Now let’s focus on some of those myths.

Myth 1: It is normal for an athlete to stop menstruating during periods of heavy training.

It is NEVER normal for an athlete to stop menstruating. Yes, you read that right. Amenorrhea should never be considered an acceptable consequence of any level of athletic or fitness training. Amenorrhea is a red flag that the body is not functioning to its full potential. Amenorrhea again can be due to exercising too much for your body, under-fueling, high stress, or a combination of these factors.

Myth 2: Amenorrhea in athletes is unique to only endurance or high-level athletes.

Amenorrhea can be seen in females from any sport and at any level from recreational to elite. Even those without sport specific goals and that exercise for health/fitness/enjoyment can develop amenorrhea. It is likely true that higher intensity and frequency of exercise might make someone more prone to FHA than those who exercise at a lower intensity, frequency. 

Iron deficiency is common in athletes. Nearly half of females who exercise may experience iron deficiency.1  While females are at higher risk for iron deficiency due to monthly loss of blood with menstruation, male athletes can also suffer from it. The International Olympic Committee 2009 Consensus Statement on periodic health evaluation of elite athletes even recommended routine screening for iron deficiency.2 Please note, unless otherwise specified, the term iron deficiency in this article solely refers to low iron and not resultant anemia, or low red blood cells. This article is also focused on adult athletes and the information discussed may not apply to children.

Stress…we all have it.  There is beneficial stress (eustress), which often brings positive results, and then there is distress, which can take its toll.  A few examples of good stress are:  exercise, enjoying a scary movie, riding a rollercoaster (if you like it), buying a new home, etc.  Some examples of distress are: loss, financial trouble, negative work environment, partner problems, etc. Eustress generally produces a good feeling while distress produces an unpleasant feeling.  And then there are combinations such as the eustress experienced by buying the new home and the distress experienced by the associated expenses and move.

Many of you may be familiar with the term Female Athlete Triad. This term was first coined in the 1990s by a task force of the American College of Sports Medicine (ACSM) in order to describe three interrelated conditions that lead to negative health outcomes in female athletes1. The three prongs of the Female Athlete Triad…

Eating healthy is valued and increasingly emphasized by many groups in our culture. For example, athletes attempt to enhance performance with diet, or individuals receiving a concerning health-related diagnosis may receive recommendations or might be advised to make dietary changes to improve health outcomes.  Making important dietary changes can be beneficial or even lifesaving for many individuals and alone do not create a disorder.  However, when the changes become obsessive and fixated the potential for developing disordered eating and potential medical compromise increases.  Often, in these cases, significant weight loss and/or nutritional deficiency first comes to the attention of a medical professional.

Here is a list of six aspects of outpatient medical care that you can advocate for in the primary care office, if you have an eating disorder. There are many medical problems that can emerge from eating disorders—some measurable, some not so much. Despite this fact, most medical practitioners get almost no training about eating disorders, size stigma, or other important social justice themes having to do with bodies. I didn’t!

I’m an internal medicine physician who cares for patients with eating disorders and disordered eating, of all shapes and sizes, all genders, and all ages, in my outpatient clinic. I’m struck by how common it is for my patients to confide in me that they don’t feel they are “sick enough” to warrant their friends’ and family’s worry, their need to have a multi-disciplinary team, or to change their behaviors. That feeling of not being “sick enough” is part of the mental illness. People with the most remarkable insight about just about everything else can utterly lack (or distort) insight into the medical and psychological issues that arise from their eating disorder.

One of the key elements of recovery from an eating disorder is nutritional rehabilitation. That means consuming enough calories at regular intervals to accommodate the needs of the body and allow it to heal. People of all genders, ages, shapes, and sizes can have eating disorders and disordered eating; you can’t tell whether someone is healthy or sick just from looking at them. In this article, we will discuss the role of supplemental feeding in the treatment of eating disorders, from oral nutritional supplements like Ensure or Boost, to the use of various types of feeding tubes.

I entered this field and worked for eight years in a medical hospital setting, caring for highly medically compromised adults with anorexia nervosa. In retrospect, practically every interaction I had with patients took place in a totally controlled environment. They were patients who, for their clinical teams at home and loved ones, were in fearsome danger of death. Their vital signs, laboratory values, nutritional intake, and bodies were all as unsafe as could be imagined. And yet, once they were admitted to the program I had helped run on a daily basis for so long, I knew they would be okay. Enveloped by expert professionals, introduced to carefully designed clinical care pathways, guaranteed to be monitored and nourished, my hospital patients were safe. Can’t get out of bed on her own due to weakness? There’s a nurse’s aide by her side all night long so she doesn’t fall. Overcome by anxiety? Their psychologist who sees them daily will be here this afternoon.

On numerous occasions over the 14 years that I have helped my clients with their psychological challenges, I have had many arrive at intake confused by what has been suggested as the problem area by well-meaning family, friends and other professionals.  This has been especially true when symptoms overlap in multiple problem areas, looking like one thing and being quite another.

In my last blog post, we started to consider how one’s brain responds to starvation, aka caloric restriction. In case you didn’t catch that one, I consider our cave person brain to be the part of our brain that keeps our body running on a day-to-day basis, operating separately from our thinking brain. And as a Cliff’s Notes version to that blog, by way of introducing today’s topic, is when your cave person brain doesn’t get adequate nutrition, it shifts into calorie conservation mode, reducing your metabolic rate (the calories needed neither to lose nor gain weight). These blogs on the cave person brain go into further details about how exactly your body achieves its goal of slowing metabolism. Remember: humans only exist today because our ancestors developed multiple mechanisms to survive famine. When food resources were scarce, humans became extraordinarily efficient at surviving and functioning. I’m always struck by the magnificence of our bodies’ innate functioning…vastly more responsive to our environments and scientifically and beautifully set up to keep us going than our own coarse attempts to over-control food and exercise.

There are so many medical complications that can occur in eating disorders and in the caloric restriction that can come with disordered eating. Let’s simplify our understanding and take a 30,000-foot view. To illustrate this concept, I’m going to use the concept of the “cave person brain.” From a not-very-neuroanatomical perspective, the “cave person brain” is the part of your brain that manages all the aspects of your body that you’re not consciously aware of. I call it the “cave person brain,” because it has kept us alive as a species through millennia of evolution. This first of two posts will review how the cave person brain affects certain vital signs.

For the past year, as I speak and write passionately about the medical complications of eating disorders, I’ve admittedly gotten a little stuck when I talk about the medical complications of Binge Eating Disorder (BED). Not everyone in a larger body has BED, and not everyone with BED is in a larger body. By no means does everyone in a larger body have medical complications of so-called obesity, a word I use as little as possible. So, when talking about the medical complications of BED, where does one start? The answer has been getting clearer and clearer to me: I believe the #1 medical complication of BED is sub-standard general medical and surgical care, arising from weight stigma.

Illness cannot always be measured, and neither can wellness. This is one of the great medical challenges facing those with eating disorders, where often the act of measuring becomes the obsessive focus of life: how many calories/miles/pounds/steps? 

Unfortunately, the Western medical system—of which I am a proud member, even while realizing its limitations—further puts the focus on measurables. In our strained system, patients can get triaged into “ok” vs. “sick” based on numbers that may have little to do with their overall suffering. No one would question that certain measurable values carry clear and present danger: an abnormal potassium level, sodium level, bicarbonate level, measure of kidney or liver function, or a very low body weight.

We are grateful to Carolyn Costin for this wonderful post! 

Thanksgiving is such a good marker of time and measurer of recovery growth. I can’t remember how bad my eating was on April 5, 1977 or June 14, 1978, but I can remember what I ate on November 24, 1979 at Thanksgiving because it was the first time I was able to eat Thanksgiving dinner and be okay, really okay about it. And every Thanksgiving dinner after that for a long time kept getting better. In some ways that is still true because it is such a great marker for me to go inside and remind myself about where I have come from and how very very hard it used to be. 

With the holiday season upon us, many people feel a mix of excitement and dread. The reasons for excitement are clear, while the reasons for dread may not be understood by well-meaning families. Folks who live with weight stigma and those who struggle with an eating disorder (of all shapes and sizes) may struggle through family gatherings, in which societally-approved topics of conversation unfortunately often include judgmental commentary on bodies, weight, and dieting. These conversations can be immensely painful and triggering. They can also threaten to undo therapeutic progress around our commitment to being kind and compassionate with ourselves.

If you or a loved one has an eating disorder, odds are that you have been failed by the outpatient medical system. That’s a big word — failed — and I don’t use it lightly.

Many of my patients tell me frankly that they don’t trust doctors, and they have good reasons. Office staff might make comments like, “Oh, you’re so thin! What willpower you must have,” dissolving a fragile intention to admit to an eating disorder and seek help. Some doctors can buy into the eating disorder’s logic and agree, “Yep, your heart rate must be 30 because you’re an athlete,” and the patient returns to their frantically worried therapist saying, “The doctor says I’m fine.” Patients are often given the message that they’re “difficult,” need to “just eat,” or feel shamed by an exasperated physician. Above all else, the average eight-minute appointment cannot possibly begin to serve the needs of a patient and family who need the opportunity to tell their whole story. Frequently, patients don’t even get time to reveal their eating disorder during an eight-minute visit. Small wonder those with eating disorders, and their families, have developed an aversion to doctors!

I’ve been lucky enough to work with patients who struggle with eating disorders for the past eight years. I adore my patients, and there are so many reasons why they inspire me.

First of all, I chose internal medicine after medical school because I love the idea of caring for the whole person and collaborating with my patients on their health care plan. Patients tell me their story, their hopes and fears, and are the expert in themselves. I bring to them my expertise in medical diagnosis and treatment.

Using language the patient connects with, and framing new or chronic medical problems in the context of each individual’s life, I give my patients a voice. This lets me be more responsive to what patients actually need from their doctor, so they don’t feel talked down to, rushed, or not seen. The mind-body connection is something I deeply believed in even before I started seeing patients with eating disorders. Who people are as individuals, set in the context of their culture, social experience, family, interests, values, and beliefs, privilege or lack thereof, absolutely affects their physical health.

We are grateful to Carolyn Costin for our first guest post and hope you enjoy her beautiful words! 

Tonight is All Hallows Eve or Halloween. In some religions it is the Eve of All Saints Day, November 1, where we honor and pray for those who have died and are in Heaven. The next day, November 2, is All Souls Day, where all who have died are prayed for.

Many believed that during this time the veil between two worlds was lifted and spirits or ghosts would be about. To scare away evil spirits and prevent them from identifying people, scary masks were worn hoping this would trick the spirits and keep them away.

Tonight is a good time to pay attention to a mask you wear all the time, to protect yourself, but perhaps have forgotten you have on.

That voice in your head is as familiar as it is judgmental and unkind: “You’re not good enough. You’re not thin/disciplined/organized/accomplished enough. You’re not meeting expectations as a partner/sibling/parent/child/professional/student. You haven’t done enough today to deserve rest and self-care.” So many people walk around every day with some version of this voice in their heads. And all too often, the next step is to take it out on your body, imagining the voice could be satisfied, or “good enough” could be achieved, if somehow the ideal body shape/size/nutrition plan/exercise regime could be accomplished.