Eating Disorders in Athletes Flashcards
1
Q
What is an eating disorder?
A
- Eating disorders are neurological disorders rooted in the brain that results in physical and psychological symptoms
- Weight and issues related to body weight are SYMPTOMS of eating disorders, not causes
- Genetics (family history of depression, anxiety, BPD), environment (abuse, sport focused on aesthetics), and personality characteristics (perfectionism) all play a role in eating disorders, not causes
- Genetics, environment, and personality characteristics all play a role in eating disorder risk
- Experiences by genders, body sizes, SES
2
Q
What is the etiology of EDs?
(Perfect storm)
A
- The etiology of EDs is very complex. There is no one cause of these conditions
- Often referred to as the “Perfect storm”
→ Environment
→ Genetics
→ Personality characteristics
→ Stress activates this combination of events - ALL EDs ARE ROOTED IN MENTAL HEALTH ISSUES
3
Q
Can EDs be treated with nutrition alone?
A
- ALL EDs ARE ROOTED IN MENTAL HEALTH ISSUES
→ Issues with the athlete’s nutritional health are collateral to the mental health condition
→ Nutrition care alone is not an appropriate treatment strategy for an individual with an ED - Individuals with EDs often manage stress through food intake (coping mechanism)
→ Anxiety disorders often underpin EDs - Need mental health support first and foremost, not just nutrition support
4
Q
What is the difference between eating disorders versus disordered eating?
A
-
Disordered eating is the term used to describe a range of irregular eating behaviors that may or may not meet the criteria associated with a diagnosis of a specific eating disorder
→Broader, health risk, need help but just doesn’t fit criteria - Eating disorders such as anorexia nervosa, or AN, or bulimeia nervosa, or BN, are diagnosed according to specific and narrow criteria of DSM
5
Q
What is the manual for diagnosing eating disorders?
A
The Diagnostic and statistical manual of mental disorders (DSM) V presents the agreed-upon diagnostic criteria for all mental health conditions including feeding and eating disorders
6
Q
What are the different most common types of eating disorders talked about in class ?
A
- Anorexia Nervosa (AN)
- Bulimia Nervosa (BN)
- Binge Eating Disorder (BED)
- Other Specified Eating or Feeding Disorders (OSFED)
- Avoidant Restrictive Food Intake Disorders (ARFID)
7
Q
What is anorexia nervosa?
A
- Restriction of energy intake: body image disturbances
- Characterized primarily by self-starvation and excessive weight loss (severe restriction of food)
- Prevalence almost double in sport than general population especially in females
8
Q
What is the diagnostic criteria of anorexia nervosa?
A
- Restriction of energy intake relative to requirements leading to a significantly low body weight in context of age, sex, developmental trajectory, and physical health
- Intense fear of gaining weight or becoming fat, even through underweight
- Disturbances in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight
- May still think they are overweight even when they are at risk of serious consequences of low body weight
9
Q
What are signs of anorexia nervosa?
A
- GI changes to hormone levels so amenorrhea, HPA axis, CV function
- Lanugo: Hair on neck and face to keep warm/changes in hormonal synthesis - this is seen in preterm infants
- Carotenaemia: Vitamin A tends to concentrate in hands, very uncommon in general population unless having a lot of orange colored vegetables (carrots/sweet potatoes)
10
Q
What are common personality/cognitive characteristics of anorexia nervosa?
A
- Don’t cause disorder per say but may be part of perfect storm that puts individuals at risk
- Perfectionism
- Personal self-imposed standards of conduct or achievement
- Anxiety
- OCD tendencies
- Rigid thinking
- Risk avoidant
- Experiential avoidant (Less likely to take a chance, fearful od situations they are unfamiliar with)
- Rule governed (Strictly adhere to rules or they will feel threatened/upset)
11
Q
What is Bulimia Nervosa (BN)?
A
Recurrent binge eating episodes and compensatory behaviors that are meant to prevent weight gain such as self-induced vomiting in an attempt to undo the effects of binge eating
12
Q
What is the diagnostic criteria for BN?
A
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
→ Eating, in a discrete period of time (e.g. within any 2 hour period) an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
→A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating) - Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxtives, diuretics, or other medications, fasting, or excessive exercise (especially in athletes)
- The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months (DE if not)
- Self-evaluation is unduly influenced by body shape and weight
- The disturbance does not occur exclusively during episodes of AN
13
Q
What are the signs of Bulimia Nervosa (BN)?
A
- Electrolyte imbalances from vomiting that can cause cardiac arrhythmias (biggest reason why they die)
- Abrasions on back of knuckles when they try to vomit
- Parotid glands swell because they produce more saliva when you vomit, hypertrophy so it can do more work
- Blood vessels in the eye popped due to increased BP when vomiting
- Unless you have all the characteristics of BN you will be classified as DE
14
Q
What are common personality characteristics of BN?
A
- Impulsivity
- Compulsiveness
- Novelty/risk seeking (shoplifting, promescuity)
- More likely to have lived/be living in a chaotic environment (compared to anorexic)
15
Q
What is binge eating disorder (BED)?
A
- Most common type in general population
- Characterized by recurrent binge eating without the regular use of compensatory measures to counter the binge eating (No purgative behaviors)
16
Q
What is the diagnostic criteria for BED?
A
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
→Eating, in a discrete period of time (e.g. within any 2 hour period) an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances
→A sense of lack of control over eating during the episodes (e.g. a feeling that one cannot stop eating or control what or how much one is eating) - The binge eating episodes are associated with three (or more) of the following:
→ Eating much more rapidly than normal
→ Eating until feeling uncomfortably full
→ Eating large amounts of food when not feeling physically hungry
→ Eating alone because of feeling embarrased by how much one is eating
→ Feeling disgusted with oneself, depressed, or very guilty afterward
→ Marked distress regarding binge eating is present
→ Binge eating occurs, on average, at least once a week for 3 months
→ Binge eating is not associated with the recurrent use of inappropriate compensatory behaviors (e.g. purging) as in BN and does not occur exclusively during the course of BN or AN - use food as a coping mechanism, taken to extreme
17
Q
What are the signs of Binge Eating Disorders?
A
- The physical health consequences of BED mirror those of obesity
- Psychologically, BED patients often suffer from depression and anxiety
- BED not as popular in sports
- Will likely become overweight or obese
18
Q
What are common BED personality characteristics?
A
- Less well defined than for AN and BN despite the fact that BED is statistically the most common ED
- Impulsivity
- Compulsiveness
- Lower expressions of self-directedness. See life happening to them, not with them
- Higher expressions of harm avoidance tendencies
→ Excessive worrying, pessimism, shyness, and being fearful, doubtful, and easily fatigued
19
Q
What is avoidant-restrictive food intake disorder (ARFID)?
A
- Avoiding food for a reason that may be complex
- Limitations on the amount or types of food intake; without distress about body shape or size or fears of fatness
20
Q
What is the diagnostic criteria of ARFID?
A
- An eating or feeding disturbance (e.g. apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversice consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
→ Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
→ Significant nutritional deficiency
→ Dependence on enteral feeding or oral nutritional supplements
→ Marked interference with psychosocial functioning
→ The disturbance is not better explained by a lack of available food or by an associated culturally sanctioned practice
→ The eating disturbance does not occur exclusively during the course of anorexia nervosa or BN and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced
→ The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder
21
Q
What is OSFED?
A
- Other specified eating or feeding disorders
- Symptoms of an eating disorder but do not meet the full diagnostic criteria of a clinical eating disorder. Has recognizable criteria attached to it but not a catch all like disorder eating
- A feeding or eating disorder that causes significant distress or impairment, but does not meet the criteria for another feedinf or eating disorder. Diagnoses of exclusion
22
Q
What are the other types of eating disorders involved in OSFED?
A
- Atypical Anorexia Nervosa: criteria for AN met but weight is not below normal
- Subthreshold Bulimia Nervosa: criteria for BN met but with less frequent occurrences
- Subthreshold Binge Eating Disorder: Criteria for BED met but occurs at a lower frequency
- Purging Disorder: purging without binge eating
- Night eating syndrome: excessive nighttime food consumption
23
Q
What is DSM V definition of Body Dysmorphic Disorder (BDD)?
A
“A somatoform disorder marked by a preoccupation with an imagined or trivial defect in appearance that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning”
- Not an eating disorder under DSM V categorization
24
Q
Where is body dysmorphic disorder found?
A
- Found in athletes (male or female) who deliberately diet and over-train in order to correct a perceived deficit in their appearance
- Is an excessive preoccupation with being muscular and fit
- Have severely distored body image
→ See themselves as small and weak
→ Possibly abuse steroids and other substances
→ Depression, low self-esteem, social withdrawal - Common in figure athletes/body building - can’t see how their body looks to others (abuse of steroids, analysis of muscles)
25
Q
What is sub-clinical disordered eating?
A
- Athletes may demonstrate forms of disordered eating behaviors that are not recognized as clinical eating disorders by the DSM-V. (Disordered eating with names, not the only ones)
- These behaviors are still concerning and benefit from intervention and treatment
→ Orthorexia nervosa
→ Anorexia athletica
26
Q
What is orthorexia nervosa?
A
- Characterized by an unhealthy obsession with the quality of foods in one’s diet
- Extreme focus on the amount of fat, sugar, calories, fibre, protein in foods
- Use significant amounts of probiotics, herbal remedies, and other supplements thought to have healthy effects on the body
- Avoid social interactions/dining out with others
- Have obsessive thoughts over the effects of food on health
- Significant food restriciton may be evident
- May demonstrate irrational concerns about the preparation of foods, relating to food washing techniques and sterilization of utensils
- May not have to do with weight, may be to do with health in general
27
Q
What is anorexia athletica?
A
- Extreme psychological focus on athletic ability and athletic performance relative to others
- Constant comparisons to successful competitors in their field - training pattern, body size/shape, diet
- Can occur in both genders
- Excessive training is viewed as a means to success even in the face of injury, pain and illness (immune system failing)
- Overtraining - trainers often pick up on this before dietitians do
28
Q
What are co-occurring disorders? What are the most common comorbidities?
A
- Many of those who struggle with eating disorders have a co-occurring mental health condition
- Can intensify eating disorders symptoms and impact treatment (recovery, level of care, drop-out)
- Most common comorbidities:
→ Depressive disorders
→ Anxiety disorders
→ Substance abuse - Treatment should prioritize the goals of care and address co-existing condisitons as well as the eating disorder (address root cause and hopefully positively effect co-occurring disorder. RDs might have to let other roles lead)
29
Q
What should you keep in mind when screening?
A
- Any client can have or could develop an eating disorder
- Don’t assume that by looking at someone you wil know. EDs are rarely recognized by how someone looks
- Initially assess in your usual manner, and keep an ED in the back of your mind
→EDs can’t exist if they can’t keep it a secret - Do no harm!
- Do not screen in ways that inadvertently make things worse
30
Q
How might a client with an eating disorder present to a Dietitian?
A
- GI disturbances - IBS, stomach pain, bloating
- Athletes
- New Vegetarians/Vegans
- Lengthy or complicated dieting histories
- DM, Type 1 (diabulimia) = focus on food and body weight so there is an enhanced risk
- “Picky Eating”
- Bariatric Surgery Patients = Requirement for them to receive psychological counselling
- Self-diagnosed food allergies or food intolerances
31
Q
What questions should you ask yourself as an RD?
A
- Is anything out of the norm:
- Are they seeking weight loss? Weight history, desired weight?
- Do they count calories? What happens if they eat more than their goal for the day/meal?
- Do they ever feel out of control around food?
- Are there foods they won’t eat because of a belief or rule? Is there flexibility around this?
- Do they “save” their calories for later in the day?
- Will they eat food they haven’t prepared or don’t know the ingredients and/or calories of?
- Do they avoid events with food or eating with other people?
- Food rituals; food rigidity
- Do they ever sneak food? Have they lied about having something or not having something?
- Do they feel the need to compensate for the calories they ate?
- Are they weighing themselves? How often are they weighing themselves? How does weight impact their food choices, mood for the rest of the day?
- Do they ever feel guilty or shameful during or after eating?
- What happens if they eat more than they wanted?
32
Q
What are the screening tools for Eating Disorders?
A
- Eating Attitudes Test (EAT-26)
- EDGE Symptom Survey
- BED Screening
- Female Athlete Screening Tool (FAST)
- Sick, Control, One, Fat, Food (SCOFF)
- Eating Disorder Screening Tool for Primary Care (ESP)
- Many team RDs, ATs, and trainers universally screen their athletes using one or more of these tools (apply to everyone!)
33
Q
What is the treatment of anorexia nervosa?
A
- Initial goal: adequate calories; dense foods are predictive of recovery outcomes (just need them to eat enough at start then work with problems)
- Normalized and balanced eating will come in time
- Meet them where they are
- Progression to full weight restoration
- 90% IBW - about 50% relapse
- % body fat better predictor than BMI/Weight
- Intuitive eating - takes time (what it means to be hungry and full)
- Need mental health support to feal with giving up coping mechanism
34
Q
What is the treatment of Bulimia Nervosa?
A
- Initial goal is to stop the purging cycle
- Often 5 pound weight gain once purging stops owing to fluid shifts. The patient needs to expect this and know it is safe
- Regular meals and snacks
- Need satisfying foods: fat
- Find the sweet spot: not too hungry/not too full
- Want to try to set them up so they aren’t extremely hungry. Normalize frequency of meals and snacks
- Discourage weighing themselves/make it known it is a good thing to gain weight!
35
Q
What is the treatment for Binge Eating Disorder?
A
- Weight loss is NOT the goal! The main goal is to stop binging
- Assessing the timing of food intake
- Regular meals and snacks
- Mindful eating
- Structure areas for eating
- Pacing
- Nutrition education - what is a reasonable portion of food
- Weight loss is not the primary goal - leads to shame and keeps people in disordered eating patterns which increases the change of binging
- What else could they do instead of using food to comfort themselves?
36
Q
Should you weigh or not weigh?
A
- The weight of the client is not the only issue or even the main issue
→ Weighing can reinforce the association between body weight and achievement, appearance, self-esteem. We don’t want this
→ Crucial to develop trust - In many cases, collecting serial weights is not necessary
- If a client must be weighed, set up a plan ahead of time with client and obtain consent
→ Explain why you need to weigh them
→ Consider masking the weight - Clients who may require and benefit from weight checks: AN, laxative abuse, purging, just out of treatment centre
- Is there something else you could look at? E.g. amount of times they ate/snacked throughout the week
37
Q
What is the purpose of a treatment team and what must you keep in mind with the clients?
A
- We cannot work with these clients alone
- Multi-disciplinary team that includes a mental health practitioner, a physician, SLP, social worker, OT, and others is needed
- Ideally the team specializes in the treatment of eating disorders
- Obtain consent to share patient information with the treatment team members
- Obtain consent before talking with a client’s parents, care takers, spouses, children, etc.
→ Underage patient parents want to know how its going but need to have consent from client
38
Q
What is essential to keep in mind when working with clients?
A
- Patients are often very hesistant to trust. You won’t automatically be seen as an ally, even if they initiated the appointment. Establishing trust and boundaries is critical
- You cannot work on weight loss and recovery from an eating disorder at the same time
- Changing a client’s food intake or restriction removes a coping mechanism that they use and on some level benefit from. Need an alternative coping mechanism that you will need to help with/work with psychologist/psychiatrist
- Do you have the skill/ability to care for this patient group? Need advanced practice skills/require skills beyond entry-to-practice competence
- Avoid linking body weight to sport performance, not always possible, easy or accurate
- Do no harm
- Remember health (physical and/or mental) trumps sport performance even if the athlete does not see this as the case
39
Q
Why are clients with EDs less likely to trust you?
A
- Secretive disorder
- Has been a driving force of their life
- On some level they are getting something that is viewed as positive out of the behaviors that are being practiced. Coping, calming down, body is better, etc.
40
Q
How can you create a safe environment for your clients?
A
- Humor, kindness, compassion, and empathy
- Tough fairness
- Safe environment for client to show frustration and anger (unless it is at you)
- Environment to share and process the relationship with the eating disorder and support them to use alternative behaviors to cope
- Explore and understand maladaptive thinking patterns that are directed at the behaviors and understanding the diseas
- Don’t be afraid of the client (if you are feeling timid/afraid you aren’t ready)
41
Q
How can eating disorders be prevented?
A
- Be aware of your own biases
- Practice patient-centred care (Don’t talk about you)
- Keep the focus and your language on health not appearance
- Model positive behaviors towards eating including the social benefits of eating together, enjoyment of eating, and the excitement of trying new foods
- Promote physical activity in ways that are not focused on a weight outcome
