Understanding Eating Disorders in Athletes

1. Chapter 13 Eating Disorders: When Rations Become Irrational By Karen D. Cogan

2. Overview • What are the diagnosable eating disorders athletes suffer from? • Why do eating disorders develop? • What places some athletes at risk for developing eating disorders? • How can athletes with eating disorders be identified? • What are the intervention strategies used to help athletes with eating disorders?

3. Disordered Eating • Does not meet criteria for anorexia or bulimia • Disturbances in eating behavior that cause distress • Dissatisfaction with body shape or size

4. Anorexia Nervosa • Refusal to maintain a minimally normal body weight based on age and height. • Intense fear of gaining weight or becoming fat. • Body image disturbance. The way in which one’s body weight, shape, or size is experienced. • In women, absence of at least three consecutive menstrual cycles (amenorrhea) or no menstrual periods by age 16. (Criteria from DSM-IV-TR)

5. Two Types of Anorexia • Restricting anorexia: Lose weight through severe dieting, fasting, and excessive exercise. • Binge-eating/purging anorexia: Maintain a below-average weight and engage in binge eating, purging, or both.

6. Bulimia Nervosa • A cycle of binge eating and purging. • Bingeing: Eating large quantities of food in one sitting, much more than most people would eat. • Purging: Self-induced vomiting; fasting; misuse of laxatives, diuretics, or enemas; or excessive exercise. (Criteria from DSM-IV-TR) (continued)

7. Bulimia Nervosa (cont) • A feeling of lack of control over eating behavior during eating binges, often followed by a sense of guilt that leads to purging. • Minimum average of two binge-eating episodes a week for at least three months. (Criteria from DSM-IV-TR)

8. Eating Disorder, NOS • Eating disorder, not otherwise specified (NOS) • Sometimes athlete has most of, but not all, the characteristics of an eating disorder. • Such cases are diagnosed as eating disorders, but as “not otherwise specified” (NOS). • An example is an athlete who has all the characteristics of anorexia nervosa, except he or she is of a normal weight.

9. Nondiagnosable Problems • Overeating • Involves bingeing without the purge cycle. • Food can be used to deal with negative emotions. • Appearance alone is not an indicator of overeating.

10. Female Athlete Triad • Identified by the American College of Sports Medicine (ACSM, 1997) and researcher Kimberly Yeager and colleagues (1993). • Consists of three components: • Disordered eating • Amenorrhea • Osteoporosis • Disordered eating leads to negative energy balance, which the body interprets as starvation. (continued)

11. Female Athlete Triad (cont) • The starving body shuts down the reproductive capability (menstruation). Estrogen production decreases. • Decreases in estrogen and dietary intake of calcium signal the bones to release calcium to replace low blood levels. This may result in bone loss or formation of unhealthy (low-density) bone.

12. Obligatory Exercise • Excessive or compulsive • Will exercise despite injury, fatigue, or personal demands • Shares characteristics of those with disordered eating: compulsions and rituals, rigid diets, perfectionism, and control over the body

13. Biogenetic Factors of Eating Disorders • Malfunction in pituitary gland? (No research evidence for this hypothesis.) • There is a relationship with disturbed eating behaviors in parents. • Is it related to depression, which is also genetically linked? • No clear explanation yet of the role of biogenetic factors.

14. Psychological Factors of Eating Disorders • Several psychological factors have been related to eating disorders: • Perfectionism, especially in high-level sports • Obsessive-compulsive traits • Some researchers view eating disorders as an addiction. Food is the abused substance. • But there are differences. An alcoholic can abstain from alcohol, but we all need food to survive.

15. Environmental Factors of Eating Disorders • Culture • The societal norm keeps shifting toward a lean, thin ideal. • Athletes face additional pressures concerning ideal body makeup, especially in sports such as figure skating and gymnastics. • Media: Ideal standards may be impossible to attain. • Gender roles: There may be stress caused by the conflict between traditional notions of femininity and the expectations of athletes. (continued)

16. Environmental Factors of Eating Disorders (cont) • Community: May reinforce unhealthy approaches to eating (e.g., wrestlers, jockeys). • Peers: Some teammates may teach each other unhealthy means of maintaining weight. (continued)

17. Environmental Factors of Eating Disorders (cont) • Coaches: Inadvertent comments about an athlete’s weight and physical appearance can contribute to the development of eating disorders. • Family: An emphasis on weight, appearance, and weight loss at home can influence the development of eating disorders.

18. Athletes at Risk • DSM (2000) reports the prevalence rate of anorexia nervosa is 0.5% for adolescent and young females. No rate is reported for men. • A prevalence rate of 1 to 3% for bulimia nervosa is reported for the general population of adolescent and young females. A rate of less than 1% is reported for males. • In general, men develop eating disorders at about a tenth the rate of women, but they face unique challenges to maintain weight in a healthy manner in many sports (e.g., football, wrestling). (continued)

19. Athletes at Risk (cont) • A survey of elite female Norwegian athletes by Sundgot-Borgen (1993) indicated that 1.3% met the DSM criteria for anorexia nervosa and 8% for bulimia nervosa. • A survey of 1,445 American athletes by Craig Johnson of the Eating Disorders Clinic (1999) found rates of 9.2% of female athletes with bulimia nervosa and 2.85% with anorexia nervosa. • These rates are higher than that found in the general population.

20. Risk: Type of Sport • The type of sport plays a role in assessing risk. Discuss the risks in the following sports as classified by Sundgot-Borgen (1994): • Endurance: rowing, cycling • Aesthetic: figure skating, gymnastics • Weight dependent: wrestling, judo • Ball-game sports: volleyball, basketball • Power sports: discus, weightlifting • Technical sports: golf, shooting

21. Identifying Disordered Eating • The following signs may indicate an athlete is having problems with disordered-eating behavior: • Expressed concerns about being fat • Fear of becoming obese • Discomfort with compliments • Dichotomous thinking • Depressed mood • Negative thoughts (guilt) • Avoidance of fat, protein, dairy

22. Warning Signs of Anorexia Nervosa • Weight loss • Extremely thin appearance • Lanugo • Refusal to maintain a minimal normal weight • Denial • Avoidance of eating with others • Refusal to eat; stating, “I’m not hungry” • Eating only tiny portions at meals • Hair loss • Complaints of being cold all the time

23. Warning Signs of Bulimia Nervosa • Wide fluctuations in weight over short time spans • Wearing baggy clothing to camouflage weight changes • “Chipmunk cheeks” (swollen salivary glands) • Sores on the back of hands from purging • Candy or laxative wrappers in the trash can • Patterns of eating large quantities of food and then disappearing into the bathroom • Bloodshot eyes, especially after trips to the bathroom

24. Medical Symptoms • Many of these symptoms can only be diagnosed by qualified professionals • Laxative abuse • Diet-pill abuse or dependence • Hair loss • Brittle nails • Diminished muscle mass • Loss of menstrual periods • Gastrointestinal problems • Tooth-enamel loss or tooth decay (stomach acid from vomiting damages teeth) (continued)

25. Medical Symptoms (cont) • Difficulty absorbing fat, protein, and calcium • Tears in the esophagus • Anemia • Ulcers • Cardiac complications • Heart arrhythmias • Bone loss • Dizziness or fainting • Electrolyte imbalance • Dehydration

26. Risk-Reduction Strategies • De-emphasize weight. Weight monitoring by coaches in unnecessary. • Eliminate group weigh-ins which are potentially the most destructive form of monitoring. • Eliminate unhealthy subculture aspects of the sport. (continued)

27. Risk-Reduction Strategies (cont) • Treat each athlete individually. • Offer guidelines for appropriate weight loss. • Control the contagion effect. Losing weight can become “contagious” if losing weight becomes the norm.

28. Prevention • Ideally, sports organizations such as collegiate, Olympic, and professional sports programs will help the most athletes by putting in place programs to prevent the development of eating disorders in athletes. • A variety of suggestions are in chapter 13.

29. Treatment Options • Individual therapy • Medications (antidepressants) • Group therapy • Family therapy • Treatment team • Inpatient treatment • Return to sport participation