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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 MD Medical Director, Eating Disorders Recovery


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Title: 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 MD Medical Director, Eating Disorders Recovery

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 MD Medical Director,
Eating Disorders Recovery Center of WNY Director,
Child and Adolescent Eating Disorder Program,
Golisano Childrens Hospital
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  • 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

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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
Mental health
Physical health
  • Absent menses
  • Cold hands/feet
  • Constipation
  • Dry skin/hair loss
  • Headaches
  • Fainting/dizziness
  • Lethargy
  • Anorexia
  • Disconnections
  • Concentration
  • Decisions
  • Irritability
  • Depression
  • Social withdrawal
  • Obsessiveness (food)

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
Physical health
Mental health
  • Weight gain
  • Bloating
  • Fullness
  • Lethargy
  • Salivary gland enlargement
  • Disconnection
  • Guilt
  • Depression
  • Anxiety

Signs Symptoms of Vomiting or Laxative Abuse
Physical health
Mental health
  • Weight loss
  • Electrolyte disturbance
  • ? K
  • ? CO2
  • Dental enamel erosion
  • Low blood volume
  • Knuckle calluses
  • Disconnection
  • Guilt
  • Depression
  • Anxiety
  • Confusion

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
  • 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
  • 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
Dental Enamel Erosion
- Dentin (yellow) visible beneath eroded enamel
(white) - Worse on lingual than buccal surfaces
A Less enamel loss on buccal surfaces B Enamel
sparing in gingival crevices
Erosion of enamel (white) and dentin (yellow)
from persistent vomiting, resulting in tooth
decay, fracture, and loss
Malnutrition and Hypometabolism
Muscle wasting
  • ? Energy intake results in wasting of lean
    (muscle) gt fat
  • Metabolism occurs in the lean body massgtgtgtgtgtfat
  • 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
  • 36.9C

Weekly visits
  • Week 5
  • Wt 91
  • S.G. 1.020
  • HR 44?82
  • 35.3Cl

Recheck Wt. (observed) and physical exam
Slow Capillary Refill
Livedo Reticularis
  • Bluish discoloration of skin
  • Reticular (lacy) pattern
  • Asymptomatic, but often associated with low core
    temperature and metabolism
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
  • 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

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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.
  • 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
  • Communicate with treatment team, parents (lt18 yo)
    to form collaborative partnership

  • (NCAA. 2005)

Symptomatic Athletes Are Unlikely to Recover
without Treatment?It is Required
  • Athlete becomes isolated, gets less support,
    making disordered eating more difficult to
  • Deterioration physically and psychologically has
    negative effect on performance.
  • Poor performance (related to self-concept)
    results in increased pressure to try to improve
  • 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 Triad
  • Focus 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 lt6
    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,

Screening Tests for Athletes with Eating
  • The Athletic Milieu Direct Questionnaire (Nagel
    et al., 2000) Newer test for detecting EDs in
    athletes but respondents know what test is
    looking for
  • Physiologic Screening Test for EDs/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
  • -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 EDs

  • - Disconnect patient from herself and others
  • - Disconnect family from other families
  • - Disconnect family from staff
  • - Disconnect treatment team from one another

  • 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, its so
    inappropriate to have different opinions,the
    smallest trace of being different makes it easier
    to not be likedI was so cautious of the way I
    sat and the words I used when I was over there
    tonight. I didnt 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 Im
    with them. I have to lock it away.
  • (Betty, 10/21/03)

  • Biopsychosocial Risk Factors
  • Biology Serotonergic Disturbance
  • Binging/Purging
  • Psychology Disconnections Relational
  • mismatches
  • Socio-Cultural Toxic Societal Values that
  • womens (and mens)
    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
  • Rapid or dramatic weight loss
  • Refusal to eat certain (unhealthy) foods
  • Frequent comments about feeling fat (despite wt
  • Anxiety about being fat or gaining weight
  • Denial of hunger
  • Food rituals
  • Consistent excuses at meal times
  • Rigid exercise routine (despite illness,
    fatigue, injury)

  • 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
  • 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?! Dont 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,
  • Contemplation able to consider change,
  • 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,
  • 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
  • Dont 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

Potential Obstacles/Challenges in Referring
Managing Students with Eating Disorders
  • School personnel anxiety, lack of education and
  • 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
  • Not understanding that the Eating disorder
  • decreases the students 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
  • 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 dont involve the eating disorder.
  • Encourage and model communication/problem-
  • solving skills.

Prevention Strategies for Coaches to Decrease
Risks in the Athletic Environment
  • De-emphasize weight.
  • Do not compare one athletes body/performance to
    another athletes body/performance (the other
    high performance athlete may have an eating
  • 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 to Decrease
Risks in the Athletic Environment
  • Foster mutual connections among athlete and
    coach/trainer, team members, and other
  • Recognize individual differences in athletes
    (athlete profiles describe but dont predict)
  • Increase education of athletes, coaches athletic
    trainers, and other sport personnel (re DE,
    eating disorders, nutrition, Female Athlete
  • 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,
  • 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 EDs/Disordered
  • Among 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.