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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 Center of WNY
Director, Child and Adolescent Eating Disorder Program,
Golisano Children’s Hospital
Overview
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Introductions
Athletes with Eating Disorders
– Medical health issues (Kreipe)
– Mental health issues (Tantillo)
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Panel: Four Perspectives
– Coach (Wright)
– Athlete (Padgham)
– Trainer (Abegglen)
– Parent (Patchen)
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Discussion
Anorexia Nervosa
(pursuit of thinness)
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Insufficient energy intake
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Wasting of the body
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Delusion of being fat
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Obsession to be thinner
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Does not diminish with weight loss
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Denial
Inadequate Energy Intake
Physical health
Mental health
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Absent menses
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Disconnections
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Cold hands/feet
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Concentration
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Constipation
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Decisions
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Dry skin/hair loss
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Irritability
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Headaches
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Depression
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Fainting/dizziness
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Social withdrawal
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Lethargy
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Obsessiveness (food)
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Anorexia
Bulimia Nervosa
(avoidance of obesity)
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Recurrent, secretive binge-eating
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Fear of not being able to stop eating
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Awareness that eating pattern is abnormal
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Depressed moods and self-deprecating thoughts
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Temporary relief via avoidance of weight gain by
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Fasting
Self-induced vomiting
Catharsis or diuresis
Exercise
Signs & Symptoms of Binge Eating
Physical health
Mental health
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Weight gain
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Disconnection
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Bloating
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Guilt
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Fullness
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Depression
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Lethargy
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Anxiety
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Salivary gland
enlargement
Signs & Symptoms of Vomiting
or Laxative Abuse
Physical health
Mental health

Weight loss
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Disconnection
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Electrolyte disturbance
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Guilt
– K
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Depression
–  CO2
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Anxiety
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Confusion
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Dental enamel erosion
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Low blood volume
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Knuckle calluses
Eating Disorders: Dispelling Myths
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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 age.”
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 fame?
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
Parotid
Submandibular
Dental Enamel Erosion
www.maxillofacialcenter.com/bulimia.html
- Dentin (yellow) visible beneath
eroded enamel (white)
- Worse on lingual than buccal
surfaces
www.thejcdp.com/issue001/gandara/
introgan.htm
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
Lanugo
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 Energy intake results in wasting of lean (muscle) > fat
Metabolism occurs in the lean body mass>>>>>fat
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;
•36.9°C
Weekly visits
Week 5:
•Wt 91#;
•S.G. 1.020;
•HR: 4482
•35.3°Cl
Recheck Wt.
(observed) and
physical exam
Edema
Slow Capillary Refill
Acrocyanosis
Carotenemia
Livedo Reticularis
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Bluish discoloration of skin
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Reticular (“lacy”) pattern
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Asymptomatic, but often
associated with low core
temperature and metabolism
www.pediatrics.wisc.edu/education/
derm/tutc/69.html
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 containers
 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 bingepurge episodes
 Behaviors and attitudes indicating wt loss, dieting
and control of food are primary concerns

www1.ncaa.org/membership/ed_outreach/healthsafety/sports_med_education/triad/triad_prevention.htm
Female Athlete Triad
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Usually begins with disordered eating in an attempt to
lose weight
Disordered Eating
– More common in sports emphasizing leanness
– Can negatively affect athletic performance
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Loss of menstrual periods
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–
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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. stress
Nutrition: key factor for good health
Health: key factor for athletic performance
(NCAA, 2005)
Risks for Disordered Eating in Athletes
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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
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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 sport
Communicate with treatment team, parents (<18 yo)
to form collaborative partnership
(NCAA. 2005)
Symptomatic Athletes Are Unlikely to
Recover without TreatmentIt is Required
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Athlete becomes isolated, gets less support, making
disordered eating more difficult to monitor.
Deterioration physically and psychologically has
negative effect on performance.
Poor performance (related to self-concept) results in
increased pressure to try to improve performance.
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, nutrientpoor foods, unusual or no schedule): need nutritional info.
2. Sleep/rest - Many student-athletes sleep <6 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, 2005)
Screening Tests
for Athletes with Eating Disorders
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The Athletic Milieu Direct Questionnaire (Nagel et al., 2000); Newer
test for detecting ED’s in athletes but respondents know what test is
looking for
Physiologic Screening Test for ED’s/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 bloating)
-8 self report items (e.g., hours exercised outside practice,
menstrual irregularity)
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Highly sensitive (87%) and highly specific (78%) for detecting athletes
who either have disordered eating or ED’s
EATING DISORDERS ARE DISEASES OF
DISCONNECTION
- Disconnect patient from herself and others
- Disconnect family from other families
- Disconnect family from staff
- Disconnect treatment team from one another
Disconnections
Disconnection: A disturbance in the flow of
relationship that prevents or interrupts the
experience of perceived mutuality and is
characterized by:
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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, it’s so inappropriate to have
different opinions,…the smallest trace of being
different makes it easier to not be liked…I was so
cautious of the way I sat and the words I used when I
was over there tonight. I didn’t 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 I’m
with them. I have to lock it away.”
(Betty, 10/21/03)
EATING DISORDERS – DISEASES OF
DISCONNECTION
Biopsychosocial Risk Factors:
Biology:
Serotonergic Disturbance; Starvation;
Binging/Purging
Psychology: Disconnections; Relational
mismatches
Socio-Cultural: Toxic Societal Values that objectify
women’s (and men’s) 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 & dieting
 Rapid or dramatic weight loss
 Refusal to eat certain (“unhealthy”) foods
 Frequent comments about feeling fat (despite wt loss)
 Anxiety about being fat or gaining weight
 Denial of hunger
 Food rituals
 Consistent excuses at meal times
 Rigid exercise routine (despite illness, fatigue, injury)
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RECOVERY IS ALL ABOUT
CONNECTIONS:
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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:”
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Self-worth
Sense of energy/zest
Increased clarity re: oneself, the other, and the
relationship
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?!” Don’t 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)
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Pre-contemplation: no perceived need to change,
denial
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Contemplation: able to consider change, ambivalent
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Preparation: ready to change
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Action: implementation of plan to change
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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, relationships)
 Discuss/write about how the eating disorder helps or
hinders the student achieve life goals and live out values
(e.g., athletic goals)
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(Prochaska,
Norcross, & DiClemente, 1994)
Coach and Health Care Provider Approach
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Validation (shame/secrecy)
Direct and specific questions
Don’t 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 splitting
Potential Obstacles/Challenges in Referring
& Managing Students with Eating Disorders
School personnel anxiety, lack of education and
training
 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 (continued)
Not understanding that the Eating disorder
decreases the student’s 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
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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 student/family.
Specify roles and responsibilities (weekly weigh-ins,
lab work, lunch supervision, etc.) for all adults
involved in treatment plan.
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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 don’t involve the eating disorder.
 Encourage and model communication/problemsolving skills.
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Prevention Strategies for Coaches to
Decrease Risks in the Athletic Environment
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De-emphasize weight.
Do not compare one athlete’s body/performance to
another athlete’s body/performance (the other
high performance athlete may have an eating
disorder)
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
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Foster mutual connections among athlete and
coach/trainer, team members, and other
adults/peers
Recognize individual differences in athletes
(athlete profiles describe but don’t predict)
Increase education of athletes, coaches athletic
trainers, and other sport personnel (re: DE, eating
disorders, nutrition, Female Athlete Triad)
Involvement by Sport Governing Bodies (NCAA).
(NCAA, 2005)
“Lean Sports” Increase Risk for
Disordered Eating and Eating Disorders
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Judged sports
aesthetic (diving, figure skating, gymnastics)
appearance (ballet, cheerleading)
endurance (distance running, ski jumping),
weight-class sports (lightweight rowing,
wrestling)
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 ED’s/Disordered Eating
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, 286297.