Illinois Athletic Trainers Association State Meeting November 4, 2012

1. Illinois Athletic Trainers Association State MeetingNovember 4, 2012 The Identification and treatment of eating Disorders Among Elite Athletes By Jenny H. Conviser, psy.d Assistant Professor, Feinberg School of medicine Northwestern University Chicago, Illinois

2. Eating Disorders Threaten Well Being 5 % will die of complications Lower quality of life Greater risk of suicide Greater risk of depression Greater risk of death

3. Risks in the Athletic Population: Anorexia occurs in 1% of females and less in males. Bulimia occurs in 1 to 3% of females in the general population. Bulimia is five to ten times more frequent among females than males. Binge eating may be more common in male athletes than female athletes. Muscle Dysmorphia-uncertain rates Athletic participation can affect risk of ED’s

4. The Prevalence of Eating Disorders Among Elite Athletes: • Among adult elite athletes, the prevalence of disordered eating and clinical eating disorders is higher in elite athletes competing in leanness sports as compared with those competing in non leanness sports and controls. • (Torstveit, MK et al. Scand J of Med Sci Sport, 2008, 18, 108-18).

5. To what extent can elite adolescent athletes self observe and report problematic eating or weight related behaviors? • The prevalence of self reported ED symptoms among elite male and female adolescent athletes was lower than among adolescent controls. • (Martinsen et al., (2010) British Journal of Sports Medicine)

6. Unhealthy Weight Management Among Elite Athletes • According to the position of the American Dietetic Association, Dieticians of Canada and the American College of Sports Medicine: • Unhealthy weight loss among athletes may include: • Severely restrictive energy intake • Eliminating one or more food groups from the diet • Consumption of unbalanced diets • Consumption of low macronutrient density foods

7. Unhealthy Weight Loss Among Elite Athletes • According to the American Dietetic Association, Dietitians of Canada and the American College of Sports Medicine, the risks of a low energy intake include: • Loss of muscle mass • Menstrual dysfunction • Loss of or failure to gain bone density • Fatigue • Injury • Illness • Prolonged recovery process • Journal of the American Dietetic Association (2009), p. 510.

8. Medical Complications of Eating Disorders Anorexia • Weight Loss >15% (Less in Athletes) • Weight Fluctuation • Emaciation • Bradycardia • Hypotension • Hypothermia • Lanugo Hair • Carotenemia • Hyperkeratosis • Edema • Anemia • Amenorrhea • Spontaneous Fractures Bulimia Nervosa • Normal or Overweight • Hypertensive • Swollen Parotid Glands • Dental Erosions • Scars on Knuckles of Hands • Edema • Esophagitis • Electrolyte Imbalance • Sore Throat

9. Medical Complications of Diuretic and/or Laxative Use or Abuse Effects of Diuretic Use • Electrolyte imbalance • Dehydration • Rebound edema: water retention when diuretics are discontinued: swelling of hands and feet Effects of Laxative Use • Electrolyte imbalance • Stomach cramping and discomfort • Chronic constipation • Dysfunctional bowel syndrome • Constipation • Impaction • Deficiency of fat, protein and calcium • Gastrointestinal bleeding • Rebound edema when laxatives are discontinued

10. Signs and Symptoms of Eating Disorders Signs and Symptoms • Fatigue • Sleep Disturbances • Dizziness/Fainting • Weakness • Chest Pain • Shortness of Breath • Depression • Anxiety • Cold Intolerance • Fractures • Brittle Hair • Hair Loss • Bloated/Heartburn • Abdominal Pain • Constipation/Diarrhea • Loss of Muscle Mass • Obsession with Calories, Food and Weight • Low Self-Esteem • Pale or “Gray” Appearances to the Skin • Vague or Secretive Eating Patterns • Use of Diet Pills, Laxatives, Syrups, or Enemas

11. Medical Complications of Self Induced Vomiting • Dehydration: Light- headedness • Erosion of tooth enamel • Dental cavities • Gum Disease • Chronic sore throat/difficulty swallowing • Bloating and digestive pain • Distention of the stomach and esophagus • Swollen parotid glands • Inflammation of the salivary glands • Pancreatitis: Nausea, vomiting, abdominal pain • Syrup of Ipecac poisoning • Aspiration of vomit: pneumonia, lung infection, or death

12. Eating Disorder Etiology • Etiology - Eating disorders: • Complex and multiply determined • Factors which may increase incidence of eating disorders: • Exposure to leanness in a sports environment • Early onset dieting behavior • Harsh or critical early environments “Eating disorders are the expression of that which is not otherwise expressed in words.”

13. Why do some athletes have greater risk of eating disorders than non athletes? • More research is needed. • Some possible contributing factors: • High expectations • Beliefs regarding weight loss • Models of weight loss or change • Thin ideal reinforced or rewarded • Independent style • Weight status or thin frame directly impacts sport performance

14. COACH COMMUNICATION MAY EFFECT DIETING AND OR WEIGHT LOSS BEHAVIOR: • The earlier the first dieting behavior presents in a life time, the greater the likelihood of an eating disorder. • A significant number of adolescent elite male athletes were told by coaches that they were to reduce weight. (Martinsen et. al., 2010)

15. Coach & Athletic Training Staff-Athlete Communication • The following comments have been shown to affect self esteem, body image and eating disorder risk and recovery among athletes: • “You would look better if you lot weight”. • “You would be a better athlete if you lost weight”. • (After a period of weight loss), “You look better”. • Any teasing or bullying related to size, appearance or shape. • Tantleff-Dunn & Gokee, 2002. • Critical comments related to weight or shape. • Piran, 2002 • Sexually harassing statements. • Stein, 1995, 1999 • Comparing one athletes weight or shape with another. • Positive or negative comments about ones own body or weight.

16. Assessment for Eating Disorders • Eating Disorders Assessment has Multiple Components: • Nutritional Status (registered dietician) • Psychological Assessment (licensed psychologist or social worker) • Medical Evaluation (physician, MD)

17. Eating Disorder Assessment Eating Disorders Assessment has Multiple Components: • Psychiatric Assessment (psychiatrist, MD) • Athletic Department Medical Staff Representative • Other (as indicated) • Chemical dependency evaluation, family therapist, academic advisors, specialists as needed

18. Guidelines for Assessing Eating Disorders Laboratory Tests • Complete Metabolic Profile • CBC, with Differential • TSH, Free T3, T4 • EKG • Phosphorus • Magnesium • Amylase • Lipase • Urine Analysis/Specific Gravity • Physical Examination • Vital Signs • Blood Pressure Standing and Sitting • Body Temperature • Body Weight and Percent Fat • Not a Public Scale • Use Most Accurate Methods Available • Wearing a Light Gown • Empty Bladder • Measurement Taken by Provider • Sometimes asked to estimate • Assess for Evidence of Self Injury

19. Medical Complications of Eating Disorders:Side effects of Self-Induced Vomiting • Electrolyte imbalance ( low potassium, sodium and chloride) • Irregular heart beat • Fatigue • Muscle weakness and Spasm • Diminished reflexes • Irritability • Convulsions • Cardiac arrhythmia or cardiac failure • Weight is not always a good indicator of the magnitude of risk.

20. Assessment is Often a Challenge • Determination of health status or risk as determined by lab results may be risky. • Lab values change in advance stages. • Lab values frequently change • Once changed, vulnerable to additional change • Downward spiral may occur suddenly

21. Factors that May Assist in Early Detection, Referral for Treatment, and Monitoring of Recovery Healthy regard for weight ………………………… ..… ………………………………………….Obsessed with weight Positive body image…………………………………… … …………………………………………..Distorted body image Infrequent thoughts about appearance……… …… ……………………………………………Incessant thoughts about appearance Willingness to restore weight………………………… …………………………………………….Refusal or inability to restore weight No anxiety at weigh in………………………………………………………………………………….High anxiety at weigh in No anxiety around food choices……………………………………………………………………..High anxiety around food choices Identity not dependent on appearance……………………………………………………………Identity contingent on appearance Train to improve athletic performance……………………………………………………………Train to compensate for caloric intake Ready to accept staff advice……………………………………………………………………………Refusal to consider staff advice Respect for others diverse size and shape…………………………………………………………Critical of others size and shape

22. Factors that may Assist in Early Detection, Referral and Treatment Monitoring for Athletes Infrequent weighing………………………………………………………………………………….…..Frequent weighing No evidence of over training…………………………………………………………………………..Evidence of overtraining syndrome Good energy………………………………………………………………………………………………….Often fatigued Accurate self observation……………………………………………………………………………….Distorted self perception No psychomotor slowing………………………………………………………………………………...Psychomotor slowing Copes well with stress……………………………………………………………………………………..Perpetually overwhelmed Full range of appropriate emotions…………………………………………………………………..Mood fluctuation Overall positive mood………………………………………………………………………………………Often irritable and/or negative Recovers quickly from training…………………………………………………………………………Slow recovery time Weight Stable…………………………………………………………………………………………………..Weight change upward or downward Constructively self advocates……………………………………………………………………………Suppression of needs and desires Comfortable expressing differences of opinion…………………………………………………..Inability to express a difference of opinion Balance in social and alone time………………………………………………………………………..Social imbalance/ isolation

23. Eating Disorders Assessment and Treatment Planning Collaborative assessment and treatment planning Athletes opinion of the assessment and treatment plan vital Periodic re-evaluation Coordinate care with family or outside providers

24. Eating Disorders Treatment Periodic treatment team meetings with the individual athlete are enormously useful. Written summaries of this meeting are given to each assessment team member and the athlete. Treatment goals and interventions are modified as needed in concert with the athletes recovery process. Progress or lack of progress means the need to re-evaluate the treatment plan and the appropriate level of care.

25. Eating Disorders Treatment • Multi-disciplinary treatment providers • Individualized treatment • Works best if the athlete believes in the process • Varied intensity and levels of care: • Single points of service • IOP (Intensive Outpatient Treatment) • PHP (Partial Hospitalization) • Transitional Living • Residential Care • Inpatient Hospitalization

26. Therapeutic Treatment Models for Eating Disorders Individual Family Couples Small Groups (5 to 7) Large Group (Lecture) Daily Weekly Monthly Outpatient Transitional Living Residential Hospital Cognitive Behavioral Therapy Dialectic Behavioral Therapy Problem Focused Coping Skills Communication Skills Trauma Recovery Art, Sound, Movement Therapy Insight /Analytic Therapy Meditation, Yoga Nutritional Education Therapeutic Meals EMDR Life Skills (Occupational, Financial) Chemical Dependency Other

27. Establish minimal body weight, BMI or percent fat criteria for athletes. • “The estimated minimal level of body fat compatible with health is 5% for men and 12% for women.” • Heymsfield S, Lohman T, Wang Z, Going S. Human Body Composition. 2nd Ed. Champaign, Il., Human Kinetics, 2005. • Percent fat is difficult to accurately measure. • Optimal percentage fat values are difficult to determine for each athlete.

28. Reduce Risk of Eating Disorders Among Elite Athletes • Prevention Efforts can: • Identify the specific needs in the athletic system that will be targeted. • policies, practices, sexual harassment, gender equity, etc. • Develop policies and procedures to identify and treat both sub clinical and clinical presentation of eating disorders. • Review and edit all printed material that may increase ED risk. • Create safe reporting procedures for concerns about fellow athletes.

29. Reducing Risk of Eating Disorders Among Athletes: • Create information and training materials to orient all primary and adjunctive staff to the prevention, identification of risk, reporting and referral process. • Plan and conduct in service training programs for all staff. • All manuals, work books, written materials, should be appropriate for the athletes age, gender, sport and culture. • Successful prevention programming will reduce future eating disorders but will also create an atmosphere to enhance recovery for those already struggling. • Levine & Smolak, The Prevention of Eating Problems and Eating Disorders, 2006,

30. Four Primary Components of Eating Disorder Prevention and Health Promotion • Consciousness Raising (Education) • Competency Building (Skill Development) • Connections with Others (Meaningful Relationships with Peers and Community) • Change (Change in Community Norms, Practices, and Systems) • Levine, Piran & Irving, 2003.

31. Reduce Risk of Eating Disorders Among Athletes • Athletes, staff, coaches and medical personnel should be well informed. • Appreciate genetics and the impact on weight and shape. • Value diversity of weight and shape. • Eliminate weight and appearance related teasing. • Be mindful of both the short and long term consequences of dieting. • Create forums for athletes and staff to safely discuss unique factors in their environment that contribute to a positive or negative body image. • Remind yourselves that the body is not infinitely malleable.

32. Reducing ED Risk Among Athletes • Build Resilience via Teaching Life Skills: • Stress Management • Effective Communication • Problem Solving • Realistic Expectations of Abilities and Goals • Life Skills Training • Utilization of Social Support • Train Staff to Foster and Respect Different Perspectives • Teach Athletes and Staff to Work Together to Clarify the Source of Negative Messages that Increase ED risk • Steiner-Adair et al. (2002) • McVey et al. (2003a)

33. Re-assess Prevention Programming Re-assess program effectiveness. Re-evaluate: Are the interventions meeting the needs of the athletes and community. Determine if programming was detrimental in any way.

34. Awareness, Information and Communication Helping to Create a Healthy Environment for Athletes Thank you for your attention and support! Jenny H. Conviser, Psy.D, Assistant Professor, Feinberg School of Medicine Northwestern University, Chicago, Illinois Director, Insight Psychological Services, LLC. Director, Sport Psych0lgy Services, DePaul University Athletic Department jconviser@insightillinois.com

36. Treatment for Eating Disorders • Eating Disorders Assessment has Multiple Components • Nutritional Status (registered dietitian) • 24 hour diet recall, nutritional status or deficiencies, frequency of binge or purge episodes, degree of restriction, diet rules or restrictions, food phobia’s etc. • Psychological Assessment (licensed psychologist or social worker) • Confirm ED diagnosis, assess for co-existing disorders such as OCD, substance use, mood and anxiety issues, mental health history etc. • Medical Evaluation (physician, MD) • Assess medical status and determine the appropriate level of care given the individual’s medical status, order appropriate lab work

37. Treatment for Eating Disorders • Multiple components continued: • Psychiatric Assessment (psychiatrist, MD) • Assess mental status and determine if medication or adjustments in medication are indicated • Athletic Department Medical Staff Representative • Medical director, head athletic trainer or team physician, etc. • Other (as indicated) • Chemical dependency evaluation, family therapist, academic advisors, specialists as needed