Ch.12 Disordered Eating and Eating Disorders

Both Elite and Recreational Athletes Can Develop the Female Athlete Triad

- Although a subset of elite athletes is at greater risk, any physically active female is at risk for developing the Female Athlete Triad - Although it is not known how many adolescent females have one or more of the factors associated with the Female Athlete Triad, health professionals are particularly worried about the effect on bone mineral density, especially in distance runners and other "lean or thin" body sports

Ultimately, Eating Disorders Have a Negative Effect on Performance and Health

- More severely dysfunctional behaviors used for a longer period of time typically have a more negative effect on health and performance. - For some athletes with mildly abnormal eating and exercise behaviors, performance may not be affected to a large degree. - However, eating and exercise obsessions likely have an effect on mental health and, over time, an effect on physical health, including anemia, frequent infections, reduced cardiovascular function, and increased risk for injury.

The characteristics of anorexia athletica are as follows:

- Reduced body mass (weight) and loss of fat mass is performance related and not related to appearance or body shape. (It should be noted that concerns about body shape could arise as the individual compares body weight, shape, or composition to the sport's most successful athletes.) - The loss of body mass results in a lean physique. Weight cycling (repeated weight gain and loss) is usually present, although maintenance of a low body weight may be seen all year (pre-season, competitive season, off-season). - Restriction of food intake and/or excessive exercise is voluntary or at the suggestion of a coach or trainer. - The abnormal eating occurs while the athlete is competing but stops at the end of the athlete's career.

Persistent and severe energy deficits force the body to adapt and begin to suppress physiological functions that are associated with normal growth and development, such as menstruation.

- Research suggests that negative effects are associated with energy availability below 30 kcal/kg of fat-free mass daily. - Although the 30 kcal/kg of fat-free mass per day is a good rule of thumb, the fact that some females still menstruate when consuming energy at this level suggests that some women are more susceptible to low energy availability than others

The prevention of low energy availability begins with preventing persistent energy deficits.

- The athletes at greatest risk restrict food intake while engaging in large amounts of exercise. - Vegetarians and other athletes who limit the types of food they consume are also at a higher risk, although the fundamental issue is that the limitations result in low caloric intake

The prevalence of the Female Athlete Triad, especially the manifestation of clinical conditions of all three factors, is hard to determine.

- The prevalence of all three factors in female athletes is low, with estimates ranging from 0 to 16 percent. - However, 3 to 27 percent may have two of the three conditions, and 16 to 60 percent may have one of the factors.

Estimates for the clinical eating disorders are lower than the estimates for disordered eating

- The prevalence of anorexia nervosa in athletes is hard to determine, but a reasonable estimate is up to 6.7% in female athletes and a few male athletes. - The prevalence of bulimia nervosa is 0 to 12% in female athletes and 0 to 7.5% in male athletes. - Those with Eating Disorders Not Otherwise Specified (EDNOS) may range from 2 to 13.4% for female athletes and 0 to 9.7% for male athletes

In a perfect world, low energy availability would always be prevented through the use of excellent screening tools to identify athletes who may be at risk

- These tools include an annual physical exam that evaluates menstrual function and assesses dietary intake and energy expenditure, along with laboratory tests such as DEXA and a complete blood count - Screening tools are also available for identifying those at risk for disordered eating and eating disorders, although more precise tools are likely needed for athletes.

Instead of being advantageous, amenorrhea should be recognized as undesirable and potentially harmful to health.

- many athletes view the lack of menstrual periods as being advantageous. - It may be perceived as evidence that they are lean or it may simply be a relief from the inconvenience of the monthly period - Athletes may also have the mistaken idea that amenorrhea may act as birth control, and that pregnancy is not possible during the time when menstruation is not present.

Amenorrhea is defined as the absence or suppression of menstruation.

- primary amenorrhea describes a female who has gone through puberty but by age 15 has not yet menstruated - In secondary amenorrhea, the female began menstruating, but menstruation has been absent for 3 or more months

Athletes should work with a physician, a sports dietitian, and an exercise physiologist to identify a biologically comfortable body composition and body weight

A low body weight must be consistent with good performance and not compromise the athlete's physical or mental health, so establishing appropriate goals is essential - After weight and body composition goals are determined, the athlete's training plan can be developed, a diet plan can be devised, and a follow-up schedule can be established - Athletes can achieve a low but biologically comfortable weight with short-term, monitored, and safe diet and exercise programs that promote slow weight loss.

Anorexia Athletica Describes an Eating Disorder Unique to Athletes

Anorexia athletica is a condition found in athletes who overly restrict caloric intake, engage in excessive exercise, or do both for the purpose of attaining or maintaining a low body weight as a way to improve performance - This eating disorder subcategory is not included in DSM-5 (APA, 2013) but is used by some sports dietitians because it better describes the characteristics exhibited by athletes with eating disorders.

A fine line separates rigorous training and eating regimens that enhance performance and support health from disordered eating and exercise dependence that hurt performance and undermine health.

Because early intervention is critical for treatment and recovery and the athlete may be unaware or in denial that problems exist, it is important for coaches, athletic and personal trainers, and others who work closely with athletes to be able to distinguish that which is "normal."

Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is characterized by an excessive concern with perceived body defects. - This leads to compulsive behaviors such as repeatedly looking in the mirror or mentally comparing one's appearance with others. - BDD causes great distress and interferes with normal social and work-related relationships. BDD and anorexia nervosa may exist at the same time, especially if the perceived defect is body weight

A nutritious diet supports training and can improve performance, and some athletes must follow fairly strict eating protocols to support their training, body composition, and performance goals

Both training and eating can become regimented, a factor that may contribute to disordered eating

In some respects, athletes with disordered eating and eating disorders are similar to nonathletes; thus, a basic understanding of eating disorders and how they develop is necessary.

Disciplined eating and high-volume exercise are often expected of athletes, and it can be difficult to distinguish when disciplined has become obsessive and when high volume has become excessive.

Disordered

Disordered eating (DE) represents a deviation from normal eating, but the individual does not meet the diagnostic criteria for an eating disorder (ED)—anorexia nervosa, bulimia nervosa, or binge eating disorder. - The deviation from normal may be occasional and minor, or it may progress and become more frequent and pathological (A condition that deviates from that which is considered normal.)

True or False? A good diagnostic criterion for exercise dependence is the volume of exercise training (that is, frequency and duration of exercise).

False; The volume of exercise training may vary widely for athletes in different sports or for individual athletes at different times of the season. For example, an amount of running that may be considered excessive for a tennis player may be appropriate for a collegiate cross-country runner.

The prevalence of disordered eating and eating disorders in athletes is very difficult to determine.

In general, female athletes are more likely than male athletes to exhibit both disordered eating and eating disorders, but male athletes should not be overlooked. - The prevalence of disordered eating (that is, subclinical eating disorders) is estimated to range from 6 to 45 percent in female athletes and as high as 19 percent in male athletes.

Functional hypothalamic amenorrhea

In the context of the Female Athlete Triad, the amenorrhea is a result of low energy availability and is not due to some other medical condition or contraceptive technique that may result in absent menstruation. - amenorrhea seems to be due to low energy availability that alters the secretion of luteinizing hormone (LH) - At 1 to 2 days prior to ovulation, there is a surge in LH secretion so that ovulation can occur. Low energy availability disrupts the normal secretion of LH, resulting in amenorrhea. The disruption can occur within 5 days when energy availability is reduced substantially

As there is no valid tool to measure orthorexia nervosa, it is hard to know the incidence or prevalence.

It is estimated that 1 to 6 percent of the general population has ON, but the prevalence in dietitians and other health care professionals may be as high as 35 percent - It is the exaggerated concern and focus on a healthy diet that becomes problematic. There is no such thing as a perfect diet, and trying to achieve it can undermine performance and health, both physical and mental.

A subcategory of BDD is muscle dysmorphia (MD), a belief that the body is not muscular enough even when, in fact, it is very muscular.

Muscle dysmorphia, also known as the Adonis complex, is much more prevalent in males than in females. - The driving factor is the internalization of the "ideal" male body, which is driven by the media portrayal of the ultramuscular male. - Body dissatisfaction and low self-esteem are important factors.

Orthorexia Nervosa

Orthorexia nervosa is an unhealthy obsession with healthy eating. - The individual becomes focused on eating only nutritious foods and seeks to consume a "perfect" diet. - To that end, he or she adopts strict rules of eating, severely limits the number of foods eaten, and develops eating rituals. - All aspects of life revolve around healthy eating, and social isolation results because friends and relatives begin to feel uncomfortable with the intense focus on a healthy diet

Athletes who begin intense training at an early age, such as gymnasts or distance runners, may exhibit primary amenorrhea, that is, they have never menstruated. Intense training may lead to a chronic energy deficit before the onset of puberty.

Other athletes may begin menstruating normally but develop secondary amenorrhea later when the training demands of their sport escalate

Individuals may be described as having a subclinical eating disorder if they demonstrate a number of disordered eating behaviors and exhibit associated psychological issues

Single disordered eating behaviors are not as severe as a subclinical eating disorder, which is not as severe as a clinical eating disorder, but any of the three conditions is cause for concern and intervention.

It seems counterintuitive that athletes suffering from eating disorders, such as anorexia nervosa, may see a positive effect on performance or that they can even continue to exercise when emaciated.

Starvation and purging both result in increases in some of the adrenal hormones, such as cortisol, epinephrine, and norepinephrine. - These hormones can mask fatigue, so it is possible that performance improves initially as weight declines as a result of starvation. - However, performance declines over the long term, along with physical and mental health - There may also be a biological reason that exercise can continue in the athlete with anorexia nervosa and substantial weight loss. Exercise produces lactate, which is a source of glucose - In a prolonged starvation state, in which the individual is still willing to exercise, the body may be desperately trying to find a source of glucose for the brain

anorexia nervosa

The prevalence (The number of cases of a condition that exist in the population at a given point in time.) of anorexia nervosa in late-adolescent and early-adult females is estimated to be 0.5 to 1.0 percent of that population - The typical age range for females exhibiting anorexia nervosa is early adolescence (~age 13) through early adulthood (mid-20s), and critical ages appear to be age 14 (often the start of high school) and age 18 (start of college, living away from family)

A moderate increase in energy expenditure and a moderate decrease in caloric intake are the cornerstones of weight loss, but the concern is the magnitude of these behaviors

The reports of excessive exercise and severe dieting or fasting are considered behaviors consistent with disordered eating patterns

In 2007, the American College of Sports Medicine released a position paper entitled, "Female Athlete Triad"

This ground-breaking work raised awareness of potential problems in female athletes. - Female Athlete Triad identifies and explains three interrelated factors—energy availability, menstrual function, and bone mineral density—each of which develop along a continuum

More Information Is Emerging about Eating Disorders in Males

Those in endurance sports, particularly distance running and cycling, antigravitational sports (jumpers), aesthetic sports, and weight class sports are at greater risk than those in other sports, but any male may develop disordered eating, and, subsequently, an eating disorder. - It is estimated that 3 percent of adolescent elite male athletes and 8 percent of adult elite male athletes have disordered eating - Studies of male cyclists and triathletes suggest that body dissatisfaction is high - One reported practice is binge eating. - Most male athletes who want to lose weight report that they perform exercise and/or diet or fast to lose weight rather than use laxatives, diuretics, or self-induced vomiting.

Orthorexia nervosa shares some characteristics with anorexia nervosa, but they are fundamentally different conditions.

Those with anorexia nervosa base their self-esteem on weight loss, and their choice of foods is driven by the need to lose weight. However, there is concern that as ON becomes more severe, it may evolve to anorexia nervosa

Low energy availability, hormonal disruption, and low bone mineral density are serious physiological issues that need to be prevented or reversed.

Treatment includes the reversal of an energy deficit by increasing food intake and/or reducing energy expenditure from exercise.

Obsessive-Compulsive Disorder and Disordered Eating May Be Intertwined

Two emerging disorders are orthorexia nervosa (ON) and body dysmorphic disorder (BDD) - Individuals with these conditions demonstrate some obsessive-compulsive disorder (OCD) behaviors, such as perfectionism, but they do not meet all the criteria for OCD, which are included in the DSM-5

Normal exercise patterns vary according to the sport and level of training

a normal amount of exercise is an exercise intensity and duration that supports training and performance and is not associated with overtraining.

Body and muscle dysmorphias are...

psychiatric diseases that require treatment

Disordered eating, eating disorders, and excessive exercise are deviations from normal

therefore, normal patterns must be known before disordered ones can be determined