Athletes and Eating Disorders
Winter 2006, Vol 5, Issue 1
Kenneth Littlefield, PsyD, Department of Psychological Services
Juliet Zuercher, RD, Rachel Daberkow, MS, RD, Department of Nutrition Services
Jennifer Hazel, MA, LPC, Patient Care Services Division
Brenda K. Woods, MD, Department of Primary Care Medicine
Remuda Ranch Programs for Eating Disorders
Athletes constitute a significant subgroup of women with eating disorders (ED). Recent research with 1022 ED inpatients found 53% were athletes (Day, 2003). Yet educators, coaches, families, and treatment professionals sometimes overlook ED evidence in athletes. Due to a relative lack of available information, they may not fully grasp the unique challenges that ED athletes face.
Awareness of ED’s signs and symptoms and the female or elite athlete triad is crucial for athletes, parents, and coaches to identify ED problems. As with all EDs, early identification predicts good outcome. The female athlete triad consists of disordered eating, amenorrhea, and osteopenia or osteoporosis. Depending on symptoms and severity, it is diagnosed as anorexia, bulimia, or eating disorder not otherwise specified. It especially affects those in sports where low body weight may be beneficial, such as long-distance running.
The Physiologic Screening Test, available online, is a brief screening tool that may be used by healthcare and athletic professionals as an early detection tool for disordered eating among female athletes (Black, Larkin, Coster, Leverenz, & Abood, 2003). Athletes in higher risk categories, such as White female athletes (Johnson et al., 2004) and those involved in certain judged sports, should be carefully monitored. Research suggests that initiatives such as ATHENA—Athletes Targeting Healthy Exercise and Nutrition Alternatives—may reduce athletes’ use of diet pills and performance-enhancing substances and increase healthy exercise, proper eating, and self-efficacy (Elliot et al., 2004). It is therefore important to ask whether a particular athlete is participating in such initiatives, to promote their use, and to closely monitor athletes who are not participating.
Current treatment approaches do not automatically recommend abstinence from exercise and sport competition for ED athletes. Abstinence may be counterproductive (Beals, 2004, p. 133). Hence, athletes’ appropriate return to sport must be addressed. In addition, although there are some compulsive exercisers for whom physical activity quickly becomes exercise abuse, this is not the case for many ED patients. Making these distinctions, however, is often difficult for treatment providers. The problem is compounded for a patient whose identity, self esteem, and
motivation for recovery arise from her role as an athlete (Heyman & Andersen, 1998).
The large population of athletes in Remuda’s inpatient milieu necessitated a systematic, objective method for making recommendations about: 1) the appropriateness of athletes’ involvement in training/competition during ED recovery; and 2) their long-term athletic participation. To develop our methodology, we combined research, clinical experience, and common sense. We have thus established a process for determining the risk factors involved in athletics and individuals’ readiness for return to sport and exercise.
Research on Eating Disorder Athletes
A review of the research regarding ED athletes reveals the need for a comprehensive, multi-disciplinary assessment of many factors to predict the most likely effects of athletic involvement on each individual. Treatment professionals, athletic departments, and families do well to collaborate together and with the athlete to improve comprehensive evaluation and formulate congruent goals.
Influential in the decision to return to athletics is the kind of sport in which a patient is engaged. EDs are not equally distributed among sports. In some sports, ED behaviors are pervasive. Zucker, Womble, Williamson, and Perrin (1999) demonstrated that judged sports like gymnastics, figure skating, diving, and dance have an ED prevalence rate of 13%. In contrast, ED prevalence in refereed sports is only 3%, comparable to a non-athlete population. Furthermore, participants in judged sports score significantly higher on measures of over-concern with weight and size. Such over-concern is the most significant psychosocial characteristic associated with ED among female athletes (Williamson et al., 1995). Judged sports may produce ED risks because they allow physical appearance to influence performance evaluation, whereas refereed sports do not (Best, 1988).
Powers (1999) indicated that judged sports are not the only athletic endeavor to increase females’ risk for ED. Endurance
sports, sports with weight categories, individual sports, female sports with revealing clothing, and lean sports all are risky. Lean sports are described as those that prefer or give an advantage to participants who lack adequate body fat. Petrie (1996) defined lean sports as those “where appearance or weight are important for success, such as gymnastics,” and non-lean sports as those “where weight is non-central, such as basketball.” Lean sport athletes may be more likely to engage in pathological weight control behavior, particularly excessive exercise and strict dieting, to achieve their desired weight or appearance (Petrie, 1996). Accordingly, men involved in sports that focus on weight and appearance, such as wrestling and body building, face ED risk (Choi, Pope, & Olivardia, 2002; Pope, Gruber, Choi, Olivardia, & Phillips, 1997; Williamson et al., 1995).
No discussion of athletics’ influence on ED development would be complete without mention of perfectionism. Sport participation can engender an obligatory, perfectionistic attitude towards exercise and training. Perfectionism increases the likelihood of ED behaviors and attitudes, such as strict dieting and negative evaluation of one’s weight and body (Seigel & Hetta, 2001). Female athletes who are more perfectionistic show significant increases in ED behaviors, especially in dietary restraint (Hopkinson & Lock, 2004).
It is critical to note that certain female sports may also be protective against ED. Although the research contains some contradictory results, non-lean sport athletes report higher self esteem, greater perception of control over external events, and fewer feelings of worthlessness, insecurity, emptiness, and inadequacy (Petrie, 1996). Overall, female athletes have less body dissatisfaction than non-athlete counterparts (Davis & Cowles, 1989). Thus, women in certain sports evidence greater self-esteem and less body dissatisfaction—key factors that protect against ED development.
It is theorized that social influence, performance anxiety, and self-appraisal each contributes to body dissatisfaction (Williamson et al., 1995). If these factors can be influenced in a positive direction, then athletes may have further insulation against EDs. One of the best influences in all three areas is an athlete’s coach or athletic department. Accordingly, Biesecker and Martz (1999) view coaching style as a significant factor in preventing athletes from developing EDs. They suggest a “person-oriented” coaching approach and discourage a “performance-oriented” approach. Their research indicates that coaching styles emphasizing the value of the individual over the outcome of their performance result in less body dissatisfaction and fear of fat.
The concept of person-oriented coaching can be extrapolated to parenting. Parents who are involved in their children’s athletics often function as primary or secondary coaches. Parents may have a deeper influence on motivation for competition and desire to perform than coaches do. Athletes are constantly subject to parents’ expectations and criticisms, and these influences may endure for a lifetime.
Treatment professionals should therefore consider the following questions to help determine a particular coach’s or parent’s style. Does the coach or parent focus more on the athlete’s wellbeing or performance? The level of competition may dictate the extent of performance focus to some degree, but not completely. What costs to the athlete are communicated as acceptable sacrifices for the sake of athletic achievement?
Our personal experiences in both athletics and ED treatment reinforce our support of person-oriented coaching. We have seen the attitudes of wrestling, track, and cross-country coaches exert positive influences in the nutritional and training practices of athletes at risk for ED behavior. We have also seen the opposite and witnessed damaging effects. We thus believe that educating coaches and athletic departments and enlisting their participation in preventing and treating EDs are essential to the athletic community’s long-term health and its influence on popular culture.
Several studies have shown that athletes are a distinct subgroup of ED sufferers. They have unique presentations, strengths, and challenges (Day, 2003; Johnson, Powers, & Dick, 1999; Petrie, 1996), with both advantages and disadvantages in treatment and prognosis (Sundgot-Borgen, Skarderud, & Rodgers, 2003). Athletes may expect more positive outcomes in treatment, possibly because they are used to conforming to the expectations of coaching and training programs. In general, athletes have less Axis II pathology than non-athletes. Disadvantages for some athletes may include limited psychological-mindedness, limited social experiences from spending much time within a narrow athlete subculture, and parents who focus primarily on their child’s competitive success rather than balance or health.
Yet most of what we know about general ED etiology, personality, treatment, and prognosis is applicable to athletes. For females, the need to perfect their bodies to fit America’s lean cultural ideal trumps all other factors, including the influence of sport participation (Hopkinson & Lock, 2004). Hence, we are best informed about ED athletes by utilizing available research on ED individuals in general. We may then refine our understanding of ED athletes by applying findings specific to this group.
Remuda’s Sports Return Assessment
It is imperative to assess the appropriateness of athletic participation given mounting evidence that permanent physiological damage is possible if EDs go untreated among athletes (Devlin, Jahraus, & Dobrow, 2004). We therefore combined research results, clinical experience, and common sense to develop Remuda’s Sports Return Assessment for Athletes with EDs. In a word, the most expedient path of return to competition is not the goal of intervention with the ED athlete. Instead, the guiding principles in making recommendations for athletes’ sport participation are to: 1) minimize factors that increase risk of ED relapse or jeopardize current or future health, and 2) maximize the individual’s opportunity for full recovery both physically and psychologically.
Remuda’s Sports Return Assessment includes a hierarchical list of six factors to consider in triaging acuity and making determinations for athletic participation. Using Remuda’s Sports Return Assessment, a multidisciplinary treatment team may determine under what circumstances or terms involvement in sport and training are permissible or even encouraged. Remuda’s Sports Return Assessment includes:
1. Medical status
2. Nutritional status
3. Eating disorder behaviors
4. Prognosis
5. Environment
6. Internal milieu
The first three are objective factors, such that these criteria can be objectively measured or observed. They are non-negotiable and consistent for all athletes. If specific criteria in each of these three areas are not met, it is generally considered unsafe or inappropriate for the individual to participate in athletics.
The second three are subjective factors. Without psychological testing, these are more difficult to measure or observe. Thresholds may also vary from one individual to another, depending on unique needs and circumstances. None of these factors alone is generally enough to decide for or against continued sport participation. They may be viewed cumulatively as trends that tip the balance from total participation toward respite or even retirement, or vice versa.
Remuda uses its Sports Return Assessment to develop an individualized, written Terms of Participation Contract that serves as a forum for collaboration between athletes and their treatment team, coach, athletic department, and, when appropriate, family. It is a tool for communicating expectations for sport participation to the athlete. Specifics include medical, nutritional, therapeutic, and behavioral criteria necessary for continued competition or training. Listing specific logical consequences is encouraged. Athletes may view the Terms of Participation Contract as less punitive, more objective, cooperative, and binding because it is a collaborative process that is written and signed by all parties involved.
We detail below each element of the Sports Return Assessment and how it culminates in an individualized Terms of Participation Contract for a specific ED athlete.
Medical Status
Remuda’s Sports Return Assessment begins with a fundamental question about the ED athlete patient: Is the patient medically stable?
Obviously, assessing current medical status is critical. This is best done by medical providers experienced with ED (Thompson & Sherman, 1993). Physical exertion may exacerbate ED’s medical complications, including orthostatic pulse and blood pressure, dehydration, bradycardia, metabolic acidosis or alkalosis, electrolyte imbalance, and seizure. Chronic complications, such as cardiomyopathy, osteoporosis, and stress fractures may indicate that demanding athletic participation may need to be discontinued permanently (Devlin et al., 2004; Mehler & Andersen, 1999).
Depending on the individual athlete’s situation, different indices measure medical stability. These include but are not limited to: lab values (e.g., liver enzymes, cardiac enzymes, electrolytes, bone morphogenetic protein), electrocardio-gram, bone mass as evidenced by dual energy x-ray absorptiometry (DEXA), injury-free status, disease state (e.g., diabetes, in or out of control), and hydration status. A primary care provider should make the determination about which indices need to be within normal limits to support the athlete’s participation in sport.
If “yes” is the answer to the fundamental question of medical stability when each of the necessary factors is considered for a particular athlete, then participation in sport can be cleared medically without Terms of Participation in the medical status domain. Providers would then proceed to assess the remaining five factors. If “no” is the answer, then the individual patient requires Terms of Participation in the medical status domain. Terms of Participation is a behavioral contract delineating medical issues that need to be measured and addressed. Terms of Participation specifies how they will be measured, how often, and what results are needed. It also points out what behaviors or medical treatments are necessary to correct any insufficiency.
For example, if lab results—such as high bicarbonate and highly elevated amylase—indicate suspicion of continued self-induced vomiting (SIV), the Terms of Participation might read as follows:
• I agree to have labs drawn 2 times/week for 2 months.
• I recognize that I will not be medically cleared for athletic participation or training until my labs are within normal limits for 2 consecutive weeks.
• If at any time my lab draw is abnormal I may be medically unable to train again until my labs are within normal limits for 2 consecutive weeks.
Nutritional Status
Remuda’s Sports Return Assessment continues with a second fundamental question: Is the patient nutritionally stable?
Individuals who cannot comply with nutritional recom-mendations or are significantly underweight should not participate in training/competition until these issues resolve. Assessment parameters include but are not limited to:
• Maintenance of weight within Ideal Body Weight (IBW) range
• No physical evidence of malnutrition (e.g., no pattern of cracked lips, dry skin, hair loss, etc.)
• Adequate body composition (percent body fat and muscle mass)
If “yes” is the answer to the overarching question of nutritional stability when each necessary factor is considered, then participation in sport is cleared nutritionally without Terms of Participation in the nutritional status domain. Providers would then proceed to assess the remaining four factors. If “no” is the answer, then the individual patient requires Terms of Participation in the nutritional status domain. Examples of entries in the Terms of Participation read as follows:
• I will increase caloric intake by 300 kcals per day and reduce intensity of cardiovascular training by one hour per day until weight is restored to (specify weight).
• I will maintain my weight within my Ideal Body Weight (IBW) range consistently.
• I will not participate in athletic conditioning or competition until I have maintained my IBW for two consecutive weeks.
• I will meet with a Registered Dietitian two times per week for meal plan accountability until weight remains within my IBW range for three consecutive weeks during athletic participation.
Eating Disorder Behaviors
Remuda’s Sports Return Assessment continues with a third fundamental question: Is the patient abstaining from ED behaviors?
Athletes currently engaging in significant ED behavior are rarely appropriate for full sport participation. Evidence of ED behaviors will be specific to the individual. It may include but is not limited to the following:
• Symptoms of self-induced vomiting (SIV):
Petechiae (burst capillaries in the facial region, especially the eyes)
Chelosis (corners of the mouth cracking)
Unusual callusing on the knuckles or fingers
• Rapid weight loss/gain (+/-10 lbs. in one month)
• Isolation (secretive binge eating)
• Bizarre food rituals or restricting food
• Physical exam revealing enlarged parotid or sub-mandibular glands
If “yes” is the answer to the question of abstention from ED behaviors when all relevant factors for an individual patient have been considered, then the individual patient can be cleared for participation in sport without Terms of Participation in the ED behaviors domain. Providers would then proceed to assess the remaining three factors. If “no” is the answer, then the individual patient requires Terms of Participation in the ED behaviors domain. The Terms of Participation may read as such:
• I will eat with an accountability partner (teammate, therapist, coach/trainer, etc.) for every meal and snack and stay with this person one hour after each time I eat.
• I will surrender all laxative and diuretic products and commit in writing to abstain from use of these products for weight manipulation.
• My exercise will be restricted to workouts approved by coaches and medical staff.
• Any ED behaviors may be considered a breach of this contract, but not necessarily lead to limited participation. I understand that I need to demonstrate a trend of abstinence, but no one expects me to be perfect.
Prognosis
Remuda’s Sports Return Assessment continues with a fourth fundamental question: Is the patient’s prognosis good?
This question is answered by considering two sets of issues.
Research Indications. Research offers some guidance concerning prognosis and risk factors that need to be taken into consideration when making recommendations about athletic participation.
The American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders (2000) indicates that persons who develop symptoms at a younger age have a better prognosis for recovery. Patients with ED symptoms of longer duration have poorer prognosis. White female athletes are more likely to engage in ED behaviors than male or black female athletes (Johnson et al., 1999; Johnson et al., 2004). The type of sport and the level of competition can also have a significant positive or negative impact on risk factors for relapse (Best, 1988; Fulkerson, Keel, Leon, & Dorr, 1999; Williamson et al., 1995; Zucker, 1999); see above.
There are several risk factors for initial ED development that may predispose patients to ED relapse as well. These include but are not limited to childhood anxiety disorders (Bulik, Sullivan, Fear, & Joyce, 1997), childhood obsessive compulsive personality traits, perfectionism (Anderluh, Tchanturia, Rabe-Hesketh, & Treasure, 2003), and a family history of ED (Agras, Hammer, & McNicholas, 1999; Russell, Treasure, & Eisler, 1998; Scourfield, 1995; Stein, Woolley, Cooper, & Fairburn, 1994; Ward et al., 2001). Low self-esteem, anxiety, social pressure, and poor body image appear to be the most prevalent risk factors in collegiate athletes (Berry & Howe, 2000).
These research indications can be considered in relation to an athlete’s sport participation. We recommend an increasingly conservative approach to athletic participation as risk factors mount.
Testing. Several measures can be utilized in combination to provide prognostic data. It is important to emphasize that none of these measures should be used alone to make decisions about athletic participation. The same test results in two individuals may also be interpreted differently depending on other factors specific to the individual.
A comprehensive literature review suggests that the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) predicts outcome for ED patients (Cumella, in press). Higher elevations on scales 1 and 2 at admission consistently predict poorer outcomes, while admission elevations on scales K and 9 predict better outcomes.
Day (2003) found two distinct EDI-2 clusters, one significantly more pathologic across EDI-2 subscales. For ED athletes whose EDI-2 scale scores place mostly above the top of the ED range using college female norms, sport recommendations should be more conservative. For those whose EDI-2 scale scores place mostly at or below the bottom of the ED range using college female norms, return to sport would be more likely.
If “yes” is the answer to the overarching question about good prognosis, then the prospect of continued athletic involvement is more likely and no specific Terms of Participation are required in this domain. Providers would then proceed to assess the remaining two factors. If “no” is the answer based on any particular concern, then Terms of Participation can be developed to bring awareness of potential weaknesses, avoid pitfalls, and bolster other areas that may improve prognosis. Terms of Participation may read as such:
• Admission MMPI-2 elevated on scale 1: I will continue to work with my outpatient treatment team to accurately identify, label, and discuss emotions, learning to express myself assertively rather than through physical symptoms.
• History of perfectionism: I will continue to challenge my automatic, rigid, perfectionistic thoughts and replace them with healthier cognitions.
Environment
Remuda’s Sports Return Assessment continues with a fifth question: Does the athlete’s environment support recovery?
A range of environmental factors may support or hinder ED recovery. Examples follow:
• Athletic involvement
Support: A basketball team that offers positive support and provides a sense of belonging
Hindrance: A gymnastics team that is focused on body image and centers on competition between individual team members
• Living situation
Support: Living with teammates who have healthy attitudes toward food and exercise
Hindrance: Living in a dorm with ED roommates or hallmates
• Coaching/training staff
Support: Person-centered approach
Hindrance: Performance-centered approach
• School scholarship
Support: Provides the athlete with sense of relief from financial responsibilities
Hindrance: Pressures the athlete with difficult conditions
• Expectations from family/classmates
Support: Unconditional acceptance
Hindrance: Conditional acceptance, judgment, unyielding expectations, attention and validation based primarily on performance or star status
If there is an abundance of positive and protective environmental factors, then “yes” is the answer to the fundamental question about positive environmental influences. The prospect of continued athletic involvement would be more likely and no specific Terms of Participation would be required in this domain. Providers would then proceed to assess the remaining factor. If “no” is the answer, then develop Terms of Participation. Athletes should not train or compete if there is significant evidence that environmental factors will play a role in perpetuating their ED (Thompson & Sherman, 1993). Hence, a goal of treatment planning is to eliminate potential environmental stressors and cultivate protective factors. Terms of Participation may include items such as:
• I commit to living in an environment conducive to recovery:
Moving back home and commuting to school and practice (or, as appropriate)
Moving away from home and choosing a supportive environment
• I will transfer to a new athletic program with a coach who understands my situation and will support my recovery over my athletic performance.
• I commit to completing my educational goals by attaining my degree regardless of my ability to participate in athletics, the quality of my athletic performance, or the status of my scholarship.
Internal Milieu
Remuda’s Sports Return Assessment culminates with a sixth question: Does the patient want to recover from the ED?
In assessing internal milieu, treatment teams should understand patients’ motives for athletic participation and attitudes toward athletics. ED patients who engage in training/competition primarily to control weight or for other compulsory reasons are unlikely candidates for prompt sport return. A healthy attitude concerning exercise is that exercise occurs in the context of an athletic event or specific training for that event. Exercise is a means to an end, not an end in itself. It is therefore important to ask why the ED patient is interested in sport and exercise. Does she exercise only to lose weight and burn energy, or is she lifting weights so she can perform to her potential on game day? It is also useful to assess the patient’s goals for school and adult life. If she reports, “I only went to this school to compete in my sport,” such external motivation could be problematic. Internal, broader motivation would be preferred, such as “I am in school first to get an education.”
Athletes’ motivation for ED recovery may benefit from objective evaluation. Formal measures exist for assessing motivation for change in ED (e.g., Connors, Donovan, & Diclemente, 2001; Reiger, Touys, & Beumont, 2002). The Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ) is a strong predictor of weight gain for anorexics (Rieger et al., 2000). Athletes in pre-contemplation or contemplation stages are likely to be given more conservative recommendations for involvement in athletics and more behaviorally-oriented specifications in the Terms of Participation, such as increasing caloric intake by 300 kcals per day or meeting with a Registered Dietitian two times per week. It is important to carefully assess motivation even for athletes who state a desire to recover from their ED. They may, for example, be motivated to stop binge eating because it is associated with the fear of weight gain, but unwilling to reach their ideal body weight, stop purging, or curtail excessive exercise. Athletes in the latter stages of action or maintenance may need less behaviorally-oriented Terms of Participation contracts.
Individuals with strong internal motivation for change are better candidates for athletic participation than those who have entered treatment and gained weight due to external pressures. Some athletes with strong internal motivation for ED recovery may even choose not to return to their sport because of the risks that training and competition may pose for them. On the other hand, athletes have often been mandated to treatment by parents, schools, or employers. They may have learned to mask ED behaviors and gained only enough weight to pacify others. Especially at higher levels of competition, the highest priority for athletes, parents, and coaches alike may be the athletes’ swift return to competition rather than long term health. Athletes with such external motivation for change may be more likely to collaborate with those who prioritize performance and achievement over health and should be given more conservative recommendations for sport return.
Recreational athletes or compulsive exercisers are more difficult to hold accountable to a behavioral contract than professional or collegiate athletes. For those who are internally motivated for recovery, we suggest assembling an outpatient treatment team. But those who seem only externally motivated or clearly prefer to continue ED behaviors may require continual monitoring. In these cases, a residential or step-down program may be needed until internal motivation for recovery develops.
Spiritual assessment of ED athletes is also important (Darden, 2005). Societal pressures and standards often contradict God's purpose for our lives. We are inundated with images of what we are supposed to look like, value, and strive after. We have been conditioned to perform—to achieve and build our identity on how successful we are. We are taught that we are accepted and valued if we excel in school, athletics, business, and so on. Thus, our self-worth may be based on accomplishments and we may feel that our value derives from achieving more than, or out-competing, other people. Because of these cultural pressures, for any ED athlete with an active spirituality it can be useful to ask several questions. Does she believe that God loves her unconditionally, or does her spiritual thinking suggest a need to earn God’s approval from athletic performance? Does she experience her identity and self-worth as lovingly given by God (Romans 8:14-17)? Is she able to compete in her sport while still remembering others’ needs and making time to serve them (Mark 10:35-45)? Is there balance in her life—does her sport leave enough time for relationships, interests, work, and spiritual growth? In light of such questions, a thoughtful discussion of spiritual issues may be warranted to assess the risk of relapse.
In short, it is the responsibility of the treatment team to know and understand the ED athlete’s internal world, discerning the difference between healthy motivation for athletic participation and a pathologic need to exercise or achieve. Using this information, treatment teams can evaluate the athlete’s best interest in the context of a full and productive life and make recommendations that will be beneficial for the rest of the athlete’s life. Above all, treatment teams should be careful not to sacrifice the athlete’s future for better statistics in next year’s athletic program or scholarship maintenance in the near term.
If “yes” is the answer to the question about the patient’s desire to recover, and more than anything else the patient wants to be healthy again, continued athletic involvement is more likely without specific Terms of Participation in this domain. If “no” is the answer, then develop Terms of Participation as needed. Terms of Participation may include items such as:
• Work with outpatient treatment team to move through the Stages of Change.
• Meet at least monthly with a spiritual director to explore the concepts of grace and unconditional love in your faith system.
Conclusion
Making recommendations for athletes’ return to sport is a multi-faceted and individualized process that requires thorough assessment and knowledge of patients’ unique needs, social context, and perceptions. We recommend a systematic approach to this process. We owe it to our athlete patients to offer recommendations that will promote their physical, psychological, interpersonal, and spiritual health for many years to come.
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