James is 31-year-old man, a former high school wrestler and now a participant in endurance sports, who is seeing Dr. Kerr for the first time at the prompting of his internist because of concerns for an eating disorder. James tells Dr. Kerr that he is sure he does not have an eating disorder, but that he would be grateful if Dr. Kerr had any suggestions for books he could read about controlling his food intake. James goes on to report that he was a successful varsity wrestler in high school, competing in a weight class at least 15 lb lighter than he felt his body would naturally have been. He maintained his weight during wrestling season (115 lb, height 5′7″; BMI 18) by drastically cutting calories before meets, and other techniques widely used by others on the team, such as forced sweating through working out in hot conditions/heavy clothing, diuretic use, and occasionally self-induced vomiting if he had eaten too much or after having a few beers (“that’s a lot of calories!”) at a party.

After an injury halted his wrestling career in college, he relaxed his eating and exercise, and his weight slowly crept up over the next five years to 180 lbs. In his mid-20s, frustrated with the extra weight he was carrying and unsatisfied in his work and personal life, he began cycling with a friend from work (“a total endurance junkie”). He increased his cycling to 100-mile rides and then began running and swimming with the hopes of doing triathlons. He has competed in a “half Ironman triathalon” (1.2-mile swim, 56-mile bike ride, and 13.1-mile run) and plans to begin training for a full Ironman soon.

He reads a lot about diet and optimizing his “racing weight” and thinks that at his current weight of 150 lb he is probably about 7–10 lb above this “ideal” weight that would enhance his performance. He is frustrated that he cannot seem to drop his weight lower, despite the number of miles he cycles, runs, and swims every week. He describes a diet that is relatively low in carbohydrates and high in protein and (mostly) healthy fats. With some prompting, he admits that one or two times a week he will get “so hungry” that he will eat a lot of starchy food late at night, such as 2 bags of chips or a large pizza.

Occasionally he will self-induce vomiting after these episodes, explaining that he is concerned about how the ingested food and water weight will affect his next workout. He will try to restrict his food intake more the next day but admits that sometimes this makes him more likely to overeat again. He drinks minimal alcohol. He denies feeling “fat,” but he says he will look at himself in the mirror some days for 10 or 15 min, inspecting every angle and chastising himself for areas that do not look toned enough or telling himself that he does not look “like an athlete.”

Preferred diagnosis: No diagnosis.

James is a man who most likely does not have a diagnosable eating disorder; however, he engages in disordered eating that could put him at risk, physically and emotionally, and thus could benefit from clinical attention.

James’s story is a fairly common one—a former competitive athlete who stops competing due to injury, a change in priorities, or awareness of limitations of his potential, who then reengages in sport later in life with all the drive of his former athletic self. In the intervening years, the individual’s intense and somewhat compulsive nature may be gratified in other ways, such as through long hours at work or aggressive engagement in recreational activities (parties, heavy drinking, drug use, etc.). In the context of rediscovering an athletic focus of attention, the person may redirect much of that energy back into physical achievement, becoming increasingly focused on performance enhancement, which—in sports—means a focus on the body. In endurance sports (as discussed in Chap. 5), performance can be directly correlated with a lean and light body composition. The competitive endurance athlete will therefore aim to optimize lean body mass and minimize unnecessary weight. This will ideally be accomplished through an optimal balance of “calories in” and “calories out,” involving the burning of calories during training and monitoring food intake. Extra measures may be taken by the athlete if his or her weight remains higher than what he or she believes would be best for performance; this might include further reduction of calorie intake or burning excess calories through additional exercise beyond the normal training routine. This is where the athlete may begin to walk (or, perhaps, more aptly stated, “run”) the fine line between weight loss for performance enhancement and the development of a pattern of disordered eating and exercise. Preoccupation with weight loss or weight maintenance may lead to more aberrant behaviors, such as self-induced vomiting, or laxative or diuretic misuse. The individual may also become more fixated on body image. The focus on numbers on the scale or inches on the measuring tape, which originally had been a means to the end of increased performance, may get distorted over time, becoming the goal, itself.