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Coaches, Trainers, Athletes and Eating Disorders: Connecting the Dots to Recovery
November 2, 2007
Mary Tantillo PhD RN CS Director, Eating Disorders Recovery Center of Western NY
Richard Kreipe MDMedical Director, Eating Disorders Recovery Center of WNY
Director, Child and Adolescent Eating Disorder Program, Golisano Children’s Hospital
Overview Introductions Athletes with Eating Disorders
– Medical health issues (Kreipe)– Mental health issues (Tantillo)
Panel: Four Perspectives– Coach (Wright)– Athlete (Padgham)– Trainer (Abegglen)– Parent (Patchen)
Discussion
Anorexia Nervosa(pursuit of thinness)
Insufficient energy intake
Wasting of the body
Delusion of being fat
Obsession to be thinner
Does not diminish with weight loss
Denial
Inadequate Energy Intake
Absent menses Cold hands/feet Constipation Dry skin/hair loss Headaches Fainting/dizziness Lethargy Anorexia
Disconnections Concentration Decisions Irritability Depression Social withdrawal Obsessiveness (food)
Physical health Mental health
Bulimia Nervosa(avoidance of obesity)
Recurrent, secretive binge-eating
Fear of not being able to stop eating
Awareness that eating pattern is abnormal
Depressed moods and self-deprecating thoughts
Temporary relief via avoidance of weight gain by – Fasting– Self-induced vomiting– Catharsis or diuresis– Exercise
Signs & Symptoms of Binge Eating
Weight gain
Bloating
Fullness
Lethargy
Salivary gland enlargement
Disconnection
Guilt
Depression
Anxiety
Physical health Mental health
Signs & Symptoms of Vomiting or Laxative Abuse
Weight loss
Electrolyte disturbance K
CO2
Dental enamel erosion
Low blood volume
Knuckle calluses
Disconnection
Guilt
Depression
Anxiety
Confusion
Physical health Mental health
Eating Disorders: Dispelling Myths An individual can have an eating disorder AND
be medically compromised AND have normal lab values
Some individuals starve themselves to look like they are in a “normal weight range for height and age.”
Eating Disorders occur in either sex, in any race, ethnic or socioeconomic group, in any neighborhood, at any age, at any height AND at any weight.
Dr. Kreepie
Keys, et al
The Biology of Human Starvation
U Minnesota Press
1950
Bonus question: What was Ancel Keys’ claim to fame?
Affected Biological Systems Neurologic (CNS and PNS) Skin and Hair Cardiovascular Hematologic Hepatic GI: motility, absorption Endocrine (hypothalamic)
– Thyroid– Growth hormone– Adrenal – Gonads
Musculoskeletal
Kreipe RE. Assessment of Weight Loss in the Adolescent. Ross Labs. Columbus, OH 1988. Drawing by C. Lyons, MD
Salivary gland enlargement
Submandibular
Parotid
www.thejcdp.com/issue001/gandara/introgan.htm
www.maxillofacialcenter.com/bulimia.html
Dental Enamel Erosion
- Dentin (yellow) visible beneath eroded enamel (white)- Worse on lingual than buccal surfaces
A: Less enamel loss on buccal surfacesB: Enamel sparing in gingival crevices
Erosion of enamel (white) and dentin (yellow) from persistent vomiting, resulting in tooth
decay, fracture, and loss
Muscle wasting
Lanugo
Malnutrition and Hypometabolism
Energy intake results in wasting of lean (muscle) > fat Metabolism occurs in the lean body mass>>>>>fat Energy conservation: BMR; Temp.; HR; Peripheral
blood flow; Physical activity ~70% of regained weight is lean body mass
Week 1:•Wt 91#; •S.G. 1.018;•HR: 62 70;•36.9°C
Week 5:•Wt 91#; •S.G. 1.020;•HR: 4482•35.3°Cl
Recheck Wt. (observed) and physical exam
Weekly visits
Edema
Slow Capillary Refill
Acrocyanosis
Carotenemia
www.pediatrics.wisc.edu/education/derm/tutc/69.html
Bluish discoloration of skin
Reticular (“lacy”) pattern
Asymptomatic, but often associated with low core temperature and metabolism
Livedo Reticularis
Signs of Eating Disorders for Coaches, Trainers, Friends, Parents and Loved Ones Social withdrawal Evidence of binge eating (large amounts of food eaten in brief time period) Hoarding food, empty wrappers and food containers Use of laxatives or diuretics (or boxes) Leaving the table immediately after meals Creation of complex life style, schedule or rituals to make excuses to not eat, or time for exercise or binge-purge episodes Behaviors and attitudes indicating wt loss, dieting and control of food are primary concerns
www1.ncaa.org/membership/ed_outreach/health-safety/sports_med_education/triad/triad_prevention.htm
Female Athlete Triad Usually begins with disordered eating in an attempt to
lose weight Disordered Eating
– More common in sports emphasizing leanness– Can negatively affect athletic performance
Loss of menstrual periods– Is often due to imbalance of eating and training– May be the “norm,” but is never “normal”– Can result in loss of bone; may be irreversible– If prolonged, increases fracture risk, esp. stress
Nutrition: key factor for good health Health: key factor for athletic performance
(NCAA, 2005)
Risks for Disordered Eating in Athletes
Belief that low body weight/body fat improves performance (implicit/explicit messages?)
Sport-body stereotypes Habits of good athlete eating disorder habits Presumption of health Revealing uniforms or sport attire Competitive thinness (college age & sports
performance related) Coping with pressures associated with sport
(NCAA, 2005)
Approach to Student with Female Athlete Triad
Someone in authority who has a good relationship with the athlete
Convey caring and concern, not criticism Talk privately – focus on health Listen non-judgmentally and with compassion Inform athlete of need for evaluation and plan Athlete considered “injured” until evaluation and
recommendations offered (standard policy) Confidence in evaluation and hope for return to sport Communicate with treatment team, parents (<18 yo) to
form collaborative partnership
(NCAA. 2005)
Symptomatic Athletes Are Unlikely to
Recover without TreatmentIt is Required Athlete becomes isolated, gets less support, making
disordered eating more difficult to monitor. Deterioration physically and psychologically has
negative effect on performance. Poor performance (related to self-concept) results in
increased pressure to try to improve performance. Ineffective attempts to improve performance
increases worry that others will be disappointed. Disordered eating becomes a coping mechanism
that helps athlete deal with the negative effects of disordered eating (positive feedback loop).
(NCAA, 2005)
The physical attributes of the athlete
establish the ceiling on performance,
the mental and emotional skills of the
athlete determine how close she/he
comes to reaching that ceiling.
(NCAA, 2005)
Female Athlete TriadFocus on health, not body weight or fat to:1. Nutrition – (over/under-eating, unbalanced diets, nutrient-poor foods, unusual or no schedule): need nutritional info.
2. Sleep/rest - Many student-athletes sleep <6 hrs/day, decreasing resilience and performance.
3. Substance use - (alcohol, prescription or illegal drugs, nicotine, and dietary or “ergogenic” supplements).
4. Psychological factors (cognitive and emotional) can affect performance.
A focus in these areas does not put the athlete at risk. These factors can enhance performance by improving physical and psychological health.
(NCAA, 2005)
Screening Testsfor Athletes with Eating Disorders
The Athletic Milieu Direct Questionnaire (Nagel et al., 2000); Newer test for detecting ED’s in athletes but respondents know what test is looking for
Physiologic Screening Test for ED’s/Disordered Eating Among Collegiate Female Athletes (Black et al., 2003); 18 items including:
-4 physiological symptoms (e.g., percent body fat, waist-hip ration, standing systolic BP, parotid gland enlargement)
-6 interviewer questions (e.g., dizziness, ABD bloating)-8 self report items (e.g., hours exercised outside practice,
menstrual irregularity)
Highly sensitive (87%) and highly specific (78%) for detecting athletes who either have disordered eating or ED’s
EATING DISORDERS ARE DISEASES OF DISCONNECTION
- Disconnect patient from herself and others
- Disconnect family from other families
- Disconnect family from staff
- Disconnect treatment team from one another
Disconnections
Disconnection: A disturbance in the flow of relationship that prevents or interrupts the experience of perceived mutuality and is characterized by:
Low self-worth Disempowerment Low energy, tension, feeling locked up or out Feeling confused re: the self, other, and the relationship;
intolerance of difference Wanting less connection; isolation
Disconnecting from Oneself to Maintain Connections
“In situations with family, it’s so inappropriate to have different opinions,…the smallest trace of being different makes it easier to not be liked…I was so cautious of the way I sat and the words I used when I was over there tonight. I didn’t want to make a wrong move, make the wrong comment, or even sit, walk wrong. I have to close off every part of myself when I’m with them. I have to lock it away.”
(Betty, 10/21/03)
EATING DISORDERS – DISEASES OF DISCONNECTION
Biopsychosocial Risk Factors:Biology: Serotonergic Disturbance; Starvation;
Binging/Purging
Psychology: Disconnections; Relational
mismatches
Socio-Cultural: Toxic Societal Values that objectify
women’s (and men’s) bodies and teach
us to value ourselves from the outside in
Spirituality: Hopelessness; Meaninglessness; Isolation
Signs of Eating Disorders for Coaches, Trainers, Friends, Parents & Loved Ones
Preoccupation with weight, food, calories, fat & dieting Rapid or dramatic weight loss Refusal to eat certain (“unhealthy”) foods Frequent comments about feeling fat (despite wt loss) Anxiety about being fat or gaining weight Denial of hunger Food rituals Consistent excuses at meal times Rigid exercise routine (despite illness, fatigue, injury)
RECOVERY IS ALL ABOUT CONNECTIONS:
Between the body and self With others Among all the adults who care for the student
at home and school and in the community
Mutual Relationships
Mutual relationships are characterized by
“The Five Good Things:” Self-worth Sense of energy/zest Increased clarity re: oneself, the other, and the
relationship Increased sense of empowerment Increased desire for more connection
Women with eating disorders require mutually empathic and empowering
relationships to work through the intense denial, ambivalence, and fear that keep
them stuck in the early stages of change. (Tantillo, Nappa Bitter, & Adams, 2000)
“Having an eating disorder is like being in a frying pan surrounded by horrendous flames. On the other side of those flames is recovery. My therapist and others are on the recovery side telling me to step out of the pan into the flames and to walk through the fire to reach recovery. I think to myself, “Are they nuts?!” Don’t they know how frightened I am to step into the fire? It will destroy me. I will die.This frying pan (eating disorder) is safe and protective because I know how to live in it. I know how to “be” in the pan.”
Cindy Nappa Bitter, 2001
Stages of Change Model (Prochaska & DiClemente)
Pre-contemplation: no perceived need to change, denial
Contemplation: able to consider change, ambivalent
Preparation: ready to change
Action: implementation of plan to change
Maintenance: feedback to maintain change
Supporting Change in College Health Settings: Consciousness-Raising, Helping
Relationships, and Social Liberation Provide information about
–How we get in our own way–Recovery process–Illness
Coaching/therapeutic relationship (alliance), support groups and recovered peer mentors Awareness of influence of language, environment and social norms Self-monitoring/Journaling (food, emotions, relationships) Discuss/write about how the eating disorder helps or hinders the student achieve life goals and live out values (e.g., athletic goals)
(Prochaska, Norcross, & DiClemente, 1994)
Coach and Health Care Provider Approach Validation (shame/secrecy)
Direct and specific questions Don’t assume Cognitive distortions, reasoning errors (all/nothing
thinking, overgeneralizations, negative mental filtering, etc.)
Be genuine, real (not opaque and distant) Warmth and humor Be consistent and persuasive Educate Team approach and good communication helps
avoid splitting
Potential Obstacles/Challenges in Referring & Managing Students with Eating Disorders
School personnel anxiety, lack of education and training Inconsistency/Lack of communication among school personnel (e.g., coach, health services, mental health), family, and/or outside professionals Family Shame/Assumption of blame, parental anxiety, denial, or anger
Potential Obstacles/Challenges in Referring and Managing Students with Eating
Disorders (continued) Not understanding that the Eating disorder
decreases the student’s ability to make healthy decisions (they are adults but are impaired) Lack of a trusted person to routinely eat with the student and monitor intake Lack of routine check-in meetings with all team members and student/family
Referral to and Collaboration with Other Health Care Providers (continued)
Ensure good communication with team members in school (school nurse, coach, counselors, teachers, etc.) Maintain consistency of treatment plan. Clearly identify for student and family supportive school personnel. Set up check-in times with team and student/family.Specify roles and responsibilities (weekly weigh-ins, lab work, lunch supervision, etc.) for all adults involved in treatment plan.
Collaboration among School Personnel, Mental Health Providers, and Family
Validate the burden incurred by the illness. Educate and share information. Encourage student and family to connect ion
ways that don’t involve the eating disorder. Encourage and model communication/problem-
solving skills.
Prevention Strategies for Coaches toDecrease Risks in the Athletic Environment• De-emphasize weight. • Do not compare one athlete’s body/performance to
another athlete’s body/performance (the other high performance athlete may have an eating disorder)
• Remember young women are sensitive about their weight and body image
• Enhance performance without a focus on weight • Promote development of mental and emotional
skills (imagery, positive self-talk, goal-setting, mental preparation, mindfulness, and relaxation training) .
(NCAA, 2005)
Prevention Strategies for Coaches toDecrease Risks in the Athletic Environment
• Foster mutual connections among athlete and coach/trainer, team members, and other adults/peers
• Recognize individual differences in athletes (athlete profiles describe but don’t predict)
• Increase education of athletes, coaches athletic trainers, and other sport personnel (re: DE, eating disorders, nutrition, Female Athlete Triad)
• Involvement by Sport Governing Bodies (NCAA). (NCAA, 2005)
“Lean Sports” Increase Risk for Disordered Eating and Eating Disorders
Judged sports aesthetic (diving, figure skating, gymnastics) appearance (ballet, cheerleading) endurance (distance running, ski jumping), weight-class sports (lightweight rowing,
wrestling) revealing sport attire (swimming, volleyball)
Screening Tests for Athletes with Eating Disorders/Disordered Eating
The Athletic Milieu Direct Questionnaire Nagel, D.L., Black, D. R., Leverenz, L. J., & Coster, D.C. (2000), Evaluation of
a screening test for female college athletes with eating disorders and
disordered eating. Journal of Athletic Training, 35, 431-440.
Physiologic Screening Test for ED’s/Disordered EatingAmong Collegiate Female Athletes Black, D. R., Larkin, L J. S., Coster, D. C., Leverenz, L.J., & Abood, D. A.
(2003). Physiologic Screening Test for Eating Disorders/Disordered Eating
Among Female Collegiate Athletes. Journal of Athletic Training, 38, 286-
297.