Eating Disorders in Athletes

1. Eating Disorders in Athletes Dave Sealy, MD, CAQSM Director, Sports Medicine, Residency Education Self Regional Hospital Family Medicine Residency Program Clinical Professor, MUSC Head Team Physician, Lander University (Div II) Greenwood, SC

2. Eating Disorders in Athletes • Goals • Case finding, diagnosis and treatment review • Application to the athletic arena • How to assist and follow these athletes • Special considerations

3. Eating Disorders in Athletes • How common is disordered eating? • Unknown but the reported range is 1%-64% • Elite female gymnasts may be as high as 80% • 4-20% of all collegiate women • Prevalence among athletes estimated to be about twice the normal population • Male/female ratio 5-20:1

4. Eating Disorders in Athletes • Which sports are the culprits? • According to the ACSM there are five groups that place the athlete at highest risk for disordered eating

5. Eating Disorders in Athletes • 1. Sports with subjective scoring • Dance • Figure skating • Gymnastics

6. Eating Disorders in Athletes • 2. Endurance sports favoring participants with low body weight • Distance running • Cycling • Cross-country skiing

7. Eating Disorders in Athletes • 3. Sports in which contour revealing clothing is worn for competition • Swimming • Volleyball • Diving • Sprinting • Luge?

8. Eating Disorders in Athletes • Sports using weight catagories for participation • Wrestling • Martial arts • Horse racing • Rowing sports

9. Eating Disorders in Athletes • 5. Sports in which prepubertal body habitus favors success (women) • Gymnastics • Figure Skating • Diving

10. Eating Disorders in Athletes • Three Clinical Catagories • 1. Anorexia Nervosa • Less than 85% IBW • Intense fear of gaining weight or becoming fat when already underweight • Disordered body image • Amenorrhea • Denial of current low body weight

11. Eating Disorders in Athletes • 2. Bulemia Nervosa • Recurrent episodes of binge eating • Much larger amounts of food than normal • Sense of lack of control over eating during the episode • May consume 5-10,000 calories at a time • Must occur at least two times per week for three months

12. Eating Disorders in Athletes • 2. Bulimia Nervosa • Recurrent and inappropriate behavior to prevent weight gain-laxatives, diuretics, enemas, fasting, excessive exercise, vomiting, medications • Self-evaluation is unduly influenced by body shape and weight

13. Eating Disorders in Athletes • EDNOS: Eating Disorders Not Otherwise Specified • Most athletes fall into this category • Sometimes called “anorexia athletica” • Often have normal weight • Frequency of pathologic behavior less than 2x/week • They have normal menses • Binge eating was reported in more than 25% of male and female athletes in the NCAA eating disorder project!

14. Eating Disorders in Athletes • Don’t forget male dysmorphia “reverse anorexia in males” • Sense of being small and weak • 8.3% Male bodybuilders • Negative impact on daily activities • Highly associated with anabolic steroid abuse

15. Eating Disorders in Athletes • How can we identify these athletes? • Clinical correlates • Lanugo hair especially on the face • Russell’s sign-abrasions or small lacerations and calluses on the dorsum of the hand • Salivary gland hypertrophy • Dental disease-caries and periodontal disease • Menstrual history • Exercise history • Stress fractures-especially recurrent

16. Eating Disorders in Athletes • How can we identify these athletes? • Clinical correlates (cont.) • % body fat (<16% for women, <7% men) • Hypotension • Bradycardia • Anemia • Acrocyanosis • Waist:hip ratio • Older patient (>16 yo female) with minimal secondary sexual changes

17. Eating Disorders in Athletes • Questions on the Preparticipation Physical assessing • Satisfaction with current weight • Menstrual history • Dietary history • Remember most of these athletes are very savvy and will answer the questions falsely

18. Eating Disorders in Athletes • HEADS assessment • Home environment • Education • Activities • Drugs and Depression Sx • Sexual Activity, Suicidal ideation

19. Eating Disorders in Athletes • Eating disorder survey sensitively administered: available through many web sites • Eating Disorder Inventory (EDI) • Eating Attitudes Test (EAT) • Eating Disorder Examination (EDE)

20. Eating Disorders in Athletes • Management • Identify and have a high index of suspicion • Look for the Female Athlete Triad: an eating disorder with (now osteopenia) osteoporosis and amenorrhea • Create an environment of open feedback for team and teammates

21. Eating Disorders in Athletes • Management (cont.) • Prevention, prevention, prevention • Once identified, a team of therapist, coach, trainer, team physician, nutritionist needs to be assembled due to the complexity of the problem

22. Eating Disorders in Athletes • Management (cont) • If suspected, the most sensitive diagnostic tool is a therapist skilled with eating disorders • Every team physician and trainer should have such a person identified and available

23. Eating Disorders in Athletes • Management (cont) • Be ready to manage, evaluate and identify the clinical complications • Stress fractures • Amenorrhea and its evaluation • Electrolyte abnormalities • Cardiovascular abnormalities • Karen Carpenter and Christy Henrich died of multi-organ failure at 32 and 22 years old, this can be lethal

24. Eating Disorders in Athletes • Goals of Therapy • Educate coaches who use body fat composition punitively • Assess and restore bone density • DEXA scanning • 1-2.5 SD below is osteopenia • >2.5 SD below is osteoporosis • May need to rescan if amenorrheic greater than six months after identification

25. Eating Disorders in Athletes • Goals of therapy • Restore normal menses-consider workup to include: TSH, preg test, PCOS evaluation • Increase body weight to above 90% of IBW • Continue sports activity and resistance training to increase bone density • Provide psychosocial support for the athlete during treatment

27. Eating Disorders in Athletes • Athlete must be agree there is a problem and be willing to change • Female nurse practitioner or therapist-cognitive therapy to change thinking • Consideration of OCPs to restore menstrual function and bone density • SSRIs to be considered if depressive sx are present or OCD • AAP recommends 1500 mg Calcium Carbonate and 400-800 IU Vit D per day

28. Eating Disorders in Athletes • How do you make the initial intervention? • Springs from an environment of caring for the individual needs of the athletes • Frequent education of all athletes done non judgmentally and with mutual accountability • Suspected athletes should be approached gently and repeatedly

29. Montana is nice but it may have some inherent problems with sports