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AT-RISKFEMALE _ .
ADOLESCENT ATHLETES-FOR EATING. DISORDERS: ‘
AN INSERVICE FOR COACHES ‘ ~

Schofiarly Project for the Degree ofMgSgni‘
MICHIGA’N'STATE UNIVERSITY ‘ .
LII-ISL MARIE ZYLSTRA ‘ , ;_
' 1998 "

 

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AT-RISK FEMALE ADOLESCENT ATHLETES FOR EATING DISORDERS:
AN INSERVICE FOR COACHES

BY

Liesl Marie Zylstra

A SCHOLARLY PROJECT
Submitted to
Michigan State University
in partial fulfillment of the requirements

for the degree of

MASTER OF SCIENCE NURSING

College of Nursing

1998

ABSTRACT

AT-RISK FEMALE ADOLESCENT ATHLETES FOR EATING DISORDERS:
AN INSERVICE FOR COACHES

BY

Liesl Marie Zylstra

Athletic coaches are a primary link to the prevention
of eating disorders in athletes, yet few educational
inservices exist to educate coaches about eating disorders,
their identification and preventive activities. The advanced
practice nurse is in a unique position by virtue of
education and experience to develop such an inservice.

This scholarly project includes: (a) a literature review
which targets eating disorders in adolescent female
athletes, (b) the examination of possible strategies for the
early identification and prevention of eating disorders, and
(c) the development of an educational inservice for athletic
coaches on the prevention and identification of eating
disorders in female adolescent athletes. The development of
this inservice was guided by Malcolm Knowles principles of
the adult learner. Implications related to advanced
practice nursing education, research and policy development

are described.

ACKNOWLEDGEMENTS

This project would not have been possible without the
assistance of my committee members Joan Wood, Jackie Wright
and Mary Jo Ardnt. Special thanks to Joan for her support,
patience and continual reminders along the way, “This is a
process."

I would also like to thank my family for their love and
support. Special thanks to my husband, David, for his
continual patience, listening ear and unending support. “I
couldn’t have done it without you!" Thanks to my parents,
to my Dad for his ability to motivate and to my Mom for her
ability to listen endlessly. Thanks also to Dad Zylstra and
Jim Zylstra for their willingness to assist with the
computer and technical aspects of this project. This
support from all of you was invaluable and allowed me to see

this project through to completion.

iii

TABLE OF CONTENTS

List of Figures ........................................... v
Introduction .............................................. 1
Problem Statement ......................................... 2
Purpose ................................................... 3
Conceptual Definitions .................................... 3
At-Risk Female Adolescent Athletes ................... 3
Eating Disorders ..................................... 4
Inservice for Coaches ................................ 5
Prevention ........................................... 6
Conceptual Framework ...................................... 7
Literature Review ........................................ 12
Eating Disorders .................................... 12
Guidelines for the Prevention/Treatment of Eating
Disorders ........................................... 17
Eating Disorder Prevention Programs ................. 21
Female Adolescent Athletes .......................... 25
Discussion ............................................... 29
Proposed Inservice .................................. 29
Eating Disorders .................................... 31
Physical Issues Related to Eating Disorders ......... 32
Self-Esteem and Societal Pressures .................. 32
Healthy/Normalized Eating Habits .................... 34
Disordered Eating/Nutrition Resources ............... 35
Implications ............................................. 36
Advanced Practice Nursing Education ................. 38
Research on the Inservice ........................... 39
Policy Development .................................. 40
Summary .................................................. 42
List of References ....................................... 43

Back Pocket: Sample Inservice Packet

iv

LIST OF FIGURES

Figure l —Knowles’ Principles of Adult Learning .......... 8

Figure 2 -Knowles’ Adult Learning Principles Applied to
Athletic Coaches ............................... 9

Figure 3 -Knowles’ Adult Learning Principles Applied to
Athletic Coaches’ Inservice ................... 37

Introduction

Eating disorders currently affect a large portion of
the U.S. adolescent female population. The Eating Disorders
Awareness & Prevention organization provides general
estimates of the prevalence of eating disorders among middle
school and high school girls: Bulimia nervosa (1-3%),
anorexia nervosa (.25-1%), and atypical eating disorders
i.e., sets of signs and symptoms which do not meet all the
criteria for bulimia or anorexia nervosa (2-l3%) (Levine,
1996).

While multiple factors including those of a
psychological, biological and social nature have been
directly linked to the onset of an eating disorder, evidence
is mounting which identifies sport settings as promoting
specific risk factors for the development of these disorders
(Brownell, 1994; Sundgot-Borgen, 1994; Taub & Blinde, 1992;
Wichmann & Martin, 1993). Recent studies have found that
the stated symptoms of eating disorders are more often
prevalent among female athletes than nonathletes (Sundgot-
Borgen; Taub & Blinde) and that detection can occur when
coaches are knowledgeable about the disorders and can
identify women athletes at risk (Dick, 1991; Fairburn, 1994;

Sundgot-Borgen). However, for this to occur the coaches of

2
female adolescent athletes must also have a good
understanding about nutrition as related to athletic
performance. The development and implementation of
prevention programs for elementary through high school
students appears lacking and programs which specifically
target coaches of this age group are virtually non-
existent. Health care providers and specifically the
advanced practice nurse are in an excellent position to
work with coaches in addressing this issue.
Problem Statement
Athletic coaches are a primary link to the prevention
of eating disorders in athletes, yet few educational
inservices exist to educate coaches about eating disorders,
their identification and preventive activities. The Healthy
E J 2000 H I' J H 1!] E !° 3 E'
Ereyentign thegtixgs (U.S. Department of Health and Human

Services, 1991) supports the need for the development of
intervention programs on eating disorder prevention.
Similarly, the Centers for Disease Control ([CDC], 1996)
provides support for the education and in-servicing of
coaches on nutrition and eating disorders. The Michigan
ErQQIAm_iQI_ALhl§§i§_99a2h§§L_EduQaLiQn (Seefeldt & Brown,
1995) reflects a lack of information on eating disorders
being provided to coaches currently. The advanced practice
nurse is in a unique position by virtue of education and

experience to develop such an inservice.

Purpose

Based on the lack of existing educational inservices
for coaches about eating disorders, the purpose of this
scholarly project is the development of an inservice for
athletic coaches to provide information on the prevalence,
prevention and identification of eating disorders in female
adolescent athletes. This scholarly project includes: (a) a
literature review which targets eating disorders in female
adolescent athletes, (b) the examination of possible
strategies for the early identification and prevention of
eating disorders, and (c) the development of an educational
inservice as described above.

Conceptual Definitions

Several terms and phrases are examined conceptually and
specific operational definitions for this project are
described. The terms defined are at-risk female adolescent
athletes, eating disorders, inservice for coaches, and
prevention.
WWW

There is no specific definition of at-risk female
adolescent athletes in the literature. However, there are
guidelines for defining this term.

According to Santrock (1993), adolescence is a period
of development and transition between childhood and
adulthood which involves biological, cognitive and social
changes. Santrock encourages the distinction between early

and late adolescence. Adolescence begins at approximately

4
10 to 13 years of age and ends between 18 and 22 years of
age for most individuals.

Athletes are those individuals trained in exercises,
games, or competitions which require physical strength,
skill, speed, stamina, etc. (Webster;s_flew_flgrld_§gll§g§
pigtignaryL 1997). The term at-risk refers to the
possibility of injury, harm or loss (Weh§;§;;§_fl§w_Wg;ld
Cgllegg_pigtignaryL 1997). The concept, risk factor, is
addressed in the literature with two important implications.
A risk factor has a probability component and “...embraces
the idea that disease (and conversely health) is
overwhelmingly multifactorial in genesis” (Milsum, 1991, p.
289).

For this project at~risk female adolescent athletes
refers to females between the ages of 10 and 18 who are
involved in an organized school sport at the junior or
senior high school level and have the potential for
developing an altered pattern of eating.

E I' I' 3

According to the literature, eating disorders occur
along a continuum with anorexia nervosa and bulimia nervosa
at the extremes of the continuum. Eating disorders are in
general “...a set of eating habits, weight management
practices and attitudes about weight and body shape” (Maine ‘
& Levine, 1997, p. 1). These attitudes and behaviors result
in: (a) loss of self-control and other behavior problems,

(b) obsession, anxiety, guilt, (c) social and self

5
isolation, and (d) physiologic imbalances which may be
life-threatening (Maine & Levine).

The definition of eating disorders for this scholarly
project is based on the conceptual definition of eating
disorders but also includes the definition of “normal”
eating. Normal eating as defined by Satter (1987, p. 69)
“...is being able to eat when you are hungry and continue
eating until you are satisfied." Normal eating is
considered to be flexible and varies in response to one’s
emotions, schedule, hunger and proximity to food (Satter).
Eating disorders in this scholarly project refers to any
deviation from normal eating.
111W

An inservice is training, “as in special courses,
workshops, etc., given to employees in connection with
their work to help them develop skills" (ng§t§;;§_flem
Wgrld_§gll§g§_pigtignazyL 1997, p. 698). The literature
generally refers to an inservice as training or education
which promotes the use and/or development of skills in
relation to one's work. A coach is defined as, one who
trains athletes or athletic teams (Webster;§_New_flg;1d
Wm).

For the purposes of this scholarly project, inservice
for coaches, is defined as an educational session for
individuals who train athletes and/or a team of athletes at
the junior or senior high school level, which promotes the

development and use of skills for the prevention and

6

identification of eating disorders in female adolescent
athletes.
mum

Prevention can be defined as medical interventions or
approaches “...to eliminate disease—related morbidity and
mortality" (Fairburn, 1994, p. 289). The Neuman Systems
Model, founded by Betty Neuman, describes “prevention-as-
intervention' (Reed, 1995, p. 539). “...it is a way to view
the links between environmental stressors, the reaction of
the client to stressors, and the role of nursing in helping
clients to retain, attain or maintain wellness" (Reed, p.
539). Furthermore, these interventions i.e., types of
prevention include primary, secondary and tertiary and are
classified according to the stage of the stressor. According
to Neuman, primary prevention refers to interventions which
assess potential stressors and strengthen and protect the
individual from the potential stressors. Secondary
prevention refers to interventions after a reaction to a
stressor has occurred and include problem/disorder
identification, e.g., screening activities and treatment of
acute episodes (Wesley, 1995). The aim is to reduce the
reaction to the stressor. Tertiary prevention refers to
approaches which occur after the treatment of the stress
reaction. The goal is to maintain adaptation and to prevent
reoccurence that result from the stressor, i.e., the

reduction of impairments that result from the stressor.

7

For the purposes of this scholarly project, the
definition of prevention includes the conceptual definitions
of primary, secondary and tertiary prevention. The main
emphasis is on primary prevention, i.e., education and
activites aimed at the prevention of eating disorders.
Coaches also need information related to secondary and
tertiary prevention for a comprehensive review, i.e., early
diagnosis, treatment and rehabilitation of eating disorders
in female adolescent athletes.

Conceptual Framework

The focus of this project is the coach of the female
adolescent athlete. Therefore, it is important to recognize
the significance of adult learning concepts when developing
an educational inservice. The work of adult education
consultant, Malcom Knowles, provides the basic framework for
this project. Knowles' (1990) principles of the adult
learner are pertinent and relevant to the development of an
educational inservice for athletic coaches of female
adolescent athletes.

While Knowles did not develop a conceptual
visualization of these principles, a model depicting Knowles
principles of adult learning, Figure 1, has been created by
this author. An adapted model specifically for this project,
the inservice for athletic coaches, is presented as Figure
2. These models reflect how the framework of adult learning
principles are applied to the inservice for athletic

coaches.

 

3. Each adult is a rich
resource of accumulated
experience.

 

 

 

4. Adults have a “readiness
to Ieam'.

 

 

 

 

2.

Adult Ieamers have a
self-concept of being
responsible for their own
decisions and lives.

 

 

 

 

5. Adults are motivated
to leam.

 

 

 

 

 

1. Adults “need to know' the
importance of why they
need to learn something
before undertaking to
learn it.

 

 

 

 

 

 

 

6. Normal adults are
motivated to keep growing
and developing.

 

 

 

Figure 1 — Knowles'

Adult Learnlng

(1990) Principles of Adult Learning

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Using educational materials in a peer
group setting allows for diversity in
problem solving based on varied 4. Coaches generally desire to
experience with eating disorders. increase their knowledge base
The small group setting promotes the regarding the athletes they are
assessment of attitudes and provides coaching. The coaches who have
individual affirmation related to the encountered or questioned an
problem of eating disorders. Coaches eating disorder in an athlete are
may examine some of their own habits likely to be more interested in
and biases and in the process open their receiving information on the
minds to new prevention and identification prevention and identification of
approaches in eating disorders. eating disorders.

2. The coaches’ responsibility 5. An inservice can facilitate
is facilitated by providing the coaches’ ability to
information via self-directed prevent/address eating
leaming. This will empower disorders in athletes.
the coaches to take care of
their athletes, understand
potential/actual eating
disorders and learn health
promotion.

1. Given information regarding 6. An inservice on eating
the current problem and disorders can serve as a
their role in the prevention/ resource for further growth
identification of eating and development as a
disorders - coaches will coach.
have the “need to know"
about eating dsorders.

Athletlc Coaches

Figure 2 - Knowles' (1990) Adult Learning Principles Applied to
Athletic Coaches

10
Knowles’ principles of the adult learner state that:
1) AW
“0. ° ‘1, ! .011‘ I! 9‘,,_.," 11"“ '._L_!. 0 .‘-__.

This “need to know" is a perfect opportunity for the
advanced practice nurse to utilize focused educational
materials. The coaches who are educated on eating disorders
and their prevalence among female adolescent athletes
should identify themselves as a key provider in the
prevention and identification of eating disorders.

2) Wham
WWWith this
self—concept is the need to be seen as self-directed.
Creating an environment conducive to adult learning
requires the educator to provide a transition from
“...dependent to self—directing learners” (Knowles, 1990,
p. 59). The advanced practice nurse can facilitate this
responsibility by providing athletic coaches with an
educational inservice which empowers them to take care of
their athletes, understand potential/actual eating
disorders and learn health promotion techniques. The
inservice can facilitate self-direction by encouraging the
coaches to investigate specific areas of interest or
concern with their own athletes.

3) W
experience; Using educational materials in a peer group
setting allows for diversity in problem solving based on

varied experience with eating disorders. The small group

11

setting promotes the assessment of attitudes and provides
individual affirmation related to the problem of eating
disorders. This affirmation is directly linked to a
realization about the importance of the coach’s role in the
prevention/identification of eating disorders. Coaches may
examine some of their own habits and biases and in the
process open their minds to new prevention and
identification approaches in eating disorders.

4) “ ' " ' 'f
they_nerceiys_this_will_effect_their_abilitx_t2_cens
effeQtiMelx_mith_prasent_life_;_situatiensl Coaches

generally desire to increase their knowledge base regarding
their athletes. The coaches who have encountered or
questioned an eating disorder in an athlete are likely to
be more interested in receiving information on the

prevention and identification of eating disorders.

5) AdulLs_are_matixated_tQ_learn_uhen_thez_nerceiye

a! '9 ,‘fi.. '9 3" 23' ' 0 9‘ can :_i_ o q 2 .E 1
pIgblema_in_§h§ix_lif§_§ituatign§*_An educational inservice
on eating disorders in female adolescent athletes can
facilitate the athletic coaches’ ability to address or
prevent eating disorders in athletes.

6) N2rmal_adults_are_matiyated_t2_keen_grguing_and

9‘ ‘ 09'99' Q'.‘ ‘ ou‘ °u‘, 92 "1. ‘.'. . ' 9 9 o .
the_cantinuatign_9f_learningl An educational inservice for
athletic coaches on eating disorders can be a resource

which allows for the further growth and development of each

12
coach. Other considerations for the inservice should be the
time and financial commitment involved for the coaches.
Literature Review

Based upon the intent of this project, several areas
have been examined through a literature review. These
include eating disorders, guidelines for the prevention/
treatment of eating disorders, eating disorder prevention
programs and female adolescent athletes.

E . I' 3

The literature review provided an extensive amount of
information about eating disorders. In order to remain
within the scope of this project the review of literature
examines the aspects of eating disorders relevant to this
project. This includes the description and classification
of eating disorders, prevalence rates and risk factors for
eating disorders.

Anorexia nervosa and bulimia nervosa are the two most
commonly identified eating disorders. The first
documentation regarding anorexia nervosa dates back to
1689, i.e., a condition “referred to as a Nervous
Consumption caused by sadness, and anxious cares”
(Silverman, 1997, p. 3). The history of bulimia nervosa is
much shorter and should be considered an illness of
contemporary times. The diagnostic term was coined in 1979
and has specific criteria (Russell, 1997). Bulimia nervosa
is closely linked to its “parent condition" anorexia

nervosa (Russell, p. 11). Characteristics of these

13
disorders may include restrained eating, binge eating, fear
of fatness, purging and distorted body image (Mellin, Irwin
& Scully, 1992).

In order to clarify the characteristics and criteria
for eating disorders, the American Psychiatric
Association’s, WW
pisgzders, fourth edition (DSM-IV; 1994) was reviewed. The
criteria for the diagnosis of anorexia nervosa are as
follows: (a) refusal to maintain body weight at or above a
minimally normal weight for age and height; the DSM;Iy
(American Psychiatric Association) guideline is weighing
less than 85% of that expected as normal, (b) intense fear
of gaining weight or becoming fat, even though underweight,
(c) disturbance in the way in which one's body weight or
shape is experienced, i.e., denial of the seriousness of the
current low body weight, and (d) in postmenarchal females,
amenorrhea, i.e., the absence of at least three consecutive
menstrual cycles.

The criteria for the diagnosis of bulimia nervosa are
as follows: (a) recurrent episodes of binge eating with an
episode of binge eating characterized by eating in a
discrete period of time an amount of food larger than most
people would eat in a similar time period and a sense of
lack of control over eating during the episode, (b)
recurrent inappropriate use of behaviors to prevent weight
gain, such as vomiting, misuse of laxatives, diuretics,

enemas, fasting or excessive exercise, (c) the use of binge

l4
eating and inappropriate behaviors at least twice a week
for three months to prevent weight gain, (d) body shape and
weight overly influence self-evaluation, and (e) the
disturbance does not occur exclusively during episodes of
anorexia nervosa.

Another very important set of diagnoses are the eating
disorders “not otherwise specified" (American Psychiatric
Association, 1994, p. 550). These diagnoses are for a
group of individuals who have eating disorders, but do not
meet the diagnostic criteria for anorexia nervosa or
bulimia nervosa. It is important to understand that the
term, “not otherwise specified", does not connotate eating
disorders of minor clinical significance (Walsh & Garner,
1997).

The prevalence of eating disorders is widely addressed
in the literature. Shisslak, Crago and Neal (1990) report
an extensive literature review which indicates eating
disorders are increasing among adolescents (Killen, Taylor,
Telch et a1., 1986; Mitchell & Eckert, 1987). Lionel W.
Rosen, MD, professor of psychiatry at Michigan State
University in East Lansing says “...eating disorders are
being found more and more in younger people" (Wichmann &
Martin, 1993, p. 128; Thompson & Sherman, 1993). A 1992
study of 494 adolescent females, nine to 18 years of age
reported that dieting, fear of fatness and binge eating in
31% to 46% of nine year olds and 46% to 81% of ten year

olds (Mellin, Irwin & Scully, 1992). As is the case with

15
many studies, one wonders about the respondents'
truthfulness about disordered eating and weight loss
practices. Eating disorders are complex and secretive in
nature; therefore insuring accurate prevalence rates and
research studies are difficult (Dick, 1991; Thornton, 1990).
Researchers continue to study the onset of these disorders
in young children.

Eating disorders reveal a complex topic for discussion
due to the multiple factors which produce an eating
disorder. The literature clearly states females are most
often affected by eating disorders (American Psychiatric
Association, 1994; Dick, 1991; Johnson, Sansone & Chewning,
1992; Thornton, 1990; Worsnop, 1992). According to the
American Psychiatric Association, “More than 90% of cases of
anorexia nervosa occur in females" (p. 543) and “...at least
90% of individuals with bulimia nervosa are female" (p.
548).

Adolescent females appear to be especially vulnerable
due to peer pressure and bodily physiologic changes which
promote increased body fat (Kilbourne, 1994). According to
the DSM;Iy (American Psychiatric Association, 1994) the mean
age at onset for anorexia is age 17 and may peak bimodally
at ages 14 and 18. Bulimia begins in late adolescence or
early adulthood.

Factors being considered in greater detail are the
influences of advertising and the societal pressures placed

upon women to be thin (Herzog & Copeland, 1985; Kilbourne,

16
1994). According to Kilbourne, the role of women in society
is changing as women are encouraged to be autonomous and
independent to be successful. In conjunction with this
message is that women must be “in control". Kilbourne
states, “One way to do this is to present an image of
fragility, to look like a waif. This demonstrates that one
is both in control and still very ‘feminine’" (p. 403—404).
Messages sent related to weight are often so subtle they may
go unnoticed. Kilbourne (p. 395) states “The current
emphasis on excessive thinness for women is one of the
clearest examples of advertising’s power to influence
cultural standards and consequent individual behavior." She
further suggests battling the “thinness” message by
observing how changes were made over time regarding
cigarette smoking and alcohol use.

Another factor influencing the development of eating
disorders is the involvement of recreational activity. This
factor is two-sided since athletes often feel pressure to .
lose weight in order to increase their ability to perform
(Sundgot-Borgen, 1994). Secondly, the use of excessive
exercise (American Psychiatric Association, 1994) is a
characteristic of eating disorders. However, this excessive
exercise may be justified by the conditioning and training
required of the sport in which the athlete is involved.
Other factors related to eating disorders are depressed
symptomatology, restrictive families and impaired

psychological development (Herzog & Copeland, 1985).

17
There are limitations to the studies done on athletes

about eating disorders. According to Brownell (1994),
diagnostic criteria have not been used, appropriate control
groups are rare and usually athletes (most often female) in
a single sport have been studied. As a result the prevalence
rates of eating disorders in athletes are not consistent
(Brownell; Thornton, 1990). Wilmore (Thornton), reported on
two national studies which suggest that eating disorders in
athletes are as high as 25% and as low as 1%. However, one
element is conclusive, eating disorders are common in
athletes and a concern for the athletic population
(Brownell; Dick, 1991; Skolnick, 1993; Thornton).
Q‘ 1‘. ,0 9‘ ' “ ‘9 0! ‘<,l!‘! 0 -_ .1. .. 0 9‘

Several different sources were investigated for

established guidelines regarding the prevention and

treatment of eating disorders. These sources included: (a)

q‘-. t "0.- “, 'i0 \3. .Q'., ,-.-7 9 out or 2-9.. D,--_ a

£fieygn;ign_9bj§gtiyg§ (U.S. Department of Health and Human
Services, 1991), (b) the recommendations from the CDC
(1996), and (c) the WW
Education (Seefeldt & Brown, 1995) provided by the Michigan
High School Athletic Association.

The U.S. Department of Health and Human Services (1991)
includes health promotion objectives for nutrition in their
objectives for healthy people in the year 2000. However,
there is no information about eating disorders or the need

to alter their incidence/prevalence. Therefore, a need

18

exists for research in the area of nutrition, specifically
aimed at eating disorders. Nutrition research is needed to
determine “The etiology, epidemiology, prevention and
treatment of eating disorders such as anorexia nervosa and
bulimia nervosa” (U.S. Department of Health and Human
Services, 1991, p. 132).

The CDC (1996) include the following recommendations
for a school-based program to promote healthy eating: (a)
a school policy on nutrition, (b) a sequential, integrated
curriculum; (c) instruction for students, (d) a school food
service integrated with nutrition education, (e) staff
training, (f) family and community involvement, and (9)
program evaluation. In these guidelines, “...nutrition
education refers to a broad range of activities that
promote healthy eating behaviors” (CDC, p. 1). One area
identified in the school-based health program is for
faculty and staff. “Provide staff involved in nutrition
education with adequate preservice and on-going in-service
training that focuses on teaching strategies for behavioral
change” (CDC, p. 9).

The CDC (1996) recommends the following guidelines be
used when developing effective training programs: (a)
design the program “...to meet the specific needs of the
teachers” and base the program at the “...teachers' level
of nutrition knowledge" (p. 15), (b) “model behavioral
change techniques and give teachers practice in using them"

(p. 15), (c) provide multiple sessions “...so that teachers

 

19
can try out the newly learned techniques...and report on
their experiences to the training group” (p. 15), and (d)
“provide post-training sessions so that teachers can share
experiences with their peers” (p. 15).

Based upon conversations with athletic coaches and the
director for the Michigan High School Athletic Association
this author found that athletic coaches in the State of
Michigan are not required to attend classes/programs which
address common issues in coaching athletes. However, the
Michigan High School Athletic Association does offer the
WWW (Seefeldt
& Brown, 1995) which many coaches in the State of Michigan
voluntarily attend. This program consists of four sessions
that are three hours each. The first session addresses the
rules and procedures of the Michigan High School Athletic
Association, legal responsibilities of the coach and
insurance for athletes and coaches. The second session
addresses prevention, the care and rehabilitation of
athletic injuries, weight training, conditioning principles
and contraindicated activities for young athletes. The
third session presents information on the pre-participation
physical exam and medical records, the role of the coach,
planning for the season, the requirements for effective
instruction of athletes, and the evaluation of coaching.
The last session provides information on motivating young
athletes, effective communication, maintaining discipline

and personal/social skills (Seefeldt & Brown).

20

A review of the content of the Mighigan_firggzam_fgr
Athletic_99achesl_fiducatign (Seefeldt & Brown, 1995)

provides minimal information for coaches on eating
disorders. The section, Nutrition for the Interscholastic
Athlete, contains a brief sub—section on weight control
including weight loss and gain. Coaches are encouraged to
“tactfully” approach the parents of athletes they feel are
excessively over- or underweight “...to suggest that they
seek medical attention for their children” (Seefeldt &
Brown, p. 8-11).

This author noticed that this program contains an
entire section on chemical health education and that eating
disorders were viewed as a serious threat to good health,
i.e., similar to alcoholism and other drug addictions
(Seefeldt & Brown, 1995). The use of laxatives, diuretics
and diet pills for weight control was discouraged due to
chemical imbalances which occur and the potential for

development of eating disorders (Seefeldt & Brown, 1995).

In conclusion the publication, Heal;hy_2§gplg_zgflg

\2 'oo. .-. , ' one '-o so! .'--. - ' - -, 7-9 09'- ' a
(U.S. Department of Health and Human Services, 1991)
supports the need for the development of intervention
programs on eating disorder prevention and their subsequent
evaluation for effectiveness. The CDC (1996) provides

support for the education and in-servicing of coaches on

nutrition and eating disorders and the Mighigan_£rggram_fgr
Athletic.§9achesl_2ducation (Seefeldt & Brown, 1995)

21
reflects a lack of information on eating disorders being
provided to coaches currently.
E . L' 3 E l' E
While the literature encourages the use of in-service
training for coaches (Baer, Walker & Grossman, 1995; Dick,
1991; Shisslak & Crago, 1994; Thompson & Sherman, 1993),
there is a paucity of information in the area of eating
disorder prevention programs targeted at junior and senior
high school athletic coaches. However, three eating disorder
prevention programs currently exist at the college level
which include the athletic coach.

The University of Texas at Austin has implemented a
prevention program for all female student athletes (Thompson
& Sherman, 1993). This program is composed of several
components, e.g., ongoing nutrition inservices for all
female athletes, a group eating disorders education session,
and targeted education inservices for the student athletes
including transfer students and the athletic coaches.
Professionals with a variety of expertise including
physicians, nutritionists and psychologists contribute to
the success of this program. Secondly, this program has an
ongoing educational series for athletes and coaches.

The University of Cincinnati has also incorporated a
team response to the prevention and treatment of eating
disorders in athletes (Baer et al., 1995). A team of
professionals involved with the athletes is responding to

those athletes who have been identified as “eating

22
disordered”. Preventive measures “...to support health and
physical performance and to decrease the incidence and
severity of disordered eating” (Baer et al., p. 316) are
being implemented for all athletes and coaches; a series of
educational sessions are included. This program (a)
promotes activities to decrease the potential for eating
disorders prior to their occurrence, (b) provides coaches
with current information regarding the identification of
eating disorders in their athletes, and (c) fosters the
return of healthy eating habits in the presence of an
eating disorder.

The National Collegiate Association for Athletes
(NCAA) has produced a three part video series for college
athletes and athletic departments (NCAA, 1991). The NCAA
(1991) acknowledges that this video series may be used by
high school athletes/coaches as well.

Following is an overview of the information covered on
each video. The first video addresses the definitions of
anorexia and bulimia, prevalence rates and the
characteristics/warning signs of these disorders.
Consequences related to eating disorders are shown. The
second video addresses the effect of nutrition and weight
on athletic performance. Proper nutrition is discussed
with an emphasis on how this must not be sacrificed in
order to achieve a difficult weight goal. The final
videotape addresses why those who are influential with

athletes need to be well informed about eating disorders.

23

The underlying causes of eating disorders, warning signs
and planning for action are discussed for coaches, medical
personnel and administration.

The majority of all prevention programs do concentrate
on junior high students at age 11, approximately grade 6,
through senior high students, approximately grade 12
(Killen, Taylor, Hammer et al., 1993; Levine & Hall, 1991;
Neumark-Sztainer, Butler & Palti, 1995; Shisslak, Crago &
Neal, 1990). These school programs are including prevention
of eating disorders in their curriculum. Levine and Hall
(1991) have published a five day lesson plan on eating
disorders for grades 7 through 12, which emphasizes
psychosocial rather than individual factors in the
development of the disorder. Some of the goals of the
curriculum are: (a) to heighten awareness of how thinness
is idealized in our society and body fat is viewed
negatively; (b) to provide information about fatness, such
as genetic determinants and set point theory; (C) to
encourage respect for different body shapes and sizes, (d)
to point out the negative effects of dieting, (e) to
describe the warning signs of eating disorders, and (f) to
discuss ways in which eating disorders can be prevented. In
general, prevention programs for elementary through high
school students appear to be lacking and programs which
specifically target coaches of this age group are needed.

The number of eating disorder prevention programs

which have been evaluated for their effectiveness is also

24
minimal. According to Shisslak and Crago (1994) only three
studies have evaluated the effectiveness of eating disorder
curriculums. One study was conducted by Killen (1993) and
his associates. This study focused on sixth and seventh
grade girls in four California middle schools. The girls
were randomly assigned to receive either the prevention
curriculum or control classes. The program had three major
components: (a) to instruct on the harmful effects of
unhealthy weight regulation, (b) to promote a healthy
weight through dietary principles and regular exercise, and
(c) to develop skills to resist sociocultural influences
toward dieting and thinness in women. The evaluation
consisted of measures administered before the curriculum
began and at four intervals throughout the two years after
completion. The evaluation included self-report measures,
anthropometric measures and clinical intervention. The
analysis of the results focused on changes in the scores of
the intervention and control groups and changes in the
scores of students who were determined in the pre-testing
phase to be at risk for eating disorder development. Both
the intervention group and the high-risk intervention group
showed an increase in knowledge about eating disorders,
however, there were no significant differences between the
intervention and control groups in eating attitudes,
dieting, and body mass index (BMI). Similarly, the high-
risk groups did not show any differences in eating

attitudes and dieting. There was only a slight difference

25
which was significant for the BMI. Follow-up evaluations
showed no significant differences between the intervention
and control groups based on the variables measured.

Thus, the prevention intervention approach of this
study failed to make a difference. The researcher
suggested it may be more cost-effective to target high-risk
students for prevention or to include an intensive
intervention for high risk students while still providing
information to all students. Another issue identified was
the effectiveness of a short term intervention as compared
to a yearly or continuous intervention.

This study adds support for the importance of an
educational inservice for athletic coaches on eating
disorders. This literature review acknowledges that
athletes are a high-risk group of individuals and that
coaches who work with these athletes could be considered as
an intervention approach. Secondly, utilizing coaches, who
most often have a continuous relationship with their
athletes, could create a continuous intervention for eating
disorder prevention, identification and treatment.
WM:

Research on female athletes continues to increase as
the number of women participating in athletics continues to
rise. A large portion of the current literature focuses on
the “female athlete triad” (Skolnick, 1993; Thein & Thein,
1996). This refers to a set of problems female athletes

are particularly at-risk for developing: (a) an eating

26
disorder, (b) amenorrhea, and (c) osteoporosis. Kimberl,_
K. Yeager, MD, MPH, Assistant Director for Public Health
Practice, San Diego (Calif) State University Graduate
School of Public Health stated at the 40th annual meeting
of the American College of Sports Medicine (Skolnick, p.
921) “ ‘The constant focus on either achieving or
maintaining a prescribed body weight goal may put the
female athlete at-risk for developing a disordered pattern
of eating.’ ” Dr. Yeager (Skolnick) further stated that
the athlete is subsequently at-risk for developing the two
associated disorders, amenorrhea and osteoporosis.
Individually these disorders are cause for concern and may
cause harm; however, combined they may be fatal. Based
upon several small studies, Yeager (Skolnick) reported that
disordered eating among female athletes may be as high as
62% in certain sports.

In the literature review on eating disorders several
risk factors for these disorders were mentioned. Lopiano
and Zotos (1992) provide some of the specific risk factors
for eating disorders in athletes: (a) performance
pressure: athletes are pushed from all directions to
compete at their best; (b) coach-athlete relationship:
athletes receive some of the pressure experienced by
coaches, which may have positive or negative results
depending on the athletes’ performance; (c) value
incongruence: athletes are taught values such as obedience,

the need to intimidate or injure opponents which are

27
dysfunctional in general life; (d) visibility of
participation: all actions can be scrutinized by many
people; (e) time demands and social isolation; (f) fatigue—
related stress: a possible result from excessive training,
anxiety and the demands of competition; (g) injury: injuries
are common, affect a major aspect of the athlete's life, and
may result in depression; (h) academic pressures: athletes
are pushed to excel in academia as well as athletics; and
(j) stereotyping and discrimination by race and gender: this
may enhance pressure and decrease social support. Taub and
Blinde (1992) address another interesting risk factor to
consider: the personality characteristics of athletes which
may predispose them to eating disorders.

Taub and Blinde (1992) compared adolescent female
athletes and nonathletes in terms of behavior and
psychological traits associated with eating disorders, the
use of pathogenic weight control techniques (laxatives,
vomiting, fasting, and diet aids), and sport-by-sport
comparison to determine if athletes in specific sports were
more at-risk. The results indicated that athletes were more
likely than nonathletes to have behavioral and psychological
correlates of eating disorders, and that there were few
differences among the various sport teams.

The coach-athlete relationship is an additional factor
to consider in the development of eating disorders in

athletes. Two issues related to this relationship are of

28
concern: (a) the coaches influence with “vulnerable”
athletes, and (b) team/athlete performance.

The athlete as stated previously has specific risk
factors for eating disorders. Coaches must understand that
the athletes with whom they are working are a vulnerable
group of individuals. The literature states that most
researchers agree “...coaches do not cause eating disorders
in athletes, although through inappropriate coaching they
may trigger or exacerbate the problem in vulnerable
individuals” (Thornton, 1990, p. 119).

Similarly, if team/athlete performance is more
important than the health and well-being of the athlete,
this is an important concern. Wilmore (Thornton, 1990, p.
119), states “for some coaches there is such ego
involvement, so much concern with the team’s overall
performance and how this makes them look, that personal
ambition may also play a role.” Similarly, Yeager (Skolnick,
1993, p. 921) stated “ ‘Athletes appear willing and eager to
attempt any measure to achieve an advantage. This at-any-
cost approach has been supported —indeed encouraged- by
coaches, athletic trainers, and parents.’” Therefore, the
literature suggests that coaches may consider team
performance, but more likely to occur is “...ignorance about
what constitutes a healthy body weight and the method
necessary to achieve it” (Thornton, p. 119). The coaches

impact on the development of eating disorders in athletes

29
should be viewed as only one part of a complex, multi-
factorial disorder.

The literature supports the need for preventive
efforts which target female adolescent athletes. The
increase in female athletes, the “female athlete triad”,
athletes predisposition for eating disorders and the coach-
athlete relationship are evidence in support of a
prevention focused inservice.

The content for the proposed inservice needs to
include five major areas of focus; eating disorders,
physical issues related to eating disorders, self-esteem
and societal pressures, healthy/normalized eating behaviors
and resources for eating disorders.

Discussion

The proposed inservice for coaches about at-risk
female adolescent athletes for eating disorders is based on
the previous literature review and Knowles’ (1990)
principles of the adult learner. It includes
recommendations related to the optimal time period,
location and financial support. The five major areas of
content for the inservice are: (a) eating disorders, (b)
physical issues related to eating disorders, (c) self-
esteem and societal pressures, (d) healthy/normalized
eating behaviors, and (e) resources for eating disorders.
W

According to the literature review, currently athletic

coaches in the State of Michigan are not required to attend

30
classes/programs which address common issues in coaching
athletes. However, due to the influence of the coach—
athlete relationship and the potential for ongoing
preventive interventions by the coach, this inservice is
recommended to be mandatory for all coaches. The coaches of
all female adolescent athletes should be involved, since as
the literature supports, one-sport cannot be singled out as
more likely for eating disorder development. Additionally,
the CDC (1996) supports staff education on healthy eating
and behavioral change techniques.

The proposed time—period for this inservice is three-
two hour sessions. The CDC guidelines (1996) support more
than one session, so that the coaches can try out new
techniques and report on their experiences. The exact time
the inservice will be offered is flexible and is based on
the needs of the coaches’ schedules.

The location and financial needs of the inservice are
not directly addressed in the literature. For ease of
attendance, a classroom at the junior/senior high school
would be appropriate. This would reduce cost, as most
schools have space available during non-school hours. Based
on the CDC guidelines (1996) which encourage education of
staff members, i.e., coaches involved in nutrition education
and behavioral change techniques, the inservice could be at
no cost to the coaches who attend. This author suggests the
proposed inservice be incorporated with that which is

currently provided by the Michigan High School Athletic

31

Association. The first step would be to present the
proposed inservice to the director of the Michigan High
School Athletic Association, other interested members of
the association and the athletic directors of a few target
schools. Based on the feedback from the trial inservice,
appropriate alterations of the inservice could be made. The
proposed inservice could then be offered to the athletic
coaches of female adolescent athletes at the target
schools. Following the trial inservice, testing and
evaluation for effectiveness should be done prior to
further implementation of the inservice.
E !' E' 3

According to Knowles (1990), adults have a “need to
know” the significance of a specific topic, before
undertaking to learn it (Principle 1). Therefore, the
first section on eating disorders includes prevalence rates
of eating disorders in athletes, risk factors of the
sport’s setting and specific risk factors for eating
disorders in athletes. In order for coaches to understand
the terms used with eating disorders the diagnostic
criteria for anorexia, bulimia and eating disorders not
otherwise specified need to be reviewed. A discussion of
the signs and symptoms of specific eating disorders would
follow.

Based on the literature review of eating disorder
prevention programs, information on the prevention of

eating disorders in athletes is necessary for the coach.

32
Therefore, the second part of the eating disorders section
addresses preventive interventions aimed at athletes.
E] . J I E J I 3 ! E !' I. 1

According to the literature review on eating disorder
prevention programs, physical issues related to eating
disorders are necessary in the inservice. The prevention
programs included information about fatness and the
negative effects of dieting. The “female athlete triad" is
referred to frequently throughout the literature in
relation to female adolescent athletes.

Knowles’ (1990) second principle of learning empowers
the coach to understand eating disorders. A review of the
physical issues is necessary for the coach to obtain this
knowledge. Similarly, the fourth principle of adult
learning entails a desire by the coach to increase his/her
knowledge base regarding their athletes. This is also
accomplished when one is familiar with the physical issues
of eating disorders. The physical issues to be discussed
include: (a) the Five Major Determinants of Body Weight,
(b) The Negative Effects of Dieting, and (c) The Female
Athlete Triad.

W

The literature review and Knowles’ (1990) principles
of adult learning provide the rationale for including
information on self—esteem and societal pressures in the

third section of the inservice.

33

The literature review points out the increased
interest in observing the influences of society and the
media on the “thin is in” message. This message which
prevails in Western society is considered a factor in the
development of eating disorders. The pressures placed on
women to succeed at home and in the work place contribute
to a woman’s need for “control”. Often this control is
achieved through body shape and size. The prevention
programs include the idealization of thinness in our
society, that body fat is undesireable, the need for
respect of different body shapes and sizes, and development
of skills to resist sociocultural influences toward dieting
and thinness.

Knowles’ (1990) third principle emphasizes self
examination of habits and biases related to eating
disorders, affirmation of a problem and the potential for
developing new approaches to eating disorders. This
inservice addresses this principle through a video which
depicts how the media influences individuals. Following
the video, small groups of the coaches will discuss the
video and share their personal “accumulated” experiences
with eating disorders. Knowles’ fifth principle
facilitates the coaches ability to prevent/address eating
disorders in athletes. Thus, a list of facts on the Basic
Tenet: of Health at Every Size and a list of interventions/
suggestions on Loving Your Body are included to promote

increased self-esteem thereby preventing eating disorders.

34
The sixth principle, normal adults are motivated to keep
growing and developing, is also encouraged through the use/
provision of these interventions to increase self-esteem.
Furthermore, a list of resources for additional information
on eating disorders is provided which should promote the
future growth and development of a coach. The coach is in a
good position to continually work on his/her personal
ability to increase self-esteem in the athletes.

In summary, the self-esteem and societal pressures
section will include: (a) a video, 811n.HopeI:

Advertising and the obsession with thinnness (Kilbourne,
1995), depicting media/societal influence on the
individual’s self image and eating disorders, (b) a small
group discussion about the video and habits/biases of the
coaches, and (c) two interventions, i.e., Basic Tenet: of
Health at Every Size and Loving Your Body.

H J 1 CH 1. i E !' H 1.!

The literature review of the prevention programs for
eating disorders includes information on healthy eating
habits. Nutrition inservices, the return of healthy eating
habits in the presence of an eating disorder and promotion
of a healthy weight through the application of dietary
principles and exercise are examples of how eating habits
have been addressed in the literature.

Knowles’ (1990) principles of adult learning are met
when information on healthy eating habits are included in

the inservice. The second principle is met when the coach

35
learns health promotion approaches. Principle four is
attained when the coach has acquired an increased knowledge
base, i.e., healthy/normalized eating habits. Principle
five, prevention/addressing eating disorders, is also
accomplished through this information. Principle six is
met when the coach continues to investigate how healthy/
normalized eating habits are most effectively explained/
modeled to the athletes.

For this section of the inservice healthy/normalized
eating habits are reviewed, i.e., (a) a definition of
“Normal” Eating, (b) a review of the Food Guide Pyramid,
and (c) Strategies for Normalized Eating. The Food Guide
Pyramid will be provided as a basis for healthy eating.
Detailed diets for athletes based on specific sport
involvement will require further investigation on the part
of the coach.

E' i i E !' [H | °!' E

Multiple resources are available to the athletic coach
via the internet, mail or telephone contact. Since the
literature review repeatedly emphasized providing current
information for coaches on eating disorders, a list of
available resources will be given to the coaches at the
inservice. Secondly, Knowles’ (1990) principles of the
adult learner will also be attained with a list of
resources for the coaches to access. The list of resources
will allow the coach to be self-directed (Principle 2),

increase his/her personal knowledge base (Principle 4),

36
prevent/address eating disorders in athletes (Principle 5)
and provide for further growth and development as a coach
(Principle 6).

In summary, the proposed inservice is composed of five
sub-sections: (a) eating disorders, (b) physical issues
related to eating disorders, (c) self—esteem and societal
pressures, (d) healthy/normalized eating habits, and (e)
disordered eating/nutrition resources. In order to reflect
the activites of the inservice within the framework of
Knowles’ (1990) adult learning principles, Figure 3, is
presented as an adapted model. A sample copyrighted packet
of this inservice is included in the back cover of this
project.

The proposed inservice was reviewed by an advanced
practice nurse and two teachers, one of whom is also a coach
of adolescent females. The inservice was reviewed for
clarity and perceived ease of implementation. Positive
feedback regarding the inservice and its content was
received from all three individuals. The teacher/coach made
some recommendations regarding the questions to be used
during the group discussions in order to facilitate an
effective discussion.

Implications

Three major areas of implications exist as a result of

the inservice for coaches on at-risk female adolescent

athletes for eating disorders. They are related to:

37

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. 4
- Video - Slim Hopes 0 Definition of ‘Normal' Eating
0 Small group discussion of the 0 Food Guide Pyramid
video and personal experiences 0 Strategies for Normalized Eating
lmmemMgmambm i-mamnmuemmowmmmn
0 Small group discussion related Resources
mcumeunmmms,
i.e., team performance versus
flwhmmhdflwambm
a a
0 Eating Disorders Definitions and 0 Prevention Interventions for the
Diagnostic Criteria Coach to Use with Athletes
- Signs/Symptoms of Eating Disorders - Frve Major Determinants of Body
0 Prevention Interventions for the Coach Weight
to Use with Athletes 0 The Negative Effects of Dieting
- Frve Major Determinants of Body Weight 0 The Female Athlete Triad
- The Negative Effects of Dieting 0 Basic Tenet: of Health at Every
- The Female Athlete Triad Size
0 Definition of 'Nonnal" Eating v Loving Your Body
0 Food Guide Pyramid - Disordered Eating/Nutrition
- Strategies for Normalized Eating Resources
0 Disordered Eating/Nutrition Resources .
1. 6.Forthecoachtousewith
0 The Prevalence of Eating athletes -
Disorders Some Tentative "Facts‘l - Prevention Interventions
0 Prevalence Rates of Eating - Basic Tenet: of Health at
Disorders in Athletes Every Size and Loving Your
. Risk Factors for the Athlete and Body
the Sports Setting 0 Strategies for Normalized Eating
'-msmMdemmmemhn
Rammun

 

 

 

 

 

 

 

 

 

 

 

 

Athletic Coachee’ Inservlce

 

Figure 3 - Knowles’ (1990) Adult Learning Principles Applied
to Athletic Coaches’ Inservice

38
(a) advanced practice nursing education, (b) research on
the inservice, and (c) policy development.
3 i E . H . E3 !'

Two issues related to advanced practice nursing
education should be addressed as a result of this inservice
development. First, advanced practice nursing education
should include detailed information on eating disorders.
This is essential for the role of the advanced practice
nurse in primary care and the community setting, i.e.,
school involvement. Second, advanced practice nursing
education should provide information on the development and
implementation of educational inservices. This could
include information on Knowles' (1990) principles of adult
learning, as this would provide an appropriate framework
for the rationale and design of an adult inservice. This
would empower the advanced practice nurse to develop and
implement an inservice based on the needs of his/her
individual practice setting.

This inservice is a model which could be presented
after minor changes in the content to other groups, i.e.,
the Parent Teacher Association, coaches and athletes of all
sports, teachers at a junior/senior high school. The
content and implications of this inservice provide further
opportunities for implementation. Post—training sessions
could also be offered to the participants of the inservice,
in order to promote the sharing of their experiences with

peers.

W

This inservice provides many opportunities for further
research. First, the inservice needs to be implemented and
evaluated. The evaluation should include the effectiveness
of the inservice, the effect on the role of the coach, and
what actions resulted from the inservice.

In order to research the effectiveness of the
inservice multiple factors may be assessed. Assessment of
the coaches’ knowledge about eating disorders in athletes
prior to and following the inservice would reflect the
knowledge acquired as a result of the inservice. The
athletes of these coaches could be assessed for eating
disorders and compared to a group of athletes whose coaches
did not attend this educational inservice. This would
require evaluating the athletes on specific factors related
to the coach-athlete relationship. The effectiveness of
the inservice may also be evaluated by assessing what the
coaches did with the information they received about eating
disorders in athletes. Furthermore, testing should include
varying time intervals between the three proposed inservice
sessions in order to assess which is the most effective
time interval for the sessions.

The role of the coach in preventing/addressing eating
disorders is a primary focus in the inservice. Research on
the effect of this inservice on the role of the coach is
necessary. This is closely related to the actions taken by

the coach following his/her participation in the inservice.

39

Wait

The development of this inservice focuses on an area
for policy development which could promote the
implementation of this inservice. Currently the State of
Michigan does not require specific classes/inservices for
coaches of athletes. Considering the literature review and
the potential effect coaches have upon athletes, the
inservice could be mandatory for athletic coaches in
Michigan. The development of such a policy could be
implemented by the advanced practice nurse. In order to
facilitate the incorporation of a mandatory inservice, the
advanced practice nurse needs to educate members of the
Michigan High School Athletic Association, principals, and
athletic directors at the junior/senior high school levels.
As a specialty group in the Michigan Nurses Association,
advanced practice nurse members could bring this issue to
the attention of the Michigan High School Athletic
Association in order to facilitate its inclusion in the
WWW (Seefeldt
& Brown, 1995).

This inservice supports the goals of the Michigan
Nurses Association. The first goal of the Michigan Nurses
Association (1997) is the advancement of nursing’s agenda
for health care delivery. Which means facilitating the
role of the nurse in a “restructured” health care delivery
system which promotes health promotion and disease

prevention. The Michigan Nurses Association (1997)

40

41
encourages the nurse to seek mechanisms to move from acute
to community-based care and to promote the utilization of
advanced practice nurses. The implementation of this
inservice would promote community-based nursing care and
the utilization of advanced practice nurses.

Implications from this inservice involve the advanced
practice nurse in advanced practice nursing education, on-
going research directed at the inservice and policy
development and implementation. In doing so multiple roles
of the advanced practice nurse are utilized through the use
and implications of this inservice. First, the advanced
practice nuse is an educator, providing information on
eating disorders and the importance of prevention and
identification of these disorders in female adolescent
athletes. The coach may consult with the advanced practice
nurse regarding specific signs/symptoms of a particular
athlete as to whether this is a concern which may require
further action. The advanced practice nurse is promoting
leadership for the role of nursing and its utilization in
the community. The advanced practice nurse is also
advocating for the health and well-being of athletes
through the use and implications of this inservice. In
summary, multiple roles of the advanced practice nurse are
evident through the development, implementation and

implications of this inservice.

Summary

Athletic coaches are a primary link to the prevention
of eating disorders in athletes, yet few educational
inservices exist to educate coaches about eating disorders,
their identification and preventive activities. The Healthy
£reyentign_9biegtiye§ (U.S. Department of Health and Human
Services, 1991) and the CDC (1996) support the need for the
development, education and in-servicing of coaches on
nutrition, eating disorders and prevention.

Thus this project focused on the development of an
educational inservice for athletic coaches on the
prevention and identification of eating disorders in female
adolescent athletes.

The framework for this inservice was Knowles' (1990)
principles of the adult learner; these principles are
applied to athletic coaches, the target audience for this
inservice. This framework which focuses on adult learners
is essential for the success of the inservice.

This inservice provides athletic coaches with current
information on the prevalence, prevention and detection of
eating disorders of at-risk female adolescent athletes. In
conclusion, the development of this inservice has
implications which reach beyond this scholarly project.
These implications involve advanced practice nursing
education, further opportunities for research and policy

development.

42

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List of References

American Psychiatric Association (1994). i n ' nd

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Baer, J. T., Walker, W. F. & Grossman, J. M. (1995). A
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practices in college athletes. QQHIDEJ 9f Athletic Training
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Brownell, K. (1994). Eating disorders in athletes. In

K. Brownell & C. G. Fairburn (Eds.), Eating_di§g;g§;§_gn§
obesity (pp. 191-196). New York: Guilford Press.

Centers for Disease Control (1996). Cpg_preyentign

0 0‘ e‘ ' r00 9.: 9 .- 00 ill 0 .- 0110 ‘ ' ‘ 09-.

healthy_eating [Electronic database]. Atlanta, GA: National
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[Producer and Distributor].

Dick, R. W. (1991). Eating disorders in ncaa athletic
programs. W 137-140.

Duffy, M. E. (1991). When a woman heads the household.

In B- W. Spradley (Ed.), BeadineLimmmuuitLhealth
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Fairburn, C. G. (1994). The prevention of eating
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difigrde;§_and_gbe§ity (pp. 289-293). New York: The Guilford

Press.
Herzog, D. B. & Copeland, P. M. (1985). Eating

disorders. Wm). 295-
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44

Johnson, C. L., Sansone, R. A., & Chewning, M. (1992).
Good reasons why young women would develop anorexia nervosa:

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Female

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