Nutrition Conditioning, Inc. Disordered Eating- Prevention, Recognition and Action The 15th FINA World Sports Medicine Congress jointly-sponsored by the

Nutrition Conditioning, Inc.

Disordered Eating- Prevention, Recognition and ActionThe 15th FINA World Sports Medicine Congressjointly-sponsored by the American College of Sports Medicine and Indiana Sports Corporation

Heidi Skolnik MS,CDN, FACSM Giants Football Team

School of American Ballet

Women’s Sports Medicine Center at HSS

Columnist, Men’s Health

Contributing Editor, SELF Magazine

On-air contributor; ESPN2’s Cold Pizza


Disordered Eating

• Define Disordered Eating vs. Eating Disorders

• Prevention and risk reduction

• Red Flags: how to identify a swimmer who maybe susceptible or already entrenched

• Intervention suggestions and a model of treatment


SPECTRUM of Behaviors, Thoughts, Feelings

DE

Anorexia Everything in between Bulimia

May or may not be ‘sub clinical’


How Prevalent?

• Estimated over 5 million Americans

• 5% females and 1% of males have anorexia nervosa, bulimia or binge eating disorder

» Position of ADA

• For female collegiate athletes estimates range from 11-32% for sub clinical DE.

• Athletes are at greater risk for DE compared to non-athletes. -Affenitio,2203


CHARACTERIZED by

• Preoccupation with food, energy intake and body weight

• Body weight dissatisfaction• Distorted body image• Undue influence of body weight on self-

evaluation• “Feeling” fat• Reduced intake or inconsistent intake of

energy, fat, and protein


GROUP ACTIVITY: Close your eyes…

(do not think about cookies for the next 30 seconds)


CHARACTERIZED by• Compulsive exercise esp. to burn

calories-

• Exercising even when injured and against advice of team Dr., coach, trainer…

• Menstrual dysfunction

• Bone injuries

• Trouble recovering form injuries


Performance hurt by

• Low energy/fatigue/staleness• Reduced strength• Reduced stamina (but not at first) • Altered body composition• Preoccupation- lack of concentration• Isolation• Shame, guilt• Increased risk of injury (overuse injuries)


Medical Implications of long term energy and nutrient deprivation

• Increased risk– Clinical eating disorder– Limited recovery from

injuries– Breakdown and overuse

injuries– Amenorrhea (reduced

testosterone) – Osteoporosis– Psychological stress


The FEMALE ATHLETE

TRIAD• Disordered Eating

• Amenorrhea

• Osteopenia/porosis


AMENORRHEA Cessation of period three or more consecutive months or failing to have menstruated by age 16


OSTEOPENIA/OSTEOPOROSIS

• Bone density formed until age 25-35

• Lifetime issue

• Increased risk for stress fractures


ENERGY DRAINENERGY DRAINStress fractures occurred more often in

dancers who had restrictive eating patterns (see below for a partial list) EVEN when matched for menstrual history and bone density!!!!

less fatmore low-calorie foodskipping mealslots of “rules” around eatingover exercising


Boys at risk too

• Body dysmorphia to triad

– Testosterone and hormonal levels off

– Especially at risk- runners, crew, diving…


What Causes Disordered Eating?Biosocial ….multifactorial

Body Image

Disturbance

Societal/

family

Self-esteem

Female Athlete

Role Conflicts

Media

Genetic

DE


Often underlying , or additional diagnosis going on:– Mood and Anxiety

Disorders– Depression– Obsessive

Compulsive Disorder– Personality Disorders– Substance Abuse

Disorders


WHICH COMES FIRST? Is there a progression from body dissatisfaction

to an eating disorder?

• “...fluctuations in ED symptoms over time are best predicted by body image” -Rosen

• “ Body image therapy by itself decreases eating guilt and binge eating.”


• Esquire magazine Poll: 54% would rather be run over by a truck than be fat. 67% would rather be mean or stupid than fat. Esquire magazine, Feb 1994


The Health of University The Health of University AthletesAthletes

Attitudes, Behaviors & Attitudes, Behaviors & StressorsStressors

267 athletes: 56% men, 44% women267 athletes: 56% men, 44% women 86.4% White, 7.5% Black, Native American 86.4% White, 7.5% Black, Native American

6.4%, Hispanic 1.9% & Asian American 1.5%6.4%, Hispanic 1.9% & Asian American 1.5% 67% men & 84 % women within acceptable 67% men & 84 % women within acceptable

weightsweights 32% of men & 8% of women in high-weight range 32% of men & 8% of women in high-weight range 27 varsity athletic teams (football, baseball, 27 varsity athletic teams (football, baseball,

basketball, swimming,, gymnastics, wrestling & basketball, swimming,, gymnastics, wrestling & diving)diving)

**Selby et al, College Health, July 1990Selby et al, College Health, July 1990


Male Male Student Athletes’ Student Athletes’ Perceptions of their Weight Perceptions of their Weight

AcceptabilityAcceptabilityQuestions Responses

Under weight

%

About Right

%

Over weight

% How do you see yourself? 18 68 14

How does your coach see you? 21 70 9

How do your peers see you? 13 80 7

How do your parents see you? 9 84 7

Selby et al, College Health, July 1990


Female Female Student Athletes Student Athletes Perceptions of Weight Perceptions of Weight

AcceptabilityAcceptability

QQQuuueeessstttiiiooonnnsss RRReeessspppooonnnssseeesss

UUUnnndddeeerrr wwweeeiiiggghhhttt

%%%

AAAbbbooouuuttt RRRiiiggghhhttt

%%%

OOOvvveeerrr wwweeeiiiggghhhttt

%%% HHHooowww dddooo yyyooouuu ssseeeeee yyyooouuurrrssseeelllfff??? 111 333666 666333

HHHooowww dddoooeeesss yyyooouuurrr cccoooaaaccchhh ssseeeeee yyyooouuu??? 555 666222 333333

HHHooowww dddooo yyyooouuurrr pppeeeeeerrrsss ssseeeeee yyyooouuu??? 555 888111 111444

HHHooowww dddooo yyyooouuurrr pppaaarrreeennntttsss ssseeeeee yyyooouuu??? 555 777444 222111 SSSeeelllbbbyyy eeettt aaalll,,, CCCooolllllleeegggeee HHHeeeaaalllttthhh,,, JJJuuulllyyy 111999999000


HIGH RISK PROFILE

• Perfectionist

• Compulsive

• Swimming is his/her identity

• Depression

• Success (esp. early success)

• Siblings who excel; family expectations high


HIGH RISK PROFILE

• Thinks “All or None” or “Black and White”

• Never complains

• Does not express feelings; family is not expressive

• Pleaser

• Poor Body Image


RED FLAGS

perfectionism

“The greatest risk factor for DE attitudes for females was perfectionism, which

crossed all athletic divisions.”-Hopkinson,2004


RED FLAGSPoor Body Image

• Wrapped in towel and last into the water

• Wearing baggy clothes or clothes to hide body

• Talking negatively about self and body, often

• Compartmentalization of body (dislike of particular body parts)


Unhealthy Eating Practices

• Deprivation• Fasting• Skipping meals• Uneducated

“Vegetarian”• Diuretics,

laxatives, vomiting• Rigid food patterns


Unhealthy eating is• Eating when not hungry• Continuing to eat after your body feels

full• Feeling out of touch with your body’s

hunger or fullness signals• Bingeing or eating excessive amounts of

food at one time.• Eat differently when alone than with

others.


PREVENTION:

OK- you may not control all influences in the world but can help to create a climate and culture within your team

Focus on function Strength and

conditioning Energy intake and

nutrition: fueling for performance

Hydration Rest and recovery


PREVENTION:Eliminate weigh ins, body

composition testing and comments about weight

If you must measure- do so only as a reference measure as part of overall physical/conditioning exam at start or end of season-NOT as a weekly/ongoing assessment—DO NOT GIVE OUT IDEAL NUMBERS


PREVENTION:Avoid comments about

appearance, good or badComment on swimming: “your stroke looks

strong” or “that was a great set” – No body talk language– No comments on weight

Focus on strength and conditioning, technique, and sports psychology which all play key roles in improving performance (not controlling body type)


Prevention

“Discipline and boundary setting have always been within the realm of coaching responsibilities, as is teaching life lessons like sensitivity. “Coaches Quarterly, USA Swimming, Disordered Eating.”

Create a culture: teach the team that negative talk is not acceptableEach swimmer can be a leader by choosing

what to talk about, which conversations to participate in and which to walk away from.


It Takes A Great Person To Make A Great Swimmer

Spiritual

Nutrition

School

Friends

Training

Family

Mental prep

Sleep

Community

Hydration

I Love Swimming

Source: CQ:USASWIM

Encourage outside activities that create a greater sense of self


INTERVENTION: how to approach a swimmer you suspect has an

eating disorder• With empathy• Without judgment• With concern• With observations• With suggestion of next step• With follow-up

• If a policy exists- with facts about policy…first step is A, B, C…..


Screening – Height

– Weight• Highest. Lowest, Current (perceived ideal)

– Menstrual history• First• Current patterns (regular or missed - if so, how

often)


Screening – Attitudes/beliefs

• What foods do you like? Are there any foods you avoid?

– Patterns• How many meals do you eat a day? How long

before practice do you eat? Do you eat/drink during practice? After?

– Exercise intensity, frequency• Is the athlete training in addition to assigned

conditioning and practice?


TREATMENT: Team Approach

• Patient• MD• Psychologist (if meds indicated)• Psychiatrist (specializing in ED)• Nutritionist (specializing in ED)• [Nurse]• [Trainer]• [Parent]• [Coach can be on a ‘health and well-being

committee’ that creates policy but not on actual treatment team


IN CONCLUSION

• Disordered eating is a spectrum of behaviors, actions and feelings that can hurt performance and compromise the health status of a swimmer

• Red flags include talking about food a lot, rigid rules around eating and body dissatisfaction


IN CONCLUSION

• Intervention should begin with stated observations and a plan for “treatment”

• A treatment team should involve an MD, nutritionist, therapist, patient, nurse and/or trainer.

Documents

Nutrition Conditioning, Inc. Disordered Eating- Prevention, Recognition and Action The 15th FINA World Sports Medicine Congress jointly-sponsored by the