Eating Disorders and High School Student-Athletes

Eating disorders afflict at least 11 million people in the United States - some of them high school student-athletes who are silently running away from a healthy future.

The dozens of e-mails Kimiko Hirai Soldati receives from female high school students break her heart. As one of the few elite athletes to overcome an eating disorder and speak publicly about it, the 2004 U.S. Olympic diver has become a sounding board for gymnasts, swimmers, distance runners, rowers, fellow divers and other athletes who participate in aesthetic-oriented sports and are haunted by eating disorders such as bulimia and anorexia. "Those girls tell me I am the only person in the world who knows they have an eating disorder," Soldati says. "It's such a secretive issue, and people don't understand how huge the problem is. There are girls out there in junior high and high school who are in the thick of dealing with eating disorders, and they have nobody to talk to about it."

In fact, it often takes up to four years for some individuals with anorexia nervosa (characterized by self-induced starvation and excessive weight loss) or bulimia nervosa (characterized by binge eating followed by self-induced vomiting or other behavior commonly referred to as purging) to work up the courage to seek help. Others never get that far; some even commit suicide.

Soldati managed to seek therapy 18 months after bulimia began devouring her diving career and personal life during her junior year at Indiana University, where her weight eventually dropped under 100 pounds. She underwent multidimensional psychological treatment for five years, including weekly one-on-one sessions with her psychologist between 1995 and 1997, as well as an intensive eight-week outpatient program. She then continued to work regularly with a sports psychologist through the 2004 Olympic Games in Athens, where she competed while battling an injury to her right shoulder.

"This isn't something that suddenly shows up in college," says Soldati, 32, who today works with her psychologist to find local help for girls who e-mail her. "For me, the thought processes were going on most of my life. I was obsessed with what other people thought about me. It's just that those thoughts didn't manifest themselves in the form of an eating disorder until college."

Ironically, personality traits common to most successful athletes - perfectionism, a high tolerance for pain, fear of failure and the need to please - also are characteristics that can lead to behaviors destructive to the human body. While an eating disorder may begin with preoccupations with food and weight, it evolves into a complex condition with long-standing behavioral, emotional, psychological, interpersonal and social factors at play. Individuals with disorders use food (and the control of food) as an attempt to compensate for emotions that may otherwise seem overwhelming. As Soldati says, "This isn't necessarily a disorder about food and the body, but rather emotions and self-worth."

"Unless you have the disorder, or you work with it, it's very hard to understand," adds the psychologist who treated Soldati, Ron Thompson, who runs the Bloomington (Ind.) Center for Counseling and Human Development. "If you try to explain an eating disorder to people, they want to be rational about it. But eating disorders are not rational. There's nothing rational, reasonable or logical about them."

According to the National Eating Disorders Association, as many as 10 million females and one million males in the United States struggle with some form of eating disorder. More than 90 percent of those affected are women between the ages of 12 and 25.

In a landmark NEDA survey conducted earlier this year, approximately 20 percent of 1,002 male and female college students admitted to personally struggling with an eating disorder, and 40 percent claimed they know someone who purges. Another 2006 survey of 170 female student-athletes between the ages of 13 and 18 at six Southern California high schools revealed that 18 percent experienced disordered eating - a trait Thompson defines as eating that "in some way puts the individual at risk," even if the condition does not meet the official diagnostic criteria for anorexia, bulimia, laxative abuse or other common eating disorders. And a 2003 study published in the International Journal of Eating Disorders indicated that 40 percent of newly identified cases of anorexia occur in girls between the ages of 15 and 19, that the incidence of bulimia has tripled in females between the ages of 10 and 39 since 1988, and that the majority of individuals affected do not receive adequate care.

"At the college level, there is a large network of individuals caring for the health of athletes," says Joanne Klossner, a certified athletic trainer and a clinical assistant professor in the Department of Kinesiology at Indiana University. "They have athletic trainers, they have team physicians, they undergo uniform physicals, and coaches pay more attention to health issues because many athletes are on scholarship. At the high school level, eating disorders are tougher to identify. Not all schools have an athletic trainer, and the school nurse only sees kids if they're sick. Athletes have to take physicals, but they probably go to different doctors who may not address the issue."

Because student-athletes with disordered eating react more sensitively to coaches' comments than their teammates, a seemingly innocuous statement such as, "You need to start watching what you eat for dinner" - as a male gymnastics coach once told Soldati in high school - can have a devastating impact. "Every coach wants his or her athletes to perform to their greatest potential," Soldati says. "A coach would want to be aware of anything that's going to be a detriment to that goal, and kids with eating disorders are not going to be at their best. But eating disorders get overlooked so much, because coaches don't know they should be looking for them."

Unless a coach chooses to discuss the topic with his or her athletes, essentially the only information about disordered eating a female high school student-athlete is likely to get - for the moment, forget about males - is from ATHENA, a national school-based prevention program designed to reduce disordered eating and the use of body-shaping drugs and other substances among girls by promoting nutrition and exercise, and emphasizing appropriate intake of protein and calcium over calorie-counting.

Developed by the Center for Health Promotion at Oregon Health & Science University, ATHENA stands for Athletes Targeting Healthy Exercise & Nutrition Alternatives, and is used by school districts in more than 30 states and Puerto Rico. In May, ATHENA and its big brother ATLAS (Athletes Training & Learning to Avoid Steroids) expanded their reach with the new SI Schools program via grants from Sports Illustrated, the Florida Department of Children and Families and the Hanley Center, a drug and alcohol treatment center in West Palm Beach, Fla. A total of 31 schools in Florida, Michigan, Oregon and Virginia were chosen to implement both programs during the 2006-07 school year. Those schools, in turn, are expected to help develop the ATLAS and ATHENA programs at other schools in their respective states, using money from federal Office of Safe and Drug-Free Schools grants, booster clubs and other sources.

ATLAS, meanwhile, is a drug-use prevention program with a nutrition element focusing on what male student-athletes should eat to improve their performance. So with only ATHENA addressing disordered eating, experts say the key to successfully preventing problems at the high school level lies with a thorough education program for all coaches and student-athletes. It should include an understanding of eating disorders and what causes them, plus recognition that problems could be lurking in their own locker rooms - especially for sports in which an emphasis is placed on appearance. "Right now, we don't have anything like that," admits Bob Colgate, an assistant director of the National Federation of State High School Associations.

The NFHS, which only last year began to address the steroids issue by taking a stance that "strongly opposes" the use of performance-enhancing drugs, hopes to develop some sort of disordered-eating awareness campaign. The groundwork for that was laid in late October when Colgate attended an annual meeting of the Female Athlete Triad Coalition in Indianapolis.

The triad - somewhat understood in medical circles but practically a foreign concept everywhere else, Thompson says - refers to three interrelated female health problems: low energy availability, menstrual disorders and weak bones. Pressure placed on young women to achieve or maintain unrealistically low body weight can trigger one, two or all three triad components, decreasing physical performance. Adolescent girls, researchers say, are most at risk because of their active biological changes, growth spurts, and peer and social pressures.

"Not all scientists are exactly lined up on issues of the triad," says Dan Henkel, director of public information for the American College of Sports Medicine, one of the lead organizations trying to spread knowledge of the triad. "As with almost anything, there are dissenting opinions. Some people have voiced concern that talking about this issue will lessen participation in sports by women, and others say there is really no greater prevalence of the triad among female athletes than among other females."

Nevertheless, introducing the triad concept to high school coaches and athletic directors, with the assistance of the National Collegiate Athletic Association and ACSM, could be a major step in recognizing disordered eating at an earlier age, Colgate says. The National Federation also plans to incorporate disordered eating into its new coaching education program (see "Sideline Schooling,") and may create a video-education component specifically addressing disordered eating. "We're behind, but we'll pick up speed and see where we can go," Colgate says, stressing that the NFHS is still in the information-gathering stage and does not want to exclude boys from the organization's efforts. "We know we have disordered eating problems in the male population, too. We want to cover both males and females with this effort."

Soldati, an assistant volunteer coach for both the men's and women's diving teams at Purdue University, has noticed that males often get overlooked in discussions of disordered eating - in large part because the term "eating disorders" conjures images of emaciated females.

Thompson, who treated an anorexic football player several years ago, says he has toyed with the idea of introducing a male counterpart to the Female Athlete Triad. Preliminary data, gathered primarily from endurance runners, suggests that testosterone levels decrease with excessive training, curtailing bone development - just as decreased estrogen levels slow bone growth in females. "It's certainly something we need to take a look at," he says. "And we also need to look at nutritional factors. Are males eating enough? The low energy availability in the male body may work in a fashion similar to the way it does in the female body."

In high school wrestling, at least, fears of undereating in boys seem to have subsided with the adoption by no fewer than 35 states of the National Wrestling Coaches Association's Optimal Performance Calculator™. The web-based, body-composition assessment tool, which also can be used by athletes in other sports, determines the lowest allowable weight class for each wrestler based on the hydrated individual's weight at the beginning of the season and then establishes a safe weight-loss/weight-gain plan. NWCA officials plan to offer a modified version of the calculator for use in middle school and high school physical-education curriculums, too.

Since the calculator's inception, prep wrestling has experienced an image reversal of sorts. "What you used to see were wrestlers starving themselves for two days before a weigh-in. Then, as soon as they made their weight, they'd gobble down food," says Bob Baly, an assistant director of the New Jersey State Interscholastic Athletic Association, which has required its member schools to use the NWCA's calculator for the past three years. "We're discouraging that kind of binge eating and encouraging proper nutrition and hydration. When I played football, coaches didn't give us water when we practiced, and that was supposed to make us tougher somehow. But as we've become more knowledgeable regarding sports medicine, common sense dictates that we guide students. Athletics are important, but we can't ever endanger a kid's health or safety."

Baly's attitude also can be considered a warning - one that disordered eating experts suggest coaches heed. "Coaches have incredible influence on their athletes," Thompson says. "If the coaches indicate to the athletes that something is important, if the coaches buy into it, they can have a lot of power in terms of making whatever educational program we put forward successful. And my feeling is that without their support, it's not going to happen."

NEDA devotes a section of its web site to athletes and eating disorders (see AB Connect, below), offering 10 ways for coaches, athletic trainers and athletic directors to help keep student-athletes healthy. Chief among them is paying attention to team members and noticing if they are chronically dieting or exhibiting even mildly abnormal eating behaviors. If so, a coach should quietly refer the student-athlete to the school's certified athletic trainer (if one is on staff) or a health professional with knowledge of disordered eating. Early detection increases the likelihood of successful treatment.

Other suggestions for coaches include de-emphasizing body weight while focusing on strength and physical conditioning; emphasizing the health risks of low weight levels; rethinking their own attitudes toward weight, dieting and body image, and how they might negatively influence student-athletes; and providing team members with accurate information regarding body weight and composition, weight loss and nutrition.

Furthermore, experts say that if coaches, particularly male coaches of female sports, are uncomfortable discussing disordered eating with their teams, they should at least recognize and acknowledge the need to address the topic by inviting a female coach from another sport to speak to their team and suggesting that team captains encourage players to look out for each other. "This is an issue that really needs to be tackled at the junior high and high school levels before it gets full-blown crazy in college," Soldati says. "I've known girls who tried to find out how many calories were in toothpaste. That's how obsessive they can be about this."

The longer eating disorders are allowed to continue unabated, the greater an individual is at risk for health problems later in life. A recent St. Louis University study looked at 76 female student-athletes playing Division I sports and determined that abnormal and low-calorie eating habits could lead to leg pain and stress fractures because of decreased estrogen production. Researchers also say that eating disorders can result in serious heart conditions, kidney failure or death.

Even Soldati, who now weighs about 120 pounds and claims her relationship with food is the healthiest it's ever been, won't be immune from osteoporosis as she gets older. "This isn't something that should be treated as a phase that hopefully will pass," she says. "This is something that can kill you."