If you are a concerned family member, care-giver or a friend, it can be very difficult to reach out or know how to help someone you think might have an eating disorder. With that in mind, I've decided to post up a series of hints and tips, in line with recommendations by the National Centre for Eating Disorders on things that might be helpful.
Recognise the warning signs
Please be aware that no individual 'warning sign' means that someone does or doesn't have an eating disorder. If you feel that any of the questions below might be adversely influencing an individual's well-being, then it could be time to speak with them.
Do they refuse to eat certain types of food/food groups?
Have they recently lost a lot of weight?
Do they eat much less than they used to?
Do they refuse to eat with others?
Do they insist on cooking their own food?
Have they had a history of complaining that they feel fat?
Have they become obsessive about exercise?
If you've discussed eating habits or their relationship with food, do they deny they have a problem?
Are they always on a diet but failing to lose weight?
Do they tend to disappear to the bathroom after meals, run bathwater or play the radio loudly (in the bathroom)?
Do they have particularly noticeable mood swings?
Again, many of the signs above might be part an parcel of a completely normal individual. But if you are concerned,
1) Make a plan to speak with them
2) Let them know your concerns in a non-confrontational, non-judgemental and calm manner
3) Let then know you care
4) Leave the door open for them to re-engage at a later point
The idea for this blog came from listening to 2-part podcast on body image and depression on Ben Coomber radio - Check out the youtube videos here (part 1 and part 2). The podcast delved into a range of issues relating to mental health and the fitness industry with some nice take homes for both practitioners and sufferers alike. In my work with eating disorders and the general population of athletes I work with, body image concerns are commonplace. Considering the prevalence these issues, I thought it would be useful to drill down in a little more detail into the topic of body image. To explain how we might think about it, and offer some things we might be able to do to work to improve it. It’ll be by no means exhaustive, but hopefully helpful for some of you. If you are interested in learning more about it, Body Image: Understanding Body Dissatisfaction in Men, Women and Children by Sarah Grogan is a pretty comprehensive and highly recommended read.
What is Body Image?
The first thing to understand is that body image it is a mutifactorial construct. That is to say, our body image is not just the picture we form in our minds of how we appear, but it relates to a collection of perceptions, thoughts and feelings about our bodies as well. While our body image can be considered to be somewhat ‘elastic’ in that it will vary over time depending on situational context, it is broadly a stable trait.
Because body image is multifaceted, it can therefore be influenced in many ways. Body image isn’t only about the way you look to yourself or others. Or should I say, how you think you look - People often assume that others see us exactly the way we see ourselves, which is not the case.
Our body image depends on the salience we place on a host of evaluative, cognitive and affective estimations. Therefore, changing just your appearance won’t necessarily improve it. If you’ve had a chance to listen to the above podcast, the listener who writes in during the 2nd part of the show finds himself in a similar position. He details his story and continual struggle with body image. Despite a remarkable personal transformation he bemoans the unhelpful and unrealistic promises of the fitness industry e.g. ’16-weeks to washboard abs’. He suggests that these types of plan spread false hope, and are in general unrealistic for most. That is of course unless you have certain substances, the correct starting point, time, genes and photoshop on your side. Now I don’t disagree with his sentiment, but I felt that he was somewhat missing the wider (flawed) assumption - that the achievement of ‘washboard’ abs or any given body image will result in personal satisfaction/happiness. Our body image is closely related to self-esteem and how we think about ourselves ‘on the inside’ too. Since almost all of us can relate to being 'embodied beings', its pretty unlikely to have a someone with a positive body image alongside low core self-worth/esteem.
Culture, male body image, female body image and sport
Generally westernised society now promotes the ideal that both men and women should be slender. Women are expected to be slim and shapely, men, slender and muscular. Women tend show significant dissatisfaction with their bodies, in particular hips their thighs and stomach. Until the 1980s, body image wasn’t so much an issue for men but is now becoming increasingly prevalent. A significant proportion of men show body image dissatisfaction with thoughts centred more around general muscle tone, biceps, shoulders, chest and the mid torso. While women mostly want to be slimmer, (despite systematically over-estimating body size, irrespective of their current size), men show an almost equal preference for being thinner or heavier. Strangely, men do not over-estimate their body size in the same way and are more likely to turn to exercise than dieting in order to try to alter the way they look.
Complex historical trends relating to portrayal of the male and female body contribute to just part of the current epidemic of body dissatisfaction however. As mentioned earlier, body image can also vary depending on situational context. In my experience, these can often be presented by the different sporting subcultures with which people engage. Each has different body ideals (triathlon subscribes to three - swimmers cyclists and runners) and different rates of social comparison (bodybuilding does this overtly, which is known to increase the influence it has on body satisfaction). The degree to which we internalise role model standards also plays a big part. If we do not have the appropriate protective influence of high self-confidence in place these feelings can quickly become toxic leading to a host of unusual behaviours.
So how can we improve body image?
Because body image can be influenced in many different ways, it can be difficult to work with, and just like boosting emotional resilience it can also often be a slow process. Several things have however been shown to be useful in promoting body image. A few of which I have listed below:
1) Boost Self-esteem. Self-esteem and body image are closely linked and improvements in self-esteem have been show to be effective in also improving body image. Approvals, assertiveness and gratitude work can all be effective in the right situation here. Again, this takes time, and much work might need to be done before this type of work can be truly effective.
2) Develop resistance to the internalisation of the thin/muscular ideal. To those that strongly internalise, just 5 minutes of exposure to images to propagate such ideals has been shown to negatively influence body satisfaction. Educate yourself to understand the processes in the development of media imagery.
Educate yourself around the motives of the diet industry and learn to continually challenge their unrealistic and polarising claims. Cognitive Behavioural Therapy can be very useful here. There is also good evidence to suggest that feminism can be protective against internalisation of such ideals.
3) Promote activities and thoughts around body mastery and control and promote positive body sensations vs those that value the aesthetic properties of your body. List all the functionally useful and valuable aspects of your body. Anecdotally I’ve seen positive changes from those moving from a bodybuilding (aesthetic-based) to a strongman/woman (strength/functionality) type of culture. Massage, yoga, tai-chi etc. are all examples of things that can help to create a positive body experience. Find something that works for you.
4) Stop checking behaviour such as pinching, squeezing, mirror-time or weighing. These only serve to reinforce the salience of body image. If your partner asks for reassurance ‘does my bum look big in this?’ be diffuse. If you feel fat, ask yourself, what else might I be feeling?
5) Mindfulness. There it is again. Is there anything mindfulness doesn’t do? Yep, but for managing and letting go of toxic thoughts about body image in a non-judgemental manner, it can be very useful
So there are just some things that might be helpful in terms of improving body image. I’ve barely scraped the surface on what is a huge topic. If you have any questions, please don’t hesitate to contact me firstname.lastname@example.org. If you think it might be useful for anyone you know, please don’t hesitate to share.
Emotional eating is a tricky topic. Whenever I talk to the people about the sort of work that I do and mention emotional eating, people will readily identify with this aspect. ‘Yeah, I definitely think I do that, is that bad?’
The fact is, we are all emotional eaters to some extent or another. We know that eating (or not eating for that matter) is intricately related to how we think and feel. Take a situation when you might have gone food shopping when you were very hungry. Now compare this to a similar situation, but you are feeling very full. You’ll probably have made very different decisions. Even if you haven’t, you’ll certainly think and feel differently about what you are putting into your basket. From very early on, the food we eat becomes entangled in a web of developmental experiences that relate to how well we emotionally attach to others (or not), how well and how we learn to regulate our emotions, and how we relate a range of emotional experiences with those of hunger and satiety.
The connection is even prominent in our day to day vocabulary. We can ‘swallow our pride’, we can literally become ‘fed-up’ with someone, or something. How many sitcoms and movies have you seen where the protagonist is encouraged by (usually her) friends to crack out a (usually large) tub of ice cream to help regulate, avoid or manage their emotionally turbulent roller coaster of a story line? Despite its prominence, it would be foolhardy to assume that emotional eating is necessarily maladaptive, or symptomatic of an underlying issue.
Is emotional eating, comfort eating?
Emotional eating is also often oversimplified. People tend to jump to the conclusion that we eat emotionally, because we are seeking comfort. In fact, there are multiple potential explanations for the cause of emotional eating in each of our lives. Yes, some people do eat to regulate emotions, others might do so to avoid, or block them. People sometimes eat to communicate emotions to themselves or others or in response to trauma or stress. Cognitive models of emotional eating explain some patterns as a result of certain schemas. Does the individual feel entitled, abandoned or deprived?
Just as there is no single cause to an eating disorder, there is no single model that would seem to fully explain the cause of emotional eating in a given individual. It is highly context specific and as ever, there is no easy answer.
What do we do about emotional eating?
If emotional eating is problematic for an individual, it is first useful to understand if there are any deficits or difficulties in the process of of managing emotions for an individual.
We might want to look at how well someone can recognise their emotions. Some people have become so disconnected from certain feelings that they can no longer easily identify them. This can be known as Alexithymia -basically an inability to identify and describe emotions in the self. In other situations, people are not disconnected, but cannot place a given emotion. Feeling fat for example, can often be the expression of another unrecognised feeling or emotion. A lot of people feel fat from time to time. A good question to ask yourself in this situation is “I wonder what else I might be feeling?”
Having recognised the emotion(s), it is then a case of learning to tolerate them. If we are to disconnect any sense of maladaptive relationship between a given emotion and eating behaviour, the individual needs to be able to ride the initial impulse of escaping, avoiding or quietening that emotion.
This can be helped through the process of validation. Emotions are a part of all of us. They are used to communicate or pass on information within ourselves, and between ourselves and our environment. Some of us need to learn that It is not ‘right or wrong’ to feel anything. Guilt is a good example. Have you ever asked yourself why do we ‘feel guilty’? One function is that it helps regulate social boundaries. We might feel guilty after minor (and major) indiscretions. For example, I still feel a pang of guilt when I think back to the actions of my 14-year old self. I still vividly remember walking into my brother’s room, who was diligently working away on an essay. In a misplaced bid for attention, I flicked the off button on his PC - cue utter chaos. In the aftermath, while I may have denied it at the time, I didn’t feel great about it. The behaviour or action may have been ill-advised, but the emotional response was appropriate. If I had somehow learned at an early age that both my actions AND my emotional response to those actions as inappropriate, I might have developed other ways of managing that emotion. Some people also then learn to associate what they consider to be ‘unacceptable’ emotions to core self beliefs. E.g. I shouldn’t be feeling this, therefore I’m flawed/I'm a bad person. We must all learn that most emotions are an entirely natural and necessary response to our behaviours and environment.
Finally, we come to management. We can all learn to develop a set of skills to manage our emotions. Whether we need to improve our communication skills, assertiveness or ability to soothe ourselves without food, we still cannot begin the process building emotional resilience without first learning to recognise, tolerate and validate the emotions we feel. It is is a complex process, and takes time, so for now, I’ll leave it there.
In another post, I’ll cover some of the strategies that might be useful to deploy throughout this process. If you have any questions or feedback, please don’t hesitate to email me (email@example.com) or follow me/tweet me (@acbcoaching). As every, any shares to people you might think would benefit from reading this post would be much appreciated.
Prevalence rates of Eating Disorders in Sports are not necessarily higher than in the general population.
Sport participants are still however at higher risk of developing Eating Disorders than the general population.
There is no single cause to an Eating Disorder
Subclinical and Partial diagnoses of Eating Disorders in Sport are high!
All Sport Participants have a responsibility to be aware of the added risk factors unique to sport that might promote the development of an Eating Disorder.
Its Eating Disorders Awareness week, and I wanted to write a blog with some useful information that might help with raising awareness of Eating Disorders, especially as they relate to Sport.
How common are Eating Disorders in Sport?
When it comes to estimating prevalence, its tricky ground for a number of reasons. For one, the diagnostic criteria of Eating Disorders (ED) has recently changed. Those who were not diagnosed before the release of DSM-V in 2013 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) could now be classified. For example, amenorrhea is no longer a necessary characteristic for the diagnosis of Anorexia Nervosa. Classifications of different types of sports, lean or nonlean, aesthetic etc also differ between studies and further the picture. Consider also, that those who suffer from an Eating Disorder often might not consider themselves to have a problem (think therefore what they might or might not say when filling out a questionnaire). Individuals also have a funny way of not fitting neatly into one box or another, and can also move from one ED to another. When you look at the research I’ll be the first to admit, there are clear limitations in some of the studies that churn out these numbers, and some quite conflicting information produced.
Some suggest that sport participation seems to have a positive effect on behaviours and attitudes relating to eating and our bodies. In others there seems to be clear patterns where individuals (especially women) competing in lean, aesthetic, endurance sport are more likely to have ED than non-athletes. But before you’ve made up your mind you can find a host of work that suggests quite the opposite, that some athletes are actually healthier, are at less risk and do not have more eating problems than non-athletes.
So do sport participants suffer from more ED than those that don’t do sport? On balance, probably a little. But the same messy research landscape presents itself when we ask other questions about ED prevalence within sport. For example, does the level of competition influence the prevalence? Again, its hard to say. You’d probably think the more competitive the worse it gets - stakes are higher, margins are finer. Eventual Conclusion? More relaxed competitive levels of sport are probably not protective, and elite levels aren’t necessarily predictive of ED.
So where does this leave us? Prevalence rates of ED within sport are variable. Its probably safer to assume that sport is but a microcosm of wider society. Personally, I am not sure that prevalence is of that great a relevance or use to the general population anyway. For those that have been through them, worked with people with ED or have had friends or family battle against them, the fact that they exist at all is bad enough. What is important to appreciate is that because the development on ED depends upon a host of developmental, genetic, and environmental factors (i.e. there is no single cause to an ED), we all have a responsibility to be aware of, and manage those risks that specific to our environment. We know that sport participants are exposed to the same risk factors as the general population, as wellas those that come from sport. Although this is not necessarily expressed in higher prevalence when it comes to the development of ‘full on’ Eating Disorder, sport does expose its participants to a greater number of risk factors associated with ED.
What is worrying, that when you drop down to partial or subclinical diagnoses of ED, we are faced with a far bleaker picture. These are the people that we might consider to suffer from disordered eating, or are symptomatic of a greater classification but don’t quite tick all the boxes. I have seen estimations of disordered eating within sport (and particularly those at higher levels of sport) range from 18-46%! Sport participation is often referred to as part of the ‘solution’ to the a worsening picture of global health (obesity, inactivity and chronic illness). I can’t help but wonder what might happen as this discussion continues to evolve. Might we exert further pressure on those in sport who are already symptomatic? Might we be trading one potential health risk for another by directing people towards sport?
Eating Disorders in Sport - What are the risks?
In order to understand, treat and potentially prevent eating disorders is it useful to know the difference between what are the general risk factors we all face, and the additional ones we might be facing that are specific to sport. As I mentioned previously there is no single cause to an eating disorder and their occurrence will come from a multitude of genetic and sociocultural (media, family, peers) factors. We don’t need to avoid sport therefore, but we should be cognisant of, and do our best to avoid/lessen the specific risk factors it brings with it.
Weight/Body Fat = Enhanced performance
This is often taken as gospel, yet you might be surprised to know that the literature is can be quite equivocal when you look at the relationship between bodyweight/fat and performance. I am sure the old school amongst you will be turning your noses up in disgust at this point. I am not denying that bodyweight is a factor in sporting performance, but neither is it an independent variable we can manipulate without consequence. Pay attention to this next sentence. It is unethical for any individual, coach or practitioner to advise weight loss to an athlete or another individual without specialist knowledge and training. If you don’t have this expertise and have not consulted with health professionals that understand the implications both from a nutritional and psychological perspective, you should not be saying anything. In sport you definitely can do more harm than good. If you work with athletes. de-emphasise weight and know your limitations.
Similarities between a 'good athlete’ and characteristics of eating disorders
The ability to perform despite pain and discomfort, mental toughness, unrelenting commitment and pursuit of excellence are all traits that are associated with what most might consider a ‘good athlete’. These are therefore behaviours that are positively rewarded within sport. These traits however are very similar to several characteristics of eating disorders. The denial of discomfort, asceticism, excessive exercise and perfectionism are all traits that might put an individual at risk of developing an eating disorder. Sport is not black and white, lines get blurred, and nothing is clear cut. Not only might these traits expose certain athletes to greater risk, but the fact that they potentially complicate the identification of a problem should also be considered a risk.
As alluded to above, the positive reinforcement of behaviour symptomatic of an eating disorder is also a big problem in sport. Consider these two examples. Excessive exercise and dieting for weight loss. I’m sure we all know many in the endurance community who might fall into these categories. You may be shaking your head here too, but bottom line is, almost all those that suffer from ED have dieted (often multiple times). For certain people it can be a precipitant of ED, or make their current ED worse. I’ll say it again, de-emphasise weight. If you want to reward and encourage others, make it about things they have done to improve their health, not lose weight (even if these might sometimes be related in overweight individuals). When it comes to excessive exercise, this can be something a bulimic does instead of purging, or to justify eating, or as a result of eating. Its also a common characteristic in Anorexia also. Often one the last symptoms to disappear and one that can cause the persistence of an eating disorder, be careful what you say. Its difficult to identify, especially in ultra-endurance sports but before you next congratulate your friend on their ‘epic run streak’, just stop and think, what else could you say?
Sport specific expectations, ideals and norms
Each sport has its own subcultural idiosyncrasies. Be aware of these. Pathogenic behaviour relating to cutting weight or maintaining a low weight are common in jockeys, in boxing, wrestling etc. Think of body ideals. Triathlon is a particularly tricky one, as each sport emphasises different ‘ideal’ body shapes. Its impossible to be all three. Are you promoting these ways of thinking in what you say, are others? If so you could be increasing the pressure on an individual to conform. When it comes to pressure relating to shape, weight and body image this is a big no-no!!
While there are other potential risk factors relating to sport I hope this has provided a bit of insight into some of the more significant and obvious dangers that sport might present with regard to the development of eating disorders. Sport can either pose a direct risk, exacerbate or obscure the identification and delay treatment of full and subclinical eating disorders.
If anyone has any questions or interested in any references that I have not mentioned, please email me (firstname.lastname@example.org) or contact me on @acbcoaching through twitter and I’d be happy to discuss. Again, I’d love it you could share this article in the spirit of eating disorder awareness week. If anyone would like to find out more about Eating Disorders, I’d recommend visiting the National Centre for Eating Disorders website.