Tracy Narins Welchoff, Ph.D.
Although eating disorders are difficult to deal with no matter what the circumstances, athletes deal with some unique pressures that complicate the recovery process. A thletes are vulnerable to developing eating disorders due to intense pressure of performance and competition combined with strenuous physical demands which require specific nutritional requirements to sustain. However, participation in certain types of sports can contribute to the development of eating issues. These include those that emphasize LEAN APPEARANCE such as swimming and diving, figure skating, and gymnastics. Also, risk is greater in sports that emphasize on LEANNESS FOR PERFORMANCE, like cross country running and swimming. Finally, there are those sports that include WEIGHT-CLASSIFICATION, such as boxing, wrestling, and crew.
Athletes require a high level of energy (i.e. calories) to fuel activity. Energy deficits can be due to dieting or purging, but they can also be the result of increased activity without increased caloric intake. Female athletes risk developing Female Athlete Triad, a constellation of symptoms including low energy availability, low bone mineral density (BMD), and menstrual dysfunction. Although BMD usually higher in athletes due to protective effects of high-impact activities, the nutritional deficiencies of an eating disorder are prone can cause low estrogen levels which can lead to bone loss, osteopenia, and osteoporosis. Male athletes with eating disorders are at risk for decreased testosterone levels (without which muscle development cannot occur).
Psychological issues affecting athletes may be similar to non-athletes, such as rigid perfectionism, trauma, fear of growing up, anxiety, depression, family issues, or cultural pressures to be thin. Driven, competitive personalities that lead to success in sports can cause problems if exercise or eating routines become rigid. The “I’m an athlete” excuse often hides compulsive exercise as the athlete is praised for “being so dedicated” and “training so hard”. To determine if exercise is compulsive, get details about exercise patterns to see if they are inflexible and do not change for illness, injury, or important life events. If an athlete cannot deviate from the training plan without anxiety or excessive guilt accompanying a day off, exercise has become compulsive.
When treating an athlete with an eating disorder, several treatment providers may be involved. The more people that are supporting the athlete, the better the chance of recovery. The Treatment Team may include a physician, psychologist, nutritionist, coach, trainer, family members, and of course, the athlete. Treatment starts with recognition of the problem, accurate identification and treatment of psychosocial precipitants, stabilization of medical conditions, and re-establishment of healthy eating patterns. Ideally, the athlete can be treated while continuing to participate in his or her sport, either fully or in a modified capacity. However, it may be necessary to pull the athlete from sports if health is compromised or if sports are used as excuse to avoid recovery behaviors.
If you suspect that an athlete you care about is suffering from an eating disorder, remember the following: Talk privately with the athlete. Focus on health rather than appearance. Convey caring and concern, not criticism. Discuss the need for an evaluation, but also express confidence that the athlete can recover and return to full sport participation. The athlete should be considered “injured” until evaluated. This can help preserve self-esteem and remind the athlete that eating disorders are medical conditions. Emphasizing treatment as a way to improve enjoyment and performance outcome is helpful as well.
Tracy Narins Welchoff, Ph.D.
Things you may notice:
• Preoccupation with food, calories, weight
• Distorted body image (seeing oneself as fat when not overweight)
• Disappearing at mealtimes or only eating alone
• Food rituals (such as cutting food into tiny pieces or making strange food mixtures)
• Sensitivity to cold
• Sleep disturbance/ fatigue
• High caffeine intake
• Sore throat/ chest pain
• Secretive behavior, mood changes
• Compulsive exercise
• Preoccupation with cooking for others but not eating
• Hoarding food
• Avoiding (or severely limiting) entire food groups, such as fats or carbs
• Wearing baggy clothing
Medical Signs of an Eating Disorder:
• Weight loss or dramatic weight fluctuation
• Slow heart rate, low blood pressure, or drop in blood pressure upon standing
• Restlessness/ inability to sit still or chronic low energy
• Irregular or absent menstrual periods
• Decreased bone density
• Severe dehydration
• Dry skin, thinning hair
• Growth or thickening of hair on arms, cheeks, or other unusual areas
• Easy bruising
• Muscle loss
• Dizziness, Light-headedness, fatigue, weakness, or fainting
• Dental problems and/or bad breath
• Scrapes on the knuckles
• Broken facial blood vessels and/or puffy cheeks
• Electrolyte imbalance due to loss of potassium, sodium, and chloride through purging
This list is by no means exhaustive, and eating disorder sufferers generally do not show all of these symptoms. Weight may be average, above, or below average. It is not always possible to tell if someone has an eating disorder just by appearance. A thorough evaluation by a trained professional is necessary to make a diagnosis, assess the severity, and help formulate a treatment plan. The Primary Care Provider is an excellent person to consult, and Dr. Welchoff is always happy to help with consultation, assessment, treatment planning, treatment, and referrals. All inquiries are welcome and will be handled promptly and confidentially.
Tracy Narins Welchoff, Ph.D.
Before approaching someone you suspect has an eating disorder, it is important that you educate yourself so as to be in the best position to help. This minimizes the chances of accidentally embarrassing or angering the person or, even worse, pushing him or her away. Eating disorders are much more complicated that simply being food and weight issues. Rather, they are a complex set of disorders can be made up of psychological, social, family, and biological factors. An eating disorder is not deliberate, even if it started out with an intention to diet. An eating disorder can start as a diet, but it becomes whipped into an out-of-control frenzy by these underlying issues and take on a life of its own.
When approaching your loved one, here are a few things to keep in mind:
• Avoid talking about food, weight, or appearance. Those are not the real issues.
• Assure them that they are not alone and that you love them and want to help in any way that you can.
• Encourage them to seek help and offer to facilitate this process.
• Never try to force them to eat.
• Do not blame the individual and do not get angry with them .
• Acknowledge the intense anxiety that is involved in the eating disorder. Often someone does not want to change his or her behavior but is willing to get help for the associated anxiety. This is a start.
• Be patient, recovery takes time.
• Mention your concern, but do not focus on your own feelings. This is not about you. Focusing on your own anger, anxiety, or stress will only cause guilt (but not change).
• Do not make mealtimes a battleground
• Listen, but do not be quick to give opinions and advice.
• Do not take on the role of a therapist.
• The person may deny the problem at first. Don’t argue, just emphasize that you care.
• Watching someone you care about suffering both physically and emotionally is frightening, frustrating, and confusing. No matter how concerned you are, you cannot force someone to accept help.
• Be careful what you say to the person who is suffering. Careless remarks will cause further pain, guilt, and withdrawal.
If you still aren’t sure how to proceed, don’t hesitate to consult with a professional.
Tracy Narins Welchoff, Ph.D.
Supporting a loved one through an eating disorder requires a great deal of time, energy, thought, and patience. However, it is important to remember that when a loved one is struggling, friends and family struggle too. It is hard to see someone you care about in psychological distress, at medical risk, and having difficulty functioning without being in a state of stress oneself. Even with the proper information, a positive attitude, and unconditional love, caregivers are likely to show signs of chronic stress if they do not pay adequate attention to their own well-being. With that said, here are suggestions to enhance caregiver self-care:
1. Do not feel guilty engaging in self-care while your loved-one struggles with a serious illness. It requires a lot of strength to be supportive, and by taking care of yourself in the process, you are increasing your ability to be helpful. If you collapse from stress and exhaustion, no one benefits.
2. It is important to have someone that YOU can talk to about your own stress. This is a hard time for you as well, and you need support. This may be your best friend, a trusted relative, or a therapist. Before talking to others, clear this with your loved one as s/he should have a say as to who knows about the eating disorder. If talking to a therapist seems like a good choice, talk to your own therapist so that your loved one’s therapist can focus on his/ her treatment goals rather than yours.
3. Educate yourself about symptoms, triggers specific to your loved one, and the treatment approach being used. This will allow you to be consistent with the treatment team and not give mixed messages that caused your loved one to have to “choose” who to listen to.
4. Take breaks from caregiving to recharge your batteries. Schedule time for yourself, even briefly, to clear your mind of problems. Take a bath, knit a scarf, watch a funny movie, go for a walk- anything you enjoy that will help you clear your head and return with fresh energy to be supportive.
5. Recognize your limits. You can support, listen, encourage, hug, etc., but YOU CAN”T FIX THIS. Ask your loved one what you can do to help, and then work on accepting what you cannot change.
6. Let go of feeling guilty for being angry, frustrated, disappointed, or having urges to give up. You are human, and this is difficult. Acknowledge your feelings, talk it out, write in a journal, or just plain scream when no one is around. Your feelings are normal because you CARE.
7. Pay proper attention to your own stresses and concerns. If you are having problems at work for example, don’t neglect this because the eating disorder is “more serious”. Your life is important too, and it is okay to reserve some of your time to keep it on track.
8. Eat, sleep, exercise, relax, and engage in self-care. You need to take care of YOU, no matter how selfish this may feel. Recovery from an eating disorder requires learning self-care, so be a good role model!
9. Find ways to interact with your loved one that have nothing to do with eating disorders or recovery. Go to a movie, visit a bookstore, play a game, or do whatever you used to do before the eating disorder invaded your relationship. If s/he is not healthy enough to participate in the “usual” activities (e.g. exercise), challenge yourself to find new ways to have fun together.
10. Reach out to other caregivers. It is healing for your loved one to connect with others going through the same thing, and it is important for you as well.
Please remember that your stress is real and that you are not alone. If these suggestions seem impossible or you don’t know where to begin, professional help is available.