Dr Carolyn Plateau on eating disorders in athletes

Ep. 14 This week is Eating Disorders Awareness Week, so I was absolutely thrilled that Dr Carolyn Plateau was able to join me on the podcast. Carolyn is a senior lecturer in sport psychology at Loughborough University. She has a particular specialism in eating disorders and disordered eating in the athlete population and has developed an online training programme to educate coaches about eating disorders and help them to react appropriately if they have concerns about an athlete.
Carolyn and I had a fascinating (and, I think, really important) chat, covering topics such as:

• The prevalence of eating disorders and disordered eating in the population at large and among athletes
• Defining eating disorders and disordered eating
• What causes eating disorders?
• Myths about eating disorders including the fact that 
  • they can happen to otherwise well-adjusted people
  • boys and men can get them (and may present differently)
  • BMI is not necessarily a reliable indicator of whether someone has an eating disorder
• Signs, symptoms and red flags
• What parents and coaches should do if they think their child or an athlete in their care has an eating problem (and why you shouldn't make the GP a last resort)
• Resources for coaches - Carolyn's online training programme for coaches
• Being careful with the language we use
• The single best thing we can do as rowers to protect our young athletes from eating disorders

Resources
You can find out more about the online CPD course here: https://deia.org.uk/about. Discounts on the individual price (£50) are available for groups and organisations - just encourage them to get in touch with Carolyn directly:
C.R.Plateau@lboro.ac.uk
Twitter: @CarolynPlateau
University webpage https://www.lboro.ac.uk/departments/ssehs/staff/carolyn-plateau/

 Other useful resources:
TrainBrave website (focuses on RED-S and eating concerns in athletes)  https://trainbrave.org/

B-eat https://www.beateatingdisorders.org.uk/ 

First Steps ED (general eating disorder support): https://firststepsed.co.uk/

Around the Dinner Table - an excellent online forum for parents and carers:  https://www.aroundthedinnertable.org/h2around-the-dinner-table-online-forum-for-parents-and-carersh2-136439
 
Books:

Eating Disorders in Sport by Thompson & Sherman https://www.routledge.com/Eating-Disorders-in-Sport/Thompson-Sherman/p/book/9781138884427

Sport Psychiatry Handbook (Currie and Owen) – gives a nice overview of mental health issues in athletes, including eating disorders. https://oxfordmedicine.com/view/10.1093/med/9780198734628.001.0001/med-9780198734628

Transcript

Patricia Carswell: 0:08

This is Girl on the River, the Podcast. Whole crew, come forward to row. Hello, and welcome back to Girl on the River, the Podcast for Episode 14. Now I had promised you the hosts of the Steady State podcast as my guests this week but I've actually moved that episode back a week. The reason for this is that this week is Eating Disorders Awareness Week, and when my guest, Dr. Carolyn Plateau, said she was able to come on the show, I couldn't pass up the opportunity because she's a real expert on this important subject. Carolyn is a senior lecturer in sport psychology at Loughborough University, and she has a particular interest and specialism in eating disorders and disordered eating in the athlete population. As Carolyn explains, in the interview, eating disorders are far more prevalent than you might imagine in athletes and as you'll hear in the interview, the stats are actually quite shocking. Eating disorders are potentially incredibly dangerous. So it's a really important subject to address. Now, full disclosure, I do have a personal interest in this subject. A close family member of mine has had an eating disorder, and although I've never had a full blown eating disorder myself, I have been prone to disordered eating at various points in my life and I've certainly struggled with my body image. As Carolyn explains, there's a spectrum and I would say I'm definitely on it, albeit at the lower end. This is not an easy thing to admit to as there's still a massive stigma around eating disorders. But the best way to counter stigma is to talk about it. So there it is. Anyway, let's dive in. And let me introduce you to Dr. Carolyn plateau. So Carolyn, welcome to the podcast.

Dr Carolyn Plateau: 2:09

Thank you very much. Thank you for inviting me to be on - it's very exciting. And yeah, a topic I'm very passionate about. So I'm really looking forward to chatting to you today.

Patricia Carswell: 2:17

Well, it's a subject close to my heart as well, as you know, and I'm curious to know, what it was that brought you into this particular field. I know that you have quite an athletic history of your own. So let's start with that.

Dr Carolyn Plateau: 2:32

Yes, I was a junior international runner. So I ran over 800 and 1500 metres when I was a junior athlete. So I spent a lot a lot of time when I was an adolescent training, competing, travelling, and still, you know, run to this day, which is which is brilliant, sadly, not not at the level that I used to be , but, yeah, so I was competing as a junior international athlete and, you know, partly through some of my experiences and observations of being involved in in sport at a high level, I became really interested in in some of the pressures around eating, and body size and body shape that happen across across lots of different sports, not just running, and was really interested in pursuing or understanding why it seems to be such a problem. And what we can do about it - you know, I've always come at this area from a kind of, Okay, how can we try to solve this problem, because it doesn't seem to be going away. And even since I've, you know, been working in this from a more academic role, it's it just uncovers how tricky this is, in terms of trying to change some of the practices and, and the cultural issues that seem to be quite pervasive in our in our elite sport environment.

Patricia Carswell: 3:45

And in terms of statistics, do we have, do we have any idea of the prevalence of eating disorders and disordered eating both in the population at large and and in the sporting world?

Dr Carolyn Plateau: 3:59

Yeah, so it's, it's always tricky. I think when we talk about statistics for eating problems, because I'm sure as you well know, that they're often quite difficult for people to admit to having an eating problem. So I always treat some of these statistics with a bit of a pinch of salt, but also suggest that perhaps they're a little bit of an underestimate, sometimes of perhaps the true nature of the problem. In the general population, we generally work on statistics that suggest around one to 2%, who will present with a clinical eating disorder, so that's a severe eating problem. And that requires usually some form of intervention and treatment. Things like anorexia nervosa or bulimia nervosa will fall into into that category. In athlete populations, you're looking at close to one in five female athletes or one in 12 male athletes. So significantly increased in comparison to the to the general population.

Patricia Carswell: 4:52

And are there particular sports that are especially... I imagine that some sports that are more affected than others.

Dr Carolyn Plateau: 4:59

Yes. So generally, it seems to be that we see higher prevalence statistics in, in sports that are, we will typically refer to them as kind of lean sports. And by that I mean sports where there is some kind of emphasis on weight, shape or appearance in terms of performance potential performance benefit. So sports that might fall into that category include things like endurance sports, where often being lighter is believed to confer some form of an advantage, sports where there's some kind of weight categorization. So where there's some weight dependency requirements, things like martial arts, or or any where there's kind of categories in which athletes are required to compete, and sports where there's an aesthetic component as well. So often where it's quite subjective in terms of the outcomes and appearance kind of forms a component of a final score, for example, gymnastics or figure skating, we often see particularly high levels of eating problems in sports which fall into those leading categories. But that's not to say that they don't happen in non-lean sports. And I think it's always really important to get that message across that if you're a coach or a practitioner working in a sport where typically we wouldn't say the risk was necessarily as high, I would still be vigilant for for eating problems, because they do occur in across the board.

Patricia Carswell: 6:27

So in rowing, I suppose our most vulnerable people must be the lightweight rowers who have to make a specific weight. And then of course, coxes. Interestingly, a lot of people don't know that the coxing specified weights are a minimum, we don't have a maximum weight, we have a minimum. And that's I imagine, I don't know for sure, but I would imagine that's to ensure that people don't feel under pressure to get below a particular weight. But the weights are still low. It's between 50 and 55 kilos, depending on which crew, you're coxing. So we're talking very, very low weights.

Dr Carolyn Plateau: 7:00

Yeah.

Patricia Carswell: 7:01

But it's, yeah, that's a really important point that it can be across the board. I suppose people imagine that in openweight, sports, it's not likely to come up.

Dr Carolyn Plateau: 7:11

Yeah. And it still can you know that there are still pressures within the sporting environment, regardless of whether or not you're competing in a lean sport or a non-lean sport. And those pressures can affect people in different ways. And you know, there's... eating disorders are really complex disorders, and it's not usually just one thing that contributes to the occurrence of that problem, it can be usually as a result of a multi factorial modelling, you know, lots of different things that can contribute to the occurrence of an eating disorder at a particular point in time for a particular person. So, you know, I always say, to treat some of these statistics with with caution, because they don't necessarily reflect the individual experience. And as we know, you know, yes, the sporting environment can certainly contribute to the occurrence of some of these problems, but it's not always it won't be the only factor that has that has had a part to play there.

Patricia Carswell: 8:02

So let's define our terms so we know exactly what we're talking about here. Help us with what an eating disorder is, and what disordered eating is.

Dr Carolyn Plateau: 8:12

Okay, so when, where it does get fuzzy and I think it's really useful to kind of define these so that we know what we're talking about. So, clinical eating disorders are severe psychological disorders that are characterised by a an extremely distorted relationship with food. And that can manifest in lots of different ways. So, it can manifest in a in a kind of anorexia nervosa type profile, which is often characterised by severe restriction of food, and severe underweight. It can manifest in relation to bingeing and purging behaviours, which would be more typical of a bulimia nervosa eating dis rder, where often weight is act ally fairly normal or even abo e normal, but it's the kind of haotic approach to eating tha is characterised as those typ s of disorders. Clinical eat ng disorders, as I said, req ire usually require some for of intervention and tre tment, they are sig ificantly or have par icularly negative impacts on som one's physical health, obv ously, their psychological hea th, and they can be quite dif icult to treat. So it can be chr nic, often it can be per asive, and it can take an awf l lot of time and energy to try and tackle those disorders. Eating problems generally exist on a spectrum. So that's very much at a small portion of the population with with kind of these clinical eating problems at the very kind of far, far end of that eating spectrum. disordered eating kind of happens a little bit before that. So typically referred to as subclinical when we're talking about disordered eating, so it's, it's not necessarily meeting those thresholds for to meet a diagnosis of a clinical eating disorder. So perhaps an individual has a dysfunctional relationship with food but isn't necessarily really underweight. Or perhaps they are bingeing and purging, but only occasionally, or they're managing to function fairly well in their day to day lives, but still have a kind of disturbed relationship with food. So it's kind of the bit before you kind of progress on to a clinical eating disorder.

Patricia Carswell: 10:20

And does it happen that people move from one to the other? Can... Do people move from one type of eating disorder to another? And can they move from disordered eating into an eating disorder?

Dr Carolyn Plateau: 10:32

Yeah, so disordered eating is actually one of the strongest predictors for a subsequent eating clinical eating disorder. So if we, if we spot someone with with disordered eating, then it's usually really important to intervene at that stage and, and to try and prevent it from escalating to a to a clinical eating disorder. So it's more than kind of just dieting it is a little bit more severe than that. And often dieting comes before disordered eating, which then becomes before a clinical eating disorder. But your point about kind of, Can people move between eating disorders. So perhaps they might initially present with a kind of restricted type profile where they're, they're not eating very much, or they're cutting out major food groups. Often people will perhaps start with that, and then then they can evolve absolutely into into other types of eating problems, perhaps characterised more by bingeing or purging behaviours. And I think from it from an academic perspective, the causes of eating problems, whether or not they present as more anorexic type behaviours or more bulimic type, and behaviours, the causes are broadly the same. And the treatments are often based on similarities. So it doesn't always matter necessarily what diagnosis you've got, it just needs to be addressed in some way, shape, or form.

Patricia Carswell: 11:45

And talking about the the causes, what do we know about what causes an eating disorder?

Dr Carolyn Plateau: 11:52

Yeah, so as I said, it's quite complicated. There's lots of different things that can contribute towards it, towards an eating disorder happening. And I don't think it's always necessarily helpful to kind of reduce it and say, Well, this was the cause of a particular eating disorder, because there's usually lots of things that have contributed towards the development of that problem. We know that some genetic factors, for example, there's growing interest, certainly, in trying to understand potential genetic vulnerabilities towards eating problems. Often it's usually a combination between perhaps genetic vulnerability with environmental factors, it can be things like stressors, particularly that have perhaps happened in in an environment. Maybe, from an athlete perspective, it could be an injury, it could be a change in changing coaching setup, it could be poor performances, it could be a whole host of things that kind of contribute towards their concerns about their, their body, or their size, or their shape. And sometimes it can be as a result of past comments from from individuals. So perhaps being told they need to lose weight or being told that they, they need to aspire to look more like somebody else who perhaps is a role model in their particular sport. So I think generally, in lots of our sporting environments, there's there's definitely an emphasis on kind of what people look like and drawing comparisons about how good someone is simply by that, by the way they look, not necessarily on the basis of their performance. And that fuels this this kind of unhealthy obsession with with what athletes look like and the importance of that in terms of their their ultimate goals and performances.

Patricia Carswell: 13:30

And how... I'm just thinking about how people sometimes feel when they encounter an eating disorder, perhaps amongst a friend or family member. I think, in a lot of cases, there's a feeling that it must be... that they must be deeply troubled, that they must come from a very troubled family, that it doesn't happen to people in kind of secure loving families. Is that a misconception?

Dr Carolyn Plateau: 13:58

Yeah, eating disorders can affect anyone. And you know, there's there's no rhyme or reason sometimes as to why an individual develops an eating disorder. I think there's there's been a lot of research that's focused on young females, adolescent females, and a lot of research has been been done to kind of explore whether or not that group of the population are particularly vulnerable. And it certainly seems to be some evidence for that. But that's not to say that perhaps male athletes and others who might be viewed initially as kind of more atypical won't suffer from an eating problem because they absolutely can. And, and as I said, it's not... sometimes it has absolutely nothing to do with a family environment. Sometimes it has nothing to do with sport, even. Sometimes it can be as a result of just too many pressures all kind of coinciding at the wrong, the wrong point. And eating or managing or controlling eating or changing eating becomes a mechanism by which to manage some of those stressors or those those issues. So yeah, it's it's not like there's a kind of one size fits all approach when it comes to trying to understand how or why an eating disorder has developed, it really is a kind of case by case basis.

Patricia Carswell: 15:05

That's incredibly helpful. And I think it's really important for people to understand that, because I think sometimes people are slow to intervene and get help, because they think it couldn't possibly be happening in their family or in their circle of friends or whatever. Because that's not the kind of thing that happens to them, they're too well adjusted, or whatever. So that's really helpful to know. Just looking at some other myths around eating disorders. Obviously, you've touched on the fact that boys and men can get them and I think that's important to underline, isn't it? Because I think, again, that can be a barrier to diagnosis.

Dr Carolyn Plateau: 15:41

Absolutely. And I think, you know, from a research perspective, historically, lots of the evidence has focused on on just females and, and often try to apply female models to try and to understand and identify when eating problems exist in males. And I'm not sure that was ever a particularly helpful approach to it, because eating disorders will manifest in different ways according to sex. And, you know, when we talk about anorexia nervosa and bulimia nervosa, the presentation of those those eating disorders will vary according to according to sex. And in males, we see perhaps,a tendency, a greater tendency towards kind of compulsive exercise traits, concerns with muscularity, which perhaps contrast quite significantly with leanness, and desire for thinness that we see in females. So I think it's really important to a acknowledge that the eating disorders do happen in males and boys, but they don't always necessarily present in the way that you might expect, you know, from a kind of more stereotypical perspective. And it's important to be vigilant and to, you know, when you have concerns, or you have worries, to try and tackle those in early stage. Because that's, that is the most important thing in terms of trying to break that link between disordered eating and the subclinical eating problems with the subsequent onset of a more serious clinical eating problem.

Patricia Carswell: 17:04

Well, let's look at that moment when someone... I know in eating disorder circles, people talk about someone going down the rabbit hole - what is going on there, because it seems to me from, from my own experience, that there's a point at which you kind of lose them - that any of the normal things that might help someone with a mental health problem just don't work anymore, because they're too far gone. So what is what is going on? Is there something changing in the brain? or What is it?

Dr Carolyn Plateau: 17:31

Yeah, and it again, it's difficult to kind of pinpoint, it can vary according to individuals, but I would say, people... distorted or disturbed eating practice become habitual over time. So the longer that people engage with unhealthy or problematic eating practices, the longer they become ingrained, and the more difficult it is to then kind of remember or recall what a normal eating practices. So this is why early intervention is so so important when it comes to kind of breaking some of those habits and breaking those cycles with people who are suffering with with eating problems, because that the kind of more habitual or the more frequently those behaviours have been engaged in, the more difficult it is to bring them back to it to a place where they can eat or have a more normal relationship with food. And we, you know, we know being underweight or, you know, not having enough food, or being in a kind of starvation cycle can affect cognition, it can affect, you know, the way that we think, and, and, again, that makes it more difficult to kind of adopt a common sense approach. You know, I'm not suggesting that we would necessarily endorse that in a kind of therapeutic way. But it's, it's just actually trying to tackle an eating problem gets more difficult if the body is really undernourished and under fueled.

Patricia Carswell: 18:53

And how dangerous is it for someone to develop an eating disorder? What actually are the physical and mental dangers to someone?

Dr Carolyn Plateau: 19:03

Yeah, so eating disorders, when it comes to psychological disorders, they're one of the most serious in relation to potential outcomes of mortality. So particularly anorexia nervosa, we see elevated levels of death as a consequence of the disorder for those who who are suffering with with a clinical eating disorder. And that can happen in bulimia nervosa as well due to the kind of disruption to the body's biochemistry as a result of purging behaviours. So very serious, in some cases, in terms of some of the physical outcomes from an athletic perspective, from a sporting perspective, being under fueled, or having this very chaotic relationship with with food will significantly affect one's ability to recover between training sessions or competitions. It will compromise coordination, it will compromise concentration - the psychological well being is also affected. So individuals will often be... experience low mood, often as a result of being under fueled. And it can also impact on on all the body systems essentially, you know, for females we would, particularly for anorexic type eating disorders, we would expect to see a cessation in the kind of menstrual cycle that can often occur, because the body is prioritising energy for other sources and for more important activities within the body. But things like cardiovascular health, gut health, all of those body systems essentially become compromised when we're when we're not eating enough. And, you know, the the REDS model of relative energy deficiency in sport model points towards all these different systems in the body that are compromised as a result of under fueling. And essentially, when we're talking about disordered eating, or an eating disorder, those those consequences become exacerbated, or they become more concerning. And unsurprisingly, an athlete will experience quite significant physical complications, psychological complications, and also performance will also often likely reduce as a result of lots of those things combined together.

Patricia Carswell: 21:14

I heard a really worrying statistic yesterday. I was at a webinar about women's health in sport and how it needs to be taken very seriously. And one of the speakers was saying that in one piece of research, 30% of female athletes were reporting some disruption to their periods at some point. So presumably, that's a big red flag is it?

Dr Carolyn Plateau: 21:37

It is a big red flag in terms of... not always necessarily clear why that, why that's happened. And for some athletes, it can be completely unrelated to their energy state. But for quite a few athletes, it's probably linked to energy availability. So as I described, when the body is experiencing under fueling, so there's not enough energy basically in the body to support all of the body systems that are going on, that is one of the first systems to to basically slow down or stop. So if the menstrual cycle becomes longer, or disappears completely, then it can sometimes indicate that there's not enough energy to sustain both training activity, and also the the other systems in the body that require energy in order to be able to work. So I think, you know, there's that, there is becoming a bit more of a discussion and a kind of environment in which we can talk about the menstrual cycle and kind of how it's linked to some of these important, fueling strategies in in female athletes, but it is a really useful marker for people to kind of get the handle on and to monitor and to see, you know, if it if it is fluctuating or changing, or it has disappeared, then is it a nutritional issue? Is there something going on there which might be potentially driving that?

Patricia Carswell: 22:55

And in terms of BMI, I've heard anecdotally about people going to their GP, perhaps with a teenage child who they're worried about, and the GP takes one look at them or weighs them, calculates their BMI and says, Well, I don't think there's anything to worry about, because you're not thin enough, or you're not so, so underweight that I'm concerned, why is that a problem in terms of understanding how the pattern develops?

Dr Carolyn Plateau: 23:28

Yeah, I mean, I think it is challenging, the funding and the resource available for eating disorder treatment is scarce. And there are really long waiting lists to seek support in the NHS in this country. So it's very difficult. And I think BMI is often used as a marker, as a means for which to access some of that support. That's not necessarily helpful. And it's particularly not helpful to athletes, when we're when we're thinking to actually, you know, just having a high proportion of muscle will often make that BMI higher than perhaps in a in a non athlete comparator. So, it's problematic because it essentially sends the message that you need to get worse before we can help you when actually lots of the evidence is telling us that the earlier we can intervene, the earlier we can provide support, the less likely that some of these disorders will become chronic, and the easier that they will be to treat and to manage. So it's absolutely problematic. It's difficult because of constraints on our systems. But it absolutely sends the wrong message to the individual who's who's gone, you know, in good faith to a doctor to seek support, to then not be able to go on and access that, as is required - it's very frustrating.

Patricia Carswell: 24:42

So let's have a look at the signs and symptoms and red flags that we should be looking for. So in terms of you know, what parents and coaches should be looking out for.

Unknown: 24:54

and

Dr Carolyn Plateau: 24:54

Eating disorders are typically quite difficult to detect. And that's often because the individual can feel quite secretive or often deny that there's any problems going on. But I would always say, you know, listen to your intuition and and think about if you're concerned that something is wrong, then be persistent. And be vigilant and and seek support as necessary in terms of some of the signs, etc. Eating disorders can affect a whole range of domains. So it can be, can affect an individual's physical health, and perhaps that presents as weight loss if restrictive eating practices that are at play. So perhaps, a young athlete might decide to cut out certain food groups, perhaps under the umbrella or the view of becoming healthier or trying to adopt a healthier diet. But I would say, you know, it's concerning if that's fundamental food groups that will be essential in supporting growth and development and also potentially high levels of training activity. So if they're changing, changing attitudes towards their their food intake, reluctance to eat with others, perhaps at mealtimes - that can be with their peers, or it can be with a family, and changing attitudes towards food and kind of mealtime type environments. Evidence of binge eating behaviour, so that could be empty packets of food, which might get stashed or evidence of eating large volumes of food and feeling out of control as a result of that binge eating episode. And evidence of purging behaviour as well. So if you suspect that someone is perhaps engaging in excessive exercise activity, or using laxatives, or engaging in self induced vomiting, again, those can be warning signs of a more serious problem. But equally look out for things like changing mood. Often, people who are in early stages or throes of an eating disorder might be experiencing changes to the psychological well being so less likely to be sociable, perhaps presenting with mood swings, or difficulty kind of managing some of their emotions, depression, anxiety, those types of symptoms are very common in co-occurring with with eating disorders. From an athletic perspective, if you're a coach, you might be thinking, well, I don't often see them at mealtimes, or, you know, I'm not privy to what they eat or when they eat it. So some of the red flags within the training environment can be things like increased vulnerability to things like niggles, so injuries, or when those are kind of severe bone related stress related injuries, or whether they're just frequent annoyances, which could indicate a perhaps a tendency not to be recovering particularly well, in between sessions, again, perhaps nutritionally, as a result of under fueling things like tendencies towards infection. So constantly fighting off colds, appearing, struggling to kind of perhaps train and compete at the level that they previously have been. That's always a difficult one because often people can be... in the early stages you need to sort of, particularly if they lose weight, their their performance might actually improve, which is slightly contradictory. So they may, as a result of a kind of increased strength to power ratio, they, they might actually temporarily experience an increase in performance, depending on what sport they're involved in. But certainly, you know, that that won't often very last very long, particularly if the eating disorder is developing. So be mindful of of kind of changes in performance and, and those things as well as kind of possible red flags there.

Patricia Carswell: 28:31

That's really, really helpful. So if a parent ... let's start with parents, because they're usually the people who will spot things earliest, if they're concerned about something that's going on at home, they feel like there's some flags being raised. What are the do's and don'ts?

Dr Carolyn Plateau: 28:50

Yeah, so I would, I would always say to a parent who's perhaps worried about a child is to approach the situation, sensitively, cautiously. Try not to use terms like eating disorder or labels, which can be often quite inflammatory and difficult for an individual to get their head around. But be persistent. And you know, don't be tempted to kind of let it lie. If your, if your intuition and your gut is telling you this, that there's still a problem here, something doesn't seem to be quite right, to try and have open honest conversations with with the child and see if you can get to the bottom of perhaps of why they perhaps started behaving differently, or if you have any concerns about their food consumption or whatever it is, that's kind of flagged up as a potential problem initially, try to convince the individual to to seek support, perhaps with your your backing, and whether that's a visit to the GP or whether it's engaging with perhaps the Performance Team that if you're involved, if your child is involved in sport, can you, is there someone at a club or regional or national level that might be able to advise or give guidance on nutrition initially perhaps, or even psychological support if if it's deemed necessary that that would be useful. And you know, don't struggle alone. Speak, try and reach out for for support through other networks as there's some fantastic eating disorder charities in the UK, B-eat being one, First Steps ED being another. There are many others. And seek guidance and support through those mechanisms as best as you can.

Patricia Carswell: 30:26

I think there can be a real fear of medicalizing it, which perhaps puts people off from actually taking action. I know, when it sort of happened in our family, the GP was kind of the last resort, which was looking back a mistake. We sort of went down the route of sports nutritionists, and all sorts of things - anything, anything, but actually acknowledging what was going on. You know, don't be afraid of talking to the GP and getting CAMHS involved or whoever it is, because you're more likely to get out of it without medical intervention, the earlier you you get involved in it.

Dr Carolyn Plateau: 31:04

Yeah, yeah, very true. And you know, the GP is in this country is a very important gateway to other support, sources of support, and more intense forms of support as well. And whilst, you know, some of our research has shown that the GPs often don't understand athletes or they find it a bit more difficult to manage when an athlete presents with with some of these issues, be persistent, as I've said, you know, keep going, keep going back. If you're not getting the answer that you want, then then keep keep going until you do until you get a referral to an eating disorder service, which is which is likely to be where most of that important support is going to be housed.

Patricia Carswell: 31:43

And what sort of support does that usually involve? What are the eating disorders teams made up of these days?

Dr Carolyn Plateau: 31:50

So there's usually ...there can be kind of two different kind of forms of support depending on the nature of the problem. Inpatient therapy is usually reserved for for people who are very low weight and who perhaps require some medical intervention to support weight stabilisation before they, before kind of really intensive counselling or support that way. Some... or eating disorders where there was perhaps less concern about the weight status of the individual can often be managed on an outpatient basis, or even on a day care type basis where an individual spends their daytimes at the centre and they might have their meals there and also engage in group therapy or individual therapy whilst they're there to help them often stabilise their eating patterns if they have become quite chaotic. Often, that can be quite a useful approach to doing that. For people under the age of 18 often, one of the approaches will be family based therapy which will often involve both the parents and often siblings as well if there are any, and you know, tackling ... aiming to tackle the ageing problem as a kind of holistic approach. So to centering the individual within that the family unit and helping the family understand how they can support the individual to develop a more functional relationship with food, and to arm the family with strategies that they can get away with and implement within their home environment. And family based therapy, particularly for anorexia nervosa, for those under the age of 18, is particularly effective. So it is a good a good option for lots of people.

Patricia Carswell: 33:25

So really, it's it's nothing to be afraid of. It's... you're talking about psychiatrists, psychologists and dieticians. Is that right?

Dr Carolyn Plateau: 33:33

Yes, absolutely, yeah, they'll probably form the core team within an eating disorder unit, you'll get counsellors and therapists within there as well. And, you know, I think that can often be a challenging environment for an athlete - from our own research we've athletes tell us that it's very difficult sometimes going into an eating disorder unit environment, because they feel very different, perhaps to some of the other clients and people that are in there. But I think it's important to pursue that. And actually, you may, as an individual have to put your sporting goals and aspirations on hold temporarily whilst you seek support and treatment in order to make sure that your body is strong enough to be able to manage intensive training and competition later on.

Patricia Carswell: 34:20

So that's parents and families. What about coaches? It's quite sensitive for them. I imagine if they've got someone and I imagine there's a lot of fear around doing and saying the wrong thing. So other protocols that that sporting coaches are provided with or if not, what should they do?

Dr Carolyn Plateau: 34:40

Yeah, I think it's really difficult for coaches, particularly in in the UK where lots of our coaches are working voluntarily. You know, they are involved in sport for the love of sport very often, and perhaps dedicate a couple of evenings a week and then you know, go to their their full time job the rest of the time and, you know, managing, supporting an athlete with an eating problem probably wasn't high upon on their list of things that they wanted to do once they're involved in, in sport. So it is very challenging from it, from a coaching perspective. And I think, historically, there's often been a lot of blame placed on coaches, which again, I don't think is necessarily helpful. And it rather minimises very often the causes of the eating problem and the you know, the fact that it's caused by by lots of different things. And perhaps, yes, a coach may have made a comment at some point. And that's escalated. But it's not usually that the kind of the only thing that's contributed to that. And actually coaches can very much be part of the solution when it comes to to managing eating problems in athletes - you know, they're, they're often one of the individuals that has the most contact with the individual - they might be the person that perhaps notices something isn't quite right, at an early stage. And, and I think one of the key things is about making sure coaches are confident in what to do next. Because from, again, from our research with with coaches, they tell us that it's often that uncertainty about what to do next, that stops them from taking action at an early stage. And also, you know, that the worry that comes with Have I done something wrong, Is this enough is this as a result of x, y, and z? So one of my missions, I suppose, has been to try and educate coaches, a little bit more about some of the signs and symptoms, around eating psychology in athletes, and to give them some kind of tools and things that they can use to be able to help them in that initial Okay, now, what do I do? How do I deal with this and what to who do I need to signpost to, because no one is asking coaches to be a therapist or to diagnose an eating problem that is absolutely not their role. Their role is more in in as a supporter, and being able to signpost that individual to appropriate sources of support. Those are the key things to make sure that the eating disorder is tackled at an early stage as possible in order to prevent that kind of possible escalation of symptoms. Again, you know, some of the key points I would say to coaches is, trust your instinct, trust your gut, if you think something's not quite right, then say something, have a conversation. Obviously, think about where and when and how you do that. So not in front of the rest of the training group, you know, privately, confidentially, sensitively, again, think about language refer to the problem is something shared rather than something that's solely the athlete's and avoid inflammatory terminology like an eating disorder or things like that which can be quite stigmatising or quite difficult for an athlete to hear if they haven't heard it from anybody before. And, you know, try to agree a strategy with with the athlete if they're, they're open and willing to have that conversation with you try to agree what the next steps are going to be and how you're going to support them in that whether it's seeking guidance from a GP, whether it's going to the medical support personnel within your club, or your your governing body, and, you know, have an open and honest discussion about the impact that might have on their training and their competition, whilst they seek guidance and around the eating problem. Athletes can sometimes respond quite well, if you frame it in terms of performance, rather than necessarily just health. You know, if you you talk about the needing to get them strong for, for competition, or needing to develop their, their, their strength and their endurance for future, their future career, rather than necessarily just focusing on your concerns or worries around their health, which is often not first and foremost in an athlete's mind.

Patricia Carswell: 38:45

Yeah. And that's sort of more authentic coming from a coach as well, isn't it if they talk about what they normally talk about, which is, you know, aiming towards the next competition, or whatever the training is that they're doing?

Dr Carolyn Plateau: 38:56

Yeah, exactly. And, and it's putting it in language that an athlete can understand and that is on board with, you know, they'll likely still have goals and aspirations to be a successful athlete, if they're still involved in the training group. They just need some support and guidance on on how to achieve that. And having an eating disorder doesn't prohibit someone from going on to be extremely successful if we can catch it at an early stage and offer that support when it's needed in order to prevent those those symptoms becoming overly severe.

Patricia Carswell: 39:25

And you and your team worked on some training for coaches. So tell me about that. Because I think this is really exciting and important.

Dr Carolyn Plateau: 39:33

Yeah, so as a result of some of the research that we've done with coaches who you know, this, the constant message that we were getting both from them from governing bodies, from athletes was, we don't know enough about this. We don't know what we're looking for. We don't know how to deal with it. We don't know where we're signposting to. And typically within the sporting landscape within the UK, eating disorders are not covered as part of kind of coach, typical standard coach education protocols. So we felt it was really important to try and fill this gap and to make sure that there was a resource out there for coaches to engage with, and to to raise awareness around the types of things that they need to be looking out for with their athletes. And also to give them some hints and tips on creating a kind of positive climate under which to look after their athletes. And, and, you know, we're not saying don't ever talk about weight, or don't ever mention this, because that's not healthy either. It's about trying to create positive fueling strategies, you know, endorsing healthy practices, and building positive relationships between food and performance in the athletes that they work with. So, yes, our online course is available at the moment. And if coaches are interested in they wanted to go through that it takes about three, three hours or so to work through the modules that we've put together with lots of advice and guidance on having some of those conversations with athletes that you're worried about - signposting, spotting some of those signs and symptoms. And yeah, it's my mission to try and make sure that coaches engage with with some of this content just so they can prepare themselves in the event that they do come across it an athlete who might be suffering with an eating problem...

Patricia Carswell: 41:20

Because the likelihood is they will at some point in their career, isn't it?

Dr Carolyn Plateau: 41:24

Absolutely. You know, if you look at the statistics, one in five female athletes, one in 12 male athletes, and I think that's probably just the tip of the iceberg. There are many others who perhaps don't meet some of those clinical criteria, who would still benefit from guidance and support around their eating practices. So it's, it is essential in my view, that the coaches are aware that these problems do exist in sport. And, you know, if, if we try and think longer term, changing the culture and sport and changing the emphasis in sport around weight and shape is going to be the one of the core ways in which we can try and prevent the occurrence of these disorders in future. And our coaching workforce sports professionals are all going to be instrumental in in trying to change that landscape for future generations of athletes to come.

Patricia Carswell: 42:12

That's absolutely brilliant. Well, I'll put details of that course in the show notes. And is there any message if there's anyone from British Rowing, our governing body, or Welsh Rowing or Scottish Rowing or Rowing Ireland -if any of them happen to be listening? Is there anything that you would love to get across to them and the things that they ought to be doing or thinking about?

Dr Carolyn Plateau: 42:32

Yeah, I mean, I think it's reinforcing some of the messages that we've obviously talked about today in terms of, you know, creating a cultural environment, a sporting culture, in which is which is safe and which is positive in relation to to weight and eating and food for our athletes in order to protect both their their long term health but also to enhance their performance. You know, I think it can't be overstated, really, how important healthy fueling is for healthy, happy, strong athletes and people of the future. So prioritising this area, in terms of education, awareness events, you know, encouraging athletes who perhaps have previously experienced concerns around around their eating to speak out, because then it makes it easier for other people to also come forward and talk about their worries and concerns. And, yeah, I think that's probably... there's many, many, many things, but I think those are probably the core ones, let's think about raising awareness and promoting positive food cultures within within sport, if we can.

Patricia Carswell: 43:39

Well, that's something that is really interesting, you know, how careful we need to be around language. And you know, when we're talking about weight, and we're talking about foods, you said that it would be weird and unhealthy never to refer to it. So is there anything we ought to definitely not say, in in front of our athletes or our young people? And because I'm thinking about, you know, just throwaway remarks we might make, you know, someone will be having a big meal, and then they'll talk about needing to work it off. And, you know, yeah, I've been at events, perhaps where I'm coxing and someone will just make a jokey comment saying, Oh, I hope you're not eating lunch? How careful do we need to be?

Dr Carolyn Plateau: 44:18

Yeah, I mean, I think it depends on on who you're talking to. But be aware that particularly, you know, young people and young athletes are highly impressionable, and I think we forget sometimes how much of that they absorb. And, you know, I'm not saying you need to think about everything you say, but I am saying that actually, something that might appear like a throwaway comment to you could be interpreted very differently by by a young person who is perhaps already experiencing body dissatisfaction or concerns around their eating, weight or shape. I mean, that there are some examples of poor practice whereby you know, you draw comparisons between different athletes in the same training group or, you know, perhaps compare notes on skinfolds, or whatever it is, which you know, those types of practices, I'm sure, are hopefully a thing of the past, but some extreme examples of how, you know, that can be extremely unhelpful if you have someone in your training group that you don't know about, who might be experiencing some concerns. So I think it's always being mindful that something that is banter or throwaway comments for one individual is not necessarily the same for somebody else. So I mean, I would just say, you know, avoid making some of those comparisons between whether it's members of the same training group or comparisons with, with role models, you know, except that, that good performances can come from athletes at every side, and they don't have to fit a one size fits all mould in order to be successful, you know, look for evidence of, of athletes who perhaps, you know, are different and don't necessarily conform to the mould, and use those as inspiration, rather than kind of always sticking with what we know all the stereotypes that exist within our within our particular sports. So, yeah, I mean, critical comments can often land very badly when we talk about weight and shape. And that's not just true in sport, it's true across the board, you know, teachers and others who are working with young people do have a perhaps more influence than they would necessarily think that they do. And, you know, even if, as a coach, you have concerns about your body or you're worried about your weight, try not to project those onto the athletes that you work with. And instead, endorse positive practices, encourage refuelling, try and have positive role models within your, within your training group, whether that's as simple as encouraging athletes to bring a recovery shake, for example, after their training session and endorsing that behaviour,and encouraging athletes to go in and have something to eat relatively soon after they've finished a training session. You know, it's all it's just incremental things and and practices that you can start to gradually build into your training environment.

Patricia Carswell: 46:59

That's really helpful. And if there were, you know, one thing that you could do that, you know, perhaps we as a, as a rowing body can do, you know, as members of rowing clubs, as people who who rub along with young people, it was sort of one message you'd like to get across to us, what what would that be?

Dr Carolyn Plateau: 47:20

Oh, crikey, putting me on the spot! I think it's about, you know, understanding that the impact that under fueling can have, and that that's not just, it's not just clinical eating disorders, it's not just people who experienced these these very severe disorders, it's about the impact that that has on you systemically, as an individual, both from your psychological and from your physical health. And actually, food does not have to be earned. You don't have to work it off, you don't have to be deserving of food, food is essential for everybody. And athletes are no different. And there will be significant benefits when it comes to performance, and also their general health and wellbeing not just as an athlete, but also, as you know, when they eventually retire and progress on, you know, it can't be understated, or overstated. They are they can have huge long term impacts and eating disorders. And it's, it's not worth it in the short run.

Patricia Carswell: 48:18

Yeah, I'm sometimes a little concerned about the healthy eating messages that we put out to young people, because obviously, obesity is is a major health problem for us as a society. But at the same time, in an effort to address that I, I do worry a little bit that sometimes we overdo the healthy sort of unhealthy idea. What are you thoughts about that?

Dr Carolyn Plateau: 48:41

Yeah. And I think it's a really tricky public discourse that we... public health discourse that we have to navigate. And I'm, you know, there's an awful lot of messaging around, as you said, around obesity around the importance of exercise, the emphasis on exercise, the emphasis on, you know, not over consuming food. And often those messages are... whilst they're important in terms of trying to, to encourage a healthier nation, they're often picked up by people who don't need to listen to those messages at all. And, you know, they become internalised and people can develop eating disorders, as a result of kind of some of these pervasive public health messages that actually don't always land in the right place. And, you know, there is a real disconnect, sometimes between some of the obesity, public health messaging and some of the eating disorders work that's going on, you know - yes, we have huge proportions of population who would benefit from support around overeating or under exercising, but there's even just because it's a smaller group of the population doesn't mean that those are these disorders don't get affected by some of this rhetoric that exists within within our landscape. I'm not sure what the solution is. It's just ... but it is really, really difficult and it does conflict, certainly, with some of the messages that are out there in regards to kind of promoting positive healthy eating practices that we would endorse within a, from an eating disorder perspective compared to some of that obesity, public health messaging is that it does exist.

Patricia Carswell: 50:08

So it's really about balance isn't just, you know, watching, being mindful of what we say, modelling kind of healthy behaviour ourselves in terms of balanced diets involving every kind of foods, no bad foods, but just in moderation.

Dr Carolyn Plateau: 50:25

Yeah, precisely. And, you know, I think weight manipulation can often be seen as a bit of a quick fix, particularly in sport, you know, it's often a quick route to success, perhaps not a particularly sustainable one. But it can be often seem to be a bit of a quick route. And I, you know, I would always advocate for staying away from that - there are, there's almost certainly 99 other things that you could do before you need to start even talking about or making changes to an athlete's weight, depending on the developmental stage, their training history, that you know, their technique, their skill development, their weight training, there's so many other things that we could talk about and address as coaches and practitioners and, and others, before we even start having that conversation about whether we need to involve start manipulating weight or making changes to body size and shape. So I would always ask yourself, you know, have you have you done everything else before you start trying to do changes to make changes to weight or nutrition, because it's that 1%, it's not necessarily relevant to the vast majority of our sports men and women. And there's so many other things that they can do first.

Patricia Carswell: 51:28

Well, that's an absolutely brilliant message to end on. Thank you so much. It's been really interesting, really important, really helpful. And I know that people are going to have a lot to take away with them. So thank you, Carolyn. It's been a real pleasure.

Dr Carolyn Plateau: 51:44

Pleasure. Yes. Thank you for having me. I really enjoyed talking about it. And yes, do reach out if there's anyone has any questions or would like more information on our cost, and then please get in touch.

Patricia Carswell: 51:54

We'll I'll put all of the details how to contact you and where people can get get hold of the online coaching. I'll put all of that in the show notes.

Dr Carolyn Plateau: 52:02

Brilliant. Thank you.

Patricia Carswell: 52:07

I don't know about you, but I'm really heartened to hear about the training programme for coaches. And I'd ask you to share this episode with all the coaches you know, as well as parents of young athletes, because I think it's incredibly valuable. Carolyn has very generously offered a discount for group bookings. And I'll put all the details of the course and the discounts in the show notes as well as details of further reading that Carolyn has recommended, and details of eating disorder resources and charities. As always, thank you for tuning in. If you can take a moment to rate and review the podcast on Apple that would be incredibly helpful. And you can find me on social media at@girlontheriver on all channels. Next week, I promise you we'll have the fabulous hosts of Steady State, Tara Morgan and Rachel Freedman, and I think you'll love them. We certainly had a lot of fun recording it. And until then, next stroke, easy oar.