Eating disorders don't get talked about much. When they do, it's usually in conjunction with a dramatic Lifetime movie. However, eating disorders do exist in real life and can even be found in strength sports.

As someone who has battled exercise bulimia and gone on to help her own athletes through their personal struggles with eating disorders, 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 how to identify troublesome behaviors early in order to prevent significant health risks, how to approach an athlete, and how to create a healthy training environment.

I want to be clear off the bat that 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 pre-existing condition –be it psychological, social, or relational-- before the individual even begins to play their sport. Examples may include physical or sexual abuse, or simply low self-esteem. Sometimes athletes use a sport as an outlet for other stressors and if the individual is triggered, he or she is 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. People struggling with eating disorders come in all shapes and sizes, from small to average to large. 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 (such as only eating certain foods, eating off a certain plate, etc.), constantly talk about or prepare food but do not eat it, and can be withdrawn.

• Bulimia: This is one of the most commonly seen eating disorders in strength sports, but one of the hardest to spot because athletes appear to be average weight. According to the National Eating Disorders Association, bulimia 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 to use 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. 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, which NEDA defines as an “unhealthy obsession with otherwise healthy eating." 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

• Living off stimulants: Caffeine. Most athletes drink it 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. 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 risk of heart attack, especially in a population whose side effects of their eating disorder 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.

• Missed periods can be a sign of exercise-induced amenorrhea: menstrual dysfunction for three or more months, which means it is completely absent or irregular. Occasionally it is accompanied by stress fractures and low to low-normal bodyweight. Amenorrhea can lead to irreversible bone density loss and is caused by the body being under too much stress: from excessive training, under recovering and 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 confidante 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 percent, (2) Increase calories 10-15 percent, (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.

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 eating disorder 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 eating disorder 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 percent of individuals suffering from eating disorders that have died from their disease's complications. That statistic makes eating disorders one of the leading causes of mental illness deaths. Eating disorders 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, 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. 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 Story

My eating 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, he noticed during one weigh-in close to competition that 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, I know he did this to make sure I was eating. Coaches can be tactful.

He made it very clear that not eating and using diuretics were simply unacceptable; we had a duty to report if we knew any of our teammates 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 waterload 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 three to five hours a day, 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 and my cheekbone, and busted the blood vessels in my eyes. After being rushed to the hospital and not having worked out for two 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.

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.

Resources

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. You can call their toll free, confidential hotline Monday through 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 therapists can be found here.

Sources
https://www.nationaleatingdisorders.org/coach-trainer
https://www.nationaleatingdisorders.org/orthorexia-nervosa
https://www.nationaleatingdisorders.org/statistics-males-and-eating-disorders
Warren MP, Chua AT., Exercise-induced Amenorrhea and Bone Health in the Adolescent Athlete. Annals of the New York Academy of Sciences, 2008
https://www.remudaranch.com/news-a-events/remuda-review-article-archive/21-eating-disorders-and-substance-abuse
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