Monthly Archives: January 2014

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The Dirt on Dieticians

Everything you’ve wanted to know that the internet won’t tell you.

“Experience is the father of all wisdom.
And assumption is his bitch” – Brett Sutton.

Cake. It's just cake....not the spawn of the devil.....

Cake. It’s just cake….not the spawn of the devil…..

If there’s one thing certain to strike fear into the bones of most humans, it’s someone knowing the intimate details of your daily doings – every morsel of food and fluid intake scrutinised, every measure of fitness and body fat calculated, every minute of calorie-sapping exercise tallied. And judged. Usually by an underweight and pale young woman sitting unusually upright on the other side of a cold desk (sorry for the stereotype but I know a lot of dieticians and it’s hard to argue with it!).
OK so they get a bad rap. But here’s the thing – they can be your ticket to freedom and your greatest ally. They can get you what you want, faster than you can get there on your own. They can take you to new heights of perfectionism in the body composition department and by default, they can lift your athletic performances through the roof. And lower your injury and illness count. They can help you learn to eat more normally, without necessarily putting on weight.

So what’s the catch? Like any industry, there are bad ones and good ones, and you need to get it right. A bad experience can be nothing short of traumatising, so do the work first to limit the chances of hitting a bad one.

Look for an Accredited Sports Dietician (whether you’re an athlete or not…).

In Australia to become a dietician requires a 4 year-degree. During that time they learn a lot about a lot….but don’t become specialists in any one field. They’re basically good at general nutrition and hospital nutrition. To then become an Accredited Sports Dietician they have to do an extremely difficult course which involves training in the specifics of manipulating body composition in athletes and also in dealing with eating disorders, which come with a host of specific challenges (physiologically, metabolically and emotionally). I actually know good dietician friends of mine who openly admit they won’t treat ED’s, so challenging is the task. So rule number 1 to avoid a horrible experience with a dietician is to find a good one with appropriate training, and you can minimise that risk by searching on the Sports Dieticians Australia website (or relevant body in your country).

Even better: Find a Sports Dietician who has an interest in treating Eating Disorders (note I did not say “find a dietician who obviously HAS an eating disorder….).

I’ve had several bad experiences with the stereotypical uptight-skinny-hospital-dietician in my time and while they were great at boosting my weight when I probably needed it, they weren’t great at inspiring my faith in the recovery process being all rainbows and unicorns (it’s not, but it doesn’t have to be as bad with the help of someone more useful and “real-world”). So how do you find a good one without totally blowing your cover? Well I was lucky enough to have a close friend go through the dietician process first, and I knew that she was seeing someone but not gaining any weight. I probed. She confided that she instructed the dietician that she wants to learn to eat more normally, but only under the proviso she didn’t gain any weight and didn’t have to stop exercising. And the dietician obliged. I booked in the next week.

Failing being that lucky, the internet is a good resource for searching – most good dieticians will have a bio on their website and state their treatment interests. Also check their photos if they have them and see if they have a glint in their eye, shiny hair, glowing skin, no collarbones sticking out…..the healthier they are the better off you’ll be with them.

“The thought of fronting up for the first time makes me want to vomit”, “they’re going to see straight through me!”, “I’m too fat to have an eating disorder”, “If they find out how little I eat they’ll tell my family” …..and other irrational fears.

I 100% understand all of the above fears and many more. So having been through it myself, here’s the actual facts of the matter.

Yes, they will likely see straight away that you have disordered eating of some type but they will not bring that up with you, at least not initially. They legally cannot tell anyone, unless you are under 18 and extremely, about-to-drop-dead underweight (if you are over 18 you will have a say in the matter). Anything that is said to them – exercise patterns, food intake, weight etc – is legally confidential. It’s a safe space. A good dietician probably won’t weight you, and especially won’t if you ask not to be. My dietician always took other measures like circumferences but never told me what they were, just whether they were up or down. People with dietary issues come in all shapes and sizes – seriously sick bulimics can be overweight, just like someone who’s had anorexia for a very long time can be normal weight due to metabolism dysfunction – so they will never, ever look at you and think “you’re too fat to have an eating disorder”. Ever. Promise.

If you’re seeing a private dietician, and you’re paying for it, their job is to facilitate you with your goal. Whatever that goal is.
If you go in and request to eat more and stay the same weight (so long as you’re not about to die on the spot from malnutrition, in which case a hospital dietician is actually more useful to you), they will work with you on that. When I first started seeing my dietician, I was 8kg less than I am now, my “healthy adult weight”. So, not grossly underweight, but not ideal either. I was hardly eating anything, exercising the house down, miserable…..and my metabolism was getting more thrifty by the year (making it harder to lose weight). I was over it.

What she did then single-handedly prompted my recovery, in earnest this time. Over the course of a long time, she introduced more foods and more volume, and – miraculously – I actually maintained weight, even lost it at one point. During this “trust” experiment, we also included a period of 2 weeks of zero exercise, to overcome my greatest fear – of putting on weight if I stopped training. It was the scariest thing and still makes me feel sick remembering how stressful it was. I actually lost weight, which gave me a huge confidence boost in my mind and body.

Of course, I did need to gain weight in order to be healthy. But she never pushed me, just gently supported me and taught me to trust food and my body. I maintained that weight for a further 3 years, then eventually when I was ready I allowed my weight to very slowly increase to where it sits today. And I can honestly say, now that my body has hit its set point, I can pretty much eat whatever I like and it stays within 1-2 kgs. I put this down to having such a good program to start with.

You don’t need a referral from a doctor to book in.
In Australia you can call and book with a private dietician without a referral. You do not need to tell the receptionist over the phone what you want to be treated for. The cost will vary, depending on the practitioner (generally better ones are more expensive); you can claim about half the fee back from your private health cover.
Ultimately you are paying for the service and hence their job is to meet your goals. They will discuss your goals with you and go through relevant information, give you little things to work on. They’ll send you off for a couple of weeks to work on it and then remeasure and continue. Every single day they see patients who have exercise addictions, want to improve body composition, have disordered eating, thrifty metabolisms and crazy dietary practices, and who think “they’re too fat to have an eating problem”. There’s nothing they won’t have seen.

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My road to recovery would have been a rollercoaster of metabolism riots and psychological warfare – as opposed to a relatively smooth upwards progress curve – had I not made the mighty step to make contact with my dietician. How do I know? Because I’d tried the other way for a decade beforehand. And it was failing miserably.

“You do not drown simply by falling into dark waters; you only drown if you stay beneath the surface” – Paolo Coelho

You can do it.

K xo

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The broken. A Survival Guide.

Part II:

So you’re fractured – body and brain. You want to scream at the world and pull your hair out and cry, simultaneously. I get it.

In the previous post I introduced the concept that perhaps it is essentially the mind that causes stress fractures in the large majority of athletes, moreso than just the body failing, as modern medicine would have us believe. Specifically, the sheer force of power that is that voice in your head that will not allow the body to stop, even when presented with increasing physical pain. We are a smart bunch; it’s not like we don’t know that something’s wrong and it’s getting worse. It’s just that stopping is infinitely harder than pushing through a little physical pain. Hell, sometimes the physical pain feels good – euphoric even – like you are fighting the beast in a different way. And yes, the pain of a stress fracture is “little” in comparison to running 35km after not eating much for a few days….there’s levels of relativity and most of you here have an abnormal sense of ‘perspective’ when it comes to matters of human suffering. I wish it wasn’t so, I really do.

Sometimes the beast wins, and you find yourself in the doctor’s or physio’s office with a full-blown stress fracture or major overuse injury, which essentially you did to yourself. Yet another kick in the guts. Facing down the barrel of 6-12 weeks off your beloved sport, you feel the red rush of hot panic bubbling up from the fracture site and seeping into your heart. Staring at the image of a clear break on a clear scan, suddenly the pain feels so much worse.

What now?

Sesamoid IV

There are hundreds of well researched and accessible texts on gold standard treatment protocols for stress fractures, ranging from stopping running right through to the extreme of surgery, depending on the site and severity of your injury. But there are very few resources written on coping with the emotional and psychological backlash of injuries, much less if you also have an eating disorder or disordered eating and you are now faced with the removal of one crutch – running (emotional) and the replacement by another crutch (literal).

1) Take time to digest the news and go through the stages of grieving, so that you can recognise what you are dealing with. If possible, have a close friend or loved one with you to help with the support and to remember information. The average patient only retains 30% of what is said to them during a medical consultation. Even better – write it down. The doc won’t mind.

2) Embrace the “Athlete Mindset”. The fact that you are in this situation means that you are dedicated enough to your pursuit of excellence that you are already in the top minority of athletes. BUT….you need to learn when that line is approaching and how to not cross it in the future. Allow yourself to recognise your best traits (discipline, commitment, passion), but also to define what you would like to work on in the future (the strategies in part I – prevention; listening to your body; allowing yourself to rest and letting go of some of that perfectionism….). Your “training” now is recovery. That is no.1.

3) Get some Sun. It’ll help with the bone healing thanks to its Vitamin-D inducing properties. It will also assist with depression, appetite and most importantly it will get you outside into the fresh air.

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4) Ensure Social Contacts. It’s more important now than ever to make sure that you stay involved somehow – whether that be with group catch-ups after training, going to training or dance class and assisting the coach or teacher, keeping up with dance or running magazines. While it seems counterintuitive, this can actually help you to keep the “athlete mindset” and to help with staying on track in order to achieve bigger goals in the future.

5) Create a different outlet. Use your emotions as a guide. Do what makes you feel good; steer away from things or people that make you feel more down or frustrated. Be aware of being pulled towards bad habits – they can be strong and start sneakily. Tune into your emotional radar early when it’s slightly easier to resist.

6) Develop a nutrition plan. And stick to it. Most notably:

a. Avoid regular and diet sodas due to the bone-leeching phosphoric acid contained in these liquids.

b. Reduce caffeine intake, ideally to less than 2 cups a day. Caffeine also leeches the skeleton of calcium, critical when the bones are in healing mode.

c. Avoid alcohol, which can induce a pro-inflammatory environment and affect absorption of important nutrients in your food. Aside from this, it is a depressant so probably not helpful on the brain given the current situation.

d. Maximise sleep, as this is where your largest surge of growth hormone occurs – crucial for healing and mental health as well. Talk to your doctor about this if you are struggling, which is common when you are used to expending so much energy on a daily basis.

e. Most challenging of all….keep the focus on nourishing the body with high quality foods, now is not the time to diet or restrict food groups. Keep in mind that healing takes up a huge amount of energy. Accredited Sports Dieticians are very experienced in this field thanks to the high injury rate in elite athletes – and yes, you can totally book an appointment and request a meal plan to maintain your current weight while injured, whatever that weight may be. Even if they suspect you have a phobia of certain foods or a controlling personality, they will respect that and all information shared is legally confidential.

7) Most importantly, give yourself permission to rest and heal. If you cannot give it to yourself, ask your health professional – whether it be your dietician, psychologist, physio, doctor or even a friend or loved one. The most weighted words you can hear are “you are not allowed to exercise with this”. You have permission, to just heal. That is your number 1 job. There will be plenty of time once you’re back on your feet to concentrate on training; for now, the more you rest, the faster you will heal.

Of course, it all sounds so practical and easy when it’s neatly typed out on a page. It won’t be – it’s going to be hard, much harder than the physical pain of the initial injury or the discipline of full training. But if there’s one thing that’s certain, it’s that with no plan at all, things will likely slip downhill fast on the sliperyslope to ED-land. You will have a much harder fight on your hands in the mental department during your down time, but it is worth fighting for and you will come through the other side a stronger, better, more passionate athlete. In my younger (Ana) darker days I had a tibia stress fracture which I couldn’t (mentally) stop running on, eventually I ended up in a cast. When the repeat XRays were done at 8 weeks there was zero evidence of healing, mainly because I had been stressing and severely restricting food during that time and had consequently lost a significant amount of weight. Yes, that can happen. Don’t muck around with it – the psychological setback is so much worse the longer it goes on.

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Stay strong, fight the good fight, and learn from your experience so that you can come out fighting.

K xo

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Stress Fractures – Dealing with the Emotional Backlash of Injury

Part I: Prevention

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“And so that I do remember
to never go that far,
Could you leave me with a scar?” – Missy Higgins

So you’ve found yourself staring down the barrel of some time away from your most-loved activity, likely due to impending injury, an exercise ban, a fatigue-related illness or something similar. It’s not bad enough that you feel like your legs have been cut out from under you however it is bad enough that you feel some fear and insecurity fast-arising in the knowledge that you need to rest, and you’re not very good at that. I’m going to focus on strategies to help specifically with preventing stress fractures in the early stages, mainly because of the high incidence of them in athletes with disordered eating of some sort. However many of you will find these tips helpful for other situations as well.

Eating disorders occur in up to 19% of male athletes and 45% of female athletes, according to the literature. Which logically speaking puts this group at the highest risk of sustaining the dreaded stress fracture, simply put – too much overload on a weakened skeleton, too much exercise, and not enough nourishment to keep up with the bone turnover. The most high-risk sports for sustaining stress fractures are also those with the highest rates of disordered eating: ballet, distance running, skating, gymnastics and rowing.

But here’s the thing: stress fractures are also arguably the easiest of the overuse injuries to prevent from happening, or at least prevent from worsening once they start. They are thoughtful little devils, in that they give you warning signs as they gently create microcracks in the bone, one painful step at a time. Should you choose to ignore the progressing microcracks, they will get crankier day by day, eventually making it painful for you to walk. Should you choose to really blow them off, you can run yourself into a full bone fracture – bringing with it night pain, throbbing and swelling at rest, and usually some time non-weight bearing (in a cast for the lower limb, crutches for the hip and femur, typically 6-12 weeks IF you eat well during recovery, longer if not).

So while health professionals and researchers are spending oodles of money researching how to best prevent and treat these debilitating injuries, I’m going to talk about the elephant in the room. The fact that most of these stress fractures wouldn’t eventuate, if the athlete made the choice to stop the aggravating activity when it first surfaced its head. A newly formed stress reaction (the stage before a stress fracture) will heal with just a couple of weeks off running – you can usually keep walking and doing all other exercise. Seems simple – just stop running, or dancing. Have a week off.

Only it’s not that simple, because you can’t. You have a voice in your head that wants you to push through the pain, because if you stop running, you’ll get fat and lose everything you’ve been working for. You try to argue with the voice, reasoning that a week off now is far better than 8 weeks in a cast if you keep running…..but you can’t. Simply put: the pain from ignoring/fighting the voice in your head is worse than the pain of the stress fracture. Far worse. And that is something that only someone who has been through an ED would understand; certainly your doctor or physio is unlikely to get it. “You have such a high pain threshold”, they say. Oh if only they could walk a day in your shoes! Physical pain is a mere annoyance; mental pain on the other hand is nothing short of crippling. And it never stops. Like a repetitious steak knife to the brain.
So, my goal for myself and others is to work out strategies to help fight the beast at this crucial moment in time when things are make or break, quite literally:

1) Fight the Fear Head-On. In this day and age, with a little Google-action combined with the high IQ of most high-achieving individuals, it is likely that you already know when you are at risk of an impending stress fracture (Google “foot pain in a runner” and see what comes up….). Next step then: google the treatment protocol. While I spend much of my work life as a Physio hating when patients self-diagnose, in this case it can be useful as a head-on tool for fighting the ED voices that are insisting that you push through the pain. Sometimes, having the weaponry of “if we keep pushing through this pain we won’t be able to run or walk for 6 weeks!” is helpful in the daily warfare and can assist in avoiding a full-blown bone break.

Sometimes fear of the impending "worst case scenario" can help you to protect your body before the worst happens....stick it somewhere you see it often

Sometimes fear of the impending “worst case scenario” can help you to protect your body before the worst happens….stick it somewhere you see it often

2) Verbalise what is going on to someone that you trust. It’s OK to say “I don’t trust myself to not run at the moment”. Even better if you can get some company – ask a friend to come walking or to the gym with you, so that they can be in charge of not letting you hurt yourself. Or tell your dance teacher or coach what you are and aren’t allowed to do. It’s OK to ask for help, and it’ll give you that exercise outlet without having to fight the self-destructive urges for at least a small amount of time.

3) Create a plan, write it down, and obsessively stick to it. Channel the beast into a set program of a different kind – one that won’t cause further hurt. If you’ve caught it early, you’ll likely need about 2 weeks off pounding activities. So write a plan filled with core work, swimming, cycling and other safe activities and commit to recording your sessions. Often the objectivity of having a written plan helps to quieten the irrational urges that surface.

4) Create a goal that relies on you not worsening this injury. You may have a dance concert in 3 months, a fun run in 4 months, an Ironman in 6 months or even a holiday or event that you’d love to be strutting around in high heels for. Get something visual to remind you of this, and stick it somewhere you’ll see it – screensaver, dresser mirror etc.

5) Visualise yourself at your fittest and healthiest. Defend your health at all costs – you only have one body. Whenever we break it down, whether it be through malnutrition or injury, it takes a huge amount of time and energy to rebuild the body. Same with the starvation cycle – every time you go through the process, your metabolism gets damaged just that bit more and it’s harder for it to bounce back (trust me after 10+ years of that cycle the body becomes very thrifty!). As painful as the ‘now’ is, try to focus on the bigger, long-term picture as much as possible.

6) Distract yourself. Plan activities ahead of time, so that idleness doesn’t allow for unhelpful thoughts to sneak in. Anything you love that maybe you usually don’t make time for when you are training – baking, art, writing, reading, coffee with friends, photography. A gratitude journal can be extremely helpful at this time for focusing on all the wonderful things that you do still have.

7) Failing all of that: get your Physio involved. I have both been a patient, and had patients of my own, who need to be “protected from themselves” (or more accurately, Ana or an exercise addiction or both). You may think you are insane asking for help, but your Physio (if they are decent) will already know that you are struggling to stop exercising, and will have treated others like you before. There are options to put patients in a cast or boot or on crutches even in the early stages of a stress reaction if they aren’t able to stop themselves from making the injury worse. ‘Do no harm’ is always the number one priority, whatever form of protection that comes in. If you can muster the strength to tell your Physio that you cannot stop yourself from running, they will take over with the rest and you are allowed to feel the sheer relief of not having to fight the beast, at least for a few weeks.

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In part II of this post I will go into strategies for psychologically coping with more serious injuries or down time from your beloved sport.

K xo