Does a hunger to win fuel eating disorders?

Feb. 26 through March 3 mark National Eating Disorders Awareness Week. The following special report appears in the spring issue of ESPNHS GIRL magazine.

It wasn’t like Sarah Sumpter had a secret. She wasn’t sneaking around eating things she shouldn’t or pretending to be in bed sleeping when she was really off exercising her brains out. Like many young, talented, determined high school athletes, Sumpter was methodical and organized in her behavior, laying her eating disorder out in public, for coaches, teammates and family members to see and react to.

For far too long, they didn’t seem to do much of either.

A high school standout in cross country and track and field, Sumpter was one of the best runners Healdsburg (Calif.) High had ever seen. She was driven and dedicated to the sport, approaching each workout with a hunger usually seen in professionals.

From freshman to sophomore year, she made huge gains in her performance. Her junior year brought even greater accolades, topped by being crowned the California Division IV cross country champion in the fall of her senior year, earning her a trip to the Foot Locker Cross Country National Championships. The harder she worked, the faster she got. It was natural to make the connection between self-discipline and excellence. “I wanted to see how good of a runner I could be if I really committed myself,” she said.

So she did. Miles went up. Gym sessions increased. Food intake went down. “I realized that as I worked harder and lost some weight, my times were improving,” she said. “So I figured that if a little weight loss was good, a lot would be even better.” She began putting herself through a grueling training schedule, adding miles on top of the usual team workouts and monitoring every morsel that passed her lips. In short order, the numbers on the scale began to drop. By the winter of her senior year, Sumpter, 5-foot-1, had dropped from 112 to barely 92 pounds.

To her surprise, her running performance stopped improving. Rather than getting faster, she found herself dogging it through more than one workout, feeling exhausted from runs that used to leave her exhilarated. At the Foot Locker Cross Country Nationals in November 2007, Sumpter finished a disappointing 22nd. “I remember just being so happy the race was over,” she said. “I was glad not to have to run anymore.” But rather than seeing a subpar performance as a sign to back off and let her body recover from the relentless routine, Sumpter doubled down on her efforts to improve. She began running 110 miles per week, determined to do better, be faster and get fitter before the spring season started.

She was literally running herself into the ground -- and as her body began to weaken, her love of the sport slowly slipped away. “That winter, I reached an emotional breaking point,” she admited. “I was so cold and miserable out there on my runs. And I was confused how something that had given me so much joy in my life now felt like this terrible chore I was forced to do.”

She needed help.

Sumpter's downward spiral into the depths of anorexia is perhaps most disturbing for its simple logic: If a few pounds were good for performance, a lot of pounds would be amazing.

Compounding the issue, the draconian, self-imposed discipline required to lose unsafe amounts of weight is something athletes like Sumpter excel at. While the average person might call it quits when they start feeling weak or unwell, top athletes are trained to push through pain and thrive on challenging their body’s limits. Restricting food intake becomes another way to build mental toughness and show dedication to one’s sport. Before she knew it, Sarah’s competitive spirit had turned against her, and she found herself fighting to regain control of her body and mind.

It is a paradox that in this time of national obesity epidemic, a segment of the teen population is suffering from health issues at the other end of the spectrum. But anorexia and bulimia are also on the rise, affecting an estimated 10 million Americans every year and taking hold of elite athletes at twice the rate of the average female population, according to the National Association for Anorexia Nervosa and Associated Disorders.

Though most studies of young athletes have been done on the collegiate population, a 2006 article in the Archives of Pediatric and Adolescent Medicine found that among high school student athletes in California, 20 percent of girls had at least one symptom of female athlete triad, characterized by disordered eating, missed menstrual periods and low bone mass. What’s more, one third of NCAA Division I female athletes show symptoms, putting them at risk for anorexia. While playing recreational sports appears to provide some protection by creating higher self-esteem and confidence in girls, this advantage is negated as soon as the athlete engages in competitive events, where her performance is critiqued and the pressure to win looms large.

“Studies show that as you move up in competition level, problems with eating disorders increase,” said Dr. Ron Thompson, a Bloomington, Ind.-based sports psychologist who specializes in eating disorders. “The same competitive personality traits and perfectionist tendencies that make elite athletes successful are also factors that contribute to eating disorders.”

High school girls are already in the highest risk group for developing body image issues because of social pressures, Thompson noted. Throw in the pressure of sports performance, and you have the perfect storm for diseases like anorexia. If the disorder doesn’t fully show itself at the high school level, just wait, said Thompson: “I’d estimate that 90 percent of the college athletes I see with eating disorders do not develop their problems in college. They begin much earlier, at the high school level.”

The problem is most high schools have a coach (often a volunteer) who is unlikely to have been trained in handling anorexia or bulimia. “You’re required to take CPR classes and first-aid sessions,” said Tanya Namad, a cross country coach at a private all-girls school in New York City. “But there’s no requirement to be trained in eating disorders.”

Though Namad hasn’t had to broach the topic with anyone on her team, she said if she did, she’d have no blueprint to follow. “There’s no formal training for high school coaches on it,” she acknowledged. “I’d look for the typical signs -- if the student looks really thin, or she’s always tired and avoiding social situations involving food.” One thing Namad’s school does support is teaching students about sports nutrition. “I talk with my athletes about proper hydration, and what to eat before a big game or during practice to keep them healthy,” Namad said. Indirectly, such information may help girls think of food as a tool for improved performance, not a detriment to it.

Lack of training and resources for coaches is a big reason why some girls fall through the cracks. “There is a real problem here,” Thompson said. “The athletes who are most at risk are the younger athletes. The NCAA trains coaches about what to look for -- college athletic departments have full-time physicians and nutritionists who work with teams. High school coaches lack the information on the issue and no medical backup is available for them if an eating disorder arises. These girls are vulnerable to going undiagnosed until the disorder becomes extreme.”

For most girls, when a health issue comes to light it’s off to the family doctor -- and therein lies another major hurdle. “When I went to see my doctor, it was not helpful,” Sumpter said. “He told me I should gain weight to reach 120 pounds. That’s more than I ever weighed before I even began running.” The well-meaning but very real disconnect between a pediatrician’s advice and the goals of an athlete leaves people like Sumpter without any constructive path to follow. Yes, she needed to add some pounds back on, but she wasn’t willing to give up her athletic dreams to do so. “I felt alone,” she said.

Whitney Post launched the website Eating For Life for young athletes like Sumpter. Post, a former Olympic rower, developed bulimia after joining the crew team at Brown University and struggled for nearly 15 years to get a grip on the disease. “I wanted to create a space where students, parents and coaches could come for advice,” Post said. Though the site caters to college students, Post feels a particular need to reach out to young athletes who are suffering and is working with the Women’s Sports Foundation and offering workshops at colleges. “It is a slippery slope for female athletes,” she admitted. “Psychologists used to think that sports would protect girls from developing eating disorders, but the new thinking is that the increased focus on body and performance may actually raise the risk.”

The locker room atmosphere can also exacerbate the problem. “When a teammate is suffering from disordered eating, there’s a lot of gossiping but no one wants to say anything in public,” Post said. “It can really throw the team dynamic off.”

The issue of “competitive thinness” also rears its head in a team environment, added Thompson, referring to girls comparing their bodies to teammates’ and feeling envious of those who are thinner. “Athletes are already competitive by nature, and in a lot of sports -- like diving, swimming and gymnastics -- they’re wearing next to nothing,” he said. “If the thinnest girl wins the meet or competition, it’s easy to think, ‘I need to look like her to be the best.’”

Navigating the weight versus performance issue is tough. “Girls may see temporary gains in their performance when they lose weight, but it’s not sustainable if they aren’t taking in enough calories,” said Dr. Kate Ackerman, a sports medicine specialist at Children’s Hospital in Boston. The female athlete triad is particularly disturbing since loss of estrogen production leads to poor bone density, resulting in stress fractures. “Ninety percent of bone mass is built by age 18,” Ackerman said. “High school years are critical for building strong bones.”

Worse, without enough nutrients to support intense workouts, the body begins to consume its own muscles for fuel. Those girls who dropped weight and started running faster? In another six months, they’re nowhere to be seen, having been sidelined by a cycle of injuries and illnesses that multiply as their eating disorder deepens.

Given the dire outcome of losing too much weight, it is confusing why girls keep drinking the dieting Kool-Aid. Part of it may be a lack of information about what really drives their successes. “When one of my athletes has a good performance, and I ask her to tell me what she did that contributed to the positive results, nine times out of 10, she doesn’t know,” said Dr. Caroline Silby, a sports psychologist and author of “Games Girls Play.” “If athletes don’t know why they’ve performed well, they also don’t understand why they perform poorly, and the easiest thing to blame for poor performance is weight.”

Also not helping: images of a sport’s elite athletes looking impossibly lean. “Paula Radcliffe does not have an ounce of body fat on her,” Sumpter said, referring to the British world-record holder for the marathon. These women may have perfectly healthy eating habits, but that doesn’t stop aspiring athletes from trying to attain the same appearance by less-healthy means. “The most important thing coaches and parents can do is to emphasize fitness,” Silby said. “If we can change the conversation from how thin these athletes are to how fit they are, it will go a long way to helping girls develop a healthier attitude toward food as fuel.”

True to her disciplined approach to training, when Sumpter finally asked for help with her anorexia -- seeking out a guidance counselor and subsequently enlisting her coaches’ support to keep her on the right track -- she was determined to beat the disease and rekindle her love affair with running.

For the most part, it worked. She added enough pounds to keep her strength up and race times down, and learned to stop beating herself up every time practice didn’t go perfectly. “Once I started eating right,” she said, “I was like, ‘Look how much more energy I have!’” Now a college standout on the UC Davis cross country and track teams, she admits she is not completely free of her demons. “It’s not something you can just turn off,” she says. “I’ve just learned to combat those thoughts more successfully.”

If she could share one thing with other athletes, Sumpter says it would be this: “Your body can’t run on nothing. Eventually, you will crash and burn. If a friend or coach says something, be open to considering what they’re telling you. The sooner you get help, the easier it will be to get your life back.”