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

Why We Need to Know: 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. Some athletes change their food intake while others just burn many more calories than they consume. Famous gymnasts Kathy Johnson, Nadia Comaneci and Cathy Rigby have come forward and admitted to fighting eating disorders. Cathy Rigby, a 1972 Olympian, battled anorexia and bulimia for 12 years. She went into cardiac arrest on two occasions as a result of it. NASHVILLE, Tenn. (Sep 27, 1995 - 20:24 EDT) -- Whitney Spannuth of Vanderbilt thought that eating less was what a cross-country runner did. She could control her own body weight and run faster. Her theory worked for nearly two years before it fell apart, as eating disorders nearly ended her Olympic dreams. "Sometimes I just wonder how I got there," said Spannuth, of Johnson City, Tenn. "It scares me how close I came to losing everything." Trying to eat less became sort of a dinnertime competition among teammates. A daily meal consisted of half a bagel, a salad with no-fat dressing and a plain baked potato. "My thoughts were, 'If I eat less than them, I'll run faster than they will," Spannuth said. She qualified for the U.S. National team and competed in the World Cross Country Meet in Budapest, Hungary. The warning signs hit when the 5-foot-6 Spannuth dropped to 112 pounds.

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.

The Female Athlete Triad Amenorrhea Disordered Eating Premature Osteoporosis Menstrual dysfunction has long been known to be associated with exercise but in the mid-80’s the term female athlete triad was coined to describe a distinct syndrome. Amenorrhea secondary to hypoestrogenism is associated with osteoporosis and eating disorders are also a cause of lower bone mineral density and premature osteoporosis.

Epidemiology of Disordered Eating in the FAT: The prevalence is unknown as eating disorders are often hidden. 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. The hallmark is distorted body image. Up to 62% of college athletes practice some form of pathologic weight control behavior. Sports participation may reduce the risk of eating disorder caused by problems of low self-esteem, guilt, anxiety, depression and a sense of helplessness.

Factors Associated With Increased Risk for Eating Disorders Chronic dieting Low self-esteem Family dysfunction Physical or sexual abuse Biological factors (?????) Perfectionism Lack of nutrition knowledge Abnormalities of eating behavior are much more common than AN or BN. Dieting or other forms of restricted or restrained eating have been hypothesized to be causative factors in the development of eating disorders in susceptible individuals. In obese patients, binge eating is most common in those on the most restricted diets. Pursuits such as ballet dancing, modeling, acting, certain sports Diseases such as Diabetes and Cystic Fibrosis Binge eating behavior typically begins after a period of dieting for weight loss. Family & twin studies suggest that eating disorders are highly heritable. Biological factors appear to determine vulnerability & twin studies indicate that 50-80% of the variance in developing eating disorders may be due to genetic factors. Prior to the development of a formal eating disorder patients have been shown to have dieted, felt social pressure to achieve low weight, intense concern r.e. their weight and fatness, and severely limited fat intake.

Sport-specific Risks Emphasis on weight for performance or appearance Pressure to lose weight from parents, coaches, judges or peers Drive to win at any cost Self-identity tied to sport Exercises through injury Over-trained and undernourished Total body fat for the average teenager is 20 percent, but for gymnasts, long-distance runners and ballet dancers, it's 10 percent.

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

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

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.

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

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

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

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

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

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

Distinct Features: Athletes vs. Anorectics Increased Plasma Volume Efficient Energy Metabolism Increased VO2 Increased HDL2 Electrolyte Abnormalities Cold Intolerance Dry Skin Cardiac Arrhythmias Lanugo hair Leukocyte Dysfunction

What to Ask Patients* Do you eat regular meals and snacks during a typical day? 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 eat large quantities of food and feel that it is difficult to stop? If yes, how often does this happen? How often and how hard do you train?

Follow-up Questions* Inquire about the nature of binge eating 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 feel disgusted, depressed or very guilty after overeating? Inquire about compensatory behaviors Do you ever make yourself vomit or take laxatives? Do you use diet pills or any other diet aids? Inquire about any prior treatment for eating problems and interest in current treatment

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. Nutrition education regarding a healthy diet: more calories are often required to improve performance and health. Early detection and intervention.

References - Material for These Slides Was Taken From the Following Sources: American Academy of Pediatrics. Committee on Sports Medicine and Fitness. Medical concerns in the female athlete. Pediatrics 2000 Sep;106(3):610-3 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 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 Manore MM. Nutritional needs of the female athlete. Clinics in Sports Medicine 1999 Jul;18(3):549-63

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