National Collegiate Athletic Association |
The NCAA News - News and FeaturesThe NCAA News -- November 22, 1999 Weighing in
Experts say eating disorders, diet and nutrition weigh heavy on scale of issues affecting college student-athletes
BY KAY HAWES
Like regular college students, they are likely to watch "Friends," "Party of Five" and "Ally McBeal," popular shows that feature many female characters who exemplify the current super-thin trend. "Everyone's concerned right now because so many of the TV stars are quite thin," said Ann C. Grandjean, founder and director of the International Center for Sports Nutrition. "It's given everybody a false idea of reality." Eating disorders and related issues first became a concern to the NCAA and its member institutions a decade or so ago, but the problem has not gone away. While experts are divided on whether eating disorders are more prevalent than ever or simply reported more often, it is clear that the issue remains one that can dramatically affect student-athlete welfare. Image is everything Body image begins with what you see, and if everyone you see is a size 2, you may have difficulty persuading yourself that fitting that size is not a healthy option for you. "Kids look miniscule walking by," said Eileen Steckler, co-director of the Rockland Center for Eating Disorders in New York. "Now, it seems a (size) 2 or 4 is average among high-school girls. When I was growing up, it was a 10 or a 12. But not every kid should be a 2 or a 4. Only 10 to 15 percent naturally are." And body image -- what each individual thinks her body looks like vs. a "normal" body -- has everything to do with eating disorders. "Eating disorders are really a distorted body image problem," Grandjean said. She said the image factor is so severe that magazines may do a disservice by publishing photos of ultra-thin celebrities, even though the accompanying article may be critical of the "thin culture." "Someone with an eating disorder looks at (those pictures) differently than you and I do," she said. "They may see it as something to emulate, even though the article is clearly critical of it. If you give someone with an eating disorder pictures of bodies in silhouette and ask them to pick the one that most closely resembles them, they will always pick one that is much larger than they really are." Grandjean also points out that student-athletes are not immune to the problems of "normal" people. "We need to remember first and foremost that athletes are people just like everyone else, and they are afflicted with all of the same problems," she said. In particular, athletes may have grown up with a poor body image and a history of dieting to excess. "Weight issues have become an obsessive concern for American children of all ages," said noted nutritionist and author Frances M. Berg. "Clearly it's a national crisis when harmful attempts at dieting are common in the third grade and even earlier. It is a crisis when more than two-thirds of high-school girls are dieting and half are undernourished. "One in five take diet pills, and many girls as well as boys are using laxatives, diuretics, fasting and vomiting in desperate attempts to slice their bodies as slim as they can. This is the point to which our weight-obsessed culture has brought us." When student-athletes get to college, there may be even more pressures to appear a certain way. "A college campus is kind of a breeding ground for eating disorders," said Mary Jo Martin, a psychologist from Dover, New Hampshire, who spoke on eating disorders as part of the Sport Psychology Institute at the University of Southern Maine this summer. "Athletics adds another pressure. The whole weight loss and thinness emphasis (in society) is getting more and more intense. That's really ratcheting up the pressure on athletes who already have a predisposition to these problems." The most common eating disorders include bulimia, which is bingeing and purging through various means, including the use of laxatives and vomiting; anorexia nervosa, which is self-imposed starvation; and binge eating. Not a new problem As more is learned about eating disorders and their long-term effects on health, the NCAA and all of intercollegiate athletics should remain concerned, said Randall W. Dick, NCAA senior assistant director of health and safety. "This is an important issue to student-athlete welfare," Dick said. "The NCAA has really taken a leadership role in raising awareness of this issue -- in intercollegiate athletics, especially -- because it's an issue that's easy to overlook. But it is one that is important to student-athlete health. "The Association has done more than any sports organization in this country. We've raised awareness, and we continue to talk about eating disorders in our education outreach efforts, even extending it to our CHAMPS/Life Skills program. We continue to assist with research in this area, and we continue to provide information on what we consider a serious health issue." Responding to concerns from the membership, the NCAA first developed a task force on eating disorders in February 1988. The task force focused on education about eating disorders and developed a three-part videotape series and related materials, which were first distributed to the membership in 1989. Also in 1989, legislation was passed at the NCAA Convention to allow universities to pay for counseling expenses related to the treatment of eating disorders. The next year, the NCAA conducted studies to determine the prevalence of eating among student-athletes at member institutions. The study was replicated again in 1992. Both studies reaffirmed that eating disorders were a problem in intercollegiate athletics. In the latter study, 70 percent of responding institutions indicated at least one eating disorder in their athletics program. "By surveying our entire membership, we were able to show the issues existed on a national level," Dick said. "After taking that initial step, we began educational activities and programs that continue today." Craig Johnson, director of the Eating Disorders Program at Laureate Psychiatric Hospital in Tulsa, Oklahoma, recently conducted a study with assistance from the NCAA that looked at 1,445 student-athletes from 11 Division I schools in 11 sports. Unlike the previous studies, this examination was not all-inclusive, but it did seek more depth, asking student-athletes to complete a variety of questionnaires. Johnson found that nearly 13 percent of the female athletes surveyed showed signs of bulimia or anorexia. Another 36 percent were at risk for developing an eating disorder. "Within the athletics community over the last number of years, there has been a preoccupation or strong belief developing that lower percentage of body fat will enhance performance," Johnson said. "But that belief is undocumented." Driven to succeed By their very nature, good athletes are driven to succeed. They are disciplined and goal-oriented, traits that are similar to those of someone at risk for an eating disorder. "Show me an athlete who doesn't have those traits, and I'll show you someone who's probably not a good athlete," Grandjean said. "Perfection, control and discipline are traits belonging to both those with eating disorders and to athletes," Clark said. "There's a very thin line between being an athlete and being an anorexic. Too many athletes put so much focus on 'If I'm thinner, I'll be better.' There's no evidence to support that." Athletes who are susceptible may be prompted to begin a disorder by what is called a "triggering event," which can be anything from group weigh-ins to a coach telling a student-athlete that she or he needs to lose weight. In some of the well-publicized incidents in intercollegiate athletics a decade ago, some student-athletes were triggered by a coach establishing a "Fat Club" whose members had to do extra exercise after the regular practice. Some student-athletes would do literally anything to avoid being labeled "fat." Other student-athletes are triggered simply by the knowledge that the person ahead of them on the roster is thinner than they are. "It's a very high-achieving population that tries to do everything right," said Randa Ryan, associate athletics director for student services at the University of Texas at Austin. "They think, 'If I'm thinner, I'll do better. I'll be faster, or I'll jump higher,' " said Sarah Ruma, a clinical psychotherapist at the Nebraska Health System's Eating Disorders Program, who has seen athletes in her practice from a cross section of sports. "Or the person thinks, 'I have to look the best in my uniform to play the best.' It's pretty amazing. And it appears to be growing among athletes." Dick says that student-athletes' health should not be sacrificed for performance. "Optimal body weight for performance is different for everyone," he said. "And the optimal body weight for performance may not be the optimal body weight for health." Ironically, it was the initiation of a weight-training program specifically to prepare for sports her junior year of high school that triggered Amy Cavanaugh's disorder. While gaining strength, she gained muscle weight as well, going to 118 pounds from her typical 111. She did not like her appearance, and began a weight-loss effort that spiraled into anorexia, leaving her at 75 pounds at one point. "I couldn't live without sports," said Cavanaugh, who overcame her anorexia in high school to play field hockey for Rider University. "I knew I had to get better to play. I love sports so much. It has always been a big part of my life. It definitely helped pull me out of it." Cavanaugh said she knows she will never completely be without the disease. "But I know better how to deal with it now. I haven't had any episodes in a long time, and that's because I can deal with my feelings better. People always used to associate me with anorexia. Now I'm Amy, who plays field hockey at Rider." Not confined to gender or sport While eating disorders have long been thought of as a problem only for women, experts say that is not true. "Eating disorders are just a sign, a symptom that something's wrong," said Ryan. "There are issues about fears, inadequacy, self-confidence -- those issues exist with young men just as they do with young women." Grandjean, who has worked with Olympic and professional athletes, said, "We thought it was a female problem for many years because females went for treatment. More and more you're seeing more men in treatment. "And, there are those who say that body building is the eating disorder of men. Taken to extremes, it's the same problem, just a different color." Nancy Clark, director of nutritional services at SportsMedicine Brookline, said that men may also be exercise bulimics, noting that in those cases the sufferer would counter excessive eating with excessive exercise rather than with vomiting or laxatives. "Some might train for marathons to hide it," she said. "But I think men are realizing that other men do have eating disorders and they can ask for help." Some sports -- gymnastics, swimming and diving, wrestling or distance running -- have been singled out as indicating an elevated risk for eating disorders, but experts say eating disorders can occur in any sport. Ryan was among those first involved in athletics eating disorder research and education in the mid-1980s. "There wasn't anyone to go to with our questions about female athletes, so we decided to do it ourselves," she said. They developed the Performance Team, which included a nutritionist, physiologist and psychologist, and it attempted to apply research to practice. Body weight as a performance factor was high on the list. "When we started looking at body weight as a performance factor," she said, "we started getting feedback from coaches saying, 'I can tell she needs to lose weight just by looking.' That comment to the student-athlete was perceived very differently from perhaps how the coach meant it. Our team quickly became focused on eating disorders in student-athletes. We immediately put a moratorium on weighing in and on coaches setting body weights." The other important action Ryan's team took was to make weight, eating and nutrition health and safety issues for team doctors and trainers. "We also tried to create shared perceptions so that the student-athletes, the coaches and the support staff were all on the same page," she said. "At the end of that first year, our athletes were leaner, their body weights were down, and there were fewer incidents of eating disorders." Ryan recommends an integrated educational approach. "You need to have lots of athlete education, and you must make it OK to talk about eating disorders and body image," she said. "Our plan was psychological support, education and awareness, and we have continued to hold that model. "Everyone on our staff is highly trained in this area. The idea is to have as many well-educated people as we can giving out the same positive message in as many ways as we can." Ryan said even the academic counselors who work with student-athletes are educated on the issue, as are all other support-staff personnel and coaches. Grandjean agreed that coaches can be part of the solution. "While there are coaches out there who may contribute to the problem," she said, "I really think that the vast majority are very caring and want to prevent eating disorders and get the athletes help. It's important for the coach to know who to go to for help." Grandjean advises athletics directors to have a plan for addressing eating disorders among the student-athlete population. "Before you ever have a problem, put your system in place to deal with it. Know before you need these people who your resources are." Grandjean also points out that professional help is required to identify eating disorders. "Many people with eating disorders are champions at hiding that disorder," she said. "They go to great lengths to appear to have normal eating habits." Al Bean, director of athletics at Southern Maine and a member of the Division III Management Council, has a campus-wide team in place to deal with eating disorder issues. The team includes someone from health services, counseling services, residential life and recreation, along with a trainer, the athletics director, and a member of the nursing faculty. "Campus-wide, we spend a fair amount of time on the issue," he said. "But I think that's the right thing to do. And from the athletics standpoint, I think the physical and mental health of the student-athletes we work with is the most important thing we do. "Self-image now is a huge issue. What used to be considered attractive is now probably considered fat. My personal opinion is that (the prevalence of eating disorders) is worse now. Also, I don't think 10 or 15 years ago we had so many students diagnosed with clinical depression as we do now. The pressures on students just seem to be more intense now." Nutrition education would go a long way toward preventing many eating disorders. "All student-athletes should meet with a registered dietician to determine the proper diet for their specific needs," said Clark, who noted that the dietician can illustrate portion sizes and set expectations. "It really helps them to know what 'normal' eating is -- just to have a concept of that. They also need to be taught that food is fuel. Coaches should be giving out that message too, asking 'Are you fueled for practice?' " Student-athletes also should be taught about body changes they can expect, both as they continue to mature in college and as they lift weights. "Incoming freshmen or transfer students who have never lifted weights are often horrified when they gain weight," Ryan said. "We need to explain that weight gain and educate them about muscle weight vs. fat." Most student-athletes would welcome more education about proper eating for maximum performance as well as about eating disorders. "I think it's an issue that needs to be addressed more," said Yashiva Edwards, a sprinter who graduated from Florida State University in 1997. "It's a very real problem for student-athletes, but it's a touchy subject. Maybe the more it's addressed, the more the female athletes would feel comfortable discussing it. I think education, especially about proper nutrition, would help. Some people want to perform so well, and they think just being thin is the answer. It's not."
Facts about eating disorders
Diet fads a bad idea for student-athletesWhen a coach tells a student-athlete to lose 10 pounds and the athlete has no guidance in doing so, even athletes not predisposed to eating disorders can engage in some unhealthy behaviors, including eating nothing for several days or trying diet fads. For student-athletes, some of the most popular diet fads could result in everything ranging from poor performance and possible kidney damage to a positive drug test. One diet fad right now is the elimination or severe restriction of carbohydrates. While the idea is not necessarily new, the diet has attracted attention as many Hollywood stars have credited their super-thin figures to the elimination of carbohydrates. This type of diet is simply not appropriate for athletes, said Nancy Clark, director of nutritional services at SportsMedicine Brookline and author of "Nancy Clark's Sports Nutrition Guidebook." "Athletes need the foundation of carbohydrates to fuel their muscles," Clark said. "If you don't have the right balance of carbohydrates in your diet, your muscles are left without adequate glycogen sources. Think of food as fuel. It's like your car -- if you put gas in it, it goes." Dietary supplements containing herbs -- which are not regulated by the government -- also are becoming more and more popular as weight-loss aids, especially among college students. "Herbals are the latest bandwagon," said Michele Cavoto, nutritionist for James Madison University's dining services. "I'm seeing a lot of ginko, green tea and blue-green algae. I discourage students from using herbs. I tell them that they're not regulated, that the concentrations aren't consistent, that we have no way of knowing what concentrations and what volume of any particular herb is helpful -- and perhaps more important -- at what concentration and volume they are harmful." In addition to issues about safety, student-athletes pursuing weight loss through herbal supplements could lose their eligibility by testing positive for an NCAA-banned substance. One immensely popular weight-loss dietary supplement is Metabolife 356, which contains the NCAA-banned substance ephedra (listed on many bottles as Ma Huang). Many similar-sounding products are available, many of which also contain the banned substance. The Association has long held that not knowing the contents of a product does not nullify the positive test and resulting ineligibility.
'Female-athlete triad' may mean osteoporosis for young athletesThe term "female-athlete triad" was coined in 1992 when a group of sports scientists and doctors became alarmed at a trend of more and more female athletes who were eating poorly, not menstruating and suffering stress fractures. This problem also can be a devastating side effect of eating disorders. It is estimated that at least 18 million Americans have low bone mass, considered a precursor to osteoporosis. According to the National Osteoporosis Foundation, another 10 million Americans have been diagnosed with the progressive disease, which can be treated but not cured. "Amenorrhea is a recognizable flag that there is a problem, although not necessarily an eating disorder," said Randall W. Dick, NCAA senior assistant director of health and safety. "Somebody may be performing well, but not having a menstrual cycle. If that's the case, they're putting themselves at risk for osteoporosis and other long-term health problems." Former Creighton University cross country runner Ann Metzner, now 23, had to give up running when she suffered three stress fractures in her left leg. Metzner's bones show the results of her nine-year battle with anorexia. "Doctors tell me my bones are like those of an 80-year-old woman -- one with osteoporosis," Metzner said. "I'm pretty scared, because if I fall, my bones could break." Metzner had to miss her final two seasons at Creighton. At 5-7, she got down to 98 pounds and was hospitalized four times. Metzner told attendees at an eating disorder symposium in Omaha, Nebraska, last spring that she thinks eating disorders are more prevalent among athletes than people think. Part of it, she said, is because of pressure to have a body type that looks like one of an elite athlete. "You see these elite runners on TV, and you know they can't be eating right and look like that," she said. In addition to maintaining adequate body fat, calcium consumption is still considered a young woman's best defense against osteoporosis. Women should be consuming at least 1,200 milligrams of calcium a day, which translates into three cartons of yogurt or four glasses of milk or fortified orange juice. Adolescents and young adults need even more: 1,200 to 1,500 per day. "We have women who are starving their bones," said Lisa Callahan, medical director for the Women's Sports Medicine Center in New York. "Twenty- and 30-year-old women still think osteoporosis is a disease their grandmothers get." In June, the National Institutes of Health and the American Academy of Orthopedic Surgery held a joint workshop to discuss the triad, and the American College of Sports Medicine and the U.S. Olympic Committee held a half-day seminar on the topic. The ACSM and the USOC also convened a panel of experts to create a consensus statement about the triad, to be released this fall.
Additional information on eating disorders
Student-athlete feeding scenarios have been impacted by NCAA legislation
Earlier this decade, a few years after the NCAA broadened its legislation to make permissible the coverage of student-athletes' eating disorder treatment, the Association changed its rules regarding the feeding of student- Dave Ellis, director of performance nutrition at the University of Nebraska, Lincoln, argues that those legislative changes limiting training-table meals have had a negative impact on student-athlete nutrition and a resulting negative impact on student-athlete welfare. "The rules have created some tremendous gaps in our ability to provide adequate nutrition and adequate fuel," Ellis said. "Athletes need to eat when their appetites and training schedules allow them to. During a period like two-a-days, this may manifest itself as two hot meals and three cold snacks. There is no one feeding scenario that will meet all the needs of an athletics population." The rule limiting institutions to one training-table meal per day was adopted in 1991 (and made effective in 1996), as was a rule making it impermissible to house student-athletes in all-athlete dorms, said Athena Yiamouyiannis, NCAA director of membership services. "The rationale published for both rules was to integrate the student-athlete into the student body," she said. "At the time, they were designed as student-athlete welfare initiatives." Student-athletes who live on campus are permitted to take a total of three meals a day (including the training-table meal) at their residence halls. Student-athletes who live off-campus receive a stipend for food, which Ellis says is an inadequate amount based on a poorly calculated formula that doesn't work in the real world. "The most common thing we see is athletes cannibalizing their meal money for their cost of living," Ellis said. "These kids will always compromise their nutrition for money." He noted that entire teams often choose cash over food when given the option on road trips. Ellis also doubts that typical "dorm food" is sufficient for student-athletes. "We are talking about uniquely stressed individuals," he said. "What do we get when we structure training for an athlete about 11 months out of the year and don't feed them? You get highly fatigable athletes who have lower capacity to overcome the forces that are demanded of their sports, which results in more muscle pulls and joint injuries. "You keep the team doctor busy because they see a lot of athletes who think that the can of ravioli they ate for lunch and dinner was enough, and those athletes fall prey to every virus that blows through campus. In reality, these athletes might need four or five intervals a day in terms of delivery of calories." Ellis believes many student-athletes turn to dietary supplements -- which can be legally provided to athletes -- when they would rather have a sandwich. "I can promise you that athlete would rather eat food than take pills and powders," he said. "But we have hungry athletes, mandatorily doing invasive work, who are suffering. Anybody with a compassionate bone in their body knows these kids are suffering and need help meeting fundamental calorie needs on a daily basis. Food should not be considered an 'extra benefit' for hard-working athletes." Ellis would like to see training-table rules deregulated so that trained nutritionists could deliver whatever type of food necessary -- whenever necessary -- to meet the individual needs of each athlete. In addition to deregulating the training-table rules, Ellis believes that there should be an increased emphasis on nutritional education and the use of nutritionists. "Athletics administrators should empower nutritionists to work alongside strength coaches," he said. "If a nutritionist is in the weight room, then when somebody asks 'How can I gain more muscle weight?' the answer includes proper information on diet. Or, when coaches have unrealistic expectation for weight loss, there's somebody there who can intervene and explain what that drastic loss would do to the student-athlete's health." Ellis also encourages athletics administrators to turn their focus from cost-containment regarding food to cost-containment regarding medical expenses. "The sooner athletics administrators start to look at nutrition as a cost-containment feature of medical costs, the sooner student-athletes will get adequate nutrition," Ellis said. "Better nutritional status means better wound healing, less downtime and less medical expenses overall. No school is saving money by not feeding its athletes." |
Thin is in, and that's a fact of life not lost on student-athletes.