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T H E D I E T I T I AN ’ S R O L E I N U N D E R S T AN D I NG AN D OV E RCOM I NG T R E A TM EN T R E S I S T ANCE

DISORDERED EATING AMONG ATHLETES:

The 29th Annual SCAN Symposium

Jenny H. Conviser, Psy.D.Assistant Professor,

Feinberg School of Medicine, Northwestern University, Chicago, Illinois

Assisted by:Kristen Botte, R.D. and Christine Elkhoury, R.D.

April 28, 2013

DISCLOSURES

• I have no relevant financial relationships with the

manufacturers(s) of any commercial products(s)

and/or provider of commercial services discussed in this CME activity.

• I do not intend to discuss an

unapproved/investigative use of a commercial product/device in my presentation.

LEARNING OBJECTIVES

Upon completion of this module,

participants will understand:

1. Risk of Eating Disorders Among Athletes

2. Medical Risks of Eating Disorders

3. Psychological Underpinnings of Eating Disorders

4. Stages of Change

5. Improving Motivation for Change

6. Communication Skills for Managing Resistance

7. Facilitating Nutritional Health Among Athletes

EATING DISORDERS THREATEN WELL BEING

� Eating Disorders are more deadly than all other psychiatric illnesses combined, including Schizophrenia and Bi-Polar illness.

� Five percent of individuals with eating disorders (ED) will die of complications of that disorder.

� Individuals with ED’s are at a greater risk of suicide than population controls.

� Death rates may be under documented.

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ED RISK AMONG ATHLETES

� Anorexia occurs in 1% of females and less in males.

� Bulimia occurs in 1 to 3% of females in the general population.

� Bulimia is five to ten more frequent among females than in males.

� Binge Eating may be more common in male athletes than female athletes.

ED RISK AMONG ATHLETES

� Muscle Dysmorphia, the preoccupation with building muscle. (Pope, Gruber & Choi, 1997)

� Sports participation may “protect” athletes from eating disorder risk in some cases.

� Among some teams and dance communities, 50 to 100% of athletes meet all criteria for eating disorders. (Johnson & Powers, 1999) (Calhoun, 1998)

� Increased testing for anabolic steroids may increase focus on diet manipulation to manage one’s physique (Longman, 2003).

EATING DISORDERS AMONG ELITE ATHLETES

� Among adult elite athletes, the prevalence of

disordered eating and clinical eating disorders is

higher in elite athletes competing in leanness sports compared with those in non leanness sports

and controls.(Torstveit, MK et al. Scand J of Med Sci Sport, 2008, 18, 108-18)

� Higher ED rates may occur when aesthetics are

critical to judging, scores or performance.(Burkes-Miller & Black, 1988) (Sungot-Borgon & Toraveit, 2004)

SELF REPORTED SYMPTOMS

� Self-reported ED symptoms among elite male and

female adolescent athletes was lower than among adolescent controls.

� Less awareness of abnormal symptoms

� Greater risk in reporting

� Greater normalization of focus on body, weight and shape

� Greater tolerance of discomfort

� Coach reluctant to report emerging concerns

� Athlete wanting to protect the team

(Martinsen et al., (2010) British Journal of Sports Medicine)

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DO SOME ATHLETES HAVE GREATER EATING DISORDER RISK ?

� Possible Contributing Factors:

� High personal standards of excellence

� Believe weight loss will enhance sport performance

�Weight loss practice modeled in the sport environment

�Associate “thin” with success and recognition

� Pursue weight loss without consulting medical or athletic

personnel

� Believe overweight conditions are not respected

� “Lean Component” required in the sport

THE SPORT CULTURE IS RELEVANT

�The sport culture communicates weight related values directly and indirectly.

�Coach communication can influence diet and weight related attitudes and behavior.

�A significant number of adolescent elite male athletes were told by coaches that they were to reduce weight.

(Martinsen et. al., 2010)

UNHEALTHY WEIGHT LOSS

�Severely restrictive energy intake

�Eliminating one or more food groups from the diet

�Consumption of unbalanced diets

�Consumption of low macronutrient density foods

(American Dietetic Association, Dieticians of Canada, American College of Sports Medicine)

UNHEALTHY WEIGHT LOSS

� Low Energy Intake Risks:

� Muscle mass loss

� Menstrual dysfunction

� Bone density loss

� Fatigue

� Injury and Illness

� Disrupted training and performance

� Prolonged recovery process

Journal of the American Dietetic Association (2009), p. 510

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MEDICAL COMPLICATIONS OF EATING DISORDERS

Anorexia

• Weight Loss >15% (Less in Athletes)• Weight Fluctuation

• Emaciation

• Bradycardia

• Hypotension• Hypothermia

• Lanugo Hair

• Carotenemia

• Hyperkeratosis• Edema

• Amenorrhea

• Spontaneous Fractures

• Ketones in the blood stream• Electrolyte abnormalities

Bulimia Nervosa

• Normal or overweight• Hypertensive

• Swollen Parotid Glands

• Dental Erosions

• Scars on Knuckles of Hands• Edema

• Esophagitis

• Electrolyte Imbalance

• Sore Throat• Kidney damage

MEDICAL COMPLICATIONS

Diuretic Use

� Electrolyte Imbalance� Dehydration

� Rebound edema: water retention

� When diuretics are discontinued: swelling of hands and feet

Laxative Use

� Electrolyte imbalance� Stomach cramping and discomfort

� Chronic constipation

� Dysfunctional bowel syndrome� Constipation� Impaction

� Deficiency of fat, protein and calcium� Gastrointestinal bleeding

� Rebound edema when laxatives are discontinued

MEDICAL COMPLICATIONS OF VOMITING

Head and Neck

� Erosion of tooth enamel

� Dental cavities

� Gum disease

� Chronic sore throat/difficulty

swallowing

� Swollen parotid glands

� Inflammation of the salivary

glands

General

� Dehydration: Light-headedness

� Bloating and abdominal pain

� Distention of the stomach and

esophagus

� Pancreatitis: Nausea, vomiting,

abdominal pain

� Syrup of Ipecac poisoning

� Aspiration of vomit: pneumonia,

lung infection, or death

SIGNS AND SYMPTOMS OF EATING DISORDERS

General

� Fatigue

� Sleep Disturbance

� Dizziness or Fainting� Orthostatic Hypotension

� Shortness of Breath

� Bloating

� Heartburn

� Chest Pain� Abdominal Pain

� Constipation/Diarrhea

� Cold Intolerance

� Pale or Gray Skin Tone

� Fractures or Stress Fractures� Fractures Slow to Heal

� Brittle Hair

� Hair Thinning or Loss

� Lanugo

Athlete Related

� Weakness

� Loss of Muscle Mass

� Slow Recovery Time Post Exertion

� Higher Incidence of Injury� Performance Plateau or Decrement

� Conditioning Plateau or Decrement

� Less Satisfaction in Sport Participation

� Erratic Sport Performance

Eating Disorder Behavior

� Obsession with Calories, Food and Weight

� Frequent Weighing

� Comments about others Weight or Shape

� Comparing Ones Body With Others� Discomfort Eating in Front of Others

� Secretive Eating Patterns

� Increasing Numbers of Eating Rules

� Use of Diet Pills, Laxatives, Syrups or Enemas

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PSYCHO-SOCIAL SYMPTOMS MAY CO-OCCUR WITH EATING DISORDERS

Mood

• Depression

• Anxiety

• Low Self-Esteem• Irritability

• Absence of Negative Affect

• Mood Fluctuation

• Independent

Experience of Self

• Persistently Unsatisfied With Oneself• Struggling to Cope

• Dichotomous Thinking• Feelings of Emptiness• Quest for Perfection

• Desire for Attention• Need for Control• Obsessive Focus

• Need for Distraction• Difficulty Recognizing Feelings• Difficulty Experiencing Feelings

• Difficulty Expressing Feelings

Irrational Beliefs

• I value thinness.

• Thinness improves performance.

• Thinness makes me feel powerful.

• Thinness gives me control.

• Overweight is not respected.• I will get more attention if I am thin.

• I will be happier at a lower weight.

• I will be a better athlete at a lower weight.

• I won’t like myself if I feel fat.

• Others won’t like me if I am at a higher weight.

DIETITIAN’S ROLE

� Monitor food and drink intake� Patterns of restriction� Reduction in variety of foods consumed� Elimination of certain food groups � Increases in food related rules

� Increases in food or eating related rituals

� Monitor physical activity

� Change in exercise regime

� Increase in exercise or training rules or rituals

� Added exercise before or after team practices

� Obsessive measurement of physical training

� Provide recommendations for dietary changes

� Record and analyze biometric data; weight, body mass index

and body composition.

DIETITIAN’S ROLE

� Monitor overall health

� Provide good nutritional information

� Address diet and food related misconceptions

� Collaborate appropriately with treatment staff, coaches,

trainers and medical personnel.

� Respect athletes privacy

� Respect personal boundaries

� Awareness of medical risk

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DIETITIAN’S ROLE

“SUPPORT GOOD HEALTH”“SUPPORT GOOD HEALTH”“SUPPORT GOOD HEALTH”“SUPPORT GOOD HEALTH”

• Will all patients or athletes want your advice and

follow your recommendations ?

• Some may actively resist change.

• What can you do to manage this resistance?

MOTIVATING CHANGE

Avoid employing the following:

� Reminders

� Lecture

� Reprimand

� Becoming frustrated

� Criticize

� Attribute lack of change to internal failure

WHAT IS MOTIVATIONAL COMMUNICATION?

“… a person-centered, goal orientated approach for facilitating change by exploring and resolving ambivalence”

(Miller, 2006)

“…a method of communication rather than a set of techniques. It is not a bag of tricks for getting people to do what they don’t want to do, rather, it is a fundamental way of being with and for people…. a facilitative approach to communication that evokes change”

(Miller & Rollnick, 2002)

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BENEFITS OF MOTIVATIONAL COMMUNICATION

� Brief

� Beneficial across age, gender, race, socioeconomics

� Enhance compliance

� Reduce attrition

� Reduce resistance to change

� Facilitate problem resolution

� Improve treatment effectiveness

EFFECTIVE COMMUNICATION

Create a Collaborative Working Relationship

� Prioritize the athlete’s personal goals and values

� Provide accurate information and support

� Allow the athlete to be the active decision maker

� Create an atmosphere conducive to change

� Affirm the athlete’s right to choose

� Align yourself with the athlete

� Presume the resources for change reside within the athlete

CHANGE: HELPING CLIENTS ACHIEVE GOALS

“Change is a process occurring in small steps”

� Relapse or lapse is normal.

� Factors Predicting “Change”:

� Confidence

� Readiness

�

� Counselor’s belief in the patient’s ability

� Empathetic Counseling

� Commitment

� Motivation

A Continuum of Readiness

for Change

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STAGES OF CHANGE IN THE MODIFICATION OF PROBLEM BEHAVIOR

� Pre-Contemplation

� Contemplation

� Preparation

� Action

� Maintenance

IDENTIFYING THE STAGE OF CHANGE FACILITATES:

� Expectations

� Attributions

� Planning

� Problem solving

Kirschenbaum, Fitzgibbon, Martino, Conviser, Rosendahl & Laatsch, 1992

MOTIVATION: HELPING CLIENTS ACHIEVE GOALS

o Motivation is considered on a continuum

o Motivation is based on the patient’s values, needs and beliefs

o Three Components of “Motivation”:

• Readiness

• Willingness

• Ability

Miller & Rollnick, 2002, p. 10

MOTIVATION IS NOT IMPROVED BY:

Health Risk Loss

Punishment Pain

Withdrawing Punishment Shame

Guilt Humiliation

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COMPONENTS OF MOTIVATIONAL COMMUNICATION

� Open-ended questions

� Express empathy

� Affirmation

� Reflective listening

� Managing resistance

� Summarize

OPEN-ENDED QUESTIONS

Closed Ended Questions

A. Are you getting 5 servings of fruits

and vegetables daily?

B. We talked about carbohydrates last week. What is your current daily

intake?

Open Ended Questions

A. How are you feeling about your

current diet?

B. Wow. It sounds like you have read a lot about carbohydrates and running.

How are your feeling about being

able to utilize this information?

OPEN-ENDED QUESTIONS

Closed Ended Questions

A. How much do you currently

weigh?

B. Do you feel your nutrition is impacted your athletic

performance?

Open Ended Questions

A. How are you feeling about your

body shape, weight, and/or

appearance?

B. Tell me about any modifications

you have recently considered

making about your diet. Tell me

about what motivated these changes.

EMPATHY

� Acknowledge that change can be difficult.

� Clarify points of difficulty.

� Identify the primary emotions that impede change.

� Understand that desired changes may have “costs” that are

challenging.

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AFFIRMATION

� Respect the athlete’s efforts.

� Understand the athlete’s perspective.

� Acknowledge strengths and weaknesses.

� Accept and respect lapses and set backs.

� Avoid blame or criticism.

REFLECTIVE LISTENING

Acknowledge the patient’s thoughts, circumstances and emotions to facilitate discussion and reduce

defensiveness.

� Let the patient hear what you are hearing:

� Heard

� Understood

� Self Observation

� Insight

� Connection

MANAGING RESISTANCE

� Acknowledge patient’s

perspective

� Acknowledge patient’s emotion

� Explore both sides of

ambivalence

� Explore short & long term

consequences

� Delay agreeing or disagreeing

� Avoid argument

� “Coming along side”

�Consider resistance to be

evidence of the interviewer’s

problem

� Reframe

�Offer amplified reflection

� Shift focus

� Emphasize personal rights and

control

�Opportunity for learning and

change

SUMMARIZE

� Here is what I heard you say about…

� I appreciated hearing more about…

� It sounds like what you most value is…

� I hear that what makes it difficult

sometimes is…

� I am happy to talk with you more

about ...

� What are your thoughts about how

you might proceed…

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PRACTICE MOTIVATIONAL COMMUNICATION

DIV IDE INTO WORKING GROUPS OF F IVE OR S IX

PRACTICE MOTIVATIONAL COMMUNICATION

ASS I STED BY:

Kristen Botte, R.D. and Christine Elkhoury, R.D.

T H E D I E T I T I AN ’ S R O L E I N U N D E R S T AN D I NG AN D OV E RCOM I NG T R E A TM EN T R E S I S T ANCE

THANK YOU !!

The 29th Annual SCAN Symposium

Jenny H. Conviser, Psy.D.Assistant Professor,

Feinberg School of Medicine, Northwestern University, Chicago, Illinois j-conviser@northwestern.edu

&Kristen Botte, R.D. and Christine Elkhoury, R.D.