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

rkreipe

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.