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Eating Disorders in Athletes

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Sasha Steinlight
Netter's Sports Medicine, 27, 200-204.e2

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• The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DMS-V), updated in 2013, and
the World Health Organization’s (WHO’s) International Statistical Classification of Diseases and Related Health Problems,
updated in 2019, identifies and defines the following eating disorders (EDs): anorexia nervosa (AN), bulimia nervosa (BN),
binge eating disorder (BED), other specified feeding or eating disorder (OSFED), unspecified feeding or eating disorder
(UFED), and avoidant/restrictive food intake disorder (ARFID).

• Disordered eating (DE) behaviors such as binging, purging, excessive exercise, calorie restriction, laxative, or diuretic use may
be present without a formal diagnosis of ED.

• EDs are thought to be the result of a combination of biologic, psychological, and social factors.

• Male and female athletes are at higher risk for developing an ED than the general population.

• Screening and early intervention of ED/DE are vital to reducing possible serious consequences.

Anorexia Nervosa

Diagnostic Criteria
• Essential features and diagnostic criteria ( Fig. 27.1 (https://www.clinicalkey.com/#!/content/book/3-s2.0-B978032379669900027X#f0010) ):

• Restriction of calorie intake relative to requirements, leading to a significantly low body weight in the context of the age,
sex, developmental trajectory, and physical health.

• Intense, pathologic fear of gaining weight or becoming fat or persistent behavior that interferes with weight gain.
• Individuals are often disturbed by their body weight or shape, their self-worth is influenced by body weight or shape, or
there is a persistent lack of recognition of the seriousness of their low body weight.
 FIGURE 27.1
Eating disorders.

• The WHO uses a threshold of body mass index (BMI) less than 18.5 kg/m 2 in adults and BMI for age under fifth percentile in
children and adolescents.

• Severity of AN (based on BMI):

• Mild: ≥17 kg/m 2

• Moderate: 16–16.99 kg/m 2

• Severe: 15–15.99 kg/m 2

• Extreme: <15 kg/m 2

Emotional and behavioral characteristics: Intense fear of weight gain, preoccupation with weight/food, overvaluation of body
image, inflexible thinking, limited social spontaneity, restrained emotion, strong need for control

Common comorbidities: Anxiety, depressive disorders, obsessive-compulsive disorders

Complications of Anorexia Nervosa

Medical complications: due to malnutrition

Endocrine/metabolic ( Fig. 27.2 (https://www.clinicalkey.com/#!/content/book/3-s2.0-B978032379669900027X#f0015) ):

• A result of the body’s attempt to conserve energy for more vital processes.

• Amenorrhea/anovulation/infertility: A decrease of pulsatile hypothalamic gonadotropin-releasing hormone secretion

causes low levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), known as functional
hypothalamic amenorrhea (FHA).

• Reduced testosterone in males (hypogonadotropic hypogonadism) can result in low libido and infertility.
 • Decreased leptin and oxytocin and increased ghrelin, protein YY, and adiponectin, which are appetite-regulating
hormones.

• Increased growth hormone.

• Increased cortisol level because of increased adrenal production and reduced renal clearance.

• Low insulin growth factor-1 (IGF-1).

• Hypothermia.

• Euthyroid sick syndrome: thyroid function abnormalities; resolves with weight gain.

• Hypokalemia, hyponatremia, hypoglycemia.

• Low bone density: The result of low estrogen; low testosterone; and increases in stress hormones, catecholamines, and
cortisol. This results in reduction of bone formation and calcium absorption. Low energy availability leads to decreased
IgF-1 and bone formation marker levels. There is also an increase in bone resorption. Changes in bone structure result in
an increased risk of stress fractures. Fracture risk persists for years after diagnosis and may be irreversible.

FIGURE 27.2
Osteoporosis associated with amenorrhea.

Cardiovascular:

• Hypotension.

• Arrhythmias.

• Sinus bradycardia (heightened vagal tone due to profound weight loss). Resting heart rate (RHR) is often seen below 60
beats per minute (bmp). If RHR is <40 bpm, hospitalization is often required.

• Prolonged QTc: Increased risk of sudden death.

• Heart block.

• Endothelial dysfunction increasing cardiovascular risk.

• Structural changes: Left ventricular atrophy, pericardial effusion.

Gastrointestinal: Elevated liver function tests, gastroesophageal reflux disease (GERD), bleeding, ulceration, dysphagia,
gastroparesis leading to early satiety and bloating, constipation, dental/gingival issues.

Neurologic: Brain atrophy, memory loss, poor concentration, insomnia.

 Integumentary: Lanugo, hair loss, acrocyanosis, carotenoderma, dry hair and nails, poor wound healing.

Hematologic: Anemia, leukopenia, thrombocytopenia.

Other: Increased injury risk and decreased athletic performance because of dehydration, reduced glycogen stores, or loss of
muscle mass. Impaired cognition and mood can also negatively affect performance.

Bulimia Nervosa

Diagnostic Criteria
• Recurrent episodes of binge eating: These episodes consist of eating significantly more food in a defined period (e.g., within 2
hours) than others would eat under the same circumstances

• Episodes are marked by feeling out of control

• Binge eating episodes are followed by inappropriate compensatory behaviors (purging, fasting, excessive exercise,
inappropriate laxative, or diuretic use)

• Must occur once weekly for 3 months

• Self-evaluation is unjustifiably influenced by body and shape

• Severity scale

• Mild: 1–3 episodes of inappropriate compensatory behaviors per week

• Moderate: 4–7 episodes per week

• Severe: 8–13 episodes per week

• Extreme: 14 or more episodes per week

• Weight is often within normal range but may be overweight

Emotional and behavior characteristics: Uncomfortable eating around others, food rituals, hoarding food, fear of eating in
public, disappearing after eating, withdrawing from friends and activities

Common comorbidities: Anxiety, depression, obsessive-compulsive disorder, self-injury, impulsivity, suicidal ideation,
substance abuse

Complications of Bulimia Nervosa

Medical complications of purging or diuretic use:

• Gastrointestinal: GERD, dysphagia, dyspepsia, hematemesis due to Mallory-Weiss tear.

• Oral/dental: Erosion of tooth enamel, mucositis, cheilitis, sialadenosis.

• Electrolyte abnormalities: Metabolic alkalosis, hypokalemia. These abnormalities can lead to cardiac arrhythmias.
Increased aldosterone as a result of volume depletion may result in edema. This may require treatment with
spironolactone.

• Integumentary: Russel sign: calluses on the back of the hand and fingers from self-induced purging.

Medical complications of laxative use:

• Electrolyte abnormalities: Hyperchloremic metabolic acidosis

• Gastrointestinal: Diarrhea, hemorrhoids, hematochezia

Binge Eating Disorder

• Recurrent episodes of binge eating as described for BN

• Episodes marked by feeling out of control as with BN

• Associated with three or more of the following:

• Eating too quickly

• Eating large quantities of food even if not feeling hungry

• Eating until uncomfortably full

• Feeling guilty, embarrassed, or disgusted

• Eating alone to hide the behavior

• Occurs at least once weekly over 3 months

• BED differs from BN in that there are no compensatory behaviors after a binge

• May occur with depression, anxiety, bipolar disorder, kleptomania, body dysmorphic disorder

Other Specified Eating or Feeding Disorders

• Atypical anorexia: meet criteria for AN without being underweight

• BED or BN at lower frequency than stated by DSM-V

• Purging disorder: purging without binging

• Night eating syndrome: recurrent eating after awakening from sleep or excessive eating at nighttime

UFED
• Symptoms of a feeding or eating disorder without meeting full criteria of diagnosed EDs

ARFID
• Lack of interest in eating food or avoiding foods based on sensory consequences of food

• Persistent failure to meet nutritional or energy needs with one or more of the following:

• Significant weight loss

• Nutritional deficiency

• Dependence on nutritional supplements

• Interference with psychosocial functioning

• Disturbance is not caused by other medical or psychological condition, lack of food availability, or cultural practice

• It does not occur during AN or BN and does not involve perception of body weight or shape

Rumination Disorder
• Repeated regurgitation of previously swallowed food or repeated chewing and then spitting out food

• Regurgitation behavior occurs several times per week

• Not due to a medical condition

• Does not occur exclusively during AN, BN, BED, or ARFID

• Severe enough to warrant individual attention if in the context of another mental health disorder

Orthorexia
• Not recognized by the DSM-V
Individuals are fixated on “healthy” or “clean” eating
• Often occurs with obsessive-compulsive disorder

• Individuals often cut out multiple food groups, compulsively check nutrition labels, or feel distressed when “safe” or
“healthy” foods are unavailable

Risk Factors For Ed/De

• General: Low self-esteem, depression, anxiety, perfectionism.

• In athletes: early sport specialization, external performance pressure or body shaming, competing at an elite level, injury. Poor
body image is a strong predictor of EDs in athletes. Athletes are also more inclined to follow a rigid diet and strenuous
exercise program.

• Endurance sports (i.e., distance running and cycling), aesthetic-based sports (i.e., gymnastics, figure skating), and weight-based
sports (i.e., wrestling, horse jockeys) are at increased risk for ED or DE.

• Risk factors in males also include gender role expectations and ideals of muscularity and masculinity. Following traditional
male gender norms may increase the dissatisfaction with an individual’s own muscularity. Males may also be less likely to
pursue help because of gender norms, shame, and thinking EDs are a female problem. Men may be more likely to control
weight through overexercising.

• Individuals with type 1 diabetes mellitus are also at increased risk

Prevalence
• Lifetime prevalence of AN reported as approximately 0.3%–1% in females; 0.1%–0.3% in males

• Males may account for up to approximately 25% of individuals with AN

• There is an increased risk of premature death (6–12 times higher) in women with AN compared with the general population

• Individuals 15–24 years old with AN have a 10 times higher risk of mortality compared with their peers

• Lifetime prevalence of BN is reported as 0.3%–4% in women and 0.1%–1% in men

• Lifetime prevalence of BED reported as 0.6%–5.8% in women and 0.3%–2% in men

• Prevalence of ED/DE in athletes reported ranges from 6% to 45% in females and from 0% to 19% in males

• Prevalence also varies by sport

• Athletes may be more likely to underreport DE than nonathletes

Diagnosis And Evaluation

• A thorough history, physical examination, and laboratory studies are required. An electrocardiogram (ECG) may also be
indicated ( Box 27.1 (https://www.clinicalkey.com/#!/content/book/3-s2.0-B978032379669900027X#b0010) ).

BOX 27.1
Diagnostic Testing For Individuals With Suspected Eating Disorder/Disordered Eating

CBC, Complete blood count; DEXA, dual energy x-ray absorptiometry; ECG, electrocardiogram; ESR, erythrocyte
sedimentation rate; FSH, follicle-stimulating hormone; HCG, human chorionic gonadotropin; LH, luteinizing hormone.

CBC

Comprehensive metabolic panel

Thyroid-stimulating hormone

ESR

Gonadotropins (LH/FSH)

Sex steroids (estradiol/testosterone)

 Prolactin

HCG

Urinalysis

Amylase (if purging)

ECG, if indicated

DEXA, if indicated

• Dual energy x-ray absorptiometry (DEXA) scan may be required to assess bone health in individuals who have been
symptomatic for more than 6 months.

• Screening can be performed during the preparticipation evaluation. The American Medical Society for Sports Medicine
(AMSSM) and American College of Sports Medicine (ACSM) include four questions regarding eating behaviors in the
Preparticipation Physical Examination monograph, fourth edition. The Female Athlete Triad Coalition also published an 11-
question screening tool that includes questions on menstrual history, hormone replacement, bone density, and stress
fractures.

• The Athletic Milieu Direct Questionnaire (AMDQ), Female Athlete Screening Tool (FAST), and Brief Eating Disorders in
Athletes Questionnaire (BEDA-Q) are screening tools that have been validated for female athletes.

• The International Olympic Committee (IOC) released its Sport Mental Health Assessment Tool 1 (SMHAT-1) and
accompanying Sport Mental Health Recognition Tool 1 (SMHRT-1) in 2020, which include a triage tool and screening tools.
The BEDA-Q is used as one of the screening tools to identify athletes who require further evaluation for ED/DE. Each
response in the BEDA-Q assessment is given a point value of 0–3. The authors of the SMHAT-1 identified a result of 4 or
more points as a cutoff where further clinical evaluation is required ( Box 27.2 (https://www.clinicalkey.com/#!/content/book/3-s2.0-
B978032379669900027X#b0015) ).

BOX 27.2
Beda-Q Screening Tool Adapted From The International Olympic Committee (Ioc) Sport Mental Health Assessment Tool 1
(Smhat-1)

Rated on a scale of Never, Rarely, Sometimes, Often, Usually, Always over the previous 2 weeks (first six questions only):

1. I feel extremely guilty after overeating

2. I am preoccupied with the desire to be thinner

3. I think that my stomach is too big

4. I feel satisfied with the shape of my body

5. My parents have expected excellence of me

6. As a child, I tried very hard to avoid disappointing my parents and teachers

7. Are you trying to lose weight now? (yes/no)

8. Have you tried to lose weight? (yes/no)

9. If yes, how many times have you tried to lose weight? (1–2 times, 3–5 times, or >5 times)

• The SCOFF is a five-question screening tool that is not validated in athletes but may be better at identifying males with
ED/DE.

• The SCOFF questions ∗

• Do you make yourself S ick because you feel uncomfortably full?

• Do you worry you have lost C ontrol over how much you eat?

• Have you recently lost more than O ne stone in a 3 month period?

 • Do you believe yourself to be F at when others say you are too thin?

• Would you say that F ood dominates your life?

• An in-person interview may be more valuable as a screening tool in athletes. Athletic trainers, who interact with the athletes
on a regular basis, are vital resources for identifying individuals at risk.

• Screening tools are not diagnostic and are meant to prompt the need for further evaluation.

• The female athlete triad is a recognized condition that includes the spectrum of EDs and DE relating to energy availability,
menstrual function, and bone health. It is important to recognize the components of the triad, as they may include the initial
presenting concern such as poor performance, stress fractures, or menstrual irregularities.

• In 2016, the IOC developed a comprehensive term, Relative Energy Deficiency in Sport (RED-S), which describes the
relationship of energy deficiency and its impairment on physiologic function, including but not limited to metabolic rate,
menstrual function, bone health, immunity, protein synthesis, and cardiovascular health. RED-S is also more inclusive of
male athletes.

Treatment
• Early identification and intervention can shorten recovery time. Initially the appropriate level of care must be determined.
Treatment can occur on an outpatient basis, partial (day) program, residential program, or inpatient hospital program.
Hospitalization may be required for acute medical stabilization (i.e., severe electrolyte disturbances, ECG abnormalities, or
hemodynamic instability) or acute psychiatric stabilization (i.e., food refusal, suicidal ideation).

• A multidisciplinary healthcare team made up of mental health professional, physician, registered dietitian, and certified
athletic trainer has been shown to be most effective.

• Psychotherapy is an essential part of the treatment plan. Cognitive behavioral therapy (CBT) has been shown to be an effective
treatment and is often first-line therapy. Family-based therapy (FBT) is also used in children and adolescents.

• Psychotropic medications may be useful to treat comorbid conditions. However, there is limited evidence that they improve
clinical outcomes. Selective serotonin reuptake inhibitors (SSRIs) may help during weight maintenance of AN. Fluoxetine is
Food and Drug Administration (FDA) approved for use in BN. Lisdexamfetamine can be used for management of BED;
however, it is a stimulant and is banned by the World Anti-Doping Agency and the National Collegiate Athletics Association
(NCAA) and requires a therapeutic use exemption.

• For individuals who are underweight, a goal of treatment is to restore approximately 90% of ideal body weight or a BMI of
greater than or equal to 18.5 kg/m 2 .

• Severely malnourished patients should begin refeeding under the guidance of a physician with expertise in management of
EDs in consultation with a nutritionist. In these cases, refeeding must be monitored closely to avoid refeeding syndrome,
which can result in severe electrolyte abnormalities such as hypophosphatemia, hypokalemia, and hypomagnesemia. Newer
evidence shows that early weight restoration may improve outcomes, and a more aggressive approach to refeeding earlier on
in EDs may be preferred. This can be accomplished by close medical monitoring and nutritional supplementation when
necessary.

• Routine outpatient follow-ups should include monitoring of vital signs, including a blinded weight, assessing daily function
and physical symptoms.

• Weight restoration and return of menses are key to improving low bone mineral density. Optimal bone health may never be
reached. There is no strong supporting evidence that hormone replacement therapy improves bone mineral density.
Transdermal estrogen patches with cyclic oral progestin have shown some improvement in adolescents. Otherwise, estrogen
therapy is not useful in AN. Calcium and vitamin D alone do not restore bone density; however, supplementation of 1500
mg/day (calcium) and 1500–2000 IU daily (vitamin D) are often recommended. Bisphosphonates may be effective after 1 year
of treatment; however, there is a known risk of teratogenicity, so these are not generally used, especially during the
reproductive years. Testosterone therapy can be considered for men; however, there are not enough data available to
determine its benefit.

• Recent studies show that recovery may take approximately 9 years for BN and longer for some with AN. Poorer outcomes are
associated with lower BMI, binging/purging behaviors, high body image concerns, depressed mood, or other comorbidities.

Return To Play
• The Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad (2014):
Cumulative Risk Assessment is a tool that can be used to guide return-to-play decisions. There are six risk factors identified
that each carry a point value based on magnitude of risk. A cumulative risk score can then be correlated to low risk, moderate
risk, or high risk.
• The IOC developed the RED-S risk assessment model for sport participation using a red light, yellow light, and green light
system. Individuals with a more severe presentation are placed in the “red light” category and are not cleared to participate.
Individuals in the moderate or “yellow light” category are given provisional clearance with close follow-up. Individuals who
are identified as low risk are given the “green light” for full sport participation.

• If an individual has a BMI <16.5 or is purging four or more times per day, it is advised that they be restricted from sport
participation.

• Ideally, an athlete will be able to participate during their treatment, which can be a strong motivating factor. Activity
participation may also aid in managing comorbid conditions.

• Some athletes may benefit from a verbal or written treatment contract with their providers, which identifies treatment
requirements and level of sport participation. These contracts can be altered to allow more participation as the individual’s
weight improves or can be more restrictive if no improvements are being made ( E-Fig. 27.A
(https://www.clinicalkey.com/#!/content/book/3-s2.0-B978032379669900027X#f0020) ). FLOAT NOT FOUND

Prevention
• Provide accurate information on nutrition and weight control to athletes

• Promote healthy body image among teammates and coaching staff

• Educate athletes, coaches, and the athlete’s entourage on pathologic eating behaviors and consequences

• Utilize peer-led groups to discuss eating habits and body image

E-FIGURE 27.A
2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad.
 A form for a multidisciplinary team to clear a female athlete for return to play. A form for the Female Athlete Triad Coalition Consensus
Statement on Treatment and Return to Play. The form is a checklist for a multidisciplinary team, including a physician, psychotherapist, and
dietitian. It lists mandatory requirements, such as weight gain and weekly weigh-ins, that must be met for a patient to be cleared to return to
play. The form also lists the consequences if the requirements are not met.

Recommended Readings
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factors in athletes: detection, management, effect on performance, and prevention: American Medical Society for Sports Medicine Position
Statement . Clin J Sport Med 2020; 30 (2): pp. e61-e87.
3.Eichstadt M., Luzier J., Cho D., Weisenmuller C.: Eating disorders in male athletes . Sports Health 2020; 12 (4): pp. 327-333.
4.Gouttebarge V., Bindra A., Blauwet C.: International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport
Mental Health Recognition Tool 1 (SMHRT-1): towards better support of athletes’ mental health . Br J Sports Med 2020;
5.Hay P.: Current approach to eating disorders: a clinical update . Intern Med J 2020; 50 (1): pp. 24-29.
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Rep 2018; 17 (5): pp. 163-171.
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