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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
Nutrition Conditioning, Inc.
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.
SPECTRUM of Behaviors, Thoughts, Feelings
DE
Anorexia Everything in between Bulimia
May or may not be ‘sub clinical’
Nutrition Conditioning, Inc.
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
Nutrition Conditioning, Inc.
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.
GROUP ACTIVITY: Close your eyes…
(do not think about cookies for the next 30 seconds)
Nutrition Conditioning, Inc.
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
Nutrition Conditioning, Inc.
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.
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.
The FEMALE ATHLETE
TRIAD• Disordered Eating
• Amenorrhea
• Osteopenia/porosis
Nutrition Conditioning, Inc.
AMENORRHEA Cessation of period three or more consecutive months or failing to have menstruated by age 16
Nutrition Conditioning, Inc.
OSTEOPENIA/OSTEOPOROSIS
• Bone density formed until age 25-35
• Lifetime issue
• Increased risk for stress fractures
Nutrition Conditioning, Inc.
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
Nutrition Conditioning, Inc.
Boys at risk too
• Body dysmorphia to triad
– Testosterone and hormonal levels off
– Especially at risk- runners, crew, diving…
Nutrition Conditioning, Inc.
What Causes Disordered Eating?Biosocial ….multifactorial
Body Image
Disturbance
Societal/
family
Self-esteem
Female Athlete
Role Conflicts
Media
Genetic
DE
Nutrition Conditioning, Inc.
Often underlying , or additional diagnosis going on:– Mood and Anxiety
Disorders– Depression– Obsessive
Compulsive Disorder– Personality Disorders– Substance Abuse
Disorders
Nutrition Conditioning, Inc.
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.
• 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.
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
Nutrition Conditioning, Inc.
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
Nutrition Conditioning, Inc.
Female Female Student Athletes Student Athletes Perceptions of Weight Perceptions of Weight
AcceptabilityAcceptability
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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
Nutrition Conditioning, Inc.
HIGH RISK PROFILE
• Perfectionist
• Compulsive
• Swimming is his/her identity
• Depression
• Success (esp. early success)
• Siblings who excel; family expectations high
Nutrition Conditioning, Inc.
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.
RED FLAGS
perfectionism
“The greatest risk factor for DE attitudes for females was perfectionism, which
crossed all athletic divisions.”-Hopkinson,2004
Nutrition Conditioning, Inc.
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.
Unhealthy Eating Practices
• Deprivation• Fasting• Skipping meals• Uneducated
“Vegetarian”• Diuretics,
laxatives, vomiting• Rigid food patterns
Nutrition Conditioning, Inc.
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.
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
Nutrition Conditioning, Inc.
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.
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)
Nutrition Conditioning, Inc.
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.
Nutrition Conditioning, Inc.
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
Nutrition Conditioning, Inc.
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.
Screening – Height
– Weight• Highest. Lowest, Current (perceived ideal)
– Menstrual history• First• Current patterns (regular or missed - if so, how
often)
Nutrition Conditioning, Inc.
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.
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.
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.
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.