Disordered Eating- Prevention, Recognition and Action

1. Disordered Eating- Prevention, Recognition and Action The 15th FINA World Sports Medicine Congressjointly-sponsored by the American College of Sports Medicine and Indiana Sports Corporation Nutrition Conditioning, Inc.

2. 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

3. 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 Nutrition Conditioning, Inc.

4. SPECTRUM of Behaviors, Thoughts, Feelings Nutrition Conditioning, Inc.

5. 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 How Prevalent? Nutrition Conditioning, Inc.

6. 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 Nutrition Conditioning, Inc.

7. GROUP ACTIVITY: Close your eyes…(do not think about cookies for the next 30 seconds) Nutrition Conditioning, Inc.

8. 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 CHARACTERIZED by Nutrition Conditioning, Inc.

9. 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) Nutrition Conditioning, Inc.

10. 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 Nutrition Conditioning, Inc.

11. The FEMALE ATHLETE TRIAD Disordered Eating Amenorrhea Osteopenia/porosis Nutrition Conditioning, Inc.

12. AMENORRHEA • Cessation of period three or more consecutive months or failing to have menstruated by age 16 Nutrition Conditioning, Inc.

13. OSTEOPENIA/OSTEOPOROSIS • Bone density formed until age 25-35 • Lifetime issue • Increased risk for stress fractures Nutrition Conditioning, Inc.

14. Stress 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 fat more low-calorie food skipping meals lots of “rules” around eating over exercising ENERGY DRAIN Nutrition Conditioning, Inc.

15. Boys at risk too • Body dysmorphia to triad • Testosterone and hormonal levels off • Especially at risk- runners, crew, diving… Nutrition Conditioning, Inc.

16. What Causes Disordered Eating?Biosocial ….multifactorial Nutrition Conditioning, Inc.

17. Often underlying , or additional diagnosis going on: • Mood and Anxiety Disorders • Depression • Obsessive Compulsive Disorder • Personality Disorders • Substance Abuse Disorders Nutrition Conditioning, Inc.

18. 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.” Nutrition Conditioning, Inc.

19. 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 Nutrition Conditioning, Inc.

20. The Health of University AthletesAttitudes, Behaviors & Stressors • 267 athletes: 56% men, 44% women • 86.4% White, 7.5% Black, Native American 6.4%, Hispanic 1.9% & Asian American 1.5% • 67% men & 84 % women within acceptable weights • 32% of men & 8% of women in high-weight range • 27 varsity athletic teams (football, baseball, basketball, swimming,, gymnastics, wrestling & diving) *Selby et al, College Health, July 1990 Nutrition Conditioning, Inc.

21. Male Student Athletes’ Perceptions of their Weight Acceptability Nutrition Conditioning, Inc.

22. Female Student Athletes Perceptions of Weight Acceptability Nutrition Conditioning, Inc.

23. HIGH RISK PROFILE • Perfectionist • Compulsive • Swimming is his/her identity • Depression • Success (esp. early success) • Siblings who excel; family expectations high Nutrition Conditioning, Inc.

24. 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 Nutrition Conditioning, Inc.

25. RED FLAGS Nutrition Conditioning, Inc.

26. perfectionism “The greatest risk factor for DE attitudes for females was perfectionism, which crossed all athletic divisions.”-Hopkinson,2004

27. 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) Nutrition Conditioning, Inc.

28. Unhealthy Eating Practices • Deprivation • Fasting • Skipping meals • Uneducated “Vegetarian” • Diuretics, laxatives, vomiting • Rigid food patterns Nutrition Conditioning, Inc.

29. 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. Nutrition Conditioning, Inc.

30. 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: Nutrition Conditioning, Inc.

31. 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 Nutrition Conditioning, Inc.

32. PREVENTION:Avoid comments about appearance, good or bad • Comment 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) Nutrition Conditioning, Inc.

33. 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 acceptable • Each swimmer can be a leader by choosing what to talk about, which conversations to participate in and which to walk away from. Nutrition Conditioning, Inc.

34. It Takes A Great Person To Make A Great Swimmer • Encourage outside activities that create a greater sense of self Nutrition Conditioning, Inc. Source: CQ:USASWIM

35. 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….. Nutrition Conditioning, Inc.

36. Screening • Height • Weight • Highest. Lowest, Current (perceived ideal) • Menstrual history • First • Current patterns (regular or missed - if so, how often) Nutrition Conditioning, Inc.

37. 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? Nutrition Conditioning, Inc.

38. 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 Nutrition Conditioning, Inc.

40. 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 Nutrition Conditioning, Inc.

41. 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. Nutrition Conditioning, Inc.