Exercise and Recovery

I’m going to be a little controversial with this post. I’m going to suggest that for a large majority of ED sufferers, recovery would be best done while they maintain their work or school, and for athletes, their training.

Before everyone gets riled up about it, I am not talking about those so severely undernourished that they are at risk of dropping dead from a massive heart attack at any minute, or those with suicidal tendencies….clearly an inpatient program would be best for these patients (at that stage in their recovery, even if those programs for the most part keep people alive but do not really assist in long term recovery and have notoriously high relapse rates….but that’s a post for another day). I am talking about the majority of ED sufferers who are under their individual ideal weight (note I did not say “under BMI 18” – how ridiculous, what about the person with a bigger frame who is still starving but able to maintain a BMI of 21? Are they “less sick”? of course not), are still participating in work or school, and particularly those who are athletes and see that as a part of their identity. I’m talking about the people who are functioning in society, but are significantly affected day to day by their eating disorder – maybe with the accompanying depression, lack of energy and concentration, fatigue, social isolation and the other joyous side effects.

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Here’s why. Think about this: What is the biggest challenge in recovery? I would argue that one of the hardest parts about recovery is learning to lose the “ED” identity and to learn who you really are as a person. Only once that has occurred can one begin to truly move on with their lives and to want to nourish their mind and body. Only then do they have a sense of self to take care of – a reason to recover, if you will. For recovering for someone else, or to get out of Inpatient care, or for the sake of a “goal weight”, will never do it. That typically leads quickly back to a relapse and the cycle that entails.

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Inpatient care, while necessary to sustain a life on the edge, takes away all the other factors in the patient’s life that will be the foundation of their true identity as they return to health: their job, their hobbies, their social network, and for athletes, their training and usually tightknit support crew – coaches and fellow athletes. Not only does it take those things away, it actually forces the patient to focus 100% of their time and energy on the eating disorder. Their days are spent focusing on food, psychology, analysis, resting, scales, and usually the added bonus of in-house competition between patients on who is the “most sick”. Statistically, success rates aren’t good – the weight is temporarily gained, yes; but in the long term, recovery rates can be as low as 20% for patients who have had an ED for an extended time period. The statistics have not improved even after a few decades of treatment in this way. Why not?

At some point, the patient needs to learn how to function in society in a healthy way, and for this to happen there needs to be a reason for the patient to want to get better. Want being the key word here. When an athlete-patient is allowed to keep training, albeit at a reduced load, there is an all-important reason for them to put in all the hard yards day to day that go with recovering from an eating disorder. There can be clear goals and rewards: you gain X weight, you get to train X amount. You eat X foods, you get to attend X training sessions. If you don’t, you can attend but you have to sit out and watch. Sure, it’s harder to gain weight while still training. But guess what? Eating like an athlete is hard, full stop. Years on I still find it a challenge day to day. When you train hard, you have to work even harder on fuelling your “machine” (body), and the sooner a patient gets used to that process the sooner they can master it. Secondly, gaining the weight as muscle, bone density and fat via increased food and some continuation of training is much healthier and less traumatic for the patient than gaining fat alone on a resting protocol. Lastly but most importantly, there are three overwhelming psychological benefits to this approach:

1) the motivation-reward system is clear and immediate;

2) the social interaction with teammates and coaches is maintained, which is so important;

3) the patient is nurtured through the process of minimising their ED identity and replacing that empty space with their “healthy athlete identity”. {You can replace “athlete” and “training” with anything else relevant – student and school, physio and work, etc.}

The key to this process is to have a fantastic support team who can facilitate this transition. For me, it was a brilliant Sports Dietician (it was her idea to allow me to keep training – every other rehab program I had entered forced me to rest and spiral into depression), a brilliant Psychologist who specialises in treating athletes with eating disorders, a Coach who was on board with the plan, and a flexible workplace (I was still studying at University but my part-time job as a research assistant allowed me to set my own work hours, so I could go in when my energy levels were highest – early in the morning). For the most part, my dietician set out my goals for the week and my rewards – when and if I could train etc. All the while she communicated with my psychologist, who from the get-go has focussed on establishing my identity as an athlete. As he reminded me recently, I have always done best when we focus on what my body can do (as an athlete), not how it looks. All body fat % and weight measures were taken away from me, and replaced by more relevant measures like time trials and power outputs. And the only way I can get stronger, fitter, faster, and keep up with my teammates? To eat. Simple as that. I know when I skimp, I fall behind, and as a competitive person, that is motivation enough to nourish my body.

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The best part is that the system WORKS. And it’s not just a bandaid fix – it works in the long term. To this day, years on from the start of my “recovery”, I still have a crappy day at work, feel “fat” as my go-to coping mechanism, and then know that if I go and do a solid training session, by the time I walk back through that door at the end I am going to be happy with my body and what it can do for me. Nothing to do with how it looks or what it weighs. Simply what it can do. And that’s pretty cool. Add in the extra bonuses of a good training session – fresh air, endorphins, improved fitness, mental clarity, relaxation – and it’s a win-win situation.

I make it sound easy and like the obvious solution, which for me, it was (obvious, not easy!). Nothing else had worked over the decade beforehand. And certainly this system wouldn’t work for everyone either, but for athletes, I would argue that it is the best way to structure treatment. Realistically, there needs to be a change in the way we treat eating disorders in Australia as the current inpatient systems are not working in terms of long-term outcomes and relapse rates. There is no easy answer.

Food for thought anyway.

Happy training xo

The Broken: A Survival Guide Part III

Right now, I am at the point where my foot is essentially 95% healed, and I’m ramping my running back up.

Cue music: “Highway to the Danger Zone”……

You see, this is the magical moment where the bones are healed enough to need adequate loading in order to reach full strength and function. This means running every other day (yippee!!), but crucially it also means having the discipline to not overdo it. And to listen to my body. And put my pride and perfectionism to the side.

This is, in many ways, the hardest part. It’s the part where I have to test my growth over the past 9 months. Have I really become more patient? Stronger? Less perfectionistic? More realistic? Hell, will my body even remember how to run, let alone with decent pace or technique?! And then the toxic seeds of doubt creep in: what will my fellow runners think of me now? What if I’m not good enough? What if I never get back to where I was before I broke my foot? Will I ever beat my husband in an Ironman again?

Of course, it’s highly likely I will come back stronger than before, will continue to kick my husband’s butt in many an Ironman to come, will have learnt a boatload about myself and my body and most importantly, learnt how to train more efficiently and with less risk (cue Britney Spears: Stronger. Yep, I went there). This is my “logical voice” talking. But we all know, that illogical voice is the one that dominates when we have been out of the loop for some time.

Hiking in NZ with my better half

Hiking in NZ with my better half

Two weeks ago, I readied myself to go to running squad for the first time in over a year. It’s a super friendly bunch of runners who I have trained with throughout all my Ironmans in the last 5 years. Saturday mornings are usually a sociable 8-12km group run, with coffee afterwards. There is a front pack, of which I’m usually a member, and then there’s everything back to a 5km jog/walk group. In all, we have about 50 people turn up, so it’s not like I would be lonely.

Only I chickened out. Why? Because according to my return to run program from my Ortho, I still have to walk 2 minutes for every 8 minutes of running. And, I knew I wouldn’t be able to stop and have the discipline to walk when everyone else was still running. And my pride didn’t want the slower runners to catch up (there I said it. I may be the world’s most competitive person). A week later and I decided to try again. I took off at decent pace with a largish pack, and I did manage to stop and walk when I was supposed to. It was harder than getting through an airport on crutches, I’ll tell you that much. My heart and soul just wanted to keep on running!!

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Whether you are getting back into training after an injury or after an eating disorder (or both), the hardest part is often sticking to the plan. I know from coaching beginner run groups that the three aspects of training that “normal” people struggle with most are 1) motivation; 2) fitness; and 3) being able to mentally push themselves. This is not the case for athletes or those of us with the ED birdy on our shoulder. These are some strategies that have helped me over the last couple of months:

1) Front and Centre: How Far You’ve Come (and how quickly it could go wrong). Its human nature to compare yourself to others, and even moreso for uber-competitive athletes like myself. There’s a bunch of people you used to be faster than lapping you around the park. But that’s OK, because they don’t have a metal plate in their reconstructed foot. They haven’t walked every step of that hard road to recovery. When the temptation to push yourself overwhelms you, it’s important to remember how broken you were and how quickly you could return there (ie another stress fracture or overuse injury). Sometimes fear can be a very good motivator! Write it on your hand, stick a photo in your wallet – whatever it takes, a not-so-subtle reminder is key.

2) Plan Ahead: The Insecurity Factor. As a flip side to point 1, remember that we are all humans and we do all have our own story and our own journey. When that little evil voice starts sprouting doubts in your mind, squash the insecurity by fighting back with basic logic. Those runners know what you’ve been through, know what kind of an athlete you are, and really couldn’t care less that you are running slower than you used to. They’re more than likely impressed by your motivation and determination, not judging you for your pace. They’re likely happy just to see you back at squad. Or they may not have even noticed that you’re not as fit as you were (you’d be surprised how remarkably un-observative “normal” people can be, really….you’d be shocked….not everyone can recite what the whole table ate at lunchtime and what times they ran on the track for the last 4 years….that’s a very unique trait!).

3) No Negotiations. Even if you feel like Paula Radcliffe today. Any changes to the plan MUST be pre-approved by your Physio/sports doc ahead of time. As with any rehab program, you have days where you just float like a butterfly….and days you feel like an elephant. Just enjoy the fact that you feel great, cherish every step, and know that if you stick to the plan, it’ll be that much sooner before you get to have another great training session. If that fails, revert to point 1.

4) Focus on how Amazing Your Achievements Are. And celebrate them. Who cares if your old training buddies smashed out 10km in sub-40min pace? YOU just did 36 minutes of quality running, and you had the discipline to stop and walk, and your technique was great, and you are coming back from major foot surgery, and you get to be outdoors in the fresh air running…you get the picture. Gratitude is the best emotion on the planet. Use it to your advantage. Write it in your training diary. You’re doing awesome. Repeat.

5) Enlist a Training Buddy who is on board. Does not have to be of the human breed. If you are going to squad, suss out who is about your pace at the moment or perhaps also coming back from injury. Or grab a friend who is willing to do walk breaks with you. My favourites for this are my husband and my dogs, the three of them are always whinging that I run too fast normally so they are happy for the walk breaks – much happier than I am!

6) Nutrition: ensure that you are adjusting your eating plan for the increased exercise load. You need to be eating for training, recovery AND healing – the triple threat. Bones have a lag time of about 3-4 weeks with increased load, so when increasing run kilometres it is best to have a training week that is about 50% of your normal current load for that week, to let your bones catch up and get stronger. Push over that and you may find another stress fracture. So if you are up to running say 40km a week, on the fourth week, stick to 20km and you can add some walking or cross training. It’s an annoying but foolproof investment, and any running coach on the planet worth their salt will stick to this plan for injury prevention. You’ll actually come out the other side feeling fitter, as your body will have “absorbed” your training up to that point and feel fresh again. Bonus!

7) Get a Hero or Two. Professional Triathlete Jesse Thomas actually broke his foot during Wildflower triathlon 2013 and subsequently had surgery about a month before I did the exact same thing. He has blogged about his rehab, the highs and lows, and I have found it hugely helpful following his progress along the way. His wife Lauren Fleshman is also a great role model and her blogs are highly entertaining for any athlete who has faced injury or childbirth and beyond. As a side note – be wary of Ironman athletes claiming to be recovered from their eating disorders. There are a lot of them around who hide behind “Ironman/triathlon” as their excuse to continue with disordered eating patterns. Chrissie Wellington’s book “A Life Without Limits” is probably one of the worst so don’t go there if you are still recovering. Same goes for any running or ultraendurance bio if you are recovering from a running injury – it’s like motivation on steroids to go do something really stupid!

I hope that helps! The journey back to health can be a long and lonely one, especially once you get towards the end and on the surface everything looks fine. Stay strong and remember how far you have come. Most importantly, reward your body for the amazing job it has done by nourishing it and letting it bloom into its full potential. It will serve you very well if you treat it right.

Happy Training xo

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