Chapter 13

Eating Disorders: When Rations Become Irrational

By Karen D. Cogan

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?

Disordered Eating

Does not meet criteria for anorexia or bulimia

Disturbances in eating behavior that cause distress

Dissatisfaction with body shape or size

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)

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.

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)

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)

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.

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.

Female Athlete Triad

Identified by the American College of Sports Medicine (ACSM, 1997) and researcher Kimberly Yeager and colleagues (1993).

Consists of three components:1. Disordered eating

2. Amenorrhea

3. Osteoporosis

Disordered eating leads to negative energy balance, which the body interprets as starvation.

(continued)

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.

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

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.

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.

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)

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)

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.

Environmental Factors of Eating Disorders (cont)

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)

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.

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

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

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

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

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)

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

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)

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.

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.

Treatment Options

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