4/16/2013 LEARNING OBJECTIVES DISCLOSURES. The 29 th Annual SCAN Symposium EATING DISORDERS THREATEN WELL BEING

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1 The 29 th Annual SCAN Symposium DISCLOSURES 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. DISORDERED EATING AMONG ATHLETES: T H E D I E T I T I A N S R O L E I N U N D E R S T A N D I N G A N D O V E R C O M I N G T R E A T M E N T R E S I S T A N C E 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. April 28, 2013 LEARNING OBJECTIVES EATING DISORDERS THREATEN WELL BEING 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 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. 1

2 ED RISK AMONG ATHLETES 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. 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 SELF REPORTED SYMPTOMS 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, ) Higher ED rates may occur when aesthetics are critical to judging, scores or performance. (Burkes-Miller & Black, 1988) (Sungot-Borgon & Toraveit, 2004) 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) 2

3 DO SOME ATHLETES HAVE GREATER EATING DISORDER RISK? THE SPORT CULTURE IS RELEVANT 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 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 UNHEALTHY WEIGHT LOSS Low Energy Intake Risks: 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) 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

4 MEDICAL COMPLICATIONS OF EATING DISORDERS MEDICAL COMPLICATIONS 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 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 SIGNS AND SYMPTOMS OF EATING DISORDERS 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 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 4

5 PSYCHO-SOCIAL SYMPTOMS MAY CO-OCCUR WITH EATING DISORDERS DIETITIAN S ROLE 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. 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 5

6 DIETITIAN S ROLE MOTIVATING CHANGE SUPPORT GOOD HEALTH Avoid employing the following: 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? 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) 6

7 BENEFITS OF MOTIVATIONAL COMMUNICATION EFFECTIVE COMMUNICATION Brief Beneficial across age, gender, race, socioeconomics Enhance compliance Reduce attrition Reduce resistance to change Facilitate problem resolution Improve treatment effectiveness 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 7

8 STAGES OF CHANGE IN THE MODIFICATION OF PROBLEM BEHAVIOR IDENTIFYING THE STAGE OF CHANGE FACILITATES: Pre-Contemplation Contemplation Preparation Action Expectations Attributions Planning Problem solving Maintenance Kirschenbaum, Fitzgibbon, Martino, Conviser, Rosendahl & Laatsch, 1992 MOTIVATION: HELPING CLIENTS ACHIEVE GOALS MOTIVATION IS NOT IMPROVED BY: o Motivation is considered on a continuum o Motivation is based on the patient s values, needs and beliefs Health Risk Punishment Loss Pain o Three Components of Motivation : Readiness Willingness Ability Withdrawing Punishment Guilt Shame Humiliation Miller & Rollnick, 2002, p. 10 8

9 COMPONENTS OF MOTIVATIONAL COMMUNICATION OPEN-ENDED QUESTIONS Open-ended questions Closed Ended Questions Open Ended Questions Express empathy Affirmation A. Are you getting 5 servings of fruits and vegetables daily? A. How are you feeling about your current diet? Reflective listening Managing resistance Summarize B. We talked about carbohydrates last week. What is your current daily intake? 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 EMPATHY Closed Ended Questions Open Ended Questions Acknowledge that change can be difficult. A. How much do you currently weigh? B. Do you feel your nutrition is impacted your athletic performance? 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. Clarify points of difficulty. Identify the primary emotions that impede change. Understand that desired changes may have costs that are challenging. 9

10 AFFIRMATION REFLECTIVE LISTENING 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. 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 SUMMARIZE 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 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 10

11 PRACTICE MOTIVATIONAL COMMUNICATION DIVIDE INTO WORKING GROUPS OF FIVE OR SIX PRACTICE MOTIVATIONAL COMMUNICATION ASSISTED BY: Kristen Botte, R.D. and Christine Elkhoury, R.D. The 29 th Annual SCAN Symposium Jenny H. Conviser, Psy.D. Assistant Professor, Feinberg School of Medicine, Northwestern University, Chicago, Illinois & Kristen Botte, R.D. and Christine Elkhoury, R.D. THANK YOU!! T H E D I E T I T I A N S R O L E I N U N D E R S T A N D I N G A N D O V E R C O M I N G T R E A T M E N T R E S I S T A N C E 11