The Legal Duty of a College Athletics Department to Athletes with Eating Disorders: A Risk Management Perspective

by Barbara Osborne Bickford, J.D.

I. Introduction

In virtually every college athletics department across the United States, there is an athlete with an eating disorder engaged in intercollegiate competition. Progressively larger proportions of eating disordered women have been identified in the general population and in college student populations, and they clearly have an analogue in the athletic sphere. Knowledge of eating disorders in athletics populations has existed for almost twenty years, yet many colleges and universities seem to be ignoring the problem. Eating disorders are a serious health threat that require prompt medical attention. Colleges owe a duty of care to their athletes: a college that ignores eating disorders may be negligent. To prevent legal liability, colleges and universities must educate their employees to be aware of and recognize symptoms of eating disorders, create a plan for intervention and treatment or referral, and engage in preventative education. As a general policy, it is unacceptable for colleges to recruit student-athletes, promise to train them to achieve peak performance, and ignore them as they simultaneously destroy their health.

II. Prevalence: A Problem Exists

Researchers and therapists have indicated for the past 15 years that athletes are a high risk group for developing eating disorders. Prevalence of disordered eating is significantly higher among athletes involved in sports in which light weight or small body size is deemed necessary to achieve performance success, weight classifications apply, and aesthetic ideals of beauty apply than compared to the general population. Although some sports seem to have a higher prevalence of athletes with eating disorders, the NCAA survey showed that eating disorders were reported in almost every sport, and that no activity should be considered exempt from the problem.

The prevalence rates reported have varied according to the population sample and the tools utilized to collect the data. Borgen and Corben reported that 20% of the athletes tested demonstrated eating disorder tendencies; Rosen, McKeag, Hough and Curley reported 32% of athletes used unhealthy weight control behavior; Costar found that 24% of female gymnasts sampled used self-induced vomiting or laxatives to control weight; Worsnop reported that ten percent of the female athletes at the University of Texas had eating disorders, and another 20 to 30 percent showed signs of eating disorders; and Overdorf found that an alarming rate of over half of the athletes tested were using pathogenic weight control methods, including exercise abuse.

In a 1985 study of college athletes, Guthrie found that 7% of the athletes were identified as weight preoccupied according to the Eating Disorders Inventory , 8% of the athletes were identified as bulimic according to strict criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) , 41% of the athletes reported binge eating tendencies and 16% purged through the use of vomiting, laxatives and/or diuretics. Twenty percent of athletes indicated on the Purging Mechanism Inventory that they engage in purging behaviors to control weight, with an additional 11% engaged in severely restrictive dieting or fasting, 47% using excessive exercise as part of athletic training, and 34% exercised additionally beyond the athletics setting. Perhaps the most alarming finding in Guthrie's study was that 23% of the athletes reported that they had an eating disorder in the past, 14% admitted to currently having an eating disorder, and 73% of female gymnasts, 41% of synchronized swimmers, 39% of cross country runners, and 36% of swimmers and divers reported pathological eating behaviors.

Whether athletics programs are a breeding ground for disordered eating behavior, or whether competitive sports attract compulsive over-achievers who are predisposed to eating disorders is not known . The athletic personality is almost a textbook definition of an eating-disorder personality: compulsive, driven, and self-motivated. The athlete who accepts the challenges of serious competition is rigidly self disciplined and a perfectionist, like the anorectic, but only in behaviors relating to athletics participation. Although athletes displayed less extreme behavior patterns, and are considered psychologically healthier than eating disordered patients, the athletes' self perceptions, and their perceptions of how they think others see them, still differ markedly from reality. A little over half of athletes in the Overdorf study saw themselves as heavy, while in reality only 3% would be in a heavy category.

The awareness of the advantage of reducing body fat for optimal athletic performance coupled with the strong negative aesthetic and moral connotations of fatness in our society creates strong pressures on athletes to abhor and reduce body fat. As athletic performance improves and records become more impressive, athletes will go to extreme lengths to improve their techniques and enhance the physical state of their bodies. The use of pathological weight control techniques is a quick way to reduce body fat to increase strength, speed and endurance. For these athletes, disordered eating is just one more sacrifice to gain a competitive advantage.

There may be a small percentage of eating disordered persons who participate in athletics because of their compulsive need to exercise. The non-athletic anorectic exercises frantically for fear of gaining weight. In comparison, the anorectic athlete trains hard with the hope of improving performance. What begins as a simple equation in the mind of many athletes, "Weight Loss = Improvement" may lead to an uncontrollable obsession with harmful and potentially fatal consequences. Optimal competitive weight and superior performance become interrelated goals, although the athlete's ideal of thinness usually represents a degree of emaciation unhealthy for a normal person.

Unfortunately, many athletics departments are choosing to look away from this serious problem. In March 1990, a one-page survey was sent to the senior women administrators of athletics programs at each of the 803 NCAA member institutions. Only 491 of the member institutions responded to the survey, although each of these institutions had previously received eating disorders educational materials from the NCAA and should have perceived eating disorders to be a serious problem for athletic populations. Of the responding institutions, only 64% indicated that at least one student-athlete had been identified as having an eating disorder. One hundred seventy eight institutions reported no incidents of eating disorders in their athletics programs. Given that a minimum of six percent of the general population has an eating disorder, and that athletic populations report even higher incidence of eating disorders, it is alarming that more than one-third of the intercollegiate athletics programs in this country do not recognize eating disorders or are ignoring this serious problem.

Eating disorders are easily the gravest health problem facing female athletes. Inattention to these problems may be related to the fact that aberrant behaviors have still not been recognized by athletics personnel as serious, or because the problem is perceived as primarily a female issue and is therefore not serious. What exactly are eating disorders? And why are athletes who engage in these behaviors at risk?

III. Definitions and Descriptions of Eating Disorders Prevalent in Athletics

There are three types of eating disorders -- anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified -- that are commonly known in athletics populations.

A. Anorexia Nervosa

The typical anorectic is a white adolescent female from a middle to upper class family. She is unrealistically perfectionistic and consequently, highly motivated. Anorectics are also described as obedient and over compliant, due to a lack of self esteem, which is highly dependent on her body shape and weight. Outwardly, she will give the appearance of being under control, while she may actually be very dependent upon others, such as parents, coaches, or advisors. She tends to be a loner, and despite expressed concern from friends and family about her emaciated appearance, she will insist that she is fine. It is rare for an individual with anorexia nervosa to acknowledge being thin, and she will typically deny the serious medical implications of her malnourished state. The clinical criteria for diagnosing anorexia nervosa is outlined in Table 1.

The physical effects and serious medical complications resulting from disordered eating are a threat to the total health of the athlete, and will ultimately be a threat to her life. Routine training and competition create additional stress on an already abused body, putting eating disordered athletes at greater medical risk than the average eating disordered population. Initially, the athlete's performance should improve with weight loss, particularly if the athlete was above an ideal competitive weight prior to training. As body fat decreases, the oxygen which was used to oxygenate the excess fat tissue, is now utilized more effectively by the muscles. However, after a certain degree of weight loss, the body becomes deprived of sufficient calories and nutrients to fuel, maintain, and regenerate the muscle tissue as required for ordinary training. Muscle power and endurance will be impacted by a diminution in protein synthesis and inadequate glycogen and fluid stores. Fatigue becomes constant and injuries repair slowly. In addition, an eating disordered athlete is likely to become ill more frequently, which negatively impacts her ability to train consistently. Ultimately, the loss of strength and concentration due to disordered eating will negatively affect performance.

Eating disorders are coupled with amenorrhea and osteoporosis in a medical grouping known as the female athlete triad. Inadequate nutrient and energy intake effect hormone production resulting in amenorrhea. The further consequence of amenorrhea is osteoporosis , which results from decreased estrogen levels in the amenorrheic women. Long term irreversible health effects are likely in the female who does not achieve peak bone density. Anorectics have suffered stress fractures just walking down the street.

Dizziness and loss of consciousness while participating in most sports may lead to serious injury. Endocrine abnormalities are well documented, and fluid and electrolyte disturbances can increase the risk of cardiac arrhythmia, renal damage, and impaired temperature regulation to the athlete who stresses her body to maximum levels. Unfortunately, by the time the athlete has driven herself to this level of depletion, she is already psychologically caught in an eating disordered behavioral whirlpool. She is not able to recognize her problem, and is likely to address her failing performance level by losing more weight.

Common medical conditions caused by anorexia nervosa include:

• dry skin and dehydration caused by reduced fluid intake and excessive fluid elimination

• constipation due to the failure to ingest or retain adequate amounts of food and/or fluid

• bloating and distention of the stomach and abdominal area due to malnutrition, long periods of starvation, frequent vomiting and/or excessive use of laxatives or diuretics

• impaired renal function, dulled intestinal nerves and general gastro-instestinal systems problems from laxative abuse

• cramps and muscle spasms from insufficient potassium and protein intake

• dizziness due to low blood pressure

• disruption of normal hormonal secretions including decreased estrogen leading to amenorrhea and osteoporosis

• cardiovascular problems, hypotension, decreased cardiac output, cardiac arrhythmia, and electrocardiogram abnormalities

• complications of self induced vomiting including dental erosion, esophagitis, esophageal laceration, internal hemorrhage, and parotid gland enlargement.

• mild anemia

• significant fluid and electrolyte disturbances.

B. Bulimia

Bulimia is often confused with anorexia because the term is used to describe both a symptom and a syndrome of disordered eating. The word "bulimia" means "gorging" or "insatiable appetite". Bulimia, the symptom, generally describes binge eating. Bulimia, the syndrome, is a serious disorder involving compulsive preoccupation with food and compulsive episodes of overeating followed by a purgative episode. The clinical diagnostic criteria for bulimia is listed in Table 2.

Like anorectics, the bulimic has poor self esteem and issues of achievement conflict. Additionally, bulimics suffer from feelings of rejection, and have difficulty expressing anger and frustration. The bulimic has a psychological feeling of inadequacy, and believes she is unable to face her problems or cope with the world directly; she may also suffer from anxiety, depression, or suicidal tendencies. Bulimics often feel that their life is dominated by conflicts about eating. The binge is a direct end-product of this feeling of lack of control; the purge is relief. Many bulimics have previously been anorectic.

Bulimics may be overweight, at recommended weight or slightly underweight and their weight can fluctuate frequently due to the binge/purge episodes. Bulimics tend to have a less distorted body image than the anorectics and will focus on their self-diagnosed trouble spots such as the hips, thighs or waist. Bulimics are also impulsive as well as compulsive, and will often times abuse other substances such as drugs or alcohol. They are ashamed of their behavior, and will be extremely secretive and protective of their habits.

If weight loss were the only consequence of bulimic behavior among female athletes, there would be little cause for concern. However, research indicates that disordered eating, when combined with strenuous exercise, leads to physical damage that often is only partially reversible. Dehydration is common in individuals who restrict food intake, self-induce vomiting, and/or use large amounts of diuretics or laxatives. Attempting to train and compete in a chronically dehydrated state will decrease performance and may lead to acute complications such as heat exhaustion or heat stroke. Dental problems are often seen in athletes who vomit in an effort to lose weight. The regurgitation of gastric acid causes enamel to erode, resulting in extensive caries and possibly periodontitis. Athletes may suffer from menstrual irregularity or amenorrhea due to weight fluctuations, nutritional deficiencies or emotional stress. Table 3 outlines some of the more common medical complications related to bulimia.

C. Eating Disorders Not Otherwise Specified

Many athletes display symptoms of eating disorders, but do not meet the strict criteria to be medically diagnosed anorectic or bulimic. However, athletes with less than clinically definable symptoms may be classified as within the realm of "eating disorder not otherwise specified" (ED-NOS). For athletes, even the relatively mild health effect of disordered eating can have a devastating impact and should not be ignored. Table 4 outlines the diagnostic criteria for an eating disorder not otherwise specified.

IV Duty of the College or University Athletics Department

Few cases have arisen in which an injured player or his parents seek recovery from the school, particularly considering the large number of injuries suffered in connection with school athletics. As of this writing, no case history has been recorded of an athlete or her parents suing her coach, athletics department, or college or university for injuries suffered from eating disorders. Many athletes may feel reluctant to sue the coach or the school, or the assumption of risk or contributory negligence defense may inhibit their filing.

According to PROSSER, LAW OF TORTS, to win a negligence suit, a plaintiff must establish:

1. a duty or obligation recognized by the law, requiring the actor to conform to a certain standard of conduct

2. a failure to conform to the standard required

3. a causal connection between the conduct and the resulting injury

4. actual loss or damage resulting to the interests of another.

Whether a defendant owes a duty of care to a plaintiff is a question of law; the court determines whether facts give rise to any legal duty on part of defendant. A negligence claim must fail if based on circumstances for which law imposes no duty of care on the defendant.

It is established that a college or university owes a duty of ordinary care under the circumstances to participants in their athletics program. Schools have been found to owe a duty to student-athletes under a variety of circumstances: there is a duty to exercise ordinary and reasonable care for safety of student athletes under their authority; a duty to intercollegiate athletes to provide preventive measures in the event of a medical emergency; a duty to prevent injured or unfit players from competing; a duty to provide medical assistance; a duty to provide competent coaching, proper supervision, and training; and a duty to take proper post injury procedures to protect against aggravation of an injury. The duty of care is heightened when the college or university actively recruited the athlete to participate in its varsity athletics program. Any of these previously recognized causes of action could logically be extended to include a duty of the college or university to athletes with eating disorders.

A duty of ordinary care is defined by the care a reasonable prudent person would provide under the same or similar circumstances. In Morris v. Union High School, the school was held liable where there was evidence that the injured player was physically unfit to play, the fitness level was known to the coach, the coach encouraged the athlete to participate although he knew the athlete was unfit, and the lack of fitness proximately caused the injuries. Like the coach in Morris who knew or should have known that an unfit athlete is likely to be injured, athletics personnel working with athletes should be aware of the symptoms of eating disorders, and recognize the risk that eating disorders place on the athlete. As the reasonably prudent coach dealing with an unfit or ill athlete would not subject the athlete to additional risk, the coach who allows an athlete with an eating disorder to continue competing without medical assistance is negligent.

Conversely, there is no duty to anticipate and guard against conditions that are not known. In the Kleinknecht case, the court held that the college had no duty to anticipate the chance of a fatal arrhythmia in a young and healthy athlete who had no medical history of heart problems, who had a medical examination by a family physician, and where actions taken by the school employees were reasonable. The Kleinknecht case provides a benchmark for establishing when a coach, college or university acts with ordinary care. In this case, the school acted reasonably in requiring a student-athlete to have a medical examination prior to athletics participation. The medical examination revealed no medical history of heart problems, or symptoms of heart disease. For these reasons, the athletics department personnel had no reason to know, and could not have known, that Kleinknecht was at risk for a fatal arrhythmia.

A thorough pre-participation medical examination is likely to indicate symptoms of disordered eating. As symptoms of eating disorders are recognizable, a duty of ordinary care would attach and the coach would be expected to act as the reasonable prudent coach in the same or similar circumstance by seeking medical attention for the athlete and guarding against further damage.

In Stineman v. Fontbonne College, the court finds a duty to provide medical assistance to a hearing impaired athlete who was struck in the eye by a softball. The court relied on the three-part test established by the Missouri Appellate Court in Kersey v. Harbin:

1. the defendant must have been able to appreciate the severity of the plaintiff's injury

2. one or more of the defendants had the skill to provide adequate medical treatment

3. providing medical attention would have avoided the injury's ultimate harm.

This test can also be used to establish duty to athletes with eating disorders. One need only look to the plethora of information available on eating disorders to establish that athletics department personnel are able to appreciate the severity of eating disorders, or that athletics department knew or should have known of the severity of eating disorders. It could be argued that athletics department personnel do not have the skills to provide adequate medical treatment for athletes with eating disorders, and therefore not satisfy the second part of the Kersey test. However, the only treatment required in the Kersey case was to get the injured person to a doctor. The only skill necessary in the case of an athlete with an eating disorder would be to refer the athlete to treatment. The third part of the test would also be satisfied: early medical intervention is key to preventing the permanent medical complications and potential death for athletes with eating disorders.

A reasonable, prudent person must be able to foresee the injury or harm in order to conform to the duty of care recognized by law. It is not necessary to prove that the very injury which occurred must have been foreseeable by the coach in order to establish that his conduct constituted negligence; negligence is established if a reasonably prudent person would foresee that injury of the same general type would be likely to happen under the circumstances. No person can be expected to guard against harm from events which are not reasonably to be anticipated at all, or are so unlikely to occur that the risk, although recognizable, would commonly be disregarded. However, if the risk is an appreciable one, and the possible consequences are serious, the question is not one of mathematical probability alone. As the gravity of the possible harm increases, the apparent likelihood of its occurrence need be correspondingly less to generate a duty of precaution. Information easily available on eating disorders and athletes indicates that coaches should be able to foresee the harm of allowing athletes to participate without medical attention. Prevalence studies show that eating disorders are to be anticipated in athletics populations. The risk is an appreciable one and the possible consequences are serious -- the most serious consequence being death.

For an athletics department to be negligent of its duty of ordinary care for athletes with eating disorders, there must be a causal connection between the conduct of the athletics department personnel and the resulting harm to the athlete. Eating disorders are complex problems with biological, psychological and sociological components. It is not the intent of this paper to show that colleges, universities, or athletics departments are the cause of eating disorders. However, it is possible for an eating disorder to be triggered by a single event, or by comments from a person who is important to the athlete. Coaches are the single most blamed source of eating disorders in athletics populations. Careless comments about fat, weight, or athlete's specific body parts may trigger pathological behaviors in athletes that can lead to serious problems with eating disorders. Although it may be inappropriate to label any single incident as "causing" an eating disorder, the coach still has a duty of care to his athletes, and breach of that duty is negligence. Under the doctrine of respondeat superior, the employer is responsible for the actions of its employees. If the coach or any athletics department personnel is found to have acted inappropriately, he is negligent, and the college or university is derivatively liable for the negligence of its employees.

As eating disorders are a self-inflicted condition, the college or university faced with this problem may use "assumption of risk" as an affirmative defense. Assumption of risk is fundamentally based on consent, and applies regardless of the care used. As a general rule, participants properly may be held to have consented by their participation to those injury causing events which are known, apparent or reasonably foreseeable consequences of the participation. To establish the athlete's assumption of risk, a college or university must show that the athlete was aware of the dangerous condition and the resultant risk, although it is not necessary to demonstrate that the plaintiff foresaw the exact manner in which his injury occurred. The reasoning applied in these cases, which generally deal with physical condition of facilities or equipment, should not be extended to waive the duty of an athletics department to its athletes with eating disorders. The athlete cannot voluntarily consent to participating in intercollegiate athletics with an eating disorder, and assume the risks inherent to that condition, because most victims of eating disorders are unable to realize they have a problem.

A participant in a contest assumes the risks inherent in the game, but does not assume the risk of injury resulting from negligence. Although research indicates that eating disorders are more prevalent in athletics populations, no study indicates that eating disorders are inherent to athletics participation. The college or university would have to prove that the athlete should have been aware of the danger to herself, or that events had occurred which should have forewarned her about the dangers of eating disorders in order to show that the athlete assumed the risk because proper instruction was given. Unless the college or university provided an eating disorders education program, the athlete would not know or have reason to know of the danger to which she was subjecting herself.

Some jurisdictions have abolished assumption of risk and treat it either as an aspect of whether the defendant owes the plaintiff a duty of care, or whether there is a question of the plaintiff's contributory negligence in undertaking the risk. Contributory negligence arises when a plaintiff fails to exercise due care. It is defined as conduct on the part of the plaintiff which falls below the standard to which she should conform for her own protection, and which is a legally contributing cause in addition to the negligence of the defendant in bringing about the plaintiff's harm. At common law, any amount of contributory negligence would bar or proportionately limit recovery by the plaintiff. To be exempted by contributory negligence, the college or university has the burden of proving that the athlete's behavior was a legally contributing cause of her damages. As eating disorders are a medical condition which the athlete cannot control, it is unlikely that a jury would bar the athlete from recovering from the school for breaching its duty of care merely for being sick.

Most states have overcome the harshness of the contributory negligence rule by adopting a comparative negligence rule. Comparative negligence allocates the responsibility for damages incurred between the plaintiff and the defendant based on the relative negligence of the two and reduces the amount of damages to be recovered by the plaintiff in proportion to her fault. Assuming that a jury would find the athlete negligent for her illness, the seriousness of her injuries and permanent physical damage would likely weigh heavily against the college or university and their "deep pockets".

V. Guidelines for the Athletics Department to Meet the Duty of Care

The college or university must take responsibility for eating disorders among athletes. To show that they have acted prudently to satisfy the duty of ordinary care under the circumstances, the college should have a comprehensive education, intervention, treatment, and prevention program which includes:

• an education program for athletics department personnel to meet the duty to provide competent coaching, proper supervision and training.

• a pre-participation physical examination and/or screening program for student-athletes to meet the duty to prevent injured or unfit athletes from participating.

• an intervention protocol and treatment plan to meet the duty to provide medical assistance.

• an eating disorders prevention and nutrition education program directed toward athletes to meet the duty to exercise ordinary and reasonable care for the safety of student-athletes under their authority as well as to address assumption of risk and contributory negligence issues to determine what the athlete knew or should have known.

A. Education for Athletics Department Personnel

In order to meet their legal duty athletics department personnel must be educated about the seriousness of eating disorders, understand their role in preventing athletes from striving for unrealistic weight and body shape goals, recognize the warning signs, and be prepared to manage problems that may arise. Because coaches are the single most blamed source of eating disorders in athletics populations, they must be trained to be sensitive to the weight concerns of athletes. The policy of the athletics department must mandate that coaches put the health and well being of their athletes first, above all other concerns including win/loss records, championships and their own personal coaching reputations. Coaches should also realize the influence that they have and be careful of what recommendations concerning weight and body fat they make to their athletes, knowing that there is a possibility that the recommendations or even careless comments made may be taken to extremes. The coach should be educated and remain current on issues concerning nutrition, diet and weight control.

Because coaches have a duty to protect the athlete's overall health, they should never encourage athlete to try crash weight loss programs. Coaches' education about safe weight control and weight loss measures would include:

• defining optimum performance weight, but not overplaying the impact of weight on performance

• setting a reasonable time frame for weight reduction with a maximum goal of two pounds lost per week.

• increasing energy expenditure at a moderate rate, not more than 1,000 calories per week above the total caloric intake

• referring athletes to a reputable nutrition source or professional dietitian or nutritionist.

Treatment of eating disorders is much more effective when the disordered behavior is detected early, so athletics department personnel need to be educated to recognize the symptoms and warning signs.

The most obvious physical symptom of anorexia is an emaciated appearance. The anorectic's shoulder blades, backbone, and hip bones will protrude, and the muscle groups are clearly visible. However, the athlete with anorexia will not be a thin or light as a non-athletics anorectic because training has increased her muscle mass, and muscle tissue weighs more than other tissue. She will have an irrational interpretation of her appearance, and will continue dieting without regard to her health.

Another common but less obvious symptom is secondary amenorrhea due to the heightened physical activity and low body fat of the anorectic. A study comparing regularly menstruating runners with amenorrheic runners showed the 62% of the amenorrheic runners had diagnosable eating disorders as defined by the DSM-III. Although common in athletics populations, amenorrhea should be considered a warning sign of a larger problem and not disregarded as a convenient by-product of training.

Anorectics may suffer from cold intolerance and complain of chills due to hypothermia. Their skin may appear blue or gray at their extremities due to acrocyanosis. Anorectics will dress in many layers of baggy, oversized clothing to psychologically cover their perceived fat and to physically stay warm. A thin layer of downy hair, called lanugo, may appear on the anorectics body as a physiological response to help maintain body temperature. Other physical changes include skin rashes, and loss or thinning of hair.

The anorectic will usually not be able to display a normal range of emotion. The pursuit of thinness becomes a sign of mastery and control and is the eating disordered athlete's way of dealing (or not dealing) with her feelings. As a result of her starvation tactics, the anorectic usually suppresses her feelings and may no longer be able to recognize other normal bodily sensations such as hunger, thirst, or pain. She may be moody, irritable and display increased anxiety or depression.

The anorectic may also be described as hyperactive and obsessed with exercise. She is constantly moving, and may workout several times each day outside of previously routine training periods. Anorectics are generally restless sleepers and early risers. This behavior has been compared to that of a hungry animal who prowls through the night in search of food.

Weight loss is generally accomplished primarily through reduction in total food intake. The athlete may binge by excluding what she perceives to be highly caloric foods, such as carbohydrates, from her diet. She will exhibit disorganized eating patterns, such as skipping meals, or claim adherence to strict diets (such as veganism) and unusual or extreme food preferences. Most anorectics eventually end up with a very restricted diet that is sometimes limited to only a few foods, such as a banana for breakfast, an apple for lunch and lettuce for dinner.

Because bulimics usually stay in a normal weight range and are secretive about their binge/purge behavior, bulimia is generally much harder to physically or behaviorally detect than anorexia. Psychologically, the bulimic may have tremendous mood swings. She can be shy and withdrawn, and feign helplessness. Moments later, the bulimic may become aggressive, angry, anxious and outgoing. Many bulimics are good actresses who may appear carefree and extroverted when they are inwardly unhappy. The bulimic may also become so adept at lying -- about eating, vomiting, money, weight, etc. -- that she may believe that her deceptions are the truth.

Behavioral symptoms specific to bulimia include obsessive rumination, difficulty swallowing and retaining food, and food sensitivities. Bulimics will chew their food well beyond what is necessary for digestion to prepare for regurgitation. They will generally choose their foods very carefully, and may avoid spicy or textured foods that create discomfort during the purge.

Anyone involved with intercollegiate athletes -- coaches, athletic trainers, administrators and advisors -- should take notice when an athlete repeatedly comments about being or feeling fat, especially if the athlete is at normal or below normal weight. The athlete's "self-talk", verbal expression of feelings and belief systems, will provide a series of clues to diagnose disordered eating. References to death, killing, or dying, such as "I'll die if I eat another bite," or "I'd kill to be under 100 pounds," should immediately raise a red flag. This type of "think thin" behavior should never be reinforced or encouraged by those supervising athletes.

Changes in eating behavior, frequent self weighing or intense fear of, or refusal to be weighed, wide fluctuations of weight over a short period of time, evidence of severe calorie restriction, alternating fasting and feasting, rigorous exercise, loss of appetite, rapid eating, ritualistic diets, and eating patterns, obsession with dieting or with a particular food, food phobias, and depression after eating are all easily identifiable behavioral symptoms of disordered eating. An athlete that always excuses herself to the bathroom immediately after eating should be suspect, particularly if her eyes are watery or bloodshot when she returns. Vomitus odor in the bathroom is a more obvious sign of bulimic behavior. Frequent complaints of constipation, and evidence of diet pills or laxatives are an indicator of pathological weight control behaviors if the athlete is otherwise healthy.

Eating disordered athletes generally become anti-social, separating themselves from their teammates. Staying up alone at night allows the bulimic to gain privacy for further bingeing. Disappearance of food from the cupboards and refrigerator, and unexplained snack or candy wrappings hidden under pillows, mattresses, or chairs can also provide clues of binge eating.

There are several times during an athlete's career that she will be more susceptible to developing disordered eating behaviors. Freshman or transfer years are extremely stressful as the athlete adapts to new living conditions, friends, routines, and responsibilities. An injured athlete can gain weight due to inactivity, or reduced activity, and may use pathogenic behavior to "crash diet". An athlete standing on a performance plateau will try almost anything to gain a competitive edge. Eating disorders also have an epidemic effect on a team -- if one athlete has a problem, it is likely that others on the team have problems as well.

It is important that athletics department personnel are aware of the behaviors which suggest an athlete has an eating disorder, but they should not attempt to diagnose or treat the athlete. The role of the coach, or other designated athletics department employee such as the athletic trainer, is to help the athlete acknowledge pathological behavior and to assist the athlete in contacting an eating disorders specialist for professional evaluation. If the athlete denies the problem, but the symptoms observed appear conclusive, the athletics department should have access to a trained clinician who can review the situation and recommend further action. This behavior would be considered prudent under the circumstances and satisfies the athletics departments duty to provide proper supervision and provide medical assistance.

B. Intervention

The athletics department should have a written protocol for athletics department personnel to confront the athlete once disordered eating behaviors are detected. Just as in alcoholism and other self-abuse illnesses, the first and most difficult step toward recovery is for the athlete to acknowledge that there is a problem. The designated representative from the athletics department, the coach, athletic trainer, or other staff member who is close to the athlete, should initiate communication about the eating disorder. It is important for the meeting to be private, to establish a confidential and mutually respectful relationship. The designee should be direct by telling the athlete that they are aware of her problem and that the university or athletics department is available to help and support her recovery. It is not helpful to ask the athlete if she has a problem, as most athletes do not recognize that they have a problem and the question only provides the opportunity for more denial. A direct approach such as, "I've noticed (these specific behaviors) and would like to help you overcome your eating disorder," is much more effective. A full explanation of the behaviors or patterns that generated suspicion of the problem should be given. The typical anorectic will deny that a problem exists and is likely to get angry and defensive. She will lie about anything to keep the coach from helping her. Athletics department personnel must not ignore the warning signs or allow the athlete to continue her pathological behaviors, but firmly insist that she receive help. Again, if the athlete denies the problem, but the symptoms observed appear conclusive, the athletics department should have access to a trained clinician who can review the situation and recommend further action. The bulimic, on the other hand, generally harbors so much guilt that she may be more receptive toward intervention. The athletics department should have a system of medical referral available for the athlete to obtain a comprehensive diagnostic evaluation.

A pre-participation examination is another way for the athletics department to identify disordered eating symptoms, and protect the college or university from liability for allowing an unfit athlete to participate in intercollegiate athletics. The physician screening for eating disorders should obtain the woman's menstrual history, including age of menarche, frequency and duration of menstrual cycles, last period, and any hormonal therapy that she may be taking. If the college or university does not require pre-participation medical examinations, the athletic trainer may screen for symptoms of eating disorders. Standard tests such as the Eating Awareness Inventory, as well as complete menstrual history, may be used to detect pathological behavior. If the pre-participation screening is positive, the athlete should be referred to a specialist for a comprehensive diagnostic evaluation.

C. Treatment

Diagnosis should only be made by a physician or psychologist trained in eating disorders. Having these key individuals in place will help ensure that the athlete will receive the proper treatment and that the athletics department meets its duty to provide medical assistance. Given the multi-determinant nature of eating disorders, specialists have found that effective treatment requires a comprehensive initial assessment as well as a range of bio-psycho-social treatment interventions.

The initial evaluation by an eating disorders specialist will be comprehensive in covering relevant factors that have influenced the course of the disorder and that would affect the course of treatment. A typical assessment may include evaluation of the following factors:

• Weight history -- questions about the patient's current, highest, lowest and desired weight to provide a historical record of how weight preoccupation and fluctuations have affected the patient's self esteem and life adjustment.

• Body image -- perception ranges from mild distortions to severe delusions and can reflect the patient's overall adjustment. Though patients have traditionally been preoccupied with being thin as a way of managing intrapersonal and interpersonal difficulties, athletes who train in the search of other forms of physical perfection may be just as pathological.

• Dieting behavior -- what age a patient began dieting, the frequency of dieting attempts, the degree of restriction, the use of fad diets, and the general pattern of dieting behavior as well as the training demands of the athlete's sport

• Binge eating -- assess the major life circumstances surrounding the onset of the behavior, the athlete's daily routine, and the specific pattern of the episodes.

• Purging behavior -- the means an athlete uses to purge unwanted calories including vomiting, restrictive dieting, excessive exercise, use of laxatives, diuretics and diet pills and the context and pattern of the behavior to determine whether it is pathological.

• Medical issues -- evaluation of the athlete's physical condition for medical complications.

• Personality disorders -- the presence of a personality disorder forecasts a slow, difficult treatment. This may be even more critical for the athlete because eating disorders, binge eating, dieting, vomiting or using laxatives, or excessive exercise may be part of a normal training regimen. It must be determined whether eating or exercise constitutes excess or abuse by considering the extent to which the training regimen is serving a defensive or compensatory function. Evidence of stormy, chaotic interpersonal relationships may suggest that training and dysregulated patterns of eating are substitutes for close, interpersonal relationships. A history of self-injury or other self-destructive behavior is of great concern. A formal assessment battery of projective and objective testing instruments may be helpful.

• Family characteristics -- family history, family dynamics, and the patient's current level of family involvement also play a crucial role in the onset and maintenance of eating disorder symptoms.

• General level of adaptive function -- the extent to which the athlete is able to work, go to school, or engage in interpersonal relationships, as well as if the athlete is willing and motivated to change, and what intellectual, emotional and financial resources she can bring to treatment.

Once the athlete is diagnosed with an eating disorder, a team treatment approach seems to be the most successful. Doctor, nutritionist, psychologist and athletics department need to work together to create an effective treatment program and to be sure that the messages sent to the athlete are consistent. Treatment will be most successful when the athlete feels that the clinician understands the central role for athletic competition in supporting identity and self-esteem. It should be recognized that there is a therapeutic aspect of participation in sport, but that continued training could be dangerous for the athlete.

Stabilizing any dangerous medical conditions is the initial goal of a treatment program; achieving a healthy target weight is next. To stabilize dangerous medical conditions, it is imperative to stop any further weight loss. A diet and workout program that addresses nutritional needs and caloric intake and expenditure must be established. For example, a runner who is 20 pounds under the recommended weight range for her height and body type needs to work out an intake/expenditure program that will allow her to maintain her present weight. After maintaining that weight for two weeks, efforts can then be made to slowly increase intake to achieve the target weight. Weight gain should be approached very cautiously, as the athlete is likely to cheat if she thinks the eating disorders support team is trying to make her fat. The athlete's progress should be carefully monitored. Recovery is an educational process, and the athlete is more likely to cooperate the more she knows about the potential serious medical risks of her behavior. The consequences of continued weight loss should be clearly defined, with emphasis on the deterioration of her health and performance. An absolute bottom weight limit should be established, and the athlete should be referred to an inpatient program should she sink below that weight.

When the athlete's weight is stable, the eating disorders support team can create a plan to increase weight. It is generally recommended that only 100 calories per day be added to the present diet. This small calorie increase will prevent a huge instant weight gain, which may psychologically reduce the athlete's willingness to continue treatment.

It will also enable the body to physically deal with added nutrients and calories. The ultimate goal is a minimum level of body fat consistent with high energy availability, good performances and good health.

Athletics department personnel and others, such as teammates or family members, that interact with the athlete should be educated about the psychological and physiological changes that occur while the athlete is recovering. As hormone levels change to a normal range, there may be tremendous mood swings. The athlete may have trouble sleeping, and she may feel feverish due to an increase in body temperature. The bulimic may experience a more traumatic recovery than the anorectic. Many will be unable to keep food down, even if they want to, as the gag reflex is retrained. Nausea and other gastro-intestinal problems are common. An athlete who has chosen to compete as an outgrowth of her need for excessive exercise may psychologically need to give up her athletics participation to recover. Most athletes who have eating disorders will return effectively to competition without the disorder.

Every eating disorder treatment plan should be unique to the individual athlete. Treatment may include several of the following common interventions:

• Time-limited Psychoeducational Group Therapy -- most useful for bulimics who are 18 - 30 years old, have high motivation for change, who are at or near normal weight, and who do not have a personality disorders. Psychoeducational groups help patients to understand the cognitive, emotional and interpersonal triggers of their symptoms and to develop normal eating patterns and alternative strategies for coping with negative influences or conflicts. Strategies include self-monitoring, goal setting, educating about nutrition and the consequences of restrictive dieting, and challenging irrational beliefs about thinness and dieting. These groups work best for athletes when there is at least one other athlete in the group.

• Individual psychotherapy -- used to treat both the symptoms of eating disorders and the underlying psychological and emotional problems. Athletes who rapidly form a working alliance with the therapist can reduce and quickly eliminate bingeing and purging in one to four months. Eliminating restrictive eating in low weight bulimics and anorectics usually requires a longer course of individual therapy.

• Nutritional counseling -- counseling by a nutritionist or a well-informed nurse of therapist is an important component in the overall confrontation of the patient's illogical assumptions about food and weight

• Medical monitoring -- athletes with very low weight, those who binge and purge several times a day, those whose laxative abuse is severe or prolonged, and those who have other illnesses should be seen regularly by an internist familiar with eating disorders.

• Psychopharmacological treatment -- those athletes prone to major depressive episodes or panic attacks and chronic anxiety may find anti-anxiety or anti-depressant medication useful.

• Hospital care -- when an athlete suffers from medical complications that endanger her life, or is self-injurious or suicidal, hospitalization should be employed.

Treatment is generally a long, slow process. Follow up interviews at one and two years indicate that only one third of eating disordered athletes will be completely recovered, one third will be significantly improved, and one third will be unchanged. Once an athlete has been diagnosed with an eating disorder, it is important that the athletics department encourage and monitor the athlete's progress throughout their entire intercollegiate athletics career to satisfy the duty to provide medical assistance.

D. Prevention With eating disorders, an ounce of prevention may literally be worth a pound of cure. Perhaps the most effective way of reducing the university's liability for athletes with eating disorders is to prevent eating disorders. An education program emphasizing diet, nutrition, weight loss, and athletics performance should be made available to all athletes, either en masse, as small groups or teams, or through individual counseling. The results of the Guthrie study indicate that athletes have some awareness of eating pathology and would be receptive to nutritional education and guidance, training emphasizing total fitness and body composition rather than body weight or body fat alone, positive interactions between athletes and athletics personnel on weight control issues, and stress management counseling. The program should include discussion about food myths, eating and dieting, psychological and sociological pressures about thinness, body fat and its relationship to athletic performance, myths about pathological weight control behavior, and the physical consequences of disordered eating. The type of educational program can range from formal to informal; many local programs as well as national organizations provide educational programs at a minimal cost. There are a number of books, articles, and pamphlets written on eating disorders which could be distributed or made available to athletes, and symposiums and workshops are frequently offered on the subject. The NCAA also has a three-part video series, Nutrition and Eating Disorders, which is targeted to athletics department personnel. Educating student-athletes about the destructive effects of disorder eating behavior may prevent them from falling into the downward spiral, and it may also protect the athletics department by satisfying the duty to exercise reasonable care for the safety of student-athletes under their authority.

VI. Conclusion

The prevalence of eating disorders in athletics populations is alarming and cannot be ignored. Information about eating disorders is readily available. Colleges and universities must take responsibility and educate their employees to conduct their athletics programs in a manner that recognizes the athlete's health and safety. Recognition of eating disorders, intervention and treatment plans should be established, as well as preventative education programs. The legal duty of the athletics department is to exercise ordinary care as the reasonably prudent person in the same or similar circumstances. A reasonable person would not look the other way.

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