Eating Disorders

By admin On Dec 10, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Eating Disorders

Kelsey Logan

Basics

There are 3 diagnosable eating disorders (EDs) under the American Psychiatric Association DSM IV criteria: Anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not specified (EDNOS).
Disordered eating is a spectrum of behaviors that focus on controlling eating and weight.
Athletes often do not meet the stringent criteria for ED diagnosis but have disordered eating nonetheless.

Description

Diagnostic criteria (DSM-IV and DSM IV-TR) (1):

AN:
- Weight <85% of normal for age and height, either due to loss or by failure to gain
- Intense fear of gaining weight even though patient is underweight
- Body image disturbance and/or denial of seriousness of current low-weight status
- Secondary amenorrhea (missing at least 3 consecutive menstrual cycles in a woman with established menses)
- 2 types:
  - Restricting type: Mainly restricts intake to achieve weight loss; does not regularly engage in binge eating or purging behavior
  - Binge-eating/purging type: Regularly uses binge eating/purging to lose weight
BN:
- Recurrent episodes of binge eating, with binge eating defined as:
  - Eating an amount of food in a discrete time period (eg, 2 hr) that would be larger than most people would eat and
  - Feeling unable to stop eating or control the amount of food eaten during this time
- Consistently uses abnormal compensatory behavior to prevent weight gain (eg, self-induced vomiting, laxative or enema misuse, diuretics, fasting, excessive exercise)
- Binge eating and compensatory behaviors occur at least twice weekly for 3 mos (on average).
- Body image disturbance
- The disturbance does not occur exclusively during episodes of AN.
- 2 types:
  - Purging type: Regularly uses self-induced vomiting, laxatives, diuretics, and/or enemas in the current episode of illness
  - Nonpurging type: Uses behaviors other than purging during the episode of illness, such as fasting or excessive exercise
EDNOS:
- Disorders that do not meet the full criteria for AN or BN
- Includes binge-eating disorder: Similar to bulimia except that individuals do not perform compensatory behaviors to avoid weight gain; these individuals are more likely to be overweight.

Epidemiology

Some research has shown an increased prevalence in athletes compared with nonathletes.
Prevalence is higher in female athletes than their male counterparts.
In adolescent girls, AN is the 3rd most common chronic illness.
Undiagnosed in 50% of cases, so true impact is unknown

Prevalence

Studies have shown that up to 47% of female athletes have diagnosable ED, depending on sport (2).
Studies have found that 0–5% of male athletes have diagnosable ED.
Particularly in males, seasonal disordered eating practices may be present in over 50% of athletes.
AN is present in 0.5–1% of older adolescent or adult women; 1–2% of this general population meets the criteria for BN.
Males account for 5–15% of patients with AN or BN and 35% of those with binge eating disorder in the general population.

Risk Factors

Higher body mass index (BMI)
Low self-esteem
Perfectionism
Depression and other manifestations of negative affect
Body dissatisfaction
Pubertal stage and timing
Pressure to conform to cultural body ideals; attempting to mimic media personalities
In males, negative weight comments by fathers
Frequent dieting in both genders
Attempting to meet unrealistic body weight goals for sport performance, especially in endurance sports
Sports with weight restrictions/classes
While lean sports (eg, gymnastics, diving, ice skating) traditionally are associated with more DE problems, that risk factor is being lessened; nearly all sports present a risk.

Genetics

Young female adolescents/children of mothers with ED history are 3 times more likely than controls to purge weekly; not true in older adolescents.
Largely influenced by maternal psychological influence in young women; genetics unclear (3)

General Prevention

Educational and behavioral programs for the athletic community
Open communication about appropriate body composition for sport
Education about abnormal weight-control methods and appropriate nutrition guidelines
Focus on healthy eating and energy balance rather than weight

Commonly Associated Conditions

Female athlete triad
Depression, anxiety, and other psychological disorders

Diagnosis

History

Body image and weight concerns
Disordered eating practices
Athletes with EDs tend to hide them: Getting information from family, coach, athletic trainer, and friends is helpful.
Amenorrhea/oligomenorrhea, especially during sport training or season
History of stress fractures
Dysfunctional bowel (eg, constipation, diarrhea)
Orthostatic symptoms
Cold intolerance
Dental and gum disease
Fatigue
Mild cognitive impairment
Mild neuropathy
May see performance decreases, but some athletes perform well despite the illness

Physical Exam

BMI (<17.5 is concerning), documentation of weight loss (weights should be done privately, often with the results masked from the patient)
Bradycardia
Orthostatic hypotension
Poor skin turgor
Emaciation/muscle wasting

P.135

Lanugo hair
Swollen parotid glands (chubby cheeks)
Poor dentition; tooth enamel erosion
Russell sign (callous on fingers owing to self-induced vomiting)
Hypercarotenemia
Neuropathy
Cognitive impairment

Diagnostic Tests & Interpretation

Lab

High urine specific gravity
Electrolytes reflecting metabolic effects of purging: Hypokalemia, hypochloremic alkalosis, hypomagnesemia, hyponatremia
Thyroid function: Low triiodothyronine and thyroxine with normal thyroid-stimulating hormone
Leukopenia, pancytopenia (if severe AN)
Low glucose
Labs often normal

Diagnostic Procedures/Surgery

Body composition testing, handled in sensitive manner (4); some athletes respond poorly to knowing body composition, but it can be helpful to have objective evidence of malnutrition. iDXA (intelligent dual energy x-ray absorptiometry) and bioelectric impedance are more accurate than skinfold calipers in measuring body composition.
ECG to evaluate for dysrhythmias
DXA if amenorrheic for >3 mos or with stress fracture history; if <18 yrs old, use Z-score (-1 or less is concerning).

Differential Diagnosis

Female athlete triad
Psychiatric conditions (depression, anxiety, etc.)
GI malabsorption syndromes
Diabetes mellitus
Malignancies
Prolactinoma
Thyroid disease

Treatment

AN and BN have high relapse rates; focus on long-term management, not cure.
BN: Help patient to establish control over eating, become educated about nutrition and weight regulation, and restructure unrealistic body image.
BN: Up to 75% comorbid depression or anxiety; important to treat
Alcohol and drug problems commonly associated

Medication

Treatment of comorbid psychiatric disorders with pharmacotherapy as indicated

Additional Treatment

Referral

Psychology for cognitive-behavioral therapy
Psychiatry for pharmacotherapy management of comorbid psychiatric disorders
Nutrition for eating strategies

Additional Therapies

Sport participation issues:

Motivation for treatment: Monitor performance (ED usually decreases performance).
Refusal of treatment despite objective evidence (performance, physical or lab abnormalities, etc.) of illness: Consider sport restriction/suspension.
Sport participation: Allowed if healthy enough to compete; keeping the athlete out of sport may be psychologically detrimental.
Develop written contract for sport participation and diet and exercise practices signed by treatment team and athlete.
Consider keeping minimum weight “guideline” with caloric intake needed to sustain that weight (4)[C].

In-Patient Considerations

Consider hospitalization if medically unstable. This includes, but is not limited to:
- Cardiac dysrhythmias (including bradycardia)
- Electrolyte disturbances
- Severe dehydration
- Severe malnutrition (<75% of expected average body weight for adolescents and <85% for adults)
- Psychiatric emergencies
Food refusal and uncontrolled binging and purging may result in hospitalization.
Hospitalization is for medical stabilization, does not cure disorder

Ongoing Care

Follow-Up Recommendations

Frequent follow-up and routine monitoring by all in treatment team (nutritionist, mental health providers, physician) (5)[C]
Open communication among team members
Weight is monitored routinely, as are BP and pulse.

Prognosis

Prognosis is poor for complete recovery. Many patients relapse after initial improvement.

Complications

Cardiac dysrhythmias
Electrolyte disturbances
Stress fractures
Lack of fertility

References

1. Beals KA, Meyer NL. Female athlete triad update. Clin Sports Med. 2007;26:69–89.

2. Torstveit MK, Rosenvinge JH, Sundgot-Borgen J. Prevalence of eating disorders and the predictive power of risk models in female elite athletes: a controlled study. Scand J Med Sci Sports. 2007.

3. Field AE, Javaras KM, Aneja P, et al. Family, peer, and media predictors of becoming eating disordered. Arch Pediatr Adolesc Med. 2008;162:574–579.

4. Bonci CM, Bonci LJ, Granger LR, et al. National athletic trainers' association position statement: preventing, detecting, and managing disordered eating in athletes. J Athl Train. 2008;43:80–108.

5. The female athlete triad. Med Sci Sports Exerc. 2007;39:1867–1882.