How to Manage the Transition From Compulsive Exercise to Healthy Activity and Sport with Young People Affected by Eating DisordersMrs Claire Knight

Specialist Dietician, Eating Disorders Team, Child and Adolescent Mental Health Services, Nottinghamshire Healthcare NHS Trust, Nottingham, UK & Newbridge House Specialist Eating Disorders Unit, Sutton Coldfield, Birmingham, UK

Dr Damian Wood MBChB, DCH, MRCPCH

Consultant Paediatrician, Nottingham Children’s Hospital, Queen’s Medical Centre, Nottingham & Newbridge House, Specialist Eating Disorders Unit, Sutton Coldfield, Birmingham, UK

What’s in a word?

Physical Activity - Any bodily movement produced by skeletal muscles that requires energy expenditure

Exercise - Physical activity that is planned, structured and repetitive for the purpose of conditioning any part of the body. Used to sustain or improve health and fitness

Sport - An activity involving physical exertion and skill with an individual or team competes against another or others for entertainment

Terminology

Compulsive exercise

Anorexia athletica

Sports anorexia

Hypergymnasia

Eating disorders in athletes

DSM V Anorexia Nervosa

Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health) .

Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain (even though significantly low weight).

Disturbance in the way one's body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Subtypes: Restricting type Binge-eating/purging type

Compulsive Exercise - Definition

Qualitative

To complete in workshop

Quantitative

T complete in workshop

Compulsive exercise

Physical activity that is associated with disordered eating attitudes and behaviours, and describes a condition characterised by an inability or unwillingness to cut down or stop exercising even though it is detrimental to health Dependence - Dysfunctional affect regulation Compulsivity - Extreme concerns about the perceived

negative consequences of stopping or reducing exercise Perfectionism - Rigid/inflexible exercise behaviour

Compulsive Exercise and ED

Longer duration of anorexia nervosa in those who exercise as part of their illness

Compulsive exercise often the last symptom to subside

Shorter time to relapse in those with anorexia nervosa who exercise compulisvely

Compulsive exercise predicts chronicity in those with anorexia nervosa

Longer IP stay or more IP stays for those who exercise

Rigid and routine

behaviour

Manage weight and shape

Inability to stop

Feelings of guilt at missing exercise

Associated with greater

anxiety levels

Exercise despite injury and

illness

Compulsive Exercise

Positive Reinforcement

Exercise - adaptive way of regulating affect Anxiolytic Anti-dpressive

Differentiates exercise from the other dysfunctional affect regulatory behaviours in that it may also positively reinforce the exercise behaviour.

“Dependence”

• affective withdrawal symptoms when they are unable to exercise (e.g. anxiety, depression, guilt, irritability, frustration, anger),

• avoidance of these adverse symptoms is a primary maintaining mechanism for the exercise behaviour (i.e., negative reinforcement).

• llittle to no empirical support for compulsive exercise actually being a type of physiological dependence/addiction,

• Similar symptoms

• Concept patients understand

Compulsivity

irrational yet pervasive fear that is grounded in false beliefs and dysfunctional assumptions (e.g. “muscle that is not used turns to fat” and/or “if I do not exercise I am a failure”).

fear is itself maintained by virtue of never being appropriately challenged

It is important to note that many of the fears will be focused around weight and shape issues, and/or emotional withdrawal symptoms.

Perfectionism

Rules - behavioural rigidity, especially in terms of dichotomous thinking operationalised as specific “rules‟ that the patient endeavours to follow.

These rules may also take the form of goals that are similarly rigid, extreme and inflexible.

Many compulsive exercisers follow rigidly structured and/or repetitive exercise routines and any deviation or failure to meet a specific goal leads to self-criticism which further reinforces the perfectionist strivings and behavioural rigidity.

Epidemiology

Compulsive exercise found in as many as 39% of Anorexia Nervosa and 23% Bulimia Nervosa admitted to an eating disorder clinic. (Cited by Goodwin et al, 2011)

Compulsive exercise test Validated Research and clinical use 24 item self report paper questionnaire 6 point Likert scale 5 subscales

Eating Disorders, Sport & Exercise

• Eating disorders are a major problem for sportsmen and women, and are often being overlooked.

• Research shows overall prevalence of eating disorders among sportsmen is 8% - 16 times the prevalence rate among non-athletic males.

• Overall prevalence of eating disorders among sportswomen is 20% –double that of female non-athletes.

Similarities

Good Athlete

Mental toughness

Commitment to training

Pursuit of excellence

Coachability

Unselfishness

Performance despite pain

Anorexic Individual

Asceticism

Excessive exercise

Perfectionism

Overcompliance

Selflessness

Denial of discomfort

Increased Risk of Developing an Eating Disorder

Desire to optimise performance

A belief that performance will be improved by weight or body fat loss (rightly or wrongly)

Involvement in sport that emphasises physical appearance, size or leanness for optimal performance

Increased body awareness, which may exacerbate body image concerns

High stakes associated with winning

Injury as a trigger for the onset of an eating disorder

Influence of parents, coaches and fellow athletes

Summary of Epidemiology/Psychopathology

Compulsive exercise is present in a significant number of young people with eating disorders

Presence of CE predicts a more severe/protracted course

Dependence, compulsivity, perfectionism are core traits

Similarities between traits which predispose to anorexia and those of elite athletes

Interventions

Medical assessment and exercise prescription Cardiac health Bone health and injuries

Nutritional assessment and advice Fuelling life Sports nutrition Fad diets

Psychological therapies LEAP FBT

Body Weight and Shape

An athlete is at greater risk if they are trying to achieve and/or maintain a weight or body composition that is physically difficult for them.

The affect of restriction on the athlete can have many different consequences including: Lack of hunger/fullness awareness Loss of connection to “normal eating.” Development of very rigid eating patterns & rules around food Obsessing about food, eating & body weight Physical consequences e.g. electrolyte imbalance, dehydration,

loss of bone mass density (BMD)

Eating Disorders vs Athletes

Healthy Eating – General population

Healthy Eating – Athletic population

Disordered Eating – Use of potentially harmful weight control measures

Eating Disorders

Figure Skating

20.5% of competitive skaters reported previous eating disorders

50% of these reported still having an eating disorder

Most – 62.5% reported symptoms of Anorexia Nervosa (Barkley 2001)

Taylor and Ste- Marie, 2001 found that 90% of figure skaters felt pressure to lose weight

Symptoms Associated with the Pressures of Skating

Weight loss was required for the sport

Needing to conform to

aesthetic ideals

Obtain better scores94% with previous eating

disorders100% with eating

disordersBarkley , 2001

Signs and Symptoms of Unhealthy or Unbalanced Exercise in Athletes (1)

Exercise is the individual’s primary means of coping

Exercise occurs despite injury

Withdrawal effects (i.e. Sleep and appetite disturbance, negative shift in mood, decreased concentration) occur when exercise is withheld

Overuse injuries

Stress fractures

Signs and Symptoms of Unhealthy or Unbalanced Exercise in Athletes (2) Menstrual irregularity in women or a decrease in

testosterone levels in men

Loss of bone density

Decreased immunity

Frequent colds or upper respiratory infections

Inflexibility of exercise schedule (i.e. Will not alter schedule, will not decrease exercise, will not not exercise)

Decrease in sports performance

Overtraining syndrome

Consequences

Disordered eating can lead to adverse effects on health and physical performance.

In some cases, the condition can be fatal.

Anorexia Nervosa has the highest rate of mortality for any psychiatric condition.

Compulsive Exercise Outcomes

Tasks of Adolescence – how affected compared to restricitve ED

Long term harms Physical – nutrition, bone health Psycholigical Social

Consequences

Consequences of disordered eating on health and performance will also depend on: the athlete’s immediate health status; the demands of sport-specific training; type, severity, and duration of the pathogenic weight

control or eating behaviours; the degree of nutrient deficiency

Decreased Performance

Results of severe energy restriction include: Reduced mental capacity or psychological fatigue Reduced muscle strength and endurance Premature muscle fatigue Decreased anaerobic performance Decreased aerobic capacity (endurance)

Female Athlete Triad

Disordered eating – low energy availability

Amenorrhoea

Reduced bone mineral density

International Olympic Committee Consensus Statement

Prevention

Sport - Education to sports coaches, encourage sport to fit body shape

Compulsive exercise in adolescence - Target individuals personality, motivation and general beliefs

Exercise Prescription

Type

Frequency

Duration

Intensity

ECG screening

Screening for athletes Specificity Sensitivity

Guidelines School College Elite

Nutrition for Adolescence

Appetite and energy intake will increase during a growth spurt

Under nutrition can inhibit bone development, lower peak bone mass, lower height increase velocity, leading to stunting

Energy requirements are higher in teenage boys (2755kcal/d) than girls (2110kcal/d)

Calcium, phosphorus and iron are higher for adolescents than adults

Adolescents conform more to peer pressure and less to their parents role modelling

Healthy Balanced Diet

http://www.nhs.uk/Livewell/Goodfood/Pages/eatwell-plate.aspx

Sports Nutrition in Adolescence

All athletes should adopt nutritional strategies for before, during and after training and competition

Physical training will increase nutrient requirements and may require individual assessment and advice to:

Meet energy requirements

Maximise nutritional intake

Optimise body size and composition

Sports Nutrition

Carbohydrate Basis of all meals and snacks Enough to fuel training programmes and replace carbohydrate

stores during recovery between training and competition

Protein Consumed in daily amounts grater than those recommended

for the general public Varied diet should achieve this Include food and snacks that contain high quality protein

throughout the day

Sports Nutrition

Low energy availability should be avoided

Dietiting in young athletes should be discouraged

Use of supplements does not compensate for poor food choices or an inadequate diet

Supplement use in young athletes must be discouraged

Focus on nutrient rich diet to promote growth and development and a healthy body composition

IOC 2010

Hydration

Athletes should be well hydrated before exercise and drink sufficient fluid during exercise to limit dehydration.

Sports Drinks

Designed to deliver a balanced amount of carbohydrate and fluid to allow an athlete to simultaneously rehydrate and refuel during exercise.

Should be within a compositional range of 4-8% (4-8 g/100 ml) carbohydrate and 23-69 mg/100mL (10-30 mmol/L) sodium (American College of Sports Medicine et al. 2007; American Dietetic Association et al. 2009)

The taste and temperature of sports drinks are also important factors in meeting hydration goals.

Nutrient Rich Snack Choices

200ml glass of semi skimmed milk

Low fat yogurt

Rice pudding

Smoothies made with low fat milk and fruit

Fruit – fresh or dried

Nuts

Cereal and milk

Cereal bars

Sandwich made with low fat cheese, lean meat and fish

Fruit bread

Biscuits: garibaldi, ginger, fig roll, Jaffa cakes

Timing of Meals and Snacks

Meal: 2-4 hours, Snack: 30-60 minutes

Allow time for the food to be digested before training or competing

This will depend on the size and content of the meal or snack eaten

The meal should be high in carbohydrate, low in fat and low to moderate in protein.

Too much protein or fat will slow down the movement of foods from the stomach, and will make you feel uncomfortable.

Refuelling

An essential part of sports nutrition is refuelling in recovery

Time frames;

As soon as possible, within 20 minutes

Within 2 hours for most effective muscle glycogen (energy stores) restoration

Recovery Snacks (1)

Amount of carbohydrate and protein content will depend on the weight of the athlete and the intensity of the session

Weight in kilos approximately equals minimum carbohydrate replacement requirement g/hr

Plus 10-20g of protein

Recovery Snacks (2)

Protein – 10g serving

50g nuts/seeds

330ml semi skimmed milk

200g yogurt

110g cereal bar

3 slices of bread

Carbohydrate -50g serving

200ml orange juice + 2 slices fruit bread

30g cornflakes (small serving) +200ml semi skimmed milk and a piece of fruit

35g jelly sweets + 150ml orange juice

2 slices of toast and jam + 200ml glass of semi skimmed milk

LEAP Programme

CBT

In-patient programme

Twice weekly one hour sessions

Taught and self directed learning

Homework

Exercisers and non-exercisers

LEAP Outcomes

First intervention designed to treat compulsive exercise in eating disorder patients

No research data

Used worldwide by 52 specialist services

Summary of prevention and intervention

Coaching advice

Sports nutrition advice

Exercise prescription simple and

Cardiac screening of athletes given the cardiac complications of eating disorders

LEAP Programme