Disordered Eating Panel Discussion (2003)


<<Unknown Question—possibly, “What do you say to a swimmer who comes to you for help, but doesn’t want to tell their parents?”>>


That’s always a tough one.  It depends on the age of the athlete as to how I would recommend you approach it.  If this is an age group swimmer who is still a minor and does not have the ability to go to the doctor by themselves, I would first say, “thank you for coming to me” and let them know that I appreciate the fact that they have disclosed [this information] to me—that right there is probably the hardest thing they have ever done in their life so they need to know that I’m not going to turn around and say, “oh gosh – yuck.”  Tell them that you appreciate what they have done. Say, “we need to help you with this and the best way to do that would be for you to start by seeing a doctor who can also help you see the other people that you need because your health is not going to tolerate this.”  They need to know that their overall health is going to suffer and so making it a medical problem makes it a little more palatable at first.


If you have a younger girl it is going to be more difficult because somehow you are going to have to get her to find some way to get into a physician. Many times, parents can be a barrier to treatment as opposed to a help.  I deal with college kids and on campus we have a lot of control over their lives.  It is harder with a younger kid, because you have got to get them plugged into a support team.


The easiest way is to do this is to go to a medical doctor because the parents are a little better about taking kids to medical doctors as opposed to immediately starting with a psychologist.  If you can’t necessarily work the doctor angle, then you could try a sports nutritionist in your town. If the kid still doesn’t want to disclose to their parents you can say, “Hey, maybe it would be a good idea for your performance to go and talk to a nutritionist about how you are fueling your body.” The nutritionist will figure out that the swimmer has an eating disorder if the kid is willing to disclose even a little bit about his/her diet. Then, slowly but surely, get a treatment team involved.


Either way, if she has some physical complaint, being really tired all the time or something like that, you can get them in the back door by seeing a physician for that physical complaint.  If she is not willing to own up to a physical complaint, then taking another approach by saying, “hey, you know, it might be good for your athletic performance if you review your nutrition and we have a sports nutritionist that you can go and see.”  You are going to be financially dependent on the parents wanting to do that, but sometimes you can get kids into treatment through the back door if they are not willing to tell all this to their parents.


That first step is so huge, though, that she tells you and you offer encouragement to continue addressing it and you continue talking about it. And if they’re not talking to anyone else, then encourage them at least talk to you if and you can keep working on them to get them into a treatment team from another angle.


There is no doubt, it is hard.  At least once a year we have to intervene on an athlete where we blind-side them—they come into a meeting and all of a sudden I am there, Kristen is there, our head athletic trainer is there, and their coach is there—maybe one of their parents is there as well. It is tough, but we have that luxury that you don’t have.


A good place to start is to identify people in your community who could be helpful.  If you don’t know any nutritionists, see if there is a task force in your city on eating disorders. Also, sports nutritionists are sometimes part of those task forces and you can call them and at least get a conversation or a relationship going.  And you don’t necessarily always have to use a sports nutritionist for eating disorders—they are great for talking to kids about how to fuel their bodies and that is a wonderful relationship to have.


If you can’t find a sports nutritionist, find a good family doctor that you know in the community and talk to them because if they don’t know anything about eating disorders they might know someone else in the community who does and just finding some of those community resources is a good way to at least know where to go when you get that kind of bomb dropped on you.


Pamphlets?  I don’t have them on me but you should certainly get them. That is something that they do have in USA Swimming.


[I have found that kids with eating disorders] will do very well early on and it is because they are running on adrenalin—they are on a big high.  If they continue in their eating disorder they are going to start to fail—hands down.  I can’t tell you of one person who has finished their career with a severe eating disorder and has finished on top.  They always crash somewhere.  That is why it is so difficult because there is a lot of positive feedback to this eating disorder initially. They lose weight.  They feel in control.  They are still performing well, these young kids they can just completely abuse their bodies for a very long time—the human body will tolerate an incredible amount of abuse, but eventually they are going to hit the wall.  I like to use the analogy that these swimmers are like bugs and they are going to be a nice little flying bug for a long time and then they are going to hit a car windshield. We need to try and prevent that windshield.


Question from the floor – inaudible.  As far as general health or nutrition information?


The disordered material that we have is pretty focused on the issue of disordered eating and eating disorders, so the degree of nutrition information included in that material is not very high because as we learn, it is not a nutrition issue. If we were to approach it from the front end and be proactive about it and make sure kids are aware of the importance of nutrition in performance. This way they understand good nutrition before they put too much emphasis on just losing weight. But that nutrition information would have to come from a good presenter, a nutritionist who understands the sport of swimming or at least sports in general.  These people can be hard to come by.  We try very hard to provide a list of resources for you in terms of sports nutritionists in terms of the sports medicine and science network which is a searchable database on our website.  Many nutritionists around the country are often willing and available to fly in—it depends on what your budget issues are like.


If you are looking simply for resources that you can read, which is very different than teaching the kids, certainly there are plenty of resources available.  Training Nutrition is one.  I believe that is Jackie Berning and Ed Burke.  Nancy Clark’s sports nutrition guidebook is pretty simple—it is about a $20 book.


Those are two books that I would recommend and for coaches to read just for general understanding, but when you are talking about educating kids, it’s a different story. Unless you are going to keep those concepts really simple and feel comfortable handling the simple things yourself in a ten minute session, I would seriously consider bringing in a sports nutritionist, someone who understands the impact of training and understands the concept of energy balance and is very performance oriented, but is also able to see the whole picture and avoid some of the language that we are discouraging coaches from using these days.


I give at least fifty nutrition talks a year to teams who come through the Olympic training center.  Swimposiums are another great way to get your kids educated—you can contact your LSC for more information on that. You may also want to see if the rest of your athletic department wants to do a collaborative effort because we have some really high profile nutritionists in our network—this way you could save a lot of money and get an excellent speaker.


[Inaudible question from the floor] When you get a group of young ladies together—particularly at the age group where we see a lot of this disordered eating that is maturing into an eating disorder, things that we generally would say, “you look really fit or you look really healthy,” it is like trying to be a parent and talk to your kids—everything you say is going to come out different from what you mean. You have to stop and really examine what you are saying and I know it makes it hard.


We had one coach who said, “I can’t say anything to my kids.” That is not really the truth, but number one, listen to what you are saying, by telling an athlete they look really fit or they look really healthy may be taken the wrong way by an individual with an eating disorder.  Things that you might consider doing are, first of all, addressing them as an athlete—say they have a really good swim.  Acknowledge that have had a really good swim even if it is in practice and say, “I have noticed you have had a lot of really good swims lately, that is awesome.  What are you doing to help yourself?  Conversely, if somebody is not swimming well and you have noticed that they have gained five or ten pounds the thing not to say is, “you would be swimming a lot better if you would lose those ten pounds you found over the summer.”  That could spin them out of control.


Something else you could say is, “I have noticed you are not just swimming as well in practice as you usually do. Lets talk about your training.  Lets talk about your schedule outside of training—maybe we need to look at your nutrition.  Lets see if you are fueling your body appropriately.”  That is a really good way to address that. There are good things to say and bad things, but anything that is really very visually based is something that they are going to misinterpret – I guarantee it.  Telling a teenage girl that she is looking great is the wrong thing to because if she is in a pathological behavior that is just major positive reinforcement for her to continue in that pathological behavior. The trick is to look at it more from an athletic basis – their activity.  Comment on their activity.  For example, “you are just not as spunky as you usually are.  What is going on?”


The other thing that we also encourage coaches to do is to look at their athletes as individuals and if you see that a kid did really well in school say I know you made the honor society, that is outstanding – I am proud of you.  That will go miles for their self-esteem and for what they feel is coming from you.  I had a lot of experience with negative coaching when I was a swimmer – I never every made it to the national level or swam in college, but my age group coach was a very negative person and it was really hard to get motivated to swim because of all the negativity.  One positive thing out of the coach goes far with the kids and one negative thing can have the opposite effect.  Try not to make visual-based comments such as, you look heavy,  you look thin, you look lean.


[Inaudible question from the floor]  If we are going to step up to the plate and do something like that we also have to step up to the plate and get coaches, physicians and parents to realize that there is a time period in an adolescent’s life where they are going to have a lot of body changes, many of which are not compatible with great swims. The worst thing that ever happened to me was getting boobs. That killed my swimming worse than anything else.  It happens.  We have to understand there are kids who are going to change.  Their bodies are going to change and we have to accept that. We have to navigate them through that time period.  That is when they start becoming vegans.  That is when they start eliminating entire food groups because all of a sudden their bodies are changing.  They have fat distribution that is hormonally driven and they don’t like it because they don’t look like boys any more.  They are not flat-chested.  They don’t have narrow hips – some of them actually get jeans that allow them to pass through puberty without having all that stuff happen, but there is a huge population of age group swimmers that are going to have body changes that coaches don’t like because they get they get an undesired fat distribution. We have to understand there is going to be a period for some kids that may be very awkward and that is when they start adopting some of these weird behaviors.


To answer your question I think we need to strongly encourage them to recognize that there are several good things in that food pyramid and the food pyramid has been around for a long time because it works.  They need to be getting some stuff from each part of the food pyramid.  As far as saying you shouldn’t be a vegan – I don’t know – it depends on why they are going to be a vegan.  If their parents are vegans you can’t tell them not to be a vegan because they are a swimmer.  You certainly can.  It is not our choice to be a vegetarian or not. I think instead of us saying you cant be a vegetarian – if they want to be a vegetarian I think it is our responsibility to say okay, I will help you do it the right way. The point is fueling for performance – its not about being a vegetarian or not – you can supply your body with the right amounts of fuel in the right proportions even if you don’t eat meat or eggs or milk. It is not just about cutting meat out of a diet, it is about making sure that you are incorporating other food products into the diet to ensure that the vitamins and minerals that aren’t being received from a meat product or an egg product or milk product are provided by other foods and they might have to eat more of certain things–we can teach them how to do that.  But that is not the difference between a vegetarian and a non-vegetarian.  That is just a fueling issue and we do try to teach kids how to eat the right portion sizes.  How much is appropriate, how much carbs, fat, protein, vitamins and minerals and water is appropriate for you to support your training and performance.  I don’t know if I have a good example for you because I don’t know all the athletes diets in particular in terms of who is vegetarian and who is not and I really don’t think that that is the issue.


If you have an individual, especially a young girl that is at risk of developing an eating disorder, if you tell her what she cannot eat or what she needs to eat, eating disorders become a lot about control. She will absolutely do the opposite of what you tell her to do and that is a big risk.


[Inaudible question from the floor] – Well, ask her, “where do you get your protein?” she’ll say she doesn’t know.  There are a lot of vegetarians, and some of them don’t even like vegetables. First ask, where do they get their food?  From their parents, so you have to talk to the parents and say, “I am really concerned about your daughter.  She wants to be a vegan and if there is some ideological reason why she wants to be a vegan then say, “ take her to someone who can tell her to get enough of each thing”. Telling a 14 year old that they can’t do something is just giving them a license to go with that.  She is going to quit eating everything if you tell her she can’t be a vegan because she swims.


It is a control issue and if they are going to be a vegetarian they need to supplement other sources of protein, such as soy products—tofu for example. There are all kinds of stuff that they can eat instead of meat that will fuel them appropriately, but they need to learn about that and if they are going to make that lifestyle choice then they also need to take the responsibility to go and find out how to do it reasonably. They definitely need to talk to the nutritionist.


Right and there is a difference too.  If there is an ideological reason or a religious reason for them being a vegetarian then we really need to make sure that they are doing it the correct way.  If there is not a reason for them wanting to become a vegetarian, that’s a red flag.  That is something that Becky mentioned.  You have got to investigate and find out why do they want to become a vegetarian all of a sudden.  Maybe at school – some people do this for a month because it is cool and their friends are doing it and they eliminate red meat.


My general concept when I talk about nutrition is it is simple, but not easy – there is a huge difference between those two words when you are talking about nutrition.  It is simple, but it is not easy, particularly given the lifestyles of these kids and these coaches.  Being a vegetarian adds a whole other dimension to it, then it might not be as simple, but it is possible and doable and they can get the nutrients they need to sustain training and performance.


[Question from the floor – males and females] Yes, we are seeing an increasing measure of eating disorders in males and particularly again in performance in sports where visual performance has a lot to do with it, such as distance runners, wrestlers, but other than the amenorrhea there is a lot of similarities between the two – the fatigue, the overuse injuries, obsession, obsession with calorie counting, obsession with fat grams.


Men who have eating disorders are also very ritualistic as well so they may have rituals, eating rituals – only eating one meal a day or eating at certain times, and they can’t eat with their team because they have to eat this certain food at this certain time, or they’ve had rapid weight loss—these are the kinds of things that can alert you.


There is also a body image disorder with males trying to get pumped. If they start spending a lot of time in the weight room and are using a lot of protein supplementation, trying to get built.  This has a lot of the same self-image issues as the true eating disorders where they are not dealing appropriately enough to maintain their body, but physiologically we don’t have as much data on men because simply we haven’t studied them as much.


It is just so much more prevalent in females, but I think a lot of the physiologic stuff is going to be the same. I think men tend to be a little bit more restrictive rather than binge and purge.  Their purging is generally vomiting like women—their purging would be running around in one of those plastic suits to try and drop water weight. Or drugs, they might take the Efedra, the laxatives and the diuretics but I don’t think nearly to the same degree as a lot of the women and again, most of my experience is with women.


I have had a couple of males – males who have come to the clinic seeing me on my regular sports time that I have identified as disordered eating but they were totally resistant to any kind of treatment and just kind of quit seeing me because they were tired of hearing me try and get them into treatment.


Question from the floor: Do you have a team physician?


If there is a concern brought up about an athlete’s behavior, such as from a roommate, team mate, coach or the athletic trainer that works with that individual, they will either be referred one of two places:  They will either be referred initially to Kristen to just kind of go and sit down and talk about what is going on or if the athlete doesn’t want to meet with Kristen because they know what Kristen does they will get forced into my office.  You have to go and see Dr. Morgan about this issue because generally they are going to have some other physical problem that will get them in the door and 99% of the time it is fatigue when they come to see me so they will get sent to me for fatigue and we will start the first visit, which is strictly me getting a history, doing a physical and doing some really very minimal lab work.


Then they come back and see me in a week and that is when I really put the screws to them because I talk to them about nutrition for the first time.  Then I really kind of sit on them on the second visit because the first visit they are never willing to do anything so the second visit is when I tell them they have to go and talk to Kristen about their situation.  If they continue – say they don’t follow up with me and they don’t follow up with Kristen and we know that they are pathological, we talk to the coach and say look, this kid is really sick and you need to tell this kid they cannot perform until they get into our treatment.


The coaches usually know what I mean, it is very rarely a big shock and we have had great success.  This is a big problem with our long-distance runners. Our new track coach is wonderful and he has backed us 100%.  We have a girl right now that we are working with that if she does not participate in our eating disorders group she can’t run and they want to do their sport more than anything. That is the way we get them into some treatment and for you it will be a little harder because you may not have as many resources at your fingertips, but you have control over whether they can get in the pool or not and if you really feel strongly about it you just say they need to go and be evaluated and then once they are evaluated they need to follow the recommendations—it’s like putting the screws on them.


[Inaudible question from floor]


Yeah, but you are not just the coach—you are so important to that athlete.  You are way more important than I will ever be.  That puts you in a hard position but if the kid is really, really sick you have to so what you have to do.


The thing is there are a lot of schools that do not have team physicians and so that is where these coaches get caught.  I mean, they are the person.  They are the one person that knows this athlete better and they may have one athletic trainer that is taking care of three sports so the athletic trainer may not know these kids as well.


In these big D1 programs, such as at Tennessee I am happy to be the bad guy. I am the one that says you are not swimming until you do this.  You are not running until you do this and that is fine, it doesn’t matter to me that they don’t like me, but there are a lot of places where there is not a me there to take the hit and you have to be the one that takes the lump and tell the swimmer they are sick and until they get in to see somebody who says they are healthy enough to swim you don’t want them here. They are just going to get sicker and sicker if you don’t help and they certainly are not going to contribute to your team.


I would like to introduce Jack Daniels – he is here with us from SUNY Cortland, PhD in physiology and will be actually speaking to us a little bit later and I appreciate that comment coming from a physiologist.


[Inaudible question from floor—weigh-ins, fat percentages?]


That is one of the things at UT that we do not allow and we often have to challenge our coaches on that, but they are not allowed to do body fat percentages and we don’t allow weigh-ins and we strictly look at it from the fuel in your body for performance. We totally eliminated all of that.  We do not have any significant change – if you look at some of our teams like who is the fitter?  A lot of athletes that I talk with never use that information for anything that was really worth anything.  They got their percentages.  They had the weigh-ins, but nothing was done with that information that was productive. It was almost used as a fear tactic a lot of times and in a sense that really killed the self-esteem, it got the food obsessions going, they had them serve themselves up until that weigh-in happened.


Did you have a question?  Well, the bottom line is you need to have enough food for your sport.  You need to look at nutritionally what is going on and you can eyeball it, if someone needs to lose a little bit of weight you can go through the back door and look at nutritional things.  Look at it as fueling your body and if they are doing it the right way, weight will just kind of come off naturally.


<Discussion from the floor> The Adkins diet, there is a lot of data right now, but let me tell you who it works for: It works for people like me, people who sit a lot, people who are inactive, people who do love their carbs.  It does not work for people who swim six hours a day. You have to have some carbohydrates.  These kids are not grossly overweight. They are maybe a few pounds over, but they don’t have enough body fat to be using protein as a primary source of energy. I think that it causes their metabolism to shift in a way that is not compatible with their highest-level performance.  I think there is a lot we don’t understand about these diets, too.  Genetically some of us would benefit from being on a high protein low carb and that others will not. And I don’t think we understand how to know whom that is right for.


Kids are still trying to grow and develop and still have very immature nervous systems, I don’t think it’s a good idea to monkey around with eliminating a large part of what they need in their diet.  I think it can cause problems and I am not speaking from a science perspective, I am just speaking from a common sense perspective.


Now in college every time we turn around there is a fad diet going around. I can say with 100% confidence that I have not seen any kid in our program who has been on a fad diet who has dramatically improved their performance. From a common sense and from a basic medical perspective I do not see that those diets are beneficial to someone who is training at the level that these kids train and certainly I would discourage it in a child – somebody who is still developing.


When we get into the issue of the relative contributions of carbs, fat and protein to a diet, which is all fad diets really are—variations in the amount of carbs, fat and protein consumed—carbohydrates are the primary fuel source for swimmers in pool and dryland training. They tap into glycogen storage every single day. It is not only an issue of putting fuel in the tank, but doing it when the body is most sensitive to making the most of those fuels.


For those who were present for John Ivy’s discussion yesterday we talked on the timing issue and recovery in nutrition is one that is very highly neglected.  When recovery and nutrition aren’t part of the training plan, the athlete can find herself in a position where performance is affected—not necessarily in terms of how fast she is going to swim, but how often she is going to be able to get to the pool when the body is chronically low on carbohydrate stores over a period of time.


We may see elevations in cortisol, which is a hormone that can do damage to the immune system and leaves your athlete susceptible to infection. There are also other things that are going around so it is not necessarily a direct impact on performance in terms of eat and swim, but maintaining a healthy body and maintaining a healthy immune system.


Carbohydrates play an enormous role in maintaining a healthy immune system so when we start eliminating carbohydrate from our diet in large quantities it can affect an athlete’s performance and cause them to get sick.


Yes – question – when you come across an athlete and you do an analysis for them – and you come to the conclusion that the athlete is eating correctly – in the way that you would recommend —— how do you approach that?  In other words, do you eat too much of the right food?


Anything that I would recommend would be based on what their training schedule is.  We would always take into consideration what they need first – that is the first part of any diet analysis.  Let’s calculate what your needs are – you as an individual – based on your training at this point in the season and then the analysis as far as what they actually are eating. For example, even if their diet looks great they are getting too many calories–500 calories extra a day, seven days a week – that is one pound–3500 calories in one pound of fat. Over a period of time that can have an impact, but you cannot be so specific as to say you need to have this many calories every single day.


It’s best to look at their diet over a few weeks or months. Even fruits or vegetables can be too much of a good thing.  I might not say that because they are very low calorie to begin with for the most part and they provide an awful lot of vitamins and minerals that are critical.


<Discussion from the floor> If the quality is great, but the quantity is an issue then we are getting into something like portion sizes and learning how to distribute your total food amount throughout the course of the day so you are getting your small meals more often. You are getting your recovering nutrition immediate post-workout twice a day if that is the case.  That means educating the swimmer.


Most times it is only if you are seeing a consistent process– like if someone is gaining weight.  Sometimes the numbers don’t always work out to be exactly the way you think they should and someone may look like they are getting too many calories a day, but there is no history of weight gain or loss. Why try to fix it if its not broken?  That is not your job.


Quality assessment can be part of it, but when you are getting into issues with weight gain and loss that is the time to enlist the help of somebody who is paid to do that – a nutritionist – that is their job.


I have a story about a nutritionist that was dealing with kids who had portion control problems and they used colors, like green was fruits and vegetables and then red was proteins and meat and another color – maybe yellow – was carbohydrates.  And they drew a picture of a plate and they drew this plate in proportion size of what they should eat based on what type of food it was and they got these kids used to looking at a plate that had a lot of green, a little bit of red and a moderate amount of yellow and when they would go to fix their plate they would say, your plate needs to correspond to this if you want to be as fuel efficient as possible.


The swimmers would get used to the portion size by a simple technique—color-coding. , They learn that fruits and vegetables are great, but three chicken breasts maybe isn’t the best thing and eating six rolls is definitely not the best thing. Just getting them used to looking at what their plate should look like worked for these athletes.


I think the point that Charlene was trying to drive home and the thing that is really hard for us to sit up here and say and for you to sit out there and listen to is that coaches don’t need to drive what their kids put in their mouths—it may not be practical, but we are shooting for what the best world is that we can have with our swimmers and how they are eating. Again, when you say to a swimmer that they are eating too much they are going to hear the wrong thing. You can enlist the nutritionist to put together a little pamphlet on portion control that you can hand out to everybody.


<Discussion from the floor> It’s not just about teaching them or encouraging them to visualize what portion sizes should be – that is why I bring those food models to the lectures. Get a plastic plate, buy a few food models, throw them on there with some variations of what dinner might look like and just have it sitting out on the pool deck.  Make sure they are also included alcohol. The quickest way to put weight on someone is alcohol so make sure they are including that in their total calorie count.  And you are working with adults – for the most part those people are pretty comfortable with themselves.  They are not going through periods of change where what you say and do is going to come out the wrong way or be interpreted by them as something different.


The first thing I would recommend is find a nutritionist who is in our network and who is interested in swimming, a lot of times they will do some stuff – just working with your team as a team talk.  If you have an individual that you really want a nutritionist to work with on a one-on-one basis, most insurance plans will pay for it if a physician says that there is a diagnosis that requires a nutritionist consult. However, it is hard to find that diagnosis, but you may want to start with a physician to see if they say. Some HMOs actually have nutrition on their panels now, but there is a real high variability from nutritionist to nutritionist.  Your best bet is to identify sports nutritionists because they are going to understand the demands that athletes have.  If you can find someone who particularly has an interest in swimming that is going to be even better.


There are nutritionists that have great interest in sports and they become sports nutritionists, if you can find someone who is that highly specialized you can kind of guess that they have some knowledge.  If you find a primary care doctor who is Board Certified on Sports Medicine like myself and Dr. Johnson back there and some others in the room – we have expressed an interest in Sports Medicine and so we have learned a little bit extra and that kind of gives you a heads up that we might be a little bit more intoned to athletes than a regular family practitioner. Nutritionists are specializing as well – some nutritionists know a lot about sports and they are not considered sports nutritionists so you just kind of have to research your community resources.


Don’t expect to call somebody up and have that person be the one – if you are lucky enough to find that that is wonderful, but as a coach looking for somebody to come in and give a talk or do individual consults with their athletes it may take a little bit of leg work in terms of interviewing and asking some key questions and we can certainly help you – credentials is a big one – background, any research – what kinds of teams have you worked with – which athletes – some pretty basic things that you have a right to know before you enlist that person’s help.  Meet with them one on one – get a feel for how they talk and what kinds of material they have and how up to date they are on current issues in sports nutrition.


But you will find a clinical registered dietitian is very different from a sports nutritionist who may not be a dietitian at all, but may be someone who was schooled, someone who has practiced, someone who has been in the community simply because they are fortunate enough to work with a team over a number of years.  You can’t just look at a credential. There is some degree of interviewing and thought in that process.


Sports medicine physicians often know good sports nutritionists and may also be able to refer you so you have a couple of avenues and if you have to go out on your own. To my knowledge there is no website aside from the online directory that we have created on the USA Swimming website which is searchable by state—there are over 250 names listed in that directory.  Some states are more populated than others in terms of people on the list.


Are there any additional questions? <Inaudible question> If you are going to be willing to take your kid out of the sport, you also need to have that network ready.  You need to have a place you can plug them in because you may be taking away the one thing that gives them reason to get up in the morning.  So, that is a really good point and I would emphasize that if you see someone who you think does need help, try to identify one professional that has some expertise in this area and that you have some relationship with. That way you can tell them you’ve got a kid who does not really want to get help, but you are concerned about their health and you want to take them out of the sport.  They need to get plugged in right away and we never take an athlete out of their sport until we have a very well defined plan of action when they are removed and when they get back into their sport.


We actually have them sign a contract and the contract outlines every thing that we expect from them in accessing care for treatment.  We never put in there that they have to meet certain treatment goals, because then you are setting them up to fail if they have a back-slide, but we put in the contract very specific expectations that we have about them accessing care, such as they have to see me every two weeks in the office.  They have to see Kristen twice a week.  They have to see our disordered eating therapy group once a week.  They have to check in with their coach and they have to check in with their academic advisor.  It is a pretty strict regimen, but as long as they continue to hold up every one of our recommendations, they can continue to be a part of the team and this is really a last resort.


We don’t just randomly pluck kids out of practice who we think have eating issues.  These are the kids that are just so entrenched in their pathology that they are spinning out of control and we take these measures because they are creating a lot of chaos on the team.  They are changing the dynamics on the team.  They are changing the dynamics with their roommates and they are starting to affect other people’s lives with their disorder and that is when we feel it is really important to stop it.  We have to stop that cycle.


One athlete was creating such disorder in her apartment that the roommates were coming to us for assistance because they were so afraid of what they were going to find when they came home.  It was like living with an alcoholic who was in rage all the time.  They were afraid to go home so we had to intervene at that point because this particular person was so sick that she was changing the lives of her teammates and roommates.


Fortunately, we have a system that can help and I know there are a lot of people out there that don’t have resources and don’t have the system. But sports medicine professionals and people who are very in tune with this are popping up everywhere now.  It is a rapidly expanding specialty so whereas two or three years ago you may not have had someone in your community who has knowledge of this – you may now.  See what your resources are and then if you do fall into a situation where you have a severely ill athlete you know that there is one person you can turn to to help you with that person.


Question – on your contract, you don’t wait right?  We don’t have any physiologic parameters.  We have some athletes who have seen our therapist – not Kristen, but another therapist who a talented eating disorder therapist and if they are on a bad binge and purge cycle she will have them weighed and she will use the weight. I don’t like to weigh them.  If I weigh them they never know what their weight is when they are in my office.  It embarrasses them to be weighed because our scale is in the hall so I have them step on the scale and I hold their folder like I am talking to them so nobody knows that I am hiding their weight. But I hide their weight and they never see their weight and then a lot of times I will call the therapist and give her the weight.  I don’t address the weight issue at all.  But a lot of times we depend on our therapist to tell us when the kids who are really sick are good to go.


As far as our contract though, our contract does not have any x number of things that you have to complete.  Our contract may just require that they are accessing care.  They have to attend their appointments.  We did require one female athlete that wouldn’t take her medicine to take it, but that was the one time we put something in there about medication. Generally contracts just deal with them keeping their appointments.


We don’t say they have to be a certain weight.  One kid had a potassium problem and I told her if her potassium was too low I wouldn’t let her swim, but it is really rare that we use those numbers because they focus on numbers.  They get so stuck on numbers then it is all about the number and it is not about their treatment so we try not to give them any kind of concrete parameters.  We just say you must be accessing care.


Right, but the kids that we put on these programs – they are not swimming well.  They are sick.  I mean, four weeks—that is almost a whole cross country season. Our coach gets chest pains when we talk about stuff like that, but the bottom line is when we are intervening at this level with these kids it is not about the sport anymore, it is about whether or not they are going to live.


And we acknowledge that it is totally frustrating and you have every right to be frustrated.  You are a coach.  That is what you are there to do.  You are not there to have athletes that aren’t in the pool for six weeks, but we can’t force time.  It’s not the same thing with ankle sprains, we have gotten really good at forcing time on ankle sprains and getting people back into their sport.  We have gotten really good with other types of injuries of compressing the time that we can get them better.  There is no time compression in eating disorders and as a matter of fact, you don’t even have any control over it.  We just have to sit back and be the best that we can and see how this kid responds to therapy—it’s frustrating for me, as well.


I will walk out from one of the numerous meetings that we will have about a particular athlete and say, “Oh my gosh, why am I doing this, you can’t fix them?” We talk to each other and we express our frustrations.  Our track coach said, “this is driving me nuts” and my answer was me, too.  We are all going to go to the Looney bin together with this one, but you just have to understand that this is not something that we can necessarily predict nor can we you know a particular rehab timeframe.


Discussion from the floor – Well, one thing that I think is very important is what Kristen brought up earlier is for coaches, parents, physicians, athletic trainers to not tolerate some of the crap that goes on out there, such as disrespect on the deck or in team meetings.  Don’t tolerate people kidding each other about the way they look.  That is the first step is just to not tolerate some of that behavior.


We are not going to change the fact that Cosmopolitan magazine air brushes women onto their covers every month.  It is just not going to change, but what we can change is the way that we allow those kids to behave in our presence. If you, someone they respect, tells them you won’t tolerate that behavior, they might listen, particularly if you are really consistent about not tolerating that kind of behavior.  We are not going to change the world, but we might change some of our culture if we don’t allow our little micro cultures to put up with a lot of this stuff.  I think that we have to start on a really basic level and you as a coach do not allow your kids to disrespect each other.  Teach them to value each other at human beings and it is a small start, but it may be a start.


I don’t think we are up against huge societal issues like I talked about earlier in my presentation and I have heard a lot of people say that they are swimming and that will keep them fit and thin so at some point you need to probably sit down and look at why they are swimming and are they swimming for the right reasons. You should have a conversation with them about that, but like Becky said, we are not going to change the societal pressures, but there are little things that we can do in your own environment to create a healthy environment.


Examples of creating a healthy environment?  Some reality checks. It is hard to convince a teenager that that the people in magazines aren’t real, that they are airbrushed people and that is not the typical human being.  Teenagers are bombarded with how they look.  Get away from the look and the image to you as a person, and how are you doing at school and I am proud of you for this and get away from commenting on image.  You have a leadership role on the team and it is really respected. Try and bring out these other personalities or characteristics that are totally different from image.


We were talking about societal pressures and a video called Behind Closed Doors– this is one of the resources listed in our booklet that will come out this fall—and it talks about magazines and how they are made. Let me read the description:


“The process by which virtually all fashion and advertising photos are digitally corrected to enhance their appearance, making models and celebrities closer to the societal ideal of thin is beautiful.  The focus of this video is on women rather than all models.”


It is about a ten-minute video, which would be an interesting thing to show the kids that the stuff they are reading isn’t real.  They can learn about makeup and hair, but realize that those ladies don’t really look like that.


Another thing I would recommend, and this is something I learned working with a pediatrician when I was a resident, is teaching kids positive self-talk.  And it works much better at a young age, but you can still impact them up to the level of high school.  I think it is very important to find something positive to say about a kid—even the most miserable kid.


I had this kid that was in my practice.  He used to tear my room up every time.  My nurse would have to put the room back together because this kid was so wild and finally one day I just said, “You know what?  You have the neatest red tennis shoes I have ever seen,” and he just stopped what he was doing and from that moment forward, our relationship as a patient and a doctor completely changed because I finally realized that kid just needed some sort of positive self-talk.


I started doing that with a lot of my patients, just finding something really interesting and nice to say about them that had nothing to do with the way their body was shaped and it has worked.  I have a great relationship with the kids who come to see me. We don’t talk very much about sport when they are in my office.


To answer your question about the magazines…we have eliminated a lot of that trash out of our student health center waiting room.  There are certain things that we just don’t allow to be put out there to be read and maybe it’s helping and maybe its not – we are not going to promote it.


Some kids will hold on to one little negative comment forever and they won’t forget.  The more you can do with positive reinforcement on anything, about the sport, about them as a person and everything else is just great.  Just by changing your language you can create a healthy environment. Looking at how your language and what your role may be and if it is a role that maintains and supports an eating disorder versus is it a really positive nurturing environment? Athletes can take those few comments that they heard that were very, very negative and they can’t forget them.  They take them and just hold onto them and then they start believing those things about themselves.


I know you came in towards the last half hour probably of the session and we actually do have a booklet, a pretty expensive booklet that is coming out in the fall issue of Coaches Quarterly, dedicated to disordered eating. It’s a Q&A format.  It has questions that came directly from the coaching community and we have all the answers to them and it includes a resource list and some other supplemental materials.


Discussion from the floor – Our hope though is to educate as many coaches as possible and by educating a newer group of coaches that knowledge hopefully will be disseminated more widely and attitudes can change and fortunately some of these older guys that are still doing this stuff aren’t going to be coaching forever.  Eventually they are going to get out of the business and hopefully new, younger coaches are going to have this knowledge and change a little bit about the way they do it.  That is the only thing that we know to do is to educate. Thank you guys for coming.  Thank you all very much.



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