1. Eating Disorders in Athletes Darwin Deen, MD, MS Department of Family Medicine and Community Health

2. Why We Need to Know: Eating disorders among athletes are common with a higher prevalence in those sports where size and weight are important: Eating disorders among athletes are common with a higher prevalence in those sports where size and weight are important: Ballet, and other dance, figure skating, gymnastics, running, swimming, rowing, horse riding, track & field, volleyball, and wrestling. Ballet, and other dance, figure skating, gymnastics, running, swimming, rowing, horse riding, track & field, volleyball, and wrestling. Some athletes change their food intake while others just burn many more calories than they consume. Some athletes change their food intake while others just burn many more calories than they consume.

3. What We Should Look For: In one study of 695 athletes, 1/3 were preoccupied with food, ¼ binged at least once per week, 15% had altered body image perception, 12 percent feared loss of control when they ate, 5 percent ate until they felt nauseated, 5 percent induced vomiting after eating, 4 percent used laxatives and 24 percent fasted for at least 24 hours after a binge. In one study of 695 athletes, 1/3 were preoccupied with food, ¼ binged at least once per week, 15% had altered body image perception, 12 percent feared loss of control when they ate, 5 percent ate until they felt nauseated, 5 percent induced vomiting after eating, 4 percent used laxatives and 24 percent fasted for at least 24 hours after a binge.

4. The Female Athlete Triad Amenorrhea Amenorrhea Disordered Eating Disordered Eating Premature Osteoporosis Premature Osteoporosis

5. Epidemiology of Disordered Eating in the FAT: The prevalence is unknown as eating disorders are often hidden. The prevalence is unknown as eating disorders are often hidden. Estimates vary from 4-39% for AN & BN. Estimates vary from 4-39% for AN & BN. Eating disorder behaviors exist on a continuum from skipping meals to using diet pills, diuretics, or laxatives, to purging to Anorexia Nervosa. Eating disorder behaviors exist on a continuum from skipping meals to using diet pills, diuretics, or laxatives, to purging to Anorexia Nervosa. The hallmark is distorted body image. The hallmark is distorted body image. Up to 62% of college athletes practice some form of pathologic weight control behavior. Up to 62% of college athletes practice some form of pathologic weight control behavior.

6. Factors Associated With Increased Risk for Eating Disorders Chronic dieting Chronic dieting Low self-esteem Low self-esteem Family dysfunction Family dysfunction Physical or sexual abuse Physical or sexual abuse Biological factors (?????) Biological factors (?????) Perfectionism Perfectionism Lack of nutrition knowledge Lack of nutrition knowledge

7. Sport-specific Risks Emphasis on weight for performance or appearance Emphasis on weight for performance or appearance Pressure to lose weight from parents, coaches, judges or peers Pressure to lose weight from parents, coaches, judges or peers Drive to win at any cost Drive to win at any cost Self-identity tied to sport Self-identity tied to sport Exercises through injury Exercises through injury Over-trained and undernourished Over-trained and undernourished

8. Menstrual Disorders Normal Cycles: 23-35 days-10-13 x/yr Normal Cycles: 23-35 days-10-13 x/yr Oligomenorrhea: >35 days-3-6 x/yr Oligomenorrhea: >35 days-3-6 x/yr Amenorrhea: Absence of menses for 3 mo. or less than 3 cycles per year. Amenorrhea: Absence of menses for 3 mo. or less than 3 cycles per year. Primary Amenorrhea Primary Amenorrhea Secondary Amenorrhea Secondary Amenorrhea

9. Amenorrhea Can be associated with: Can be associated with: Infertility Infertility Osteoporosis Osteoporosis Cholesterol abnormalities Cholesterol abnormalities Etiology: disrupted release of GnRH leading to lower LH levels. Etiology: disrupted release of GnRH leading to lower LH levels.

10. Training-related menstrual dysfunction Luteal phase deficiency: short luteal phase, decreased progesterone levels, normal cycle length and menses. Anovulatory cycles: estrogen is normal but no progesterone, cycles are long and irregular. Exercise-associated amenorrhea: can be reversed by an increase in calorie intake or a reduction in training intensity.

11. Evaluation of Amenorrhea Hx & PE Hx & PE Pregnancy Test, FSH/LH, TSH/T4, Prolactin Pregnancy Test, FSH/LH, TSH/T4, Prolactin Progesterone Challenge: Progesterone Challenge: If (+)->unopposed estrogen: If (+)->unopposed estrogen: Anovulation, PCOS, Adrenal Androgen Excess Anovulation, PCOS, Adrenal Androgen Excess If (-)-> Progesterone and Estrogen: If (-)-> Progesterone and Estrogen: EAA, Anorexia Nervosa, Ovarian Failure EAA, Anorexia Nervosa, Ovarian Failure

12. Osteoporosis Risk Factors Female sex Female sex Asian or Caucasian race Asian or Caucasian race Age Age Sedentary Lifestyle Sedentary Lifestyle Thinness Thinness Tobacco use Decreased bone mineral density Prolonged corticosteroid use Decreased calcium intake Estrogen deficiency

13. Shared Features: athletes & anorectics Fad diets Fad diets Controlled caloric consumption Controlled caloric consumption Specific carbohydrate avoidance Specific carbohydrate avoidance Low body weight Low body weight Resting bradycardia and hypotension Resting bradycardia and hypotension Increased physical activity Increased physical activity Amenorrhea or oligomenorrhea Amenorrhea or oligomenorrhea anemia anemia

14. Distinct Features: Athletes vs. Anorectics Purposeful training Purposeful training Increased Exercise Tolerance Increased Exercise Tolerance Good Muscular Development Good Muscular Development Accurate Body Image Accurate Body Image Body Fat Level in Normal Range Body Fat Level in Normal Range Aimless physical activity Poor or decreasing performance Poor muscular development Flawed Body Image Low Body Fat

15. Caloric Requirements for Sport 2200-2500 Cal/day for 10-20 hours of exercise per week. 2200-2500 Cal/day for 10-20 hours of exercise per week. Up to 4000 Cal/day for endurance exercises. Up to 4000 Cal/day for endurance exercises. Endurance athletes require increased protein (1.2-1.4 g/kg). Endurance athletes require increased protein (1.2-1.4 g/kg). 5-8 g/kg of carbohydrate 5-8 g/kg of carbohydrate

16. Symptoms of Inadequate Calories Fatigue Fatigue Irritability, hunger, difficulty concentrating Irritability, hunger, difficulty concentrating Frequent injuries Frequent injuries Poor athletic performance Poor athletic performance Growth failure in adolescence Growth failure in adolescence Weight loss Weight loss Amenorrhea Amenorrhea

17. Distinct Features: Athletes vs. Anorectics Increased Plasma Volume Increased Plasma Volume Efficient Energy Metabolism Efficient Energy Metabolism Increased VO 2 Increased VO 2 Increased HDL 2 Increased HDL 2 Electrolyte Abnormalities Cold Intolerance Dry Skin Cardiac Arrhythmias Lanugo hair Leukocyte Dysfunction

18. What to Ask Patients* Do you eat regular meals and snacks during a typical day? Do you eat regular meals and snacks during a typical day? Do you feel distressed in any way about your eating pattern? Do you feel distressed in any way about your eating pattern? Do you ever feel that your eating is very chaotic or out of control? Do you ever feel that your eating is very chaotic or out of control? Do you ever eat large quantities of food and feel that it is difficult to stop? Do you ever eat large quantities of food and feel that it is difficult to stop? If yes, how often does this happen? If yes, how often does this happen? How often and how hard do you train? How often and how hard do you train?

19. Follow-up Questions* Inquire about the nature of binge eating Inquire about the nature of binge eating Do you ever eat large amounts of food even when not physically hungry? Do you ever eat large amounts of food even when not physically hungry? Do you ever eat alone because of being embarrassed by how much you are eating? Do you ever eat alone because of being embarrassed by how much you are eating? Do you ever feel disgusted, depressed or very guilty after overeating? Do you ever feel disgusted, depressed or very guilty after overeating? Inquire about compensatory behaviors Inquire about compensatory behaviors Do you ever make yourself vomit or take laxatives? Do you ever make yourself vomit or take laxatives? Do you use diet pills or any other diet aids? Do you use diet pills or any other diet aids? Inquire about any prior treatment for eating problems and interest in current treatment Inquire about any prior treatment for eating problems and interest in current treatment

20. Prevention Education to dispel myths regarding body weight and body fat and their relationship to performance: athletes often mistakenly feel that the lower their body fat the better their performance. Education to dispel myths regarding body weight and body fat and their relationship to performance: athletes often mistakenly feel that the lower their body fat the better their performance. Nutrition education regarding a healthy diet: more calories are often required to improve performance and health. Nutrition education regarding a healthy diet: more calories are often required to improve performance and health. Early detection and intervention. Early detection and intervention.

21. References - Material for These Slides Was Taken From the Following Sources: 1. American Academy of Pediatrics. Committee on Sports Medicine and Fitness. Medical concerns in the female athlete. Pediatrics 2000 Sep;106(3):610-3 2. Walsh JM, Wheat ME, Freund K. Detection, evaluation, and treatment of eating disorders the role of the primary care physician. Journal of General Internal Medicine 2000 Aug;15(8):577-90 3. Sanborn CF, Horea M, Siemers BJ, Dieringer KI. Disordered eating and the female athlete triad. Clinics in Sports Medicine 2000 Apr;19(2):199-213 4. Manore MM. Nutritional needs of the female athlete. Clinics in Sports Medicine 1999 Jul;18(3):549-63

22. References – (cont.) 5. Putukian M. The female athlete triad. Clinics in Sports Medicine 1998 Oct;17(4):675-96 6. Anorexia Nervosa and Related Eating Disorders http://www.anred.com/ath.html http://www.anred.com/ath.html 7. National Association of Anorexia Nervosa and Related Eating Disorders http://www.anad.org/ http://www.anad.org/ 8. The American Anorexia/Bulemia Association http://www.edap.org/athletes.html http://www.edap.org/athletes.html 9. Patient Information: http://www.caringonline.com/eatdis/topics/athlet ics.htm http://www.caringonline.com/eatdis/topics/athlet ics.htm http://www.caringonline.com/eatdis/topics/athlet ics.htm