Eating Disorders (EDs) aren’t talked about much. If they are, it’s usually in conjunction with a dramatic Lifetime movie. However EDs do exist in real life and can even be found in strength sports. 33% of males and 62% of females in sports focused on aesthetics and weight classes are affected by them (Thompson, PhD. 2010).
This week is National Eating Disorder Awareness week. As someone who has battled exercise bulimia and gone on to help her own athletes through their personal ED struggles, I understand how crucial it is for coaches to be educated. As a coach you are in a position of trust with your athlete; this article will teach you (1) how to identify troublesome behaviors early in order to prevent significant health risks, (2) how to approach the athlete, and (3) how to create a healthy training environment.
National Eating Disorders Association
As you read this article, remember I’m not against weight classes in strength sports; I love and support athletics. At the end of the day, eating disorders are mental diseases and should be treated as such. There is generally a psychological, social, or relational pre-existing condition before the individual even begins to play their sport (ex: low self esteem, physical or sexual abuse). Sometimes the sport is being used as an outlet for other stressors and if the individual is triggered, then they are more likely to use that sport excessively. This is why it’s important to know your athlete as an individual and to make sure you know about outside stressors so you can be on the lookout. A lifetime of physical health and happiness is more important than a performance victory; give your athletes decreased training loads or a break if you suspect they are stressed and using the physical activity to their detriment.
Common Eating Disorders
While the media has a tendency to latch onto anorexia, eating disorders come in many different forms, sizes and shapes. I’m hesitant to put any pictures with this piece due to the pre-existing misconceptions of what EDs look like: they come in all shapes and sizes from small to average to large. As you read this post, make sure you arm yourself with signs to look for that aren’t just related to weight.There are ways to monitor and spot them in your athletes.
Below are some classifications of the disorders and how to spot them:
- Anorexia: Characterized by self-starvation and excessive weight loss done through restriction and purging (exercise, laxatives or diuretics). These athletes will be constantly tired, fatigued during workouts, lethargic and you will see a marked and consistent drop in performance due to lack of nutrients. Individuals suffering from it have an intense fear of gaining weight, have ritualistic eating habits (will only eat certain foods, eat off a certain plate, etc), constantly talk about or prepare food but do not eat it, and can be withdrawn from friends.
- Bulimia: This is one of the most commonly seen EDs in strength sports but one of the hardest to spot because athletes appear to be average weight. According to the National Eating Disorders Association (NEDA) it is characterized “by a cycle of bingeing and compensatory behaviors such as self-induced vomiting designed to undo or compensate for the effects of binge eating.” A common purge tactic in athletes is laxatives, diuretics, and excessive exercise outside what is prescribed by their Coach. It’s important to closely monitor your athletes training and behaviors because bulimia recovery is successful with early interventions. Individuals suffering from bulimia will find every excuse to continue to work out despite injury, weather, illness, or chronic fatigue; it goes beyond the healthy athletic mindset. Some outward signs of bulimia include mood swings, frequent trips to the bathroom post meals, and swollen cheeks or jaw areas. The biggest issue with bulimia is the individual’s sense of guilt after eating and when eating they may seclude themselves, eat large quantities of food, and hide the wrappers. Individuals that constantly talk about diets, clean eating, and cheat days should be monitored…especially on days after they have had a “cheat day”; while talking about food is not indicative of a disorder, excessive discussion should raise a red flag to a coach.
- Muscle Dysmorphia: This is more prevalent in bodybuilders and males but with the “Strong is The New Skinny” resurgence, females are at risk at well. The easiest way to understand this disorder is to think of it as “reverse anorexia”. According to NEDA, “compulsions include spending hours in the gym, squandering excessive amounts of money on ineffectual sports supplements, abnormal eating patterns or even substance abuse.”
- Disordered Eating and Feeding: Unhealthy relationships with food don’t always occur in the same manner as the big three (anorexia, bulimia, binge eating). Something I’ve seen a lot is Orthorexia–this is not defined in the DSM but NEDA defines this as an “unhealthy obsession with otherwise healthy eating” and it literally means “fixation on righteous eating.” These athletes characterize foods as “good” and “bad”, self punish when they “slip up” (more exercise, even more rigid dieting and restrictions), and find themselves being unable to enjoy social interactions. Other disorders include Rumination Disorder, where someone will chew food but spit it out, and Avoidant Food/Restrictive Disorder where people will avoid food due to fear of vomiting or dislike of the texture. A lesser known disorder is the eating of non-food items like ice, paper, hair, or other objects known as Pica.
- Eating Disorders Not Otherwise Specified (EDNOS or Other Specified Eating Disorders): If something doesn’t sit well with you about your athlete, they can still be seen by a professional to ensure their symptoms do not develop into one of the DSM-V categories (listed previously). EDNOS would be atypical anorexia and bulimia where the body weight may not yet be at the point of an official diagnosis but the mentality and other symptoms are there, less frequent binge eating disorder episodes, purging disorder where binging is not involved, and night eating syndrome.
Other Warning Signs
- Common Warning Signs:An athlete suffering from any of these disorders will have frequent injuries, decreased recovery and performance, and may seem lethargic. Other signs may be intense mood swings, irritability, brittle hair, discolored teeth, callused knuckles (not related to the barbell), unusual breath (common in bulimics; can be a pungent smell), irregular perspiration (excessive or lack thereof).
- Living off stimulants: Caffeine. Most athletes consume it with their pre-workout. It’s not uncommon to see energy drinks or Starbucks cups near a training facility or practice. That’s not a problem. It is a problem when that athlete hasn’t eaten much that day and is regularly using the stimulant because of that or turns to drugs for an added stimulant effect. Excessive caffeine consumption in athletes needs to be monitored for a host of reasons. Caffeine can act as a diuretic and helps disordered people feel “full”. Excessive amounts can lead to increased heart risks especially in a population whose side effects of their ED includes heart complications. Part of recovery and treatment programs have provisions to ween patients off of caffeine due to its harmful effects to their bodies and psyche. Compounds in caffeinated products can inhibit absorption of calcium, B12, iron, magnesium and a host of other important vitamins and minerals.
While not pretty to think about, illegal drug use, whether street or prescription, does happen in strength sports and should not be not tolerated by a coach.
- Missed periods can be a sign of exercise induced amenorrhea: menstrual dysfunction for 3 or more months which mean it is completely absent or irregular. It can lead to irreversible bone density loss and is caused by the body being under too much stress: from excessive training, under recovering or failure to take in enough nutrients. Missed periods in female athletes should not be ignored. This isn’t exactly a subject a male coaches want to approach with female athletes. I suggest a team doctor or same gendered trusted confident regularly ask female athletes about their cycles. That will open the door for discussion. If an athlete misses periods, and is not pregnant or suffering from a pituitary condition, they can do a few things to try to get their cycle back: (1) Decrease training volume 10-15%, (2) Increase calories 10-15%, (3) Increase calcium, (4) See a doctor and nutritionist. In addition to meeting with a nutritionist, x-rays and bone scans to measure bone density and check for stress fractures should be performed and maintained regularly.
How Disorders Affect The Body
ED affects the body in many ways. The following are examples of the damage caused by the disorders listed:
- Irreparable bone loss
- Heart irregularities and heart failure
- Kidney and liver failure
- Electrolyte imbalances
- Irreparable bowel damage
- High blood pressure
- Death. 8x gold medalist Bahne Rabe and elite gymnast Helga Brathen died due to ED related complications.
Approaching The Athlete
What you say to an athlete who may be suffering can speed up their recovery or push them to relapse. If you have cause for alarm, then usually something is not right and needs to be addressed.
- Before anything else, approach a nutritionist or professional with any questions you have before talking to the athlete to ensure you handle the situation tactfully.
- Approach your athlete in a calm manner. Do not berate them if you suspect they have an ED or if they tell you they are seeking treatment for one. If they are a minor, then consult with the parents first ensuring them you have their child’s best interest at heart.
- Take your athlete aside, not in front of others, and tell them your concerns. If they insist they don’t have a disorder, simply tell them you hope not but the only way for everyone to be sure is to undergo an examination and some test by a healthcare professional.
- Do not ask them to keep a food log. If someone is suffering from an ED this is the WORST thing you can do. Please leave this to the professionals with training in these disorders.
- If you are the opposite gender of your athlete and feel uncomfortable approaching them directly, find someone of the same gender who has the same level of trust with the athlete to talk to them with you.
How To Create A Positive Strength Sport Environment
“Someone else will talk about it.” Tell that to the 10% of individuals suffering from EDs who have died from their disease’s complications. That statistic makes EDs one of the leading causes of mental illness deaths. EDs are not something you can pass the buck on. Silence destroys lives. If you even have an inkling that an athlete may suffer from a disorder, as their coach, you have a duty to speak up. These diseases love secrets and isolation. The more dialogue you engage your athlete in, the less room disorders have to hide.
As a coach, you are in a position of great power and influence over your athletes. You create the environment your team lives and works in.
- Focus on performance, not body weight. This is crucial with youth and teen athletes during their development.
- Do not reward unhealthy behavior such as diuretics, under or over-eating, malnutrition, lack of sleep, or substance abuse among other things.
- Be cognizant of your words and behaviors about body image and weight around the team.
- If your sport requires weigh-ins like power lifting or weightlifting, do regular weigh-ins to monitor athlete health and do so in an open and friendly environment. If you know your athlete needs to drop weight for a competition, start working towards that cut in a healthy time frame.
- Never make any kind of comment about your athlete’s size (good or bad; if an individual is being unhealthy to get to a certain size, praising them can exacerbate the illness); if you want an athlete to move up or down a weight class, please consult a trained professional on whether this is feasible, how to do it, and what to say/not to say to your athlete.
- Weight cuts need to be assessed on an individual basis. Some athletes can fluctuate in weight safely and without issue. Others can’t. Keep your athletes healthy and if they cut, then do it safely.
No game or match is more important than your athlete’s health. If they refuse to seek or comply with treatment, consider taking them out of the game, practice, or match until they comply; reiterate you are doing it for their safety and that you want them healthy and back to performing with the team. It is advised to keep them active if at all possible; defer to trained health professional’s advice. If they have to sit out for a while during treatment, and if allowed by their professional team, give them an assistant coach role so they are included and still able to help without feeling stigmatized.
My disorder started when I was 12 and competing as a youth in powerlifting; it stemmed from body dysmorphia and childhood trauma. Fortunately, I had a coach who noticed and kept me from injuring myself. Because he safely monitored our weights, one weigh in close to competition I was severely under my weight class. Unbeknownst to him I had been living off a bowl of soup daily. He asked me how everything was going and every day after that he always made a trip to my lunch table. Looking back it was make sure I was eating. Coaches can be tactful.He made it very clear that not eating and diuretics were simply unacceptable; we had a duty to report if we knew any of our team mates were doing that. I recall a prominent lifter was hospitalized before our Regional powerlifting meet and he refused to let her lift for health reasons. I remember seeing people running around to sweat weight off, some trying to water load before weigh ins, others trying to maneuver locks or weights in body orifices where they didn’t belong (that was illegal and no one ever actually succeeded from what I saw).
In college I developed exercise bulimia where I was eating 500 calories, working out 3-5 hours a day, loosing my hair, skipping school and work if I didn’t work out that morning, and never having a rest day. One day I was overtraining on a bicycle when a van, through no fault of my own, ran me over. I fractured my hip, my cheekbone, and busted the blood vessels in my eyes. After being rushed to the hospital and not having worked out for 2 hours, I was found trying to do sit ups in the bathroom for fear of getting fat. I sought therapy for my underlying issues and disorder. Later I learned my constant exercise and lack of nutrients led to my L3 through S1 becoming bulged.
Naturally I made a collage of the incident. My brother’s first words to me were that of Chris Tucker: “You Got Knocked The ___ Out!”
In law school I relapsed into exercise bulimia and orthorexia training for a national event. I would cry at weigh-ins and have panic attacks. If I heard my weight being announced I would want to run out the door of the event. I was unnecessarily fasting before events and wouldn’t refuel after I weighed in. My performance suffered, I was unhappy, and I got injured again. Since then I’ve sought professional treatment and been under the guidance of a coach who understands my disorder. Unfortunately I am not an athlete who can cut weight safely; I have decided to remain a superheavy weight. I tell those who weigh me in at meets to not tell me what I weigh and cover it up on my card. It sounds drastic but it’s what works for me and keeps me able to do what I love: lift.
I’ve taken my experiences and used them to help others. I’ve worked with many athletes and stepped in a few times when I saw the inklings of ED behaviors. I called parents and took necessary precautions. I sought professional treatment contacts for my older athletes. But above all else, I refused to let them become a statistic.
There are local resources you as a coach or administrator can turn to for guidance:
National Eating Disorders Association is a great resource for help and guidance. Visit their website here. Call their toll free, confidential hotline Monday- Thursday between 9:00 am and 9:00 pm and Friday between 9:00 am-5:00 pm at 1-800-931-2237. They also have a “Click To Chat” free service on their website
Counselors, nutritionists, and therapists: In addition to guidance counselors and services provided by schools and universities, a list of therapist can be found here http://therapists.psychologytoday.com/rms/prof_results.php?state=MS&spec=9
- Warren MP, Chua AT., Exercise-induced Amenorrhea and Bone Health in the Adolescent Athlete. Annals of the New York Academy of Sciences, 2008
- Holly Pohler, Caffeine Intoxication and Addiction, The Journal for Nurse Practitioners, Volume 6, Issue 1, January 2010, Pages 49-52, ISSN 1555-4155, http://dx.doi.org/10.1016/j.nurpra.2009.08.019. (http://www.sciencedirect.com/science/article/pii/S1555415509004991)
- Striegel-Moore, R. H., Franko, D. L., Thompson, D., Barton, B., Schreiber, G. B. and Daniels, S. R. (2006), Caffeine intake in eating disorders. Int. J. Eat. Disord., 39: 162–165. doi: 10.1002/eat.20216