Jan 29, 2015No Looking Back
When an athlete has an eating disorder in their history, the objective is not to diagnose or treat, but to keep them moving forward. Here’s how an athletic trainer can help.
By Brina Jergenson
Brina Jergenson, RD, CSSD, is an eating disorder specialist at A New Beginning, an outpatient treatment center in Scottsdale, Ariz. She helps clients overcome their eating disorders by providing education and support throughout their recovery process, and can be reached at: [email protected].
The transition to college is a difficult one for most students, but for an athlete who has a history of an eating disorder, it can be even more challenging. More and more young teens are being diagnosed and treated for eating disorders before they enter college. And while they may be stable upon graduating high school, all the challenges of being a freshman student-athlete can threaten that stability.
Changes in living situations, schedules, and support systems can easily lead to relapse. Eating situations may suddenly be more or less structured than the athlete is used to. The types and amounts of food available at team training tables will likely be different. And things that may have been taken for granted, like portioning plates, suddenly are gone.
When someone has struggled with an eating disorder, it is often wondered whether he or she will ever be able to completely recover. There are varying opinions on this. Some believe that once diagnosed, an eating disorder is something the person will struggle with on and off for the rest of their life, even if they display healthy eating patterns and a healthy mindset about food.
However, others believe that total recovery is possible. The person may have fleeting eating disorder thoughts and urges, but they never materialize into actual behaviors. Regardless of which is true, it is rarely helpful to promote the former as it can lead to a sense of hopelessness that interferes with recovery.
For an 18- or 19-year-old, it would be rare that he or she feels completely recovered from an eating disorder diagnosed and treated at a younger age. So what is the college athletic trainer’s role when history of an eating disorder is on a student-athlete’s medical form? The keys are to gain a thorough understanding of the student-athlete’s situation and then to join his or her treatment team.
UNDERSTANDING THEIR PAST
In order to best help an athlete who is in recovery, it is important to understand the different levels of treatment they may have experienced prior to arriving on campus. The four main levels of treatment for someone who has been diagnosed with an eating disorder include inpatient treatment, residential treatment, intensive outpatient treatment, and outpatient treatment. The severity of eating disorder symptoms and medical stability determine the appropriate level of care.
Inpatient treatment: The most closely monitored form of treatment is inpatient. This is typically the recommendation when someone isn’t able to maintain medical stability or if their weight drops below 85 percent of their recommended weight.
Most inpatient facilities, which generally require 45 to 60 days of treatment, are very structured. Patients’ days are planned to include group meals and snacks of specific caloric content with a table monitor present, along with therapy sessions–individual, group, and in some cases, family therapy. Activities are usually part of the daily schedule as well, though exercise may be limited if a patient previously abused exercise as part of their eating disorder or are underweight.
The goal of inpatient treatment is to medically stabilize the patient, gain insight into their eating disorder, establish a period of time without eating disorder behavior, and restore their weight to a healthy range. The inpatient experience can be very intense emotionally and possibly even painful physically depending on the patient’s symptoms and behaviors.
Residential treatment: Though it is structured similarly to inpatient treatment, residential treatment patients are not monitored as closely. Patients live in a group house or apartment together with staff who supervise them daily and throughout the night. Patients have much more free time and face fewer restrictions regarding when and what they eat. However, individuals absolutely must be medically stable before entering residential treatment.
Because residential treatment is often recommended following inpatient treatment, patients are sometimes required and often encouraged to take on more “real world” responsibilities as they begin to transition back to their normal lives. Examples include sharing cooking responsibilities and household chores, going out to eat with the group and ordering something on the menu they had previously labeled as “bad,” and attending school or getting a job.
Intensive outpatient treatment: This level of care means that the patient lives on his or her own or with their family, but attends a specified number of group meetings and/or hours of therapy per week. Depending on the program, patients may be asked to eat in a group setting. The goal of intensive outpatient treatment is for the patient to get back to their life as it was prior to their eating disorder, but with some structure and support as they do so.
Outpatient treatment: The least structured form of treatment is outpatient. The patient lives independently or with his or her family and is completely responsible for their own nutrition needs, while regular therapy sessions, dietitian meetings, and/or group meetings are encouraged. The goal of outpatient treatment is to allow the patient to fully return to their life and balance it with recovery.
Upon learning that an athlete has struggled with an eating disorder, the first step an athletic trainer should take is to have a one-on-one meeting with them as soon as possible. The goal of the discussion is to determine how to help them continue their recovery. Here are some good questions to ask in this meeting:
What is the history of your eating disorder? Finding out how long the athlete spent in treatment, at which level(s), and when provides insight into the severity of the athlete’s eating disorder. It will also help determine how much support they may need.
For example, an athlete who has a recent history of an eating disorder with one or more inpatient stays and who still attends outpatient treatment will require much more support than an athlete who is no longer undergoing any treatment. The first athlete may be comfortable with weekly meetings with you for support in addition to their outpatient treatment, while the second may not need more than a monthly check-in.
Are you comfortable with others knowing about your history? In general, an athlete with a fairly recent history of treatment is comfortable with a larger support network and may be open to their coaches and teammates knowing about their struggles. However, some may prefer that others not know about their eating disorder history. This is an important point to clarify.
Do you have a treatment team? A treatment team generally includes a physician, dietitian, and therapist, psychologist, or psychiatrist. If the athlete has a treatment team, ask the athlete if you may contact a member of the team, and which person is best to talk to.
When you talk to a member of the athlete’s treatment team, explain your role as the athletic trainer and ask how you can help. Other good questions include: Do you have any concerns about the athlete participating in their sport? Have you seen any warning signs that would indicate the athlete should not participate in their sport? What behaviors would indicate that the athlete is struggling? What is the athlete’s “danger weight” that indicates they should not be competing?
Especially if the athlete is currently receiving treatment, it is a good idea for you to become part of the team. This may entail attending staff meetings when all team members are present or speaking to different team members on the phone to discuss the progress of the athlete or any concerns you may have. It is essential to the athlete’s recovery that everyone involved in his or her care agrees on the course of treatment and sends a consistent message of concern for the athlete’s health and well-being.
Are you following a meal plan? Most athletes who have struggled with an eating disorder were at one point on a meal plan. If the athlete is still following one, it should lay out what, how much, and when they are to eat during the day. Having a meal plan helps them to get enough calories and also gives them a sense of security in knowing that their plan doesn’t allow for too many calories and hence, weight gain.
A typical meal plan is divided into macronutrients with specific servings laid out in a pattern. A breakfast meal plan may look like this: two grains, one protein, one to two fats, one fruit, and one dairy. This means breakfast could include one cup of cereal with milk (one grain and one dairy) one to two scrambled eggs (one protein), one slice of toast with butter (one grain and one fat), and one banana (one fruit).
Knowing what the meal plan entails and how it works can help an athletic trainer spot when the athlete may be struggling at meals. For example, if the athlete is eating at the training table and consistently leaves items from the meal plan off of their plate, that is a warning sign. The athletic trainer can also help the athlete by asking whether they have been following their meal plan or what other support they need at meals.
Do you have any “triggers” that I can help you avoid? This is an especially important question if the athlete participates in a sport like wrestling, gymnastics, competitive cheer, or track and field and cross country where bodyweight and body composition are regular topics of discussion. For example, a common “trigger” for the athlete might be hearing how much they weigh. He or she may have weighed themselves numerous times per day or been obsessed with knowing their weight and body measurements when they were struggling with their eating disorder.
If weighing in is a requirement for their sport, or you perform body composition tests on all of the athletes in your program, establish with this athlete how to best discuss their weight and body composition. The solution may be to have them stand backwards on the scale when they weigh in so they can’t see their weight. Then you may only want to discuss their weight or body composition in terms of range: “You are right where you should be,” or “your weight should be higher or lower.”
Sometimes the trigger is comparing their body or caloric intake to others on the team. If this is happening, remind the athlete that bodies come in all shapes and sizes and that the way his or her body is allows him or her to compete well at their sport. In terms of caloric intake, remind the athlete that everyone has different caloric needs and his or her needs may be higher due to a higher metabolism.
Another trigger may be eating at restaurants or even in front of other people. Encourage the athlete to sit next to people he or she feels safe eating with. If restaurants are an issue, plan ahead with the athlete what to order by looking at the menus online. Try to steer clear of any references towards the caloric values of items and don’t pick low calorie items from the diet portion of the menu.
How else can I support you in your recovery? A recovering athlete knows what tools and support systems work for them, but you will never know how you can help unless you ask them directly. The athlete may benefit from a weekly check-in with you, or from having a buddy to eat with who can provide them with a distraction during meals and snacks. This is also a good time to discuss with the athlete how best to approach him or her if you have any concerns about their recovery.
Throughout your initial discussion with the athlete, it is best to proceed with compassion and understanding. The athlete may fear being treated differently than their teammates, or they may be worried that the coaching and athletic training staff is watching them incessantly. Reassure them that they will be supported in their recovery, even if they struggle. Remind them that their health and well-being are most important.
It would not be supportive to threaten the athlete with removal from their sport if they begin to struggle with their eating disorder again. It is also not helpful to judge how “sick” the athlete was or wasn’t. For example, asking them how much weight they lost while struggling with their eating disorder, then saying that it doesn’t sound like very much is one of the worst things you can do.
Also, never comment on the athlete’s appearance, even if you think it’s a compliment. A common remark made to someone with an eating disorder is that they don’t look like they had one. This undermines the athlete’s struggles and belittles their eating disorder, which can easily trigger a reoccurrence. IT TAKES A TEAM
As the athletic trainer, you are in a great position to help an athlete who has a history of an eating disorder. But it’s important to note that these athletes usually need an entire team of supporters. You can’t, and shouldn’t, take on the responsibility alone.
In addition to the athlete’s treatment team, the on-campus supporters who may be able to help include the athletic department dietitian, the athlete’s coach(es), and his or her teammates. The athlete’s parents may also be a part of this equation. As mentioned earlier, make sure to discuss with the athlete who they are comfortable with having knowledge of their eating disorder history. Though you can encourage them to do so, it should always be up to the athlete whether or not they want to share their struggles with anyone else.
One of the most important people who should be privy to the athlete’s history is the athletic department dietitian. If the athlete is still seeing their treatment team, the athletic department dietitian should be communicating with the treatment team dietitian. They should discuss any past or current meal plans and if the athlete has any special nutritional needs.
The athletic department dietitian must also be very aware of how any recommendations he or she gives to a team may affect this specific athlete. For example, the guideline to eat more calories during preseason practices or add a recovery meal between practice and dinner can make the athlete fearful. They may become worried about an increase in calories leading to weight gain. If the athlete is on a meal plan already and still sees a dietitian, contact the dietitian to discuss what and where to add calories to the athlete’s meal plan. If the athlete does not see an outpatient dietitian, then the athletic department dietitian should meet individually with the athlete to discuss how to increase the athlete’s caloric consumption in a way that does not threaten his or her stability.
Another area where the athletic department dietitian can be helpful is when the team is on the road. The sports dietitian can obtain copies of restaurant menus in advance so that they can discuss with the athlete what to order before the team leaves on its trip. The dietitian may also be able to help the athlete identify a teammate, coach, or athletic trainer they can sit by for support during the meal.
Some athletes may also be open to having their coach or coaches be part of their support system. This can be extremely helpful since it allows for a coach to be assigned the task of checking in with the athlete on a regular basis. During the athlete’s season, they see their coach almost every day, so coaches are in a great position to be support staff members.
Teammates are another possibility. The athlete may find a supportive confidante (or an entire team’s worth of them) if they choose to share their eating disorder history with their teammates. Because teammates are also the same age and going through the same life changes at college, the athlete may find it easier to talk to them if they are struggling. In addition, teammates are more likely to notice if the athlete is avoiding eating or eating less than usual, and they can be encouraged to ask the athlete about it or bring their concerns to you.
Finally, some athletes’ parents may be a big part of their support system. If an athlete’s parents are already involved with their child’s care, you can talk to the athlete about keeping their parents informed of their progress and explore setting up a communication system with them.
Overall, in all your communication with these athletes, be open. Start talking early, and talk often if the athlete is willing to discuss their challenges with you. Always remind the athlete that they are supported, even if they suffer a reoccurrence. And remember that you have the chance to help the athlete make a positive change.
Sidebar: CASE STUDY
Sara is a college freshman on the women’s basketball team. She was diagnosed with an eating disorder toward the end of her junior year in high school. At that time, she went to inpatient treatment for 60 days, then was transferred to residential treatment for an additional 30 days.
Sara is now at a healthy weight, but is struggling to accept it. She still sees her outpatient team and attends a weekly support group meeting. She knows she needs a lot of outside support to be successful in her recovery.
At Sara’s initial meeting with the team’s athletic trainer, she is open and honest about her struggles and asks the athletic trainer to communicate with her treatment team back at home. They discuss who at the school and on the team is allowed to know her history. Sara decides that all of the coaches can know about her history, but only the athletic trainer and team dietitian will check in with her.
Since Sara knows she needs a lot of support, she agrees that the athletic trainer will check in with her weekly and ask her questions such as: Have you experienced any eating disorder behaviors? Have you had any urges to follow through on eating disorder behaviors? Are you following your meal plan? Is there any other support you need?
They also discuss other ways the athletic trainer might know Sara is struggling, such as certain behaviors she might exhibit. The athletic trainer then communicates with the therapist on Sara’s treatment team to discuss the plan they have come up with.
The athletic trainer also sets up a meeting between Sara and the team dietitian. They determine together that they will also meet weekly to check Sara’s weight and discuss how she’s doing with following the meal plan. The team dietician then contacts the treatment team dietitian and discusses the specifics of Sara’s eating disorder behaviors and meal plan. They agree to be in touch weekly to talk about Sara’s weight and any concerns that might have come up.
During Sara’s first few weeks of practice, she quickly grows close to some of her teammates and decides to tell one of them about her eating disorder history. She asks the teammate not to tell anyone but to occasionally ask her how she is doing in her recovery. Sara continues her weekly check-ins with the athletic trainer and team dietitian. Her weight is steady and she appears to be doing well in her recovery.
On campus, Sara is often surrounded by classmates who are concerned about their current weight or gaining the “freshman 15.” Sara has to distract herself so as not to compare her body to any of her classmates’ or teammates’ bodies. She knows dieting and losing weight is not okay for her.
When the season starts and the team begins to travel to away games, Sara begins to struggle. It starts slowly with some restricting behaviors at team meals. She discusses this with the athletic trainer and team dietitian and they make a plan to have the teammate who knows her history quietly encourage her during difficult meals. However, Sara continues to struggle and begins restricting some of her snacks. Her weight starts to drop and her performance on the court becomes sluggish.
The athletic trainer and team dietitian meet with Sara together to discuss her difficulties and performance. They call the outpatient treatment team and decide together to provide Sara with more structure by having her eat some meals and snacks with either the athletic trainer or team dietitian. Sara seems relieved with the increased structure.
She follows through and begins to follow her meal plan more closely, even when the team is traveling. Her weight is still slightly below her healthy weight range so she agrees to add more calories for weight gain.
During this time, Sara has opened up about her struggles to a few more teammates who are eating snacks with her on a regular basis. She continues her weekly meetings with the athletic trainer and team dietitian to discuss her concerns and challenges whenever they pop up. Her weight gets back into her body’s normal range and she begins to slowly accept that her weight is healthy.