Disordered Eating Patterns and Clinical Eating Disorders in Athletes and General Populations

Fundamental Distinctions: Eating Disorders vs. Disordered Eating

• Disordered Eating:

  • Represents a temporary or mild change in eating behavior.
  • Patterns typically occur after a specific illness or a stressful life event.
  • Often related to a dietary change intended to improve health or athletic performance.
  • These behaviors rarely persist and generally do not require professional intervention.

• Eating Disorders:

  • Represent serious illnesses that interfere significantly with daily activities.
  • Characterized by a persistent preoccupation with food, stress, and anxiety.
  • Major classifications include Anorexia Nervosa, Bulimia Nervosa, and Binge-Eating Disorder.
  • A defining clinical characteristic, according to the Manual of Clinical Dietetics, is a "persistent inability to eat in moderation."

Prevalence and Risk Factors in Athletic Populations

• Prevalence and Demographics:

  • Clinical observations suggest the prevalence of eating disorders among athletes ranges between $15\%$ and $70\%$.
  • Female athletes are at higher risk, particularly in aesthetic, low-body-fat, and weight-category sports.
  • Aesthetic Sports: Ballet, Body building, Diving, Figure skating, Cheerleading, and Gymnastics.
  • Low Body Fat Sports: Distance running, Triathlon, and Body building.
  • Weight Category Sports: Light-weight rowing, Jockeys, and Combat sports.

• Risk Factors:

  • Pressure and desire to optimize athletic performance and/or modified appearance.
  • Increased body awareness.
  • Psychological factors: Low self-esteem, poor coping skills, perceived loss of control, perfectionism, obsessive-compulsive traits, depression, and anxiety.
  • Underlying chronic diseases related to caloric use or injuries acting as triggers.

• Influence of Coaches and Weight Management:

  • Coaches can compound the problem: $67\%$ of USA female collegiate gymnasts reported being told by coaches they weighed too much.
  • Among those athletes, $75\%$ utilized weight-loss strategies involving vomiting, laxatives, or diuretics.
  • Weight reduction attempts average $85\%$ in female weight-class athletes and $93\%$ in male weight-class athletes.

• Impact on Performance:

  • Semistarvation, purging, and excessive exercise adversely affect energy reserves and physiologic function.
  • Chronic energy restriction or reduced availability through purging rapidly depletes glycogen reserves.
  • Reduced intake of protein and carbohydrates leads to the loss of lean tissue.

Anorexia Nervosa: Diagnostic Criteria and Multisystemic Consequences

• DSM-V Diagnostic Criteria:

  • Criteria A: Refusal to maintain body weight at or above a minimally normal weight for height (loss leading to body weight less than $85\%$ of expected, or failure to make expected gain during growth).
  • Criteria B: Intense fear of gaining weight or becoming fat, even when underweight.
  • Criteria C: Disturbance in the experience of body weight or shape, undue influence of weight on self-evaluation, or denial of the seriousness of current low weight.
  • Criteria D: Amenorrhea in postmenarchal women (absence of at least three consecutive menstrual cycles).

• Types of Anorexia Nervosa:

  • Restricting Type: The individual has not engaged in binge eating or purging behavior.
  • Binge Eating/Purging Type: The individual regularly engages in binge eating or purging behavior (self-induced vomiting, misuse of laxatives, diuretics, or enemas).

• General Characteristics:

  • Distortions of body image and crippling obsession with body size.
  • Preoccupation with thinness and refusal to eat sufficient food.
  • Compulsive exercise: The "anorectic" fanatically expends as many calories as possible through physical activity rather than strictly starving or vomiting.
  • Mortality rate: If untreated, between $6\%$ and $21\%$ of sufferers die prematurely from suicide, heart disease, or infections.

• Common Signs and Symptoms (Table 15.9):

  • General: Appetite loss, fatigue, inability to exercise, impaired memory, anxiety, and depression.
  • Skin and Hair: Dry, cool, mottled/blue skin; bruises or self-inflicted cuts; scalp hair loss; Lanugo (soft, downy baby hair growth to trap air and increase insulation); yellowing skin; brittle nails.
  • Mouth: Sores, cracking around lips, tooth decay, gum disease, parotid gland enlargement, bad breath.
  • Circulatory/Cardiovascular: Cool/blue feet and hands, hypotension (low blood pressure), dizziness, fainting, dehydration, shortness of breath, swelling (edema), bradycardia (low resting heart rate), cardiac arrhythmias (from electrolyte imbalance), diminished cardiac mass (particularly the left ventricle), and anemia.
  • Digestive: Heartburn, nausea, abdominal pain/cramping, constipation, early satiety, bloating, vomiting, and decreased gastric emptying (related to GI tract disuse atrophy).
  • Neuroendocrine: Loss of menstrual cycle, cold intolerance, lowered core temperature, lowered BMR, reduced sexual desire, and Euthyroid sick syndrome (low to normal $T_4$, low to normal $T_3$, and elevated reverse $T_3$).
  • Musculoskeletal: Aching joints/muscles, fractures (spine, hip, wrist), and low estrogen levels leading to brittle bones and stress fractures.
  • Urinary: Increased frequency (especially at night) and diminished urine output.

Bulimia Nervosa: Characteristics and Clinical Profile

• DSM-V Diagnostic Criteria:

  • Criteria A: Recurrent episodes of binge eating. This is defined as eating in a discrete period (e.g., within 2 hours) an amount of food significantly larger than what most people would eat, combined with a sense of lack of control.
  • Criteria B: Recurrent inappropriate compensatory behaviors to prevent weight gain (vomiting, laxatives, diuretics, enemas, fasting, or excessive exercise).
  • Criteria C: Binge eating and compensatory behaviors occur at least twice a week for 3 months.
  • Criteria D: Self-evaluation is unduly influenced by body shape and weight.
  • Criteria E: The disturbance does not occur exclusively during episodes of anorexia.

• Types of Bulimia Nervosa:

  • Purging Type: Regular engagement in self-induced vomiting or misuse of laxatives/diuretics.
  • Non-Purging Type: Use of other compensatory behaviors such as exercise or fasting without regular vomiting or laxative abuse.

• Psychological and Physical Consequences:

  • High overlap with major depressive disorders: loss of interest, low mood, shortened attention span, disrupted sleep, and suicidal thoughts.
  • Abuse of alcohol and drugs at higher rates than the general population.

• Case Study: Jana Pittman:

  • Former Olympian whose bulimia started at age 18 and continued throughout her international career (starting around 2000).
  • Struggled with the conflict of maintaining performance weight while wanting to lead a "normal life" (eating popcorn/chocolate with friends).
  • At her worst, she binged and purged up to 8 times a day.
  • Mentally attributed her athletic achievements (winning medals) to the disorder. She did not seek treatment until 2008.

Atypical Eating Disorders and Binge-Eating Disorder (BED)

• Atypical Eating Disorder Criteria (DSM-V):

  • Atypical Anorexia: Key symptoms are present, but the patient fails certain criteria (e.g., weight is still within normal range or they continue to menstruate).
  • Atypical Bulimia: All criteria met except for the specific frequency or duration of episodes.
  • Compensatory Behavior in Normal Weight: Individuals of normal weight using purging behaviors after eating normal amounts of food.
  • Binge Eating Disorder (BED): Recurrent binge eating without the compensatory behaviors (purging) seen in bulimia.
  • Chewing and Spitting: Repeatedly chewing and spitting out large amounts of food without swallowing.

• Focus on Binge-Eating Disorder (BED):

  • Defined as episodes of binge eating at least twice a week for at least 6 months, causing significant emotional distress.
  • Individuals eat more rapidly than normal until they can no longer consume more food.
  • Prevalence: Affects approximately $2\%$ of the U.S. population ($1$ to $2$ million people) and roughly $30\%$ of Americans being treated for obesity.

Anorexia Athletica and The Female Athlete Triad

• Anorexia Athletica (AA):

  • A continuum of subclinical eating behaviors in physically active persons who do not meet full ED criteria.
  • Requires exhibiting at least one unhealthy weight control method.
  • Common Personality Traits: Compulsive behavior, high drive, dichotomous ("all-or-nothing") thinking, perfectionism, competitiveness, compliance, and being "eager to please"/coachable.

• Diagnostic Criteria for Anorexia Athletica (Table 15.5):

  • Weight loss greater than $5\%$ of expected body weight.
  • Delayed puberty (no menstrual flow by age 16).
  • Menstrual dysfunction (primary/secondary amenorrhea or oligomenorrhea).
  • Gastrointestinal complaints.
  • Absence of medical illness explaining weight loss.
  • Fear of becoming obese and distorted body image.
  • Restricted caloric intake (use of diets at or below $1200\,kcal$).

• The Female Athlete Triad:

  • A clinical condition consisting of three interrelated components: 1. Eating Disorder/Disordered Eating; 2. Amenorrhea; 3. Osteoporosis.
  • Prevalence: Approximately $66\%$ of female athletes experience amenorrhea, a sign of low energy intake.
  • Driven by restrictive dieting and over-exercising leading to a lack of body fat, diminished hormones, and loss of calcium from bones.

• DXA Assessment Comparison:

  • Anorectic Female: Mass of $44.4\,kg$ and $7.5\%$ Body Fat. Bone Mineral Density (BMD) in the spine may be comparable to a 70-year-old.
  • Typical Female: Mass of $56.7\,kg$ and $25\%$ Body Fat.

Orthorexia Nervosa and the "Clean Eating" Phenomenon

• Definition:

  • A pathological fixation on eating only "healthy" or "pure" foods.
  • Literal meaning: "Fixation on righteous eating" (Bratman & Knight, 1997).
  • Recognized as a form of obsessive-compulsive disorder associated with "negative" nutrition marketing.

• Triggers and Influences:

  • Concepts of "good" vs. "bad" foods introduced by journalists and marketers.
  • "Clean eating" fads and food elimination diets (e.g., Paleo, CHO-free, high protein) as common triggers.
  • "Internet fear-mongering" and social media use (negative correlation between Instagram use and ORTO-15 scores).

• Lists Associated with Orthorexic Concerns:

  • The Dirty Dozen (Buy Organic): Apples, Strawberries, Grapes, Celery, Peaches, Spinach, Sweet Bell Peppers, Nectarines, Cucumbers, Potatoes, Cherry Tomatoes, Hot Peppers.
  • The Clean Fifteen (Conventional OK): Onions, Pineapples, Avocados, Cabbage, Sweet Peas, Papayas, Mangoes, Asparagus, Eggplant, Kiwi, Grapefruit, Cantaloupe, Sweet Potatoes, Mushrooms, Watermelon.

• Characteristics and Issues:

  • Starts with an attempt to eat more healthily; links food with identity, safety, or spirituality.
  • Suffixers feel superior based on their food choices.
  • Leads to severe nutritional deficits, social isolation, loss of intuitive eating (hunger cues), and a sense of failure when the diet cannot be maintained.
  • Example: Vegan bloggers suggesting diets can stop menstrual "toxins" (clinically recognized as amenorrhea due to malnutrition).

• Diagnosis (ORTO-15 Questionnaire):

  • Scoring: A score below $40$ indicates risk in the general population; a score below $35$ indicates risk in athletes.
  • Higher occurrence is observed in Exercise Science, Dietetics, and Biology students compared to Business students.
  • Men show higher rates of ON than women in some studies.

Muscle Dysmorphia: "Reverse Anorexia" and Masculinity

• Definition:

  • Also known as "Adonis Disorder" or "Bigorexia."
  • A pathological preoccupation with muscle size and masculinity, categorized as both an eating disorder and a body dysmorphic disorder.
  • Characterized by a perceived defect in one's physique (feeling too small or weak).

• Prevalence and Risk Factors:

  • UK: $10\%$ of gym attendees have muscle dysmorphia.
  • Studies show men (Austrian, French, USA) often consider the "ideal man" to have $12\,kg$ more muscle than themselves.
  • Risk behaviors include excessive weightlifting, anabolic steroid use, bingeing/purging, and obsession with low-fat, high-protein diets.

• Australian Weightlifter Study (648 Males):

  • Highest incidence in bodybuilders ($250$ subjects).
  • $67.5\%$ reached clinical levels for Eating Disorders (EAT-40).
  • $58.3\%$ reached clinical levels for Muscle Dysmorphic Disorder (MDDI).
  • Strong correlation between EAT-40 and MDDI scores ($r = 0.614$, $p < 0.001$).

• Treatment: Includes Cognitive Behavioral Therapy (CBT) and SSRIs/antidepressants.

Clinical Management: The Non-Diet Approach and HAES

• Health At Every Size (HAES):

  • A weight-neutral, client-centered care model.
  • Promotes self-compassion, mindfulness, and "joyful movement."

• The Non-Diet Approach (Fiona Willer, 2016):

  • Empowers individuals to feel good about food and embrace life regardless of weight.
  • Key pillars: Accept and embrace Body Cues, All Foods, Body Shape, Joyful Movement, and Non-Diet Nutrition.
  • Applications: Useful for eating disorders, weight worry, high cholesterol, type II diabetes, IBS, and PCOS.