Archive for February, 2015

I Had No Idea: a “healthy” passion can become a problem

February 26, 2015

Passion drives many athletes and outdoor enthusiasts here in Jackson Hole, Wyoming. Surrounded by rugged mountain ranges and access to raging rivers, this recreational Mecca is a sort of proving ground for athletes who want to push their limits skiing, rock climbing, boating, biking, running and more. There is a strong subculture here that sets a high bar for “normal” exercise.

Passions Can Become Problems

Passions Can Become Problems

More than 20 years ago during my early years in Jackson a friend and I did a 24-mile day hike up in Grand Teton National Park, a major feat for us east coast transplants. We got an early start and crested the top of the divide feeling pretty good about our accomplishment until a couple of local friends came jogging up the trail and passed us wearing fanny packs with water. If you climb or ski something here someone has climbed or skied it faster, or as part of a multi-peak day, or they first biked from town, swam across a lake, and were heading down to reverse their route after passing you. Seriously.

This Uber-athlete mentality makes it difficult to define “excessive exercise.” Disordered eating patterns that often accompany problem exercise are also normalized here. Sometimes eating takes obvious disordered forms such as severely restricting all food intake or bingeing and purging food. Less obvious disordered eating can be adhering to rigid food rules such as “eating clean” or following any number of fad diets that are socially accepted. This does not mean anyone who is consciously eating well to improve health or athletic performance has an eating disorder but points to the difficulty in identifying problems in subcultures like ours where extreme behaviors are normalized.

A group of friends on a long backcountry ski tour together may have no idea one member of the group has not eaten for 12 hours because she “ate too much” yesterday. Or she needs to hike, skin and ski first to “earn” her next meal. Or she “feels too fat” to eat. Or the food available doesn’t meet her strict guidelines of acceptable food. And with the exercise itself, if someone works out despite illness or injury or never takes a rest day, she is badass, dedicated, someone to be admired.

Excessive exercise as a form of purging in Bulimia Nervosa was added to the DSM-5 (the manual that outlines criteria for a variety of mental illnesses including eating disorders) in June of 2013. Exercise has long been recognized as a problem in a variety of eating disorders but it was not previously defined as a form of purging in place of other purging behaviors such as self-induced vomiting.

Unfortunately, the general public health messages that encourage people to “move more and eat less” don’t acknowledge any downsides to either of these mandates. “Earning” meals or treat foods with exercise is commonly encouraged and the fine line between balancing calories and physical activity or obsessing about these habits is often blurred. Exercise habits can’t be adequately assessed based simply on the number of hours or days each week, the type of activity, or even the intensity, we must look at what drives the exercise.

Is it enjoyable?

What happens if you miss a day of working out?

Has exercise replaced time you spend doing other things you enjoy or time you spend with friends and family?

Do you fuel and hydrate to support your activities?

Do you feel better afterwards or do you just feel relief that you exercised?

All of these questions must be considered in the context of the whole person. An elite or professional athlete may have to train on days conditions are less than ideal and training can appear compulsive to an outside observer and a recreational athlete who sometimes overdoes it may not have a problem. The point is we need to know that despite all of tNEDA - Exercisehe positive benefits associated with physical activity, exercise can have a dark side. People who exercise while malnourished and underweight can experience accelerated bone loss and exercising after food restriction or other forms of purging can cause dangerous electrolyte imbalances.

If you suspect someone you care about has no idea that their passion may have crossed a line into dangerous territory – seek support. NEDA has a free Coach and Athletic Trainer toolkit with ideas that may apply to recreational athletes who are not being coached. Also from the NEDA website are the following risk and protective factors for athletes that may be helpful to consider in the broader context of appropriate or “healthy” exercise.

Risk Factors for Athletes:

  • Sports that emphasize appearance, weight requirements or muscularity. For example: gymnastics, diving, bodybuilding or wrestling.
  • Sports that focus on the individual rather than the entire team. For example: gymnastics, running, figure skating, dance or diving, versus teams sports such as basketball or soccer.
  • Endurance sports such as track and field/running, swimming.
  • Overvalued belief that lower body weight will improve performance.
  • Training for a sport since childhood or being an elite athlete.
  • Low self-esteem; family dysfunction (including parents who live through the success of their child in sport); families with eating disorders; chronic dieting; history of physical or sexual abuse; peer, family and cultural pressures to be thin, and other traumatic life experiences.
  • Coaches who focus primarily on success and performance rather than on the athlete as a whole person.
  • Three risk factors are thought to particularly contribute to a female athlete’s vulnerability to developing an eating disorder: social influences emphasizing thinness, performance anxiety and negative self-appraisal of athletic achievement. A fourth factor is identity solely based on participation in athletics.

Protective Factors for Athletes:

  • Positive, person-oriented coaching style rather than negative, performance-oriented coaching style.
  • Social influence and support from teammates with healthy attitudes towards size and shape.
  • Coaches who emphasize factors that contribute to personal success such as motivation and enthusiasm rather than body weight or shape.
  • Coaches and parents who educate, talk about and support the changing female body.



Fire & Smoke: I Had No Idea

February 23, 2015

This year’s eating disorder awareness catch phrase put forth by the National Eating Disorder Association (NEDA) is “I Had No Idea.” The list of I Had No Idea moments I have experienced as an eating disorder professional is long. From my first client struggling with Anorexia, the inadequacy of my standard formal education as a Registered Dietitian, even with a Master of Science degree in Foods & Nutrition, was obvious. I immediately began reading, studying, and consulting with more experienced colleagues about eating disorders. I attended a workshop specific to CBT (Cognitive Behavioral Therapy) for eating disorders led by Christopher Fairburn and a national conference featuring several high profile experts in the eating disorder field back in 2008, and still I had much to learn. As most eating disorder professionals will admit (in candid moments at least), we learn the most from our clients and patients.

Eating disorders work is about more than learning for me – I am truly inspired by my clients. Their perseverance in the throes of incredibly difficult challenges humbles me. One of the best I Had No Idea professional moments for me was learning that eating disorder clients can fully recover. While not all clients do for a variety of reasons, knowing that full recovery is a possibility and believing each of my clients has this potential is an idea I am grateful to know now.

In addition to the important work I do with clients, one of the incredible aspects of being part of the eating disorder treatment community is just that – a sense of community. We work in an area of nutrition, mental health and medicine that requires us to incorporate what we have learned over the past few decades about good practice, and perhaps more importantly, to stay open to new developments. I feel honored to work among so many dedicated, intelligent, and passionate professionals doing this work.

I plan to write this week about some of the topics the National Eating Disorder Association (NEDA) has made a part of this year’s awareness campaign. [See the list and more info here.] Beyond busting myths and stereotypes, encouraging more people to recognize disordered eating and related issues (like problematic exercise), and advocating for people struggling with eating disorders everywhere, I also want to be open about some of what I have learned on my professional journey working with eating disorders.

Fire and Smoke

I begin with an analogy I learned from a colleague at the intensive outpatient clinic for eating disorders where I worked for two years in the Seattle area. Jeanne Wiccomb, Director of the Intensive Outpatient Program, described the outward behaviors we see in eating disorders as the smoke. Beneath the smoke is the fire, with a variety


Smoke of the Eating Disorder

of “fuels” that can start the fire or keep it going.

Those of you who have attended one of my eating disorder presentations here in Jackson over the past year and half have probably seen the poster I made depicting this Fire and Smoke analogy for eating disorders. For those who have not I include pictures here of the newest rendition of my Fire & Smoke poster.

As you can see the smoke consists of the various behaviors we often use to define an eating disorder. Food restriction, binge eating, various forms of purgeing (including dysfunctional exercise), and the “other” category with additional forms of self-harm such as cutting that we see commonly with eating disorders.

Many people, including health and medical professionals, have no idea that these behaviors (the smoke) are not the eating disorder itself. This smoke is how the eating disorder presents itself but is only part of the whole picture.

The fire that produces the smoke can be caused by a number of “fuel” sources. Sometimes the fuel that starts the fire differs from fuel that keeps the fire going. Potential eating disorder fuel sources include:




Fire & Fuel

Fuel for the Eating Disorder Fire

Chemical dependency

Addictions (drugs, smoking, shopping, sex, exercise, gambling)

History of Trauma or other abuse (physical, sexual, emotional, psychological)

Poor body image

Low self-esteem

Personality characteristics & temperament (perfectionist, rigid, compulsive traits, obsessional, harm avoidant, sensitivity to rejection, reward dependent, anxious)

Feeling of Powerlessness

Life Transitions – life cycle, lifestyle changes, loss (death, divorce, move)

Troubled Personal Relationships

Sensitivity to rejection

Peer pressure

History of Bullying or Teasing Related to Weight/Size

Media Messages and Images (Unrealistic Thin or Muscular “Ideals”)

Cultural Ideals of Beauty – emphasis on outward appearance

Prejudice Against Obesity – Body Shaming

Inability to express emotion in healthy or appropriate way (emotional dysregulation)


Brain chemical imbalance?


There are many things I love about this analogy (in addition to the opportunity to do a really fun art project making this poster!). The treatment process and recovery journey is often long and complicated. Conceptualizing the eating disorder as a fire with many possible fuel sources helps us “see” why it can take so long to recover, why simply getting rid of the outward behaviors (or clearing smoke) is not enough, and why relapse is common or considered part of the process.

I have worked with eating disorder clients for nearly 15 years and I have yet to meet a client with only a single fuel source. When I show this poster to clients and their families they often immediately identify several possible contributors. This helps families, especially parents to feel less guilt, and clients to feel validated in the difficulty of their struggles. This also helps all of us see that socio-cultural factors such as the media portrayal of the “Thin Ideal” for females and the “Muscular Ideal” for males or problematic relationships may not cause eating disorders, though these can be significant contributors.

If you know someone who has no idea what eating disorders really “look like” I invite you to share this analogy and graphic with them.