What would I do?

Imagine you're a coach.

Maybe you already are.

Your star female athlete, after months of concern, has finally plucked up the confidence to speak to you. She’s heard and read much about the consequences of amenorrhoea, and feels that it’s time she shared with you the things that have been bothering her.

She hasn’t had a period since she upped her mileage and became more disciplined (read: “obsessive”) about her diet, eighteen months ago. The nagging pain in her foot, which gets worse the further she runs, is also a concern.

How, as a coach, do you respond?

Is your first reaction: “Oh no, the ‘P’ word! Periods are too embarrassing for me to talk about!”

Now, just imagine you’ve got past the initial discomfort, and accepted that it’s probably more awkward for the athlete to talk about periods than it is for you. Do you then question why you need to know?

Are you unaware of the risks of amenorrhoea (i.e. the absences of a regular period), under-eating, increased training and the resultant energy imbalance? And that the persistent, nagging pain might indicate a stress fracture?

Or maybe you know a bit about the issues (or have quickly educated yourself via your search engine of choice), but still question how this is relevant to you? Afterall, you’re a coach, not a doctor!

And it can’t be that bad, can it? Your athlete doesn’t have an eating disorder. If she had an eating disorder you’d know about it, wouldn’t you? She’s not even that thin, you think. If she’s not that thin, there can’t be a problem, right?

Wrong!

Now, let’s just suppose that your athlete is excessively thin. Everyone has been remarking about how ‘in shape’ she looks. She is lean and running well. Changes have happened since she’s upped her training and visited the nutritionist. And there’s been the big race wins, the personal bests and international call-ups.

Long may the good-times roll!

Then someone suggests that her thinness may be becoming excessive. Having been away at university all term, her parents haven’t seen her in a few months. When they do see her, they barely recognise her, and express their concern.

Do you try to reassure them by saying that’s all part of the bigger plan? She’s turning into a real athlete now, and being thin is all part of that.

Are you too close to notice just how excessive, dramatic and damaging the changes have been?

When the parents suggest that her absent periods may also be an issue, do you explain that away too as a normal by-product of training harder. Do you remind them that this happens to many female athletes? Do you suggest that it’s more difficult to find an endurance athlete with a regular period than it is to find one that doesn’t?

Are you naive enough to question if she’s better off without them anyway?

Or do you know and understand the risks, and the devastating long-term affect on an athlete’s health, but either consciously, or unconsciously, feel that this is something that just happens to athletes in other training groups?

Or do you know and care, and want to help, but just don’t know where to start, or who can help? Afterall there’s lots of information out there on the dangers, but very little advice on what to do next!

Have you tried seeking assistance for cases like this in the past, and struggled to get the assistance and advice you needed?

Are you being told by the ‘professionals’ that this is ‘normal’, or that issues with your athlete are not yet bad enough to warrant intervention?

Or, do you fall into the most dangerous category of all? Do you see all the warning signs, and say nothing? Do you simply hope that your athlete will be the one athlete that gets away with it?

Long may the good times roll, eh?

But they don’t, do they? The bad times roll much longer.

Always!

Amenorrhoea: the next steps

Much has been written about RED-S (relative energy deficiency in sport) and the Female Athlete Triad - the causes and consequences in particular – but considerably less information has been provided on what to do next and where someone who is experiencing amenorrhoea can seek help.

Unfortunately, delayed menarche (primary amenorrhoea), and the absence of periods (secondary amenorrhoea) have all too often become accepted consequences of endurance training. While common, these hormonal imbalances, which have severe long-term consequences, should never be considered normal, or even an expected side-effect of training for endurance events.

RED-S and the Female Athlete Triad

The Female Athlete Triad – the co-existence of disordered eating, menstrual irregularities and sub-optimal bone health among female sportspeople – has been expanded over the years.  RED-S recognises that poor bone health isn’t the only consequence of energy imbalance; that males can be affected too; and that the energy imbalance resulting in menstrual disruption isn’t always due to an eating disorder, or even intentional energy restriction.

And while the shift in terminology removes the blame and has helped break down the taboo around the subject, there are some potential pitfalls. While not all energy deficit is the result of an eating disorder, the softer terminology associated with RED-S means that eating disorders are sometimes overlooked.

Eating disorders are a group of complex and serious mental illness, with potentially fatal consequences, which will not be cured by simply increasing energy intake. They must be treated with specialist support, including psychotherapy.

Amenorrhoea: a major warning

Another potential downfall of the softer language of RED-S is that we lose how big a red flag the absence of menstrual bleeding is.

Yes, in some cases, hormone levels can be reduced, and bone health compromised, long before menstrual function disappears. But amenorrhoea is the best single warning sign we have that something is not quite right, and should always be followed up.

As with eating disorders, the GP is the best first port-of-call, but, as with eating disorders, a GP may well explain amenorrhoea away as a normal response to endurance training.

Common? Yes. Normal? No. Serious? Absolutely!

Get your bone mineral density checked

Osteopenia - reduced bone mineral density - is the most common, significant, and long-lasting side-effect of reduced energy intake and low hormone levels. Low body mass, low body fat, and a limited variety of impact forces can add to osteopenia risk in distance runners.

Distance runners, particularly females, should have their BMD checked every few years. The short, pain-less DEXA scan can give you a good indication of your current bone mineral health, and relevant populations can often have these scans done free as part of research studies.

Treatment

Amenorrhoea can be caused by things other than energy deficiency, including genetics, and the first step a GP should take is to rule out underlying medical causes, such as Polycystic Ovary Syndrome (PCOS) and hypothalamus or pituitary gland issues.

Athletes experiencing RED-S, or the components of the Female Athlete Triad, are likely to be treated in a variety of ways. In the past individuals would have routinely been prescribed oral hormonal contraceptives and sent away, hoping for the best, and while this may often still be the case, it is not current best practice.

The best treatment is a return of regular menses. This may involve increasing energy intake, gaining weight and/or reducing exercise volume. For already obsessed athletes, missing training and increasing weight may be daunting, and this is where coach, family and peer group support is crucial, and long-term development must be emphasised.

Other dietary interventions, including increased calcium and vitamin D intake (or supplementation), are likely to also be recommended. As is some form of hormonal replacement therapy, particularly if bone mineral density is already impaired.

The sooner the issues are resolved, the better the outcome. Athletes experiencing primary and secondary amenorrhoea should seek medical help as early as possible. If your GP is reluctant to intervene, see the help of a specialist sports doctor.

Get involved in research

Research continues to be an important component in expanding our current knowledge and treatment of amenorrhoea and osteopenia. DEXA scans, while great for picking up osteopenia, are poor at predicting osteopenia in the future. Bone marker tests may be better.

Similarly, there may be better prevention and treatment methods than those currently applied. And if we enhance our understanding of why some athletes are more susceptible to menstrual dysfunction than others, then we can become better at prevention.

It is important, therefore, that athletic individuals donate their body to science as and when the opportunity arises.

What coaches, parents and other support staff can do

Coaches shouldn’t be afraid to ask female athletes about their current menstrual status. While this shouldn’t be a public conversation, the topic should be one that is openly discussed.

Stress fractures – particularly recurrent or slow healing ones – are often an indication of underlying low bone mineral density and hormonal or dietary issues. They can be used as a conversation starter, and a prompt to encourage an athlete to discuss RED-S with their GP.

Always encourage athletes to seek professional advice and treatment when they are experiencing some or all of the elements of the female athlete triad.

Be prepared to provide support around the treatment that they are receiving and any training adjustments that are required. As previously mentioned, reducing training volume or increasing weight may be a difficult proposition for some athletes.

Always take a long-term approach to training and development, and encourage athletes to do the same. Advising against dieting, sudden weight loss, and an obsession with being thin can help, and positive body image, no matter what an individual’s current shape or size, should always be encouraged.

Prevention is always better than cure, and we all play a role. Too many athletics careers are prematurely derailed by stress-fractures and other injuries resulting from RED-S.

Eating disorders: what we can do to help

I turn away in tears, no longer able to watch the near-skeletal figure on the treadmill across the gym pounding out mile after joyless mile.

I am upset not just because of how thin this individual is, and the potentially-fatal strain their body is under, but also because I am aware how much someone is inevitably hurting, emotionally, by the time they reach this point.

Most of all, I am upset because I feel unable to help.

How many of us have been in similar situations, where we’ve encountered someone clearly suffering from an eating disorder, with or without exercise addition or other mental health issues, and felt that we could not intervene?

Is it a lack of expertise that is holding us back? Or the feeling that it is not our place to say something? With denial a major feature of eating disorders, are we simply afraid that the individual will turn down our offer of help?

We can’t force a grown adult to seek treatment against their will. At least not unless they are an immediate harm to themselves or others. But we can certainly offer help.

And while we’re considering whether or not it’s our place to say something, or our responsibility to intervene, we should take a moment to put the taboo of eating disorders aside.

If this was an individual standing on a bridge, ready to jump, I wouldn’t be concerned that my offer of help was untimely or out of place. Nor would I worry that I might make matters worse. I probably wouldn’t even think twice before dialling 999.

If I was a barman and a customer was clearly over-indulging in my goods, to the point that their health and wellbeing were clearly in danger, I would be legally obliged to stop serving them.

Why does the same not apply to those exercising to the point of self-destruction?

Why are eating disorders so different?

Not all eating disorders are visible

And this is just with anorexia that has progressed to the point that it is physically obvious! If we can’t support with these, how can we even consider supporting the large number of individuals who are engaging in destructive eating behaviours that have no obvious physical signs.

Most individuals suffering from Bulamia, for example, maintain a constant weight, but the binging and purging practices which characterise the illness also have severe physical and mental consequences for the individual.

Those with early stage anorexia may also not display any excessive weight loss or physical changes. Particularly in a distance running environment, where thinness is common, the individual’s health may already be severely compromised by the time their illness becomes physically evident.

Changes in mood, feelings and behaviours may be better early warning signs in these cases.

A comprehensive list of warning signs can be found on the website of Beat (the British Eating Disorder Charity).

Intervention is not easy, but it’s unquestionably necessary

Did you know that anorexia nervosa has the highest mortality rate among all mental illnesses and psychiatric disorders? People aged 15-24 years with anorexia have 10 times the risk of dying compared to their age-matched peers. Approximately half of these deaths are sudden cardiac deaths.

In the US, one person dies as the direct result of their eating disorder every 62 minutes! We don’t have similar figures for the UK or Ireland, but death rates are high and sudden death is a real possibility!

Add to that the fact that the earlier an eating disorder is treated, the greater the chance of recovery. Oh, and that many individuals suffering for an eating disorder often do not realise the extent of their destructive behaviour, and the importance of intervening becomes a little bit more obvious.

Many athletes, when sharing their eating disorder stories, will mention a trigger point to them seeking help – often somebody else intervening – or a wish that someone had said something sooner.

Eating disorders are mental illnesses. They very, very rarely improve without professional treatment, and early treatment significantly increases the chance of recovery!

So, while we’re worrying whether now is the best time, or wondering what the right thing to say is, there’s someone who just needs us to say something.

Denial an issue

Denial is a major characteristic of eating disorders. If you suggest to an individual that you think they aren’t eating enough or are too thin, then the chances are that they have an answer for that. They are likely to explain it away.

In a distance running context this is even more likely, where extremely low body weight is not only highly accepted, but often expected.

The general advice when offering support to someone with an eating disorders is to approach in a place which is private, quiet and comfortable for them. Avoid approaching at meal times, or in any other environment in which they may be more uncomfortable or anxious that they normally are.

You should listen and communicate non-judgementally. Ask the individual about how they are feeling, and care about their answers. The Mental Health First Aid (MHFA) manual recommends that you focus on specific behaviours that concern you and the underlying emotional distress they may be feeling, rather than weight, food or appearance.

There is the possibility that your sensitive, non-judgemental approach is brushed off, or treated with defensiveness or even anger. But that doesn’t mean that your conversation has not been worth the effort. The individual may need time before accepting help.

There is even a chance that they are relieved to have the opportunity to talk about their feelings. They may even have been waiting for someone to reach out. It’s just as important to be prepared for a positive response to your offer of help.

First steps

Both Beat and Bodywhys, the Irish Eating Disorders Association, recommend that visiting the GP is the first step on the road to treatment. However, with stretched healthcare resources, it is not without its drawbacks!

B-eat has an excellent resource on their website to prepare individuals for the reluctance to refer they may experience. It has advice and prepared answers to possible misunderstandings they may encounter.

No individual who feels they have an issue should come away from a GP appointment without a referral for a specialist eating disorder assessment. They especially shouldn’t be told that their eating disorder is not yet severe enough.

It is also worth noting that while many dietitians will have some awareness of and training in eating disorders, anorexia and bulimia are mental illnesses, and will not be resolved by dietary intervention alone.

Treatment

Once an individual has been assessed, depending on the stage of the eating disorder and the severity of the weight loss, inpatient treatment may be required.

National Institute for Health and Care Excellence (NICE) guidelines recommend outpatient psychological support involving Cognitive behavioural therapy (CBT), psychotherapy or other appropriate therapy or counselling delivered by an eating-disorder specialist.

For those under 18, family therapy should also be recommended. Exercise may be contraindicated, particularly in the early stages of treatment.

The Beat and Bodywhy helplines both give advice not just for those suffering with an eating disorder, but also for those supporting them. Parents, friends and, potentially, coaches will play an important role in recovery, which may take some time.

In summary

If you know someone who may be suffering from an eating disorder, approach them in an empathetic and non-judgemental way. Yes, it will be a difficult conversation, but it may just be the one that enables them to seek the support that they need.

The Beat and Bodywhys helplines can provide advice on how to raise the issue with an individual, who may or may not respond in a receptive way. But don’t give up hope.

The GP is the first port-of-call on a long road to recovery. No individual should be turned away because they are “not yet thin enough”, or that they are “just going through a phase”.

Early intervention is crucial! With the right support recovery is not only possible, but likely.

If that was me on the treadmill, slogging through my third gym session of the day, I might not fully appreciate the offer of help from a caring, non-judgemental stranger. It might not be what I want. 

But it might just be what I need.