sport Nutr 1991;1(2):104-117
  3. Sanborn CF, Horea M, Siemers BJ, et al: Disordered eating and the female athlete triad. Clin Sports Med 2000;19(2):199-213
  4. American Psychiatric Association Work Group on Eating Disorders: Practice guidelines for the treatment of patients with eating disorders (revision). Am J Psychiatry 2000;157(suppl 1):1-39
  5. Johnson MD: Disordered eating in active and athletic women. Clin Sports Med 1994;13(2):355-369
  6. Joy E, Clark N, Ireland ML, et al: Team management of the female athlete triad, part 2: optimal treatment and prevention tactics. Phys Sportsmed 1997;25(4):55-63
  7. Olmsted MP, Kaplan AS: Psychoeducation in the treatment of eating disorders, in Brownell KD, Fairburn C (eds): Eating Disorders and Obesity: A Comprehensive Handbook. New York City, The Guilford Press, 1995, pp 299-305
  8. Kirschenbaum DS, Flanery RC: Toward a psychology of behavioral contracting. Clin Psychol Rev 1984;4:597-618
  9. Position of The American Dietetic Association: nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and binge eating. J Am Diet Assoc 1994;94(8):902-907
  10. Joy E: Evaluation and treatment of disordered eating. Presented at American College of Sports Medicine Team Physician Course: part 1, St. Petersburg Beach, FL, February 2000

An Illustrative Case

An 18-year-old female freshman at a rural liberal arts college was recruited to play goalie for the school's intercollegiate field hockey team.

History. Six months prior to the season, the patient weighed 125 lb. Over the next several months, she began intense training and developed a restrictive eating pattern that resulted in a rapid 25- to 30-lb weight loss.

She had been a successful high school athlete and student with no psychiatric history. When diagnosed by her family physician as having a restrictive eating disorder, she began medical, nutritional, and psychological treatment at an outpatient eating disorder center in her hometown during the summer before field hockey season. At her final visit, 4 days before preseason training began, her treatment team decided to permit her to participate as long as she maintained a minimum weight of 104 lb. At that visit she weighed 98 lb. She left home for college expecting to play field hockey.

Preparticipation exam. The team physician met the patient at her preparticipation evaluation on the first day of preseason. She minimized her illness as "no big deal" but revealed that she was consuming only about 750 kcal/day. The patient reported no history of substance abuse or purging behaviors and denied symptoms of fatigue, depression, cold intolerance, dizziness, and constipation. She had been amenorrheic for a year but had never had a stress fracture.

The patient was 5 ft 1 in. tall, weighed 100 lb, was bradycardic (heart rate, 55/min), and her blood pressure was 90/62 mm Hg with no orthostasis. The rest of her exam was normal. The patient's laboratory data revealed a normal complete blood count, erythrocyte sedimentation rate, chemistry profile, thyroid profile, electrocardiogram, and bone mineral density, and a negative pregnancy test.

Treatment at school. After reviewing her experiences from the summer, which she described as "overwhelming," a plan was devised for ongoing care. She agreed to see the team physician weekly for follow-up. A goal weight of 104 lb was set, and a written contract—upon which her participation in field hockey was contingent—was established outlining incremental (0.5 lb/wk) gains toward that end. Because of the rural location of the college, no certified dietician was accessible for regular nutritional counseling. The nearest nutritionist who had any significant experience with eating disorders was 75 miles away, and the student did not have a car.

The patient was hesitant to pursue counseling, stating that it "did no good" over the summer. Because the physician did not want to undermine her sense of control, the patient was encouraged, but not mandated, to contact the college psychologist to continue exploring issues of body image and self-esteem.

Over the next 8 weeks, her weight fluctuated between 95 and 100 lb. She was seen regularly by the team physician for weight checks, symptom review, serial exams, and basic nutritional counseling. Several renegotiations of the original contract were made, usually after a period of restricted participation in field hockey when she showed some trend toward normalizing eating habits and weight gain. A pattern of "on again, off again" participation emerged related to meeting or missing weekly goals. With about a month left in the season, it was agreed that if she maintained her weight above 95 lb she could participate, even if she lost weight during a given week.

On completion of the season, she approached the school counselor, whom she had seen once at her parents' insistence. The patient was deeply depressed and requested a leave of absence. She was referred to an in-patient treatment center near her home. After treatment, she returned to college and successfully participated in competitive field hockey.

Dr Brubaker is an assistant professor of clinical family medicine in the department of family medicine, and Dr Leddy is an associate professor of clinical orthopedics in the department of orthopedics at the Sports Medicine Institute in the School of Medicine and Biomedical Sciences at the State University of New York in Buffalo. Address correspondence to David A. Brubaker, MD, 9788 Circle Dr, Houghton, NY 14744; e-mail to [email protected].

Disclosure information: Drs Brubaker and Leddy disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.