When Kristen Martin talks to a student-athlete with an eating disorder, her words come from the heart -- and from her own history.

As the Team ENHANCE coordinator for the University of Tennessee, Knoxville, Lady Volunteers, Martin works with student-athletes on a variety of mental-health issues, including eating disorders. A former swimmer at Pepperdine University, Martin knows the pressures of competing at the collegiate level, and how those pressures can sometimes lead to unhealthy behaviors.

For 15 years of her life, dating back to high school, Martin was anorexic and bulimic, meaning she would try to control her weight through starvation or binge-eating followed by periods of purging. The disease affected her athletics performance. In her freshman year at Pepperdine, Martin swam to a conference title, but by her senior year, the disease had sapped so much of her strength and energy that she finished well out of the top 10, even while serving as captain of the team.

"I was a distance swimmer, so (the eating disorders) just absolutely killed me," Martin said. "It doesn't help (athletic performance) if you're not eating."

Finally faced with the reality that she wasn't getting better on her own, Martin wrote a letter to her coaches describing her behaviors and asking for assistance. They helped Martin into treatment through the school's counseling center, and then the real work began.

"You really fight that desire to get better, you don't want to let go," she said. "It's very complicated. In your mind you have these dual voices that battle each other every single day. It's just very powerful and hard to let go."

Student-athlete risk factors

It took years, but Martin is now well and can use her own experience to help the student-athletes she comes into contact with through Team ENHANCE.

Team ENHANCE was formed at Tennessee from an NCAA initiative in the late 1980s and early 1990s to study and combat the problem of student-athletes with eating disorders. The program has expanded to include other aspects of health as well. ENHANCE is an acronym for enhancing nutrition, health, athletics performance, networking, community and education. It is geared toward young women in the athletics department, but also educates coaches, athletic trainers and other professionals. The program employs nutritionists, therapists, consultants, mental-health and addiction professionals, and eating-disorders specialists.

Student-athletes like Martin and the thousands of others who develop eating disorders have more of the risk factors for developing such behaviors than the average college student.

Ron Thompson, psychologist and co-director of the Bloomington Hospital's Eating Disorders Program affiliated with Indiana University, Bloomington, said symptoms often connected with eating disorders in a nonathlete, such as lowering of body fat and the cessation of menstruation, are seen as normal or even valued in those students who participate in sports.

Some sports are regarded as "thin sports," in which success often is related to a small body size or shape, including gymnastics, cross country, and swimming and diving. Thompson said any behavior or activity that emphasizes small body weight or size will increase the likelihood of a participant developing an eating disorder.

"If you're in a sport where thinness is sort of the stereotype for good performance, say distance running, you may strive more to be thin, you may diet more, you may feel worse about eating, you may train harder," Thompson said. "The sports themselves, those that emphasize thinness, can put athletes more at risk."

Martin said she herself adopted the "thinner is faster" philosophy while competing in her sport. When her times kept rising even as she got thinner, she grew frustrated.

"It's a myth that is somehow stuck in the minds of athletes," she said. "You lose the rational thinking when you get so involved in your eating disorder."

The "thin culture" that permeates society can be heightened for student-athletes forced to compete in uniforms that make comparing physiques easy, Thompson said. When a student-athlete loses a competition to a thinner opponent, she often believes weight is to blame.

According to a recent survey Thompson and his partner, Roberta Sherman, conducted in conjunction with the NCAA, 37 percent of coaches believe amenorrhea, the cessation of menstruation, is normal. In actuality, amenorrhea is a serious medical problem and requires medical consultation. Amenorrhea is a key component in the female athlete triad, which also includes disordered eating and osteoporosis. The three conditions often are related and found in the same student-athlete.

Another factor that puts athletes at greater risk for developing eating disorders such as anorexia and bulimia is the value placed on exercise. Excessive exercise often can be a method that bulimics use to purge any calories ingested during a binge, but it can also be a sign of an elite, dedicated athlete.

"We think one of the risks for athletes is that it is harder to identify eating disorders in the sport environment," Thompson said. "Outside, it's a little bit easier. We know that amenorrhea is not helpful, and we can recognize excessive exercise a little bit easier."

Martin said the pressure sometimes contributes to pushing an athlete over the edge.

"Unfortunately, coaches don't always know the best way to handle things, and it's really not their fault," she said. "They're just coaches, they're not therapists. One thing I have learned is that athletes take what their coaches say, whether they love their coach or they hate their coach, like it's gospel, the ultimate truth."

Martin said comments such as "you need to be leaner" and "lose five pounds" sound fine, but to an already at-risk student-athlete, they can be a trigger.

Treatment available

Student-athletes often continue to perform at a high level in their sport even with significant eating disorders, another risk factor. While no research has been done, Thompson said he believes that because the risk is greater, student-athletes might develop eating disorders more often than other students.

Treating anyone with an eating disorder is a complex and multi-dimensional endeavor. The behaviors often are rooted in issues that have little to do with food, and every aspect of the person's life must be examined and treated. Thompson said student-athletes benefit from someone who is not only an eating disorder expert, but somebody who has experience working with athletes in a sport environment.

Martin said she sometimes draws on her own experience in her discussions with student-athletes who suffer from eating disorders.

"I think it helps make the connection. It's such a hard thing to talk about, and if the student-athlete knows where I'm coming from, we can work through it," she said.

She said she often shares her own past and then answers any questions the student-athlete has, leaving it up to them to decide how much information they want about her own experience. She estimated that 99 percent of student-athletes referred to her for treatment -- few come forward on their own -- are resistant initially.

Some student-athletes can continue to compete while in treatment, while others can not. Both Martin and Thompson said decisions such as whether to continue in competition or even in practice are made individually. Treatment can last for weeks, months or even years.

Successful treatment is defined by not only an absence of symptoms, but also a change in the way a person deals with emotional factors.

"Most of these folks will use their eating-disorder symptoms to try to help them deal with their emotions," Thompson said. "What we try to do in treatment is to separate all of that and help them learn to deal more directly with their emotional issues in ways that have nothing to do with eating or food or weight."

The long-term effects of an eating disorder can result in more fractures and stress fractures due to the dip in hormones that comes with most eating disorders. Thompson said estrogen in women and testosterone in men contribute to healthy bone growth, and a lack of the hormones can lead to medical problems. Recovered patients also occasionally develop gastro-intestinal problems and some, particularly bulimics, have dental problems.

Treatment is where Thompson sees student-athletes as having an advantage over others.

"They're the best patients I've had. They're used to working harder than other people; they're motivated to get back to their sport and they're mentally tough," he said. "They're used to being faced with difficult decisions. They're tough enough to do what needs to be done, and even though they're afraid, they'll do it anyway. That's really what I think helps them get better."

Education for the future

Educating coaches, athletic trainers and others who interact with student-athletes is Thompson's top priority. He recommends the NCAA Web site as a resource (www.ncaa.org/ nutritionandperformance) when he speaks to groups about the topic. He also recommends that people in the sport environment learn to de-emphasize weight and eliminate dieting.

"We're not going to eliminate eating disorders unless we can stop dieting. That's not realistic, but that's basically what we need to do," he said. "I think coaches can focus on having their athletes eat well, have them work with dieticians and sports nutritionists, make sure that they're eating enough, make sure that they're eating a well-balanced diet."

He said educating sports professionals who work with student-athletes about the dangers of amenorrhea and eating disorders will help combat the problem.

"Everybody gets their information from Oprah or Dr. Phil or Cosmo, and really there's good information out there. The (NCAA) Web site has a link to the American Dietetic Association, which is absolutely the best place to get your information," he said.

Martin said that some schools, like Tennessee, have made coming forward and receiving treatment easier, though each school is different. She said often schools will call her to talk about Team ENHANCE, and she's glad to help out where she can.

Thompson, a member of the NCAA Speak-ers Bureau, and said he is astounded at the lack of accurate information that is circulated.

"For some reason, there's more misinformation and myths in the area of eating, weight, nutrition and performance than any other," he said. "I think with the right kind of education we can get the job done."