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Mental Note

Episode 25 - Do Sports Cause Eating Disorders?

By Ellie Pike, MA, LPC

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Check out our podcast, Mental Note. In this episode Traci Carson tells us about the dark side of competition that prompted her to get off the field and into a doctoral program for epidemiology to study the link between female athletes and eating disorders.

Most people assume athletics and healthy bodies are synonymous. But the truth is much more complicated. For researcher Traci Carson, sports were her world - from elementary school through college she excelled at soccer, track, football, and women’s rowing. But a dark side of competition prompted her to get off the field and into a doctoral program for epidemiology to study the link between female athletes and eating disorders. Her story of recovery and research are the focus of today’s episode — giving you the information needed to find balance in athletics.

For a male perspective on the connection between sports and body image, check out episodes 8 & 19 with former Seattle Seahawk Patrick Devenny, and former Seattle Mariners catcher Mike Marjama.

Transcript

Ellie Pike:
I think we all have a pretty consistent image of what a top tier female athlete looks and acts like. Tall, muscular without being bulky, dedicated to her sport and a, quote-unquote, "clean" eater. Seems normal. Right? You might even follow people like this on Instagram to inspire your own fitness goals. Well, today we're investigating just how normal it really is for our bodies to be put under stress by, quote-unquote, "clean eating" and hyper scrutiny in search of athletic excellence. Our guide will be Traci Carson.

Traci Carson:
My name is Traci Carson. I'm currently a second year doctoral candidate in epidemiology at the University of Michigan School of Public Health. Right now, my research focuses on eating disorders in female athlete populations, specifically female distance runners, really interested in the female athlete triad, particularly the outcomes of amenorrhea and bone stress fractures in that group of women.

Ellie Pike:
We'll spend about half the episode discussing Traci's unexpected journey from wearing jerseys to lab coats, and then dive into what her research tells us about the culture around sports and how it affects our bodies. Also, I want to point out that while today's episode may feel slanted it towards the female experience, I invite you to check out episode numbers eight and 19 with former Seattle Seahawk, Patrick Devenny, and former Seattle Mariners catcher, Mike Marjama for a male perspective on sports culture and body dysmorphia. You're listening to Mental Note Podcast, and I'm your host Ellie Pike.

Traci, could you tell us a little bit about your own personal story as you went through female athletics in high school and college?

Traci Carson:
Absolutely. So I started sports really young. My first love of sports was soccer. I played soccer for about 13 years starting at age three up until midway through high school. And then I found running. So I got into track and cross country. I ended up kicking for my high school football team for a year. And then in college, I found the women's rowing team as an opportunity to stay a part of a team environment as I entered into college at the University of Michigan.

Ellie Pike:
So Traci, what were some of the messages you got through your coaches and your teammates about body image and food?

Traci Carson:
Kind of just broadly, the sport mentality of quote-unquote, "no days off", that mentality, comments about pushing yourself past the boundaries, hitting that red line, all of those comments really promote this culture that you want to push yourself beyond your breaking point. And I think that over time, if that's being exercised every single day for several years, that becomes really harmful to an athlete's physical and psychological health. Especially in this population where a lot of athletes really are that that Type A perfectionist personality. And that personality really latches onto those messages of pushing our bodies beyond what is healthy and okay, and really taking that to the extreme.

Ellie Pike:
By age eight, these messages had seeped into Traci's imagination, twisting herself image in a dangerous direction.

Traci Carson:
I would say from a pretty young age, I think probably as young as eight or 10-years-old, I remember just being really self conscious of my legs. My legs were always my target area of focus. And from then on out, I just started becoming really aware of food and how much food I was eating, really trying to learn how to quantify the food I was eating. And so throughout middle school and high school began personally researching how to count my calories, how to weigh and measure food. I wouldn't say I was incredibly restrictive at that time. It was just more this fascination with food and how I could learn to control it.

My eating disorder really came out during college. And so I would say starting freshman year, I was away from home. I had full control over my food and exercise choices. And it was really at that time where I began to restrict food to a level that just was not okay. Particularly given the amount of exercise I was engaging in because of being on the women's rowing team. For me, fad diets were a big issue. And when I say fad diets, particularly Whole30 and Paleo were things that I really latched onto and believed in. And those really contributed to my first entry into really restrictive diets and orthorexic behaviors.

Ellie Pike:
So how did you start to notice that affecting you physically and mentally?

Traci Carson:
I really isolated myself a lot of times when it came to being invited to go out to dinner or eating lunch out with friends, it was always a big stressor. And I always wrote it off as, "Well, I'm an athlete. So I have to stick to a certain diet and I have to uphold these food values and rules that I've created for myself." But upon reflection of that time, I can really see how my eating style, my eating behaviors were just really problematic and limited my ability to engage with friends and family when it came to food.

Ellie Pike:
Rather than noticing Traci's decline, coaches and other authority figures praised her for her dedication, prompting her to adopt disordered eating as part of her identity.

Traci Carson:
I'm a very competitive person by nature, which shouldn't shock you, I'm sure, as a female athlete. But it almost became that I had to uphold these restrictive behaviors I was having. So it was a point of pride if I could be the only one who didn't reach for that cookie at the table or the one who would order a salad instead of something else at dinner. Because I held that as part of my identity, that very disciplined girl. And that carried over into pretty much every part of my life. I really saw how that contributed to both my eating just disorder and disordered eating behaviors, but also spills over into other parts of who I am.

Ellie Pike:
So at what point, Traci, did anyone start to notice that your habits were starting to change your wellbeing?

Traci Carson:
I truly think that my older brother Ross was a really big part of me starting to recognize that how I was treating my body wasn't healthy. Ross has always been a huge part of my recovery journey. He's a fourth year medical student and so I think just having the ability to know me really well, we were always really close through college and he would just say things to me out of a place of love and care that started to build up over time. And I knew that he had my best interests at heart and that he wouldn't have been telling me that I needed to work on some of these behaviors unless he truly meant it and saw it.

Ellie Pike:
You know, I think a lot of people who listen to this podcast are those support people. And they're trying to get some guidance on, "How do I approach someone who has restrictive eating behaviors or just unhealthy eating behaviors? How do I approach them without them pushing me away or feeling attacked?" So was there anything specifically that Ross did that was really helpful in that confrontation where it allowed you to be more receptive to his feedback?

Traci Carson:
Yeah, I truly think that making sure you tell that person you're concerned about that you love them and this is coming from a place of just wanting them to be as healthy and happy as possible and it's in no way a judgment of them. I think that's a great starting point. I also think that it's important to be okay with knowing that what you say to somebody, it may not be enough at that time, but I like to think of it as like a domino effect, because that's how I thought it worked in my experience.

Ellie Pike:
Those dominoes began tipping over and led Traci to a major turning point during a routine physical exam.

Traci Carson:
I ended up going in for my annual physical and they took some routine blood work and I was called the next day and told that my estrogen levels were nearly menopausal. And so that really terrified me. And so a little bit of background on estrogen. Estrogen is so important for our reproductive system as women, also for lots of different functions, but in female athletes particularly maintaining and preserving bone health and bone strength. I guess for me, it took seeing those numbers, so those blood test results, to really validate my experience and I could no longer deny that what was going on in my life was okay anymore that my eating and exercise routine and behaviors were serving me in a, any positive way.

Ellie Pike:
And were you able to find exactly what you needed as far as treatment and care immediately or did it take some time to piece it together?

Traci Carson:
I ultimately ended up finding an amazing therapist who I still see today. I first really pushed back against going to therapy, seeing a nutritionist. Actually my therapist recommended a nutritionist. She's been really helpful in not only helping me recognize how much fuel my body really needs and bring back some rational thought to what I actually need to thrive and for my body to be functioning properly, but also she's really empathetic and compass. And so she really understands and is there to listen to the eating disorder thoughts and why it's challenging for me and has been for many years to change the way that I eat and exercise.

Ellie Pike:
I think that you're talking about something that's really easy to talk about in retrospect, but in those moments of starting therapy, going to see a dietician, changing your whole way of thinking around food and your body, I know that it must have been really hard. Can you talk about just a little bit of the obstacles that you overcame?

Traci Carson:
I would say the biggest struggles for me were getting over those really rigid behaviors that I had relied on for so many years or that my eating disorder demanded of me for so many years. So things like weighing and counting all the food that I ate was something that had just become so habitual to me. And so getting rid of the food scale, also getting rid of my body weight scale, those are things that were really challenging, but I actually felt so much better once those mechanisms were just gone from my daily routine. Another thing that was so challenging for me was cutting down the amount of workouts I was doing.

So I went from even a couple years ago I was still working out maybe twice a day three to four times a week, taking maybe one rest day at most. And changing that was huge for me. And I was able to just regain back so much of my life and energy, both my emotional energy and physical energy. I had relied on exercise to numb a lot of my emotions for so many years. And so removing that mechanism was really, really challenging. But moments like those are when I was so thankful to have the support systems that I have in my life, that being my family, but also the therapists and nutritionists that have really helped me so much over the last couple of years.

Something I always like to touch on, I think particularly in the athlete population is that body size and body weight is not enough to indicate that somebody may be struggling. So you can have a very... I'm saying this in air quotes, quote-unquote, "normal" body weight, or seemingly normal body size and your body can still be under severe physiological stress due to not eating enough or to over training, not recovering enough. And so I think as a community, we need to work together to recognize that eating disorders do not look a singular way, and validate the experiences of women and men who may look, quote-unquote, "healthy", but are really struggling.

Ellie Pike:
Yes. And did you ever have anyone say like, "Oh, it's normal for you to lose your period. You're an athlete."?

Traci Carson:
Oh my goodness. Yes. So I haven't touched on this yet, but amenorrhea is part of the female athlete triad that I studied, but amenorrhea was my experience for about eight years. And so I had several doctors right from the start tell me, "Oh, you're just very athletic. You're involved in sports so it's normal to lose your period. It's okay to lose your period." And it's really not okay. And I really truly believe that to my core. The menstrual cycle is a vital sign of the body functioning properly and thriving. It's a sign that our hormones are balanced and our hormones are where they need to be to be at our optimal health. And so I think that it's so important to break that myth and that taboo, that losing your period as an athlete is okay. It's not okay.

Ellie Pike:
Can you tell us a little bit about how your story has informed what you're doing now?

Traci Carson:
I never, never thought I would be in the field of epidemiology. I grew up and science was not my specialty. I never was very interested in it. And now I have found myself getting a PhD in the science of public health. I really came to this place due to personal experience and really inspired by the experiences that I had, but also experiences that my teammates and friends went through. And epidemiology just was ultimately the best fit to allow me to pursue the research questions that I had in novel ways. I love the hard skills that epidemiology brings, so the analysis and statistical skills that we gain in this program, but also having a masters in more health behavior and health theory has also been great as I work towards my research goals.

Ellie Pike:
So your main research right now is on women runners, is that correct?

Traci Carson:
Yes. I started off my dissertation research with interviews with NCAA Division I distance runners. All of these women screened into my study being at risk of an eating disorder or already experiencing outcomes of the female athlete triad. So already exhibiting bone stress fractures, or menstrual disturbance. And so I completed 30 qualitative one-on-one interviews with these women. And my goal with that research was really to understand the culture in distance running around body image and diet eating practices, and to ultimately understand how these women came to the being in this state of restricting their food, over training, what were the environmental factors that led them to engaging in those behaviors? And so that research was probably my most ideal way to spend a summer. I just got to sit down with these incredible athletes and hear about their life stories and it was so fulfilling, and I'm just lucky to be in the place where I can work with these women, capture their experiences and give back to them throughout this research process.

Ellie Pike:
Before diving into Traci's research, I'd like to introduce you to Dr. Kendrin Sonneville.

Dr. Kendrin Sonneville:
My name is Kendrin Sonneville. I'm an assistant professor in the Department of Nutritional Sciences is at the University of Michigan. I'm a dietician by training, but do mostly research now focused on the prevention of eating disorders.

Ellie Pike:
She's one of Traci's academic mentors and also created the lab that Traci collaborates with on projects about eating disorder prevention.

Dr. Kendrin Sonneville:
The work we do on our lab is really wide ranging because there's so much that actually falls under the umbrella of eating disorders prevention. Some of our work is focused on epidemiology, which is really understanding who has eating disorders on a population level, who is not getting treated for those eating disorders, what might be causing the onset of eating disorders in those particular populations. And then we do some intervention work to understand how we can intervene in groups of people that may be at high risk to reduce their risk from ever developing disordered eating or full syndrome eating disorders.

Ellie Pike:
And what are you noticing can cause someone to be at higher risk, especially among female athletes?

Dr. Kendrin Sonneville:
Athletes are a really unique example because messages about thinness are also linked to sports performance and athletic identity. And for athletes, sometimes it's message just about thinness, like we see the in media, but it can also be about physique and other elements of body weight and shape control. And it's messages that link the importance of having a particular body type to excellence in a sport that can put athletes at a particularly high risk.

Ellie Pike:
You bring up such a good point. And so I'm curious what would differentiate an athlete with disordered eating versus a full blown eating disorder?

Dr. Kendrin Sonneville:
Yeah, so disordered eating and eating disorders involve the same constellation of symptoms or behaviors. And everyone that has either disordered eating or eating disorders has their own combination of those symptoms. So it could include severe body image concerns or body dissatisfaction. It could be using extreme behaviors to control weight. And for one person it could be rigid dieting or dietary restriction. For another person, it could be using laxatives or diet pills or vomiting to control weight. With athletes, there's also the added risk of performance enhancing products or products that are designed to control weight or shape that can also be another disordered eating behavior. And then they are behaviors like binge eating that are part of many people's disordered eating or eating disorder presentations.

And what differentiates the people between disordered eating and eating disorders is a fairly rigid set of criteria. In order to have a diagnosis of a full syndrome eating disorder, you need to have a certain combination of symptoms for a certain amount of time in order to, quote-unquote, "count" as having an eating disorder. And I think the line between these two presentations, disordered eating and eating disorders is rather gray. And I think sometimes there's a real risk at saying that you have these symptoms, but they're not bad enough to warrant treatment or to warrant us being concerned. Because the vast majority, or many people who have disordered eating, go on to develop eating disorders and many people who have disordered eating and don't actually meet criteria for these full syndrome disorders still suffer many long-term complications. So there's a risk of us framing them as being less severe, because in fact, for many people they are significant source of suffering and are actually quite severe.

The other distinction we make is that we do a better job of referring people to treatment when they meet criteria for full syndrome eating disorders. And folks with disordered eating are left to figure it out on their own. And so again, there's this message that there's nothing you can do or perhaps you should not be that worried about it. So again, it's a bit of a false distinction, but for everyone I think disordered eating or eating disorders really exist on the continuum. And the constellation of behaviors is really individualized, it really differs between people.

Ellie Pike:
What kind of help is out there for an athlete who's dealing with rigid eating, maybe they're not experiencing weight loss or electrolyte imbalance, but they're still experiencing some sort of disordered eating?

Dr. Kendrin Sonneville:
Yes, so the first line treatment for disordered eating or eating disorders is therapy, because sometimes eating disorders are only referred to medical providers, and bodies are shockingly resilient in the short term to disordered eating. So what I mean by that is people can be doing really extreme things to control their weight, they can lose a lot of weight or be already low weighted, and they still will look fairly healthy on a medical exam. Their electrolytes will often look normal. Their blood pressure will often look normal. And I think when we assume that a medical clearance is the only clearance we need to be thinking about, we really are missing the boat and, again, missing this idea that people need treatment. So it's really important that particularly coaches and teams are encouraging that people who are struggling are reaching out to mental health professionals to provide treatment for the behaviors. Because even if in the short term they're not suffering performance consequences or these medical consequences, these consequences do catch up with people. And performance ultimately suffers and mental health is certainly suffering the whole time.

Ellie Pike:
Thank you. You and I would even add to that to make sure that that mental health provider is specialized in eating disorders, because that can make a big difference in their treatment. Even though Traci's research has yet to conclude, she's already started to notice themes that help illuminate why athletes are especially susceptible to disordered eating.

Traci Carson:
My preliminary results have revealed that there were four key themes so far that we've seen in the data from these women. The first theme that a lot of women mentioned was wanting to have this ideal, quote-unquote, "runner body", and how they just didn't feel that they had this ideal body to type to be a runner. I asked a lot of women, "What is this ideal? What are you striving for?" And they all described very tall, lean women who have muscles, but they're not too muscular. And so that seemed to be really present in the minds of these women is not only achieving very high performance outcomes, but also having a body to match that performance.

And the next theme that we really saw was a power dynamic on the team. So this dynamic where college coaches seem to be commenting a lot about women's bodies, about the foods that they should be eating or should not be eating. That also was a factor that seemed to contribute to a lot of women engaging in dieting behaviors, trying to lose weight to please their coaches and to meet the standards that their coaches were putting out to the team.

Ellie Pike:
So what is your goal with this research? I know you're still working on it.

Traci Carson:
I have probably two more years left in my PhD program. So my next step will be to finish analyzing these data and then I'm going to be launching a survey component, so hoping to reach a lot more women through surveys. And these will all be NCAA runners of Divisions I, II and III. So trying to understand the experience across divisions. With that data, I am hoping to better understand the outcomes that runners face when it comes to both psychological and physical health and understanding the risk factors in their environment that lead to those negative health outcomes. And so ultimately hoping to inform prevention intervention efforts in this population of female runners, but also female athletes more broadly.

Ellie Pike:
Awesome. That's so wonderful you're doing this work. I'm curious if you've noticed any specific diet trends that are problematic within runners that different than other sports?

Traci Carson:
Yeah, that's an interesting question. So from the work I did this summer, there didn't seem to be a particular fad diet these women were following or that they had teammates that were following. Just keep in mind, that was only 30 women, but it just seemed to be this broader energy restriction mentality. Several women would say, "Oh, I don't eat dessert. I try to eat less sugar." But that was really the most common thing that I heard from the interviews I completed this summer.

Ellie Pike:
And did any of them exhibit over exercise?

Traci Carson:
I think in this specific population, because they are on collegiate teams where they have coaches prescribing their workouts, the issue with the ultimate health outcomes in these women pertained more to the energy balance or energy availability. And so by that I mean the combination of not eating enough mixed with really high training demands of their sport, that was more problematic than over training alone.

Ellie Pike:
Yeah and I don't know if you know anything about this, but I remember reading at one point that someone with restrictive eating and over exercise can cause one of the most dangerous and lethal eating disorders. Do you know anything about that?

Traci Carson:
So in the female athlete trial literature that's what we know is the fundamental cause of menstrual disturbance and then those bone health outcomes that I mentioned earlier via hormonal disruption. So that mismatch, again, really can mess with our hormones, especially as women, and impact our health in really negative ways, both our physical and psychological health.

Ellie Pike:
Well, thank you so much for bringing your expertise into this podcast. And we're looking forward to seeing where this research goes. To close this out, I want to bring back Kendrin to explain what options are out there for athletes dealing with eating disorder behavior.

Dr. Kendrin Sonneville:
The first line treatment for disorder eating or eating disorders is therapy, is psychotherapy. And there are different types of evidence based approaches that have been found to be effective for either eating disorders or disordered eating, types of therapeutic approaches that are used for other mental health issues. Things like cognitive behavioral therapy, CBT, or DBT, or there's lots of different therapies. But I think it's connecting to a mental health provider. Because sometimes eating disorders are only referred to medical providers and bodies are shockingly resilient in the short term to disordered eating. So what I mean by that is people can be doing really extreme things to control their weight, they can lose a lot of weight or be already low weighted, and they still will look fairly healthy on a medical exam. Their electrolytes will often look normal. Their blood pressure will often look normal.

And I think when we assume that a medical clearance is the only clearance we need to be thinking about, we really are missing the boat and, again, missing this idea that people need treatment. So it's really important that particularly coaches and teams are encouraging that people who are struggling are reaching out to mental health professionals to provide treatment for the behaviors. Because even if in the short term they're not suffering performance consequences or these medical consequences, these consequences do catch up with people. And performance ultimately suffers and mental health is certainly suffering the whole time.

Ellie Pike:
I think my biggest takeaway from Traci and Kendrin's work is that health feels good. It's not strict denial, deep exhaustion or striving for an ideal you see in someone else's body. Instead, it's about an investigating what strength, speed, and prowess look like in our own bodies. Our arms, legs, torsos and brains are incredible. So let's not allow coaches, influencers or fad diets to make us question how beautiful and capable we really are.

Mental Note Podcast is sponsored by Eating Recovery Center and Insight Behavioral Health Centers. To talk to a licensed therapist and see if treatment is a good idea for you, call 877- 411-9578. To learn more about Traci and Kendrin's research, check out Instagram of all places. Traci is @traci_carson and University of Michigan Public health is @umichsph. We'll link to both in the show notes. This episode was produced by Sam Pike, with editing by Josh Wright, Erica Prather and Sam Pike. I'm Ellie Pike. Until next time.

Presented by

Ellie Pike, MA, LPC

Ellie Pike is the Sr. Manager of Alumni/Family/Community Outreach at ERC & Pathlight Behavioral Health Centers. Over the years, she creatively combined her passions for clinical work with…

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