Thin at Any Cost

The restriction of food that accompanies the struggle to be perfectly thin creates health problems for casual exercisers and competitors alike. It can greatly reduce the intake of vitamins, minerals, protein, and carbohydrate, placing the athlete at risk of poor nutrition status. Food restrictions can also lead to health problems such as chronic fatigue, compromised immune function, poor or delayed healing, anemia, electrolyte imbalance, menstrual dysfunction, reduced bone density, and a four times higher risk of stress fracture (ACSM 2007).

I counsel many people with eating disorders and disordered eating; they fill the majority of my counseling hours. They come in believing that if only they were thinner, they'd be better athletes (and their overall lives would be better). I disagree. Their efforts to achieve their desired thinness reduce their energy and performance. They would be better athletes if they fed themselves better. Such was the case with Gretchen, an avid cyclist. She came to me complaining about her inability to lose 5 pounds (2.3 kilograms): "If only I could shed this extra fat, I'd be so much faster climbing hills." She was severely restricting her food intake. I pointed out how few calories she was eating compared with what her body required. Once she started to eat adequately, she discovered she could keep up with the other cyclists. Food works!

The following case studies are typical of the clients I treat. They may sound familiar and might help those of you who constantly struggle with food and exercise.

The Stair-Stepper Mistress

Alicia, a 41-year-old teacher, had never been concerned about her weight and had never dieted until her 39 th birthday. But in the past two years, she had gained a few pounds because of the stress of a new job. Not liking the extra weight, she decided to join a health club. She forced herself through 60 minutes of stair stepping every morning before school, ate very little during the day, but would then devour any food in sight on arriving home from work. "I feel so guilty about the boxes of crackers, pretzels, and cookies I devour. After a binge, I won't eat dinner. Instead, I'll go back to the health club to burn off the excess calories. I'm exhausted all the time. I'm doing a poor job of teaching. I get easily irritated and feel like yelling at the students. I'm frustrated that I'm unable to do something as simple as lose a few pounds. I can't even eat normally now. I either starve or binge. I don't know if I should be seeing you or a therapist."

To help Alicia balance her food and exercise goals and to normalize her disordered eating patterns, I measured her percent body fat (a lean 18 percent) and calculated how many calories her body required each day. She needed about 1,200 calories for her resting metabolic rate, 600 calories for moderate daily activity, and 500 calories for purposeful exercise, adding up to about 2,300 total calories per day. Then I devised a meal plan to stabilize her eating.

Like many of my clients, she dieted too hard and unrealistically restricted her calories. She would burn off 500 calories at the health club but would not eat anything until lunch, when she limited herself to 250 calories of a frozen meal. No wonder she felt starved and stuffed herself with food the minute she arrived home after school. I advised her to stop dieting, start eating breakfast and lunch, and eat reasonably at night. She changed her habits and stopped binge eating after school.

Alicia followed my recommendations to eat 2,300 calories, divided into four even-sized meals: breakfast, first lunch, second lunch (after school), and dinner. When she returned two weeks later she reported with a big smile, "When I get home after school, I no longer act like a maniac in the kitchen, eating whatever I can get my hands on. I feel so much better and am even losing a little weight because I'm not binge eating. Having a substantial breakfast and lunch helps me feel better and gives me enough energy to have fun with my students. I'm less irritable—back to my old happy self. And, most important, I'm back in control of my food."

Alicia normalized her eating by stopping her dieting and starting to eat appropriate meals at breakfast and lunch. She simply needed a better food plan to correct her food binges, which stemmed from extreme hunger, not from an eating disorder. She'd thought that dieting would help her lose weight, but instead she learned that normal, healthful eating is really the better path to weight management.

The Exercise Addict

Bill, a regional sales manager for a computer company, was addicted to exercise. He'd get up at 5:15 a.m. and arrive at the front door of the health club when it opened at 6:00. He'd do a stationary cycling class from 6:00 to 7:00 and then lift weights from 7:00 to 8:00. At lunchtime, he'd do a step-aerobics class at his company's fitness facility. After work he'd swim laps for an hour at his local YMCA. Because he exercised at three different locations, few people knew how much time he spent exercising, except his wife and family. They constantly complained that he was never home.

Holidays brought even more complaints. "Why do you have to exercise on Christmas morning?" his eight-year-old daughter complained when Bill announced that he was going for his two-hour Merry Christmas run, his present to himself. His family knew he would be incredibly irritable if he didn't run, so they waited patiently for his return before opening gifts.

Without question, Bill was addicted to exercise. He'd feel irritable, anxious, guilty, and depressed if he was unable to do at least four hours of exercise a day. He needed to do increasingly more exercise to achieve the same physical and emotional highs. He'd exercise even when injured or sick. He had little energy for the rest of his life and was fearful that he would lose his job because of a steady decline in his work performance.

Bill's ability to exercise came to a halt when he experienced debilitating back pain. He could barely walk without severe anguish. While seeing the back doctor, he admitted he needed help. "I can no longer exercise the way I'd like to, and I'm petrified of getting fat. I'm trying not to eat because I cannot exercise, but I end up sneaking food—and stealing my daughter's M&M's." The doctor insisted that Bill make an appointment with me. To my eyes, Bill had a long way to go before anyone would consider him fat. He was 5 feet, 10 inches (178 centimeters) and weighed 130 pounds (59 kilograms), but I listened to his fears. I reminded him that people in the hospital do little or no exercise, and they still eat and don't get fat; in fact, they often lose weight.

I worked with Bill on normalizing his eating and exercise practices, suggested some reading material (such as Hooked on Exercise by Rebecca Prussin), and convinced him that meeting with a counselor would help keep his life from falling apart. With a doctor, therapist, and nutritionist on his treatment team, as well as a family therapist and the love of his wife and children, he evolved into a happier person. He learned to communicate his wants and needs so that he no longer felt the desire to run away from his problems. He came to understand that his underlying belief that he wasn't good enough was a misperception. He came to like and accept himself as the truly loving person he wanted to be.

How Much exercise Is enough?

Exercise should be a way to train and improve athletic performance, not a means of purging calories. If you are an exercise bulimic who spends too much time working out, note these recommendations from the 2005 Dietary Guidelines for Americans (www.health.gov/dietaryguidelines) as well as from the American Heart Association (Mosca et al. 2007).

For health, fitness, and reducing the risk of disease, adults should participate in the following most days of the week:

  • A minimum of 30 minutes of moderate activity to prevent chronic disease
  • 60 minutes of moderate-to-hard activity to manage body weight and prevent gradual weight gain in adulthood
  • For people who have been obese, 60 to 90 minutes to keep from regaining lost weight

If you are an athlete training for a sport, you might spend more time than this. But consider getting help if you are a compulsive exerciser whose motivation is to burn off calories.

The Marathon Runner With Bulimia

Carol, a 29-year-old graduate student, had gained 12 pounds (5.4 kilograms) in the two years since she had started studying for her MBA. She tended to overeat when schoolwork became overwhelming and she felt as if she couldn't do all that was expected of her. "I binge at night and then vomit and go for a long run. I'm exhausted all the time and think of little else other than what, when, and how I'll binge. I've stopped socializing with my friends at mealtimes because I'm afraid I'll overeat and be unable to purge. Instead, I spend my time studying and training for a marathon. I'm hoping the added exercise will contribute to weight loss. But I'm a foodaholic. When I finish my run, I inevitably end up at the corner store, where I buy at least two big muffins and heaven only knows what else. I just can't seem to control my food intake."

After listening to Carol's story, I recognized that she seemed addicted not only to food but also to schoolwork and exercise. She constantly pushed herself to meet self-imposed deadlines, weight goals, and exercise demands. She always felt stressed and overextended. She lacked healthy balance in her life.

I asked if anyone in Carol's family had trouble with alcohol. She quietly admitted that her mother was an alcoholic. She seemed ashamed of this family secret. At least one-third of my clients with eating disorders grew up in families with some type of dysfunction, most commonly related to alcohol. The clients themselves may not be addicted to alcohol, but some are recovering alcoholics or drug abusers (Varner 1995). Alternatively, they express other addictive behaviors through overworking, overeating, overachieving, and overexercising. The traits and attitudes outlined in table 16.1 are characteristic of people who grew up in an alcoholic or otherwise dysfunctional family.

Table 16.1 Red-Flag Traits

Characteristic trait

Drive for perfection Desire for control Compulsive behavior

Feelings of inadequacy Difficulty having fun

Trouble with relationships

Common expression of trait

"I've exercised for an hour every day for the past 2 years" "I never eat after 7:00 p.m."

"I work out for 2 hours every day, even if I have to get up at 4:00 a.m."

"I could have biked even faster if I'd lost more weight"

"Thanks for inviting me to the movie. I'll pass-I have to do my workout at the gym"

"My spouse complains that I spend too much time exercising and not enough time with my family"

Carol displayed all these traits. She had a strong drive to be perfect and a desire for control. Since childhood she had tried to be perfect to compensate for her family's problems. Now, she was trying to eat the perfect diet, achieve the perfect weight, develop the perfect career, and maintain the perfect training schedule. She ran 10 miles (16 kilometers) every day, despite blizzards, illness, or fatigue. She lived on calorie-free coffee, diet soda, and fat-free foods, until ravenous hunger overwhelmed her good intentions. After a binge, she'd vomit to bring a feeling of control back to her life and compensate for her imperfect eating.

I helped Carol get a better perspective on an appropriate weight by measuring her percent body fat. By designing a meal plan, I helped her eat an appropriate diet. A referral to a coach at the local running club allowed her to train with an appropriate program. I also advised her to read some books about adult children of alcoholics (see appendix A), seek guidance from a suitable counselor, and perhaps join a support group such as Al-Anon or ACoA (Adult Children of Alcoholics).

"For the past two years, I have tried to avoid food, thinking it was fattening," she wrote in a follow-up letter. "I've come to learn that food wasn't the problem. My inability to handle stress was the problem. I'm now gentler on myself. I no longer strive to be the perfect student. For example, I took three days off from both school and running when I went on a ski weekend with my friends! I'm eating well and exercising healthfully rather than punishing myself with megamiles to burn off calories. I feel better and am at peace with myself and my body."

The Figure Skater With Anorexia

Emily, a 16-year-old student at a highly competitive figure skating program, was sent to me by her coach. Emily's mother made the appointment for her. Because she was chronically tired, Emily was compromising her ability to jump high and skate hard. Emily's first words to me were, "My coach and mother made me come here. They think I don't eat enough."

Emily weighed 92 pounds (42 kilograms). A year ago, she had weighed 110 pounds (50 kilograms), and at 5 feet, 3 inches (160 centimeters), she could have appropriately weighed 115 pounds (52 kilograms). She was limiting herself to 1,000 calories per day but required about 1,800 calories, if not more. Because she was eating so little food, she was consuming inadequate amounts of protein, calcium, iron, zinc, and numerous other vitamins and minerals that her body needed to be healthy.

Emily was so afraid that she'd get fat if she were to eat more, I had to constantly remind her that food is fuel and health. She was currently unhealthy. She had stopped menstruating (one sign of poor health), and her complexion was splotchy and grayish (a second sign). Emily needed to eat a wider variety of food than cottage cheese, egg whites, and apples to balance her diet and provide the nutrients in which she was deficient. She also needed to include more dietary fat.

I reminded Emily that she deserved to eat, even if she was not exercising. I asked her to take notice of all her friends who were nonexercisers. All ate, and most were lean. Eating more would not provide excess calories but fundamental fuel. We agreed on the following goals for a food plan that would optimize her health:

  • Fuel her body appropriately by gradually increasing calories at meals and snacks.
  • Rebuild her body to an appropriate weight to optimize her strength and health.
  • Reduce the risk of stress fractures and future osteoporosis by eating enough to support regular menstrual periods.
  • Attain peace with food and weight.

Emily agreed to increase her intake gradually, by 100 calories per week, adding more food at breakfast and lunch until she ate three 500-calorie meals that included at least three or four kinds of foods (such as cereal, milk, and fruit; pita bread, turkey, and yogurt; fish, rice, broccoli, and milk) as well as a snack with food from two food groups. These dietary improvements would help her have more energy to concentrate better at school and skate with enthusiasm. I suggested that she practice eating more healthfully, just as she practiced her skating, and that she focus on how much better she felt when she fueled herself better.

Over the course of weeks, Emily stopped rigidly controlling her food and started to eat more appropriately. My nutrition advice had provided helpful guidelines, but a key factor in her recovery was counseling. A psychologist skilled in handling eating disorders counseled her, as did a family therapist who met with Emily and her parents and sister. By communicating and resolving many of the family's issues, Emily was able to express her needs rather than withhold words and use food restriction to starve her feelings and be her silent cry for help.

Within three months, Emily started to menstruate, a good sign that she was adequately nourishing her body. She was feeling physically stronger, was happier with her family, and felt at peace with food and her body. She no longer felt that she had to be perfect to earn her parents' love, nor did she need to be perfectly thin, eat the perfect diet, and be the perfect student and figure skater. She learned to enjoy being human, like the rest of her family and friends. She let go of her fantasy that a perfect body would bring a perfect life. "I thought I'd be happier once I was thinner, but I was wrong. I've learned that happiness comes from loving myself from the inside out, not from the outside in."

Athletes and Amenorrhea

Athletes with eating disorders commonly stop menstruating (amenorrhea). Athletes without eating disorders can also stop menstruating. This can happen, for example, if a woman steps up her exercise program without boosting her calorie intake. In either case, if you are an athlete who previously had regular menstrual periods but have stopped menstruating, don't ignore it. Although you may think amenorrhea is desirable because you no longer have to deal with the hassles of monthly menstrual periods, amenorrhea can lead to problems that interfere with your health and ability to perform your best. These problems include the following:

  • A four-times-higher incidence of stress fractures that put you on the sidelines (Nativ 2000)
  • Premature osteoporosis that can affect your bone health in the not-too-distant future
  • An inability to conceive easily should you want to start a family

Amenorrhea Is Complex

If you believe you miss periods only because you are too thin and are exercising too much, you may be wrong. Studies have shown no body-fat differences between athletic women who menstruate regularly and those who don't (Sanborn et al. 2000). Many very thin athletes do have regular menses. Clearly, leanness and intense exercise are not the simple explanation to the complexities of amenorrhea.

But the question remains unanswered: Why are you amenorrheic when your peers, who have similar exercise programs and the same low percent body fat, are not? You are likely eating inadequate calories to support your training program and are experiencing nutritional amenorrhea.

Resolving the Problem

Current research suggests that amenorrhea is not caused by exercising too much, but by eating too little food. To resume menses, you need to eat enough calories to support not only your exercise program but also your body's ability to reproduce. To be able to menstruate, your body requires at least 13.5 calories per pound (30 calories per kilogram) of lean body mass (weight without any body fat) (Loucks 2004). By comparison, the average (nonathletic) woman maintains energy balance at about 20.5 calories per pound (45 calories per kilogram) of lean body mass.

An athletic woman who weighs 120 pounds and has 20 percent body fat, for example, has a lean body mass of 96 pounds (20% X 120 lb = 24 lb fat, which means she has 96 lb LBM). She needs to eat at least 1,300 calories (13.5 cal/lb X 96 lb LBM = 1,300 cal) that are not burned off, that are "available energy." If she burns 500 calories in exercise, she needs to consume at least 1,300 + 500 = 1,800 calories; this is still far too little to fully fuel her muscles and enjoy optimal performance.

A registered dietitian or sports nutritionist can help you improve your patterns of skimpy eating—a task that for some women is easier said than done. The following tips may also be of help:

  1. Throw away the bathroom scale. Rather than strive to achieve a certain number on the scale, let your body weigh what it weighs. Rather than exert willpower to achieve a desired weight, let your body acquire its genetic weight. The information in chapters 13 and 15 can help you estimate a weight you can comfortably maintain without constantly dieting. Your physician or dietitian can also offer unbiased professional advice.
  2. Don't restrict calories by more than 20 percent. If you have weight to lose, do not eat less than 1,200 calories (Woolsey 2001) per day or, more precisely, no less than 13.5 calories per pound of lean body mass (Loucks and Thuma 2003). By following a healthy reducing program, you'll not only have greater success with long-term weight loss but also have enough energy to enjoy participating and improving in your sports program.
  3. Practice eating as you did when you were a child. If you are at an appropriate weight, focus on eating when you are hungry and stopping when you are content. If you are always hungry and constantly obsessing about food, you are undoubtedly trying to eat too few calories. Your body is complaining and requesting more food; hunger is simply a request for fuel. The information in chapter 15, plus advice from your doctor and dietitian, can help you determine an appropriate calorie intake.

Amenorrheic women commonly eat in nontraditional ways, with chaotic eating patterns (Wilmore et al. 1992). They may eat little at breakfast and lunch, only to overeat at night, or they restrict themselves on Monday through Thursday and then overeat on the weekends. If your weight is stable, you have somehow consumed the number of calories you need, so you might as well eat them on a regular schedule of wholesome, well-balanced meals. A registered dietitian can help you develop an appropriate food plan if you are struggling on your own.

  1. Eat adequate protein. In one study, 82 percent of the women with amenorrhea ate less than the recommended intake for protein (Nelson et al. 1986). Vegetarians, in particular, need to be sure to get adequate protein. Vegetarian women who consume adequate protein and calories tend to have regular menstrual periods (Barr 1999).
  2. Eat at least 20 percent of your calories from fat. Some fat is absolutely essential for your health and well-being. Your body needs fat to build healthy cell membranes and to make hormonelike substances called prostaglandins. You want to boost your intake of good fat and carefully balance in the saturated ("bad") fat in red meats and other protein-rich foods. For most active women, eating 40 to 60 grams of fat per day would be an appropriate low-fat diet. This plan clearly allows salmon, peanut butter, nuts, olive oil, and other health-promoting fats, as well as smaller amounts of saturated fat as found in lean beef, low-fat cheese, and other nourishing foods that provide balance to a sports diet. If you just cannot bring yourself to add butter to bread or oil to salads, then o sprinkle sunflower seeds or slivered almonds on salads, o enjoy trail mix with nuts and raisins for snacks, o choose whole-wheat breads and cereals (they have more healthy fat),

° eat fatty fish twice a week, o use olive or canola oil for cooking, and o skip the fat-free products (they are devoid of taste).

6. Maintain a calcium-rich diet. If you are amenorrheic, you should regularly consume three or four 8-ounce (250 milliliter) servings of low-fat milk or yogurt (or other calcium-rich foods) daily to protect your bones. Your bones benefit from the protective effect of exercise, but exercise does not compensate for lack of calcium. Although you may cringe at the thought of spending 300 to 400 calories on dairy foods, remember that milk is a wholesome food that contains many important nutrients. Women who consume three or more glasses of milk or yogurt tend to be leaner than those who do not (Pereira et al. 2002). If you are eating a diet that includes lots of bran cereal, fruits, and vegetables, you may have an even higher need for calcium because the fiber may interfere with calcium absorption.

Many amenorrheic women worry about their bone health, and rightfully so. If the amenorrhea is associated with anorexia, you might be losing bone density at the rate of 2.5 percent a year (Miller et al. 2006). Multiply that by several years, and it's no wonder many of my clients have bones similar to those of 70-year-old women and problems with stress fractures. Teenagers, in particular, need to optimize their bone density because about 90 percent of bone density is gained by age 17. If you don't have dense bones as a teenager, you may never reach your peak bone mass and will have a higher risk of osteoporosis in later life (Weaver 2002). You can recover much of the bone loss by eating well enough to rebuild muscles and gain weight, but not always all of it (Dominguez et al. 2007). A case study of a 31-year-old distance runner indicates she was able to bring her bone mineral density back to within normal values by eating better and rebuilding her body, despite a long history of anorexia and amenorrhea (Fredericson and Kent 2005). Not everyone is as lucky.

Many amenorrheic athletes have been advised to take the birth control pill to resume menses, and theoretically, this would help prevent bone loss. Research does not support that theory. Eating adequate calories to negate an "energy drain" and rebuilding muscles is the key to reversing bone loss. Adequate calories include adequate carbohydrate to replace depleted glycogen stores, adequate protein to build muscles, and enough fuel to maintain energy balance (Zanker and Cooke 2004; Nativ 2007).

Although female athletes fear that eating more and exercising less will hurt their performance, this is not the case. A 19-year-old amenorrheic runner reduced her training by one day per week, increased her daily food intake with one can of a 360-calorie liquid meal supplement, gained 6 pounds (2.7 kilograms) over about four months (from 106 to 112 pounds, or from 48 to 51 kilograms), and resumed menstruation. She set more personal records than she did during any prior season, broke two school records, and qualified for a national track meet (Dueck et al. 1996). What are you waiting for?

How to Help

Perhaps you have friends, family, or teammates who struggle with food, and you wonder what you can do to help resolve the problem. Seeing a healing Mantras and Affirmations

If you are determined to start eating better, you might find the task easier said than done. Here are some mantras that have helped my clients as they strive to fuel their bodies appropriately:

  • My body is hungry; that means it has burned off what I fed it, and it now needs more fuel. Hunger is simply a request for fuel.
  • This food is fundamental, not "extra," not "fattening."
  • One meal is not going to change my life forever.
  • Let me be more flexible. I can always go back to my old ways, if I need to.
  • My body is stronger when I fuel better, and I become a better athlete.
  • I don't need to have a perfect diet to have a good diet.
  • I can be human, not perfect.
  • Starving my body will not solve my problems.
  • Being happy and healthy is more important than any number on the scale.
  • I have a choice: Do I want to be a person with anorexia or a well-fueled athlete?
  • Everything will work out OK. I just need to keep focused on the big picture—I need to be healthy.

loved one seemingly waste away can be sad and scary. Often it's hard to tell if the person is really struggling or just being a dedicated athlete. Even health professionals can have trouble distinguishing between the person who is lean and mean and the one who is battling anorexia.

An athlete with anorexia is generally a compulsive exerciser who trains frantically—out of fear of gaining weight—and never takes rest days. In comparison, a dedicated athlete trains hard with hopes of improving performance but also enjoys days with no exercise. Both push themselves to perfection—to be perfectly thin or to be the perfect athlete. Sometimes the two intertwine. Unfortunately, too many coaches, parents, friends, and teammates fail to confront the devastating stressfulness of this struggle for ultimate thinness. After all, how can anyone who is training hard and seems happy be sick?

If you suspect that your friend, training partner, child, or teammate has a problem with food, don't wait until medical problems prove you right. Speak up in an appropriate manner. Anorexia and bulimia are life-

threatening conditions that shouldn't be overlooked. Here are 10 tips for approaching this delicate subject.

1. Heed the signs. You may notice that people with anorexia wear bulky clothes to hide their abnormal thinness or that their food consumption is abnormally restrictive and sparse in comparison to the energy they expend. Runners with anorexia, for example, may eat only a yogurt for dinner after having completed a strenuous 10-mile (16 kilometer) workout. Perhaps you'll never see them eating in public, at home, or with friends. They find some excuse for not joining others at meals. Or if they do, they may push the food around on the plate to fool you into thinking they're eating. You may also notice other compulsive behaviors, such as excessive studying or working.

Bulimic behavior can be subtler. The athlete may eat a great deal of food and then rush to the bathroom. You may hear water running to cover up the sound of vomiting. The person may hide laxatives or even speak about a magic method of eating without gaining weight. She or he may have bloodshot eyes, swollen glands, and bruised fingers (from inducing vomiting).

2. Express your concern carefully. Approach these individuals gently but persistently, telling them you are worried about their health: "I'm concerned that your injuries are taking so long to heal." Talk about what you see: "I've noticed that you seem tired, and your race times are getting slower and slower." Give evidence for why you believe they are struggling to balance food and exercise, and ask if they want to talk about it.

Individuals who are truly anorexic or bulimic commonly deny the problem, insisting they're perfectly fine. Continue to share your concerns about their lack of concentration, light-headedness, or chronic fatigue. These health issues are more likely to be stepping-stones for the athlete to accept help, given that she or he undoubtedly clings to food and exercise as attempts to gain control and stability.

  1. Do not discuss weight or eating habits. The athlete takes great pride in being perfectly thin and may dismiss your concern as jealousy. Avoid any mention of starving and bingeing as the issue. Focus on life issues, not food issues.
  2. Suggest unhappiness as the reason for seeking help. Point out how anxious, tired, or irritable the athlete has been lately. Emphasize that he or she doesn't have to be that way.
  3. Be supportive, and listen sympathetically. Don't expect someone to admit right away that there's a problem. Give it time, and constantly remind your friend that you believe in him or her. Your support will make a difference in recovery.
  4. Offer a list of professional resources. If someone you know has a full-blown or subclinical eating disorder, you may feel frustrated about your unsuccessful efforts to resolve the problem. You may think, "If only my friend would eat normally, everything would be OK." Likely not. Food is just the symptom. The problem is this person is unhappy. To help you understand more about these underlying issues, you might want to read Surviving an Eating Disorder: A Survival Guide for Parents and Friends by Michelle Siegel, Judith Brisman, and Margot Weinshel. This helpful resource can teach you what to say to your friend.

Your job is to help your friend or loved one by taking her or him to get professional guidance. This might mean finding a registered dietitian in your area who specializes in sports nutrition and eating disorders. Remind your friend that no weight will ever be good enough to create happiness. Happiness comes from within, not from a number on the scale. And although the athlete may deny the problem to your face, she or he may admit despair at another moment. If you don't know of a mental-health counselor skilled in the treatment of eating disorders, the resources and national organizations listed in appendix A can help you find an expert where you live. You can also call your local sports medicine clinic and ask to speak to a physician or nutritionist, your university health center or eating disorders program, or your local medical center and ask to have an eating disorders assessment.

  1. Limit your expectations. You alone can't solve the problem. It's more complex than food and exercise; it's a life problem. Share your concerns with others. Seek help from a trusted family member, medical professional, or health service. Don't try to deal with the problem alone, especially if you are making no headway and the athlete is becoming more self-destructive.
  2. Recognize that you may be overreacting. Maybe there is no eating disorder. Maybe the athlete is appropriately thin for enhanced sports performance. But how can you decide? To clarify the situation, insist that he or she have a mental-health evaluation. If necessary, make the appointment, and take the athlete there yourself. Only then will you get an unbiased opinion of the degree of danger, if any. The therapist may tell you to go home and stop worrying, or the therapist might detect misery and suicidal tendencies in the athlete and encourage immediate care.
  3. Seek advice from health care professionals about your concerns.

You may need to discuss your feelings with someone. Remember that you are not responsible for the other person's health. You can only try to help. Your power comes from using guidance counselors, registered dietitians, medical professionals, or eating disorders clinics.

10. Be patient. Recognize that the healing process can be long and arduous, with many relapses and setbacks, but your reward will be that you can make a critical difference in that person's life. People die from anorexia and bulimia.

Preventing Eating Disorders

Many people think, or feel pressured to believe, that by restricting their food intake to lose weight they will exercise better, look better, and enhance their overall performances. Ironically, dieting precedes the onset of obesity, disordered eating, and eating disorders. Dieting is a risky behavior; it can result in depleted muscles, amenorrhea, stress fractures, fainting, weakness, fatigue, impaired performance, and sooner or later, disordered eating or eating disorders. Clearly, dieting is not a solution to weight issues.

Eating disorders would fade if people could learn to love their bodies and feel good about themselves. You might want to stop reading glamour magazines; they can make you feel worse about yourself to the extent that you end up exercising to punish yourself for how you look and buying cosmetics and hair products to "fix" yourself.

As a society, we must

  • dispel the myth that diets "work" and that thinness equates to happiness and success,
  • discourage the notion that the thinnest athlete is the best athlete,
  • love our bodies for what they are rather than hate them for what they are not,
  • emphasize being fit and healthy as more appropriate goals than being skinny, and
  • be careful about how we acknowledge weight loss.

When Your Friends Lose Weight, What Should You Say?

When someone has lost weight, the knee-jerk response is to exclaim, "Wow! You look great!" This praise is intended to be positive, but it implies that

  1. the dieter looked horrible before,
  2. physical size is more important than health, and
  3. the person is somehow better or more valuable because of the weight loss.

Be it 2 pounds or 20 (1 kilogram or 10), the better way to acknowledge weight loss is to shift the focus away from physical weight change and focus instead on the praiseworthy aspect: the person's improved health status. Here are some recommended phrases to share with people who are losing or have lost weight:

  • quot;It looks as if you've been working hard at losing weight." The dieter will be ever ready to talk about how proud she or he is of the hard work it took to lose weight. Listen to the story and be sure that the person is healthy.
  • quot;You look smaller. . . . Is there less of you to love?" The message is that your friend is not better for having lost weight, just smaller.
  • quot;You look pleased with your weight loss. How do you feel about it?" The person may feel healthier and more energetic, but you may also hear him or her express some frustration in not being quite thin enough yet.
  • quot;You are looking fit. How are your workouts going? How is your energy level? How do you feel?" If your friend is losing weight appropriately, she or he will feel great.
  • quot;You appear to be trading some of your excess fat for muscle." Acknowledge what you see, but don't suggest that dieting has made him or her a better person.

Regardless of the response, the goal is to help the dieter hold a solid appreciation of her or his value as a person. Beauty is in the sincere smile shared, the friendship offered, the positive qualities exhibited—not in being a size 2 instead of a size 12. People need to know they are loved from the inside out, not judged from the outside in. When dieters lose weight, they need to realize that there is simply less of them to love. They are not better or more likable. They are just smaller. With appropriate dieting, they are healthier, stronger, more energetic, and happy about these benefits of weight loss.

PART IV

Quick Weight Loss Action

Quick Weight Loss Action

Why Indulge In Self-Pity When You Can Do Something About Your Weight Now. Say Goodbye to Your Weight Problems That Have Only Make Your Life Nothing But Miserable. Have you often felt short-changed because of your weight or physical appearance?

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