Eating Disorders in Athletes

Question 1

What is an eating disorder?

Answer 1

• 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

Question 2

What is the etiology of EDs?

(Perfect storm)

Answer 2

• 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

Question 3

Can EDs be treated with nutrition alone?

Answer 3

• 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

Question 4

What is the difference between eating disorders versus disordered eating?

Answer 4

• 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

Question 5

What is the manual for diagnosing eating disorders?

Answer 5

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

Question 6

What are the different most common types of eating disorders talked about in class ?

Answer 6

• Anorexia Nervosa (AN)
• Bulimia Nervosa (BN)
• Binge Eating Disorder (BED)
• Other Specified Eating or Feeding Disorders (OSFED)
• Avoidant Restrictive Food Intake Disorders (ARFID)

Question 7

What is anorexia nervosa?

Answer 7

• 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

Question 8

What is the diagnostic criteria of anorexia nervosa?

Answer 8

• 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

Question 9

What are signs of anorexia nervosa?

Answer 9

• 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)

Question 10

What are common personality/cognitive characteristics of anorexia nervosa?

Answer 10

• 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)

Question 11

What is Bulimia Nervosa (BN)?

Answer 11

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

Question 12

What is the diagnostic criteria for BN?

Answer 12

• 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

Question 13

What are the signs of Bulimia Nervosa (BN)?

Answer 13

• 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

Question 14

What are common personality characteristics of BN?

Answer 14

• Impulsivity
• Compulsiveness
• Novelty/risk seeking (shoplifting, promescuity)
• More likely to have lived/be living in a chaotic environment (compared to anorexic)

Question 15

What is binge eating disorder (BED)?

Answer 15

• 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)

Question 16

What is the diagnostic criteria for BED?

Answer 16

• 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

Question 17

What are the signs of Binge Eating Disorders?

Answer 17

• 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

Question 18

What are common BED personality characteristics?

Answer 18

• 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

Question 19

What is avoidant-restrictive food intake disorder (ARFID)?

Answer 19

• 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

Question 20

What is the diagnostic criteria of ARFID?

Answer 20

• 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

Question 21

What is OSFED?

Answer 21

• 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

Question 22

What are the other types of eating disorders involved in OSFED?

Answer 22

• 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

Question 23

What is DSM V definition of Body Dysmorphic Disorder (BDD)?

Answer 23

“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

Question 24

Where is body dysmorphic disorder found?

Answer 24

• 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)

Question 25

What is sub-clinical disordered eating?

Answer 25

• 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

Question 26

What is orthorexia nervosa?

Answer 26

• 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

Question 27

What is anorexia athletica?

Answer 27

• 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

Question 28

What are co-occurring disorders? What are the most common comorbidities?

Answer 28

• 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)

Question 29

What should you keep in mind when screening?

Answer 29

• 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

Question 30

How might a client with an eating disorder present to a Dietitian?

Answer 30

• 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

Question 31

What questions should you ask yourself as an RD?

Answer 31

• 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?

Question 32

What are the screening tools for Eating Disorders?

Answer 32

• 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!)

Question 33

What is the treatment of anorexia nervosa?

Answer 33

• 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

Question 34

What is the treatment of Bulimia Nervosa?

Answer 34

• 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!

Question 35

What is the treatment for Binge Eating Disorder?

Answer 35

• 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?

Question 36

Should you weigh or not weigh?

Answer 36

• 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

Question 37

What is the purpose of a treatment team and what must you keep in mind with the clients?

Answer 37

• 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

Question 38

What is essential to keep in mind when working with clients?

Answer 38

• 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

Question 39

Why are clients with EDs less likely to trust you?

Answer 39

• 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.

Question 40

How can you create a safe environment for your clients?

Answer 40

• 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)

Question 41

How can eating disorders be prevented?

Answer 41

• 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