4/16/2013 1 THE DIETITIAN’S ROLE IN UNDERSTANDING AND OVERCOMING TREATMENT RESISTANCE DISORDERED EATING AMONG ATHLETES: The 29 th 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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4/16/2013
1
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
� 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