1. How to Manage the Transition From Compulsive Exercise to Healthy Activity and Sport with Young People Affected by Eating Disorders Mrs Claire Knight Specialist Dietician, Eating Disorders Team, Child and Adolescent Mental Health Services, Nottinghamshire Healthcare NHS Trust, Nottingham, UK & Newbridge House Specialist Eating Disorders Unit, Sutton Coldfield, Birmingham, UK Dr Damian Wood MBChB, DCH, MRCPCH Consultant Paediatrician, Nottingham Children’s Hospital, Queen’s Medical Centre, Nottingham & Newbridge House, Specialist Eating Disorders Unit, Sutton Coldfield, Birmingham, UK

2. What’s in a word?  Physical Activity - Any bodily movement produced by skeletal muscles that requires energy expenditure  Exercise - Physical activity that is planned, structured and repetitive for the purpose of conditioning any part of the body. Used to sustain or improve health and fitness  Sport - An activity involving physical exertion and skill with an individual or team competes against another or others for entertainment

3. Terminology  Compulsive exercise  Anorexia athletica  Sports anorexia  Hypergymnasia  Eating disorders in athletes

4. DSM V Anorexia Nervosa  Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health).  Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain (even though significantly low weight).  Disturbance in the way one's body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.  Subtypes:  Restricting type  Binge-eating/purging type

5. Compulsive Exercise - Definition Qualitative  To complete in workshop Quantitative  T complete in workshop

6. Compulsive exercise  Physical activity that is associated with disordered eating attitudes and behaviours, and describes a condition characterised by an inability or unwillingness to cut down or stop exercising even though it is detrimental to health  Dependence - Dysfunctional affect regulation  Compulsivity - Extreme concerns about the perceived negative consequences of stopping or reducing exercise  Perfectionism - Rigid/inflexible exercise behaviour

7. Compulsive Exercise and ED  Longer duration of anorexia nervosa in those who exercise as part of their illness  Compulsive exercise often the last symptom to subside  Shorter time to relapse in those with anorexia nervosa who exercise compulisvely  Compulsive exercise predicts chronicity in those with anorexia nervosa  Longer IP stay or more IP stays for those who exercise

9. Rigid and routine behaviour Manage weight and shape Inability to stop Feelings of guilt at missing exercise Associated with greater anxiety levels Exercise despite injury and illness Compulsive Exercise

10. Positive Reinforcement  Exercise - adaptive way of regulating affect  Anxiolytic  Anti-dpressive  Differentiates exercise from the other dysfunctional affect regulatory behaviours in that it may also positively reinforce the exercise behaviour.

11. “Dependence” affective withdrawal symptoms when they are unable to exercise (e.g. anxiety, depression, guilt, irritability, frustration, anger), avoidance of these adverse symptoms is a primary maintaining mechanism for the exercise behaviour (i.e., negative reinforcement). llittle to no empirical support for compulsive exercise actually being a type of physiological dependence/addiction, Similar symptoms Concept patients understand

12. Compulsivity  irrational yet pervasive fear that is grounded in false beliefs and dysfunctional assumptions (e.g. “muscle that is not used turns to fat” and/or “if I do not exercise I am a failure”).  fear is itself maintained by virtue of never being appropriately challenged  It is important to note that many of the fears will be focused around weight and shape issues, and/or emotional withdrawal symptoms.

13. Perfectionism  Rules - behavioural rigidity, especially in terms of dichotomous thinking operationalised as specific “rules ‟ that the patient endeavours to follow.  These rules may also take the form of goals that are similarly rigid, extreme and inflexible.  Many compulsive exercisers follow rigidly structured and/or repetitive exercise routines and any deviation or failure to meet a specific goal leads to self-criticism which further reinforces the perfectionist strivings and behavioural rigidity.

14. Epidemiology  Compulsive exercise found in as many as 39% of Anorexia Nervosa and 23% Bulimia Nervosa admitted to an eating disorder clinic. (Cited by Goodwin et al, 2011)  Compulsive exercise test  Validated  Research and clinical use  24 item self report paper questionnaire  6 point Likert scale  5 subscales

15. Eating Disorders, Sport & Exercise Eating disorders are a major problem for sportsmen and women, and are often being overlooked. Research shows overall prevalence of eating disorders among sportsmen is 8% - 16 times the prevalence rate among non-athletic males. Overall prevalence of eating disorders among sportswomen is 20% –double that of female non-athletes.

16. Similarities Good Athlete  Mental toughness  Commitment to training  Pursuit of excellence  Coachability  Unselfishness  Performance despite pain Anorexic Individual  Asceticism  Excessive exercise  Perfectionism  Overcompliance  Selflessness  Denial of discomfort

17. Increased Risk of Developing an Eating Disorder  Desire to optimise performance  A belief that performance will be improved by weight or body fat loss (rightly or wrongly)  Involvement in sport that emphasises physical appearance, size or leanness for optimal performance  Increased body awareness, which may exacerbate body image concerns  High stakes associated with winning  Injury as a trigger for the onset of an eating disorder  Influence of parents, coaches and fellow athletes

18. Summary of Epidemiology/Psychopathology  Compulsive exercise is present in a significant number of young people with eating disorders  Presence of CE predicts a more severe/protracted course  Dependence, compulsivity, perfectionism are core traits  Similarities between traits which predispose to anorexia and those of elite athletes

19. Interventions  Medical assessment and exercise prescription  Cardiac health  Bone health and injuries  Nutritional assessment and advice  Fuelling life  Sports nutrition  Fad diets  Psychological therapies  LEAP  FBT

20. Body Weight and Shape  An athlete is at greater risk if they are trying to achieve and/or maintain a weight or body composition that is physically difficult for them.  The affect of restriction on the athlete can have many different consequences including:  Lack of hunger/fullness awareness  Loss of connection to “normal eating.”  Development of very rigid eating patterns & rules around food  Obsessing about food, eating & body weight  Physical consequences e.g. electrolyte imbalance, dehydration, loss of bone mass density (BMD)

21. Eating Disorders vs Athletes  Healthy Eating – General population  Healthy Eating – Athletic population  Disordered Eating – Use of potentially harmful weight control measures  Eating Disorders

22. Figure Skating  20.5% of competitive skaters reported previous eating disorders  50% of these reported still having an eating disorder  Most – 62.5% reported symptoms of Anorexia Nervosa (Barkley 2001)  Taylor and Ste- Marie, 2001 found that 90% of figure skaters felt pressure to lose weight

23. Symptoms Associated with the Pressures of Skating Weight loss was required for the sport Needing to conform to aesthetic ideals Obtain better scores 94% with previous eating disorders 100% with eating disorders Barkley, 2001

24. Signs and Symptoms of Unhealthy or Unbalanced Exercise in Athletes (1)  Exercise is the individual’s primary means of coping  Exercise occurs despite injury  Withdrawal effects (i.e. Sleep and appetite disturbance, negative shift in mood, decreased concentration) occur when exercise is withheld  Overuse injuries  Stress fractures

25. Signs and Symptoms of Unhealthy or Unbalanced Exercise in Athletes (2)  Menstrual irregularity in women or a decrease in testosterone levels in men  Loss of bone density  Decreased immunity  Frequent colds or upper respiratory infections  Inflexibility of exercise schedule (i.e. Will not alter schedule, will not decrease exercise, will not not exercise)  Decrease in sports performance  Overtraining syndrome

26. Consequences  Disordered eating can lead to adverse effects on health and physical performance.  In some cases, the condition can be fatal.  Anorexia Nervosa has the highest rate of mortality for any psychiatric condition.

27. Compulsive Exercise Outcomes  Tasks of Adolescence – how affected compared to restricitve ED  Long term harms  Physical – nutrition, bone health  Psycholigical  Social

28. Consequences  Consequences of disordered eating on health and performance will also depend on:  the athlete’s immediate health status;  the demands of sport-specific training;  type, severity, and duration of the pathogenic weight control or eating behaviours;  the degree of nutrient deficiency

29. Decreased Performance  Results of severe energy restriction include:  Reduced mental capacity or psychological fatigue  Reduced muscle strength and endurance  Premature muscle fatigue  Decreased anaerobic performance  Decreased aerobic capacity (endurance)

30. Female Athlete Triad  Disordered eating – low energy availability  Amenorrhoea  Reduced bone mineral density  International Olympic Committee Consensus Statement

31. Prevention  Sport - Education to sports coaches, encourage sport to fit body shape  Compulsive exercise in adolescence - Target individuals personality, motivation and general beliefs

32. Exercise Prescription  Type  Frequency  Duration  Intensity

33. ECG screening  Screening for athletes  Specificity  Sensitivity  Guidelines  School  College  Elite

34. Nutrition for Adolescence  Appetite and energy intake will increase during a growth spurt  Under nutrition can inhibit bone development, lower peak bone mass, lower height increase velocity, leading to stunting  Energy requirements are higher in teenage boys (2755kcal/d) than girls (2110kcal/d)  Calcium, phosphorus and iron are higher for adolescents than adults  Adolescents conform more to peer pressure and less to their parents role modelling

35. Healthy Balanced Diet http://www.nhs.uk/Livewell/Goodfood/Pages/eatwell-plate.aspx

36. Sports Nutrition in Adolescence  All athletes should adopt nutritional strategies for before, during and after training and competition  Physical training will increase nutrient requirements and may require individual assessment and advice to:  Meet energy requirements  Maximise nutritional intake  Optimise body size and composition

37. Sports Nutrition  Carbohydrate  Basis of all meals and snacks  Enough to fuel training programmes and replace carbohydrate stores during recovery between training and competition  Protein  Consumed in daily amounts grater than those recommended for the general public  Varied diet should achieve this  Include food and snacks that contain high quality protein throughout the day

38. Sports Nutrition  Low energy availability should be avoided  Dietiting in young athletes should be discouraged  Use of supplements does not compensate for poor food choices or an inadequate diet  Supplement use in young athletes must be discouraged  Focus on nutrient rich diet to promote growth and development and a healthy body composition  IOC 2010

39. Hydration  Athletes should be well hydrated before exercise and drink sufficient fluid during exercise to limit dehydration.  Sports Drinks  Designed to deliver a balanced amount of carbohydrate and fluid to allow an athlete to simultaneously rehydrate and refuel during exercise.  Should be within a compositional range of 4-8% (4-8 g/100 ml) carbohydrate and 23-69 mg/100mL (10-30 mmol/L) sodium (American College of Sports Medicine et al. 2007; American Dietetic Association et al. 2009)  The taste and temperature of sports drinks are also important factors in meeting hydration goals.

40. Nutrient Rich Snack Choices  200ml glass of semi skimmed milk  Low fat yogurt  Rice pudding  Smoothies made with low fat milk and fruit  Fruit – fresh or dried  Nuts  Cereal and milk  Cereal bars  Sandwich made with low fat cheese, lean meat and fish  Fruit bread  Biscuits: garibaldi, ginger, fig roll, Jaffa cakes

41. Timing of Meals and Snacks  Meal: 2-4 hours, Snack: 30-60 minutes  Allow time for the food to be digested before training or competing  This will depend on the size and content of the meal or snack eaten  The meal should be high in carbohydrate, low in fat and low to moderate in protein.  Too much protein or fat will slow down the movement of foods from the stomach, and will make you feel uncomfortable.

42. Refuelling  An essential part of sports nutrition is refuelling in recovery  Time frames;  As soon as possible, within 20 minutes  Within 2 hours for most effective muscle glycogen (energy stores) restoration

43. Recovery Snacks (1)  Amount of carbohydrate and protein content will depend on the weight of the athlete and the intensity of the session  Weight in kilos approximately equals minimum carbohydrate replacement requirement g/hr  Plus 10-20g of protein

44. Recovery Snacks (2) Protein – 10g serving  50g nuts/seeds  330ml semi skimmed milk  200g yogurt  110g cereal bar  3 slices of bread Carbohydrate -50g serving  200ml orange juice + 2 slices fruit bread  30g cornflakes (small serving) +200ml semi skimmed milk and a piece of fruit  35g jelly sweets + 150ml orange juice  2 slices of toast and jam + 200ml glass of semi skimmed milk

45. LEAP Programme  CBT  In-patient programme  Twice weekly one hour sessions  Taught and self directed learning  Homework  Exercisers and non-exercisers

46. LEAP Outcomes  First intervention designed to treat compulsive exercise in eating disorder patients  No research data  Used worldwide by 52 specialist services

47. Summary of prevention and intervention  Coaching advice  Sports nutrition advice  Exercise prescription simple and  Cardiac screening of athletes given the cardiac complications of eating disorders  LEAP Programme