by Thomas Incledon, PhD(c), RD, LD/LN, RPT, NSCA-CPT, CSCS
The Female Athlete Paradox
There is indeed a paradox when it comes to female athletes and energy intake. On the one hand, they may need to consume a high calorie diet because of their extreme training intensity. On the other hand, they may feel that they are eating too much compared to non-athletes, they may develop self-imposed weight restrictions, and coaches may propose team-imposed weight limits. These factors can influence behaviors to the point where an athlete can develop disordered eating patterns. This week Lori Gross describes disordered eating and its relationship to The Female Athlete Triad. In this article, Thomas Incledon presents treatment and nutritional strategies for eating disorders.
Treatment
The general principles of treating an athlete afflicted with a disordered eating behavior (i.e. anorexia nervosa or bulimia nervosa) involve education about the physiological and psychological consequences, encouragement to begin eating a healthy diet and control eating behaviors, and emotional support for the patient and family. Mild cases of disordered eating behavior can be managed by the family physician, but a great deal of time and sincere interest are required. More severe cases are best treated by those experienced in treating the disorder. These cases require various combinations of support, psychological counseling, and diet counseling.
Outpatient treatment addresses the patient’s fears and misconceptions surrounding eating. Psychological counseling addresses personal, family, and social issues that exist. For younger patients under parental supervision, the parents must be involved in the treatment program. While a variety of treatment techniques exist, none appear to be better than the others. Important factors in determining the success of the treatment program are considering the individual needs of the patient in planning the treatment program and the characteristics of the patient and the illness.
When weight loss, binging, or purging continue despite outpatient treatment efforts, intensive hospital treatment is required. The decision to hospitalize a patient is based on the extent of weight loss, the inability to control a self-destructive eating behavior, presence of a severe electrolyte disturbance, depression, family conflicts, and the patient’s lack of motivation for change. Hospital treatment requires the teamwork of a physician, psychiatrist, social worker, nurse, and dietitian. All of the involved personnel should be familiar with the patient’s treatment plan and individual needs. While the patient does not need to be admitted to an “eating disorders unit”, the hospital unit that is treating the patient should be geared towards treating eating disorders.
Nutritional Strategies
Treatment of disordered eating syndromes involves the joint efforts of a physician and a dietitian. They usually meet with the patient separately, once per week. With anorexic patients, the dietitian deals with the effects of semi-starvation diets, energy needs, nutrient needs (allowing for growth if an adolescent) and the dietary modifications necessary to reestablish normal eating patterns and the restoration of normal weight. Given the lack of calories and nutrients in anorexic patients, it is not surprising to find nutritional deficiencies. Increased oxidative stress due to inadequate Vitamin E intakes [1], elevated plasma total-homocysteine due to a folate deficiency [2], and various other deficiencies have been reported in the scientific literature. In addition, resting energy expenditure is reduced, but often increases markedly in association with refeeding.
A review of previous studies that examined micronutrient status in anorexia nervosa concluded that due to the tremendous variability of the population, the cross-sectional nature of the investigations, and the use of inappropriate methods to determine nutrient status reported inconsistent and sometimes contradictory conclusions [3]. Abnormal nutritional findings in patients with anorexia nervosa are primarily a consequence of semi-starvation. Neuroendocrine abnormalities, degree of recovery, and the phase of treatment can affect the interpretation of the data. Despite the importance of nutritional rehabilitation, few controlled studies that address the clinical efficacy of various dietary treatment regimens have been conducted [3].
In the case of anorexia nervosa, the initial nutritional strategy should involve the cessation of weight loss and improvement of the nutritional state. During this period weight may be maintained while nutritional status is improved. Over time the focus is shifted towards gaining weight gradually through normal self feeding. Supplemental foods or parenteral feeding (delivering nutrients through the vascular system) is not necessary. It must be remembered that since anorexic patients have hypometabolic rates, their energy needs and nutrient needs may be quite low. So initially, unusually small quantities of food may be sufficient. Calorie needs should be adjusted based upon the measured basal metabolic rate. The initial use of small quantities is sound therapeutically because it meets the psychological needs of the patient who may be guarding against gaining weight. Encouraging the patient to consume large quantities of food or high calorie products like weight gain shakes is counter-therapeutic at this stage. As the patient becomes less fearful of gaining weight, physiologically acceptable weight goals can be established based upon the patient’s height, frame size, and weight history.
In the case of bulimia nervosa, the initial nutritional strategies are for the patient to gain control over eating binges, to encourage regular eating habits, to avoid fasting, and to minimize the likelihood of eating binges. The emphasis during the early stages should be on weight stabilization while a normal, healthy eating pattern is developed. Treatment plans used in anorexia nervosa can be adapted for use with bulimia nervosa. The treatment plan should include an educational component about the nutritional and health consequences of bulimic behaviors. After the patient has demonstrated confidence in controlling binges and follows a consistent eating pattern, the need for a weight loss plan can be assessed.
Important Reminders for the Female Athlete
It may be helpful in treating athletes with disordered eating patterns to discuss the fact that poor nutrition and weight loss can eventually result in poor sports performance. The combination of low caloric intake and the resulting fluid and electrolyte reduction decreases endurance, strength, reaction time, speed, and concentration. These conditions impair athletic performance and increase the risk for injuries [4]. In addition, the harmful physiological side effects of food restriction can manifest themselves in amenorrhea, osteoporosis, and possibly even death.
Prevention
To reduce the potential for disordered eating, everyone involved with the female athlete, including the athlete herself, should make decisions regarding weight loss. The coach, athlete, medical, and nutritional personnel should all agree if weight loss is necessary, the amount of weight loss needed, and the method. All weight loss plans should be designed for an individual, not a team. Eating disorders begin when athletes are made to conform to unrealistic weight goals or when coaches, friends, or parents comment negatively on an athlete’s weight [5]. Athletes should be discouraged from fad and crash diets as that will promote disordered eating patterns and result in unhealthy weight loss. Remember that disordered eating patterns have psychiatric, physiological, and social factors that make a team approach the most effective treatment strategy [6].
References
1. Moyano, D., et al., Antioxidant status in anorexia nervosa. Int J Eat Disord, 1999. 25(1): p. 99-103.
2. Moyano, D., et al., Plasma total-homocysteine in anorexia nervosa. Eur J Clin Nutr, 1998. 52(3): p. 172-175.
3. Rock, C.L. and J. Curran-Celentano, Nutritional disorder of anorexia nervosa: a review. Int J Eat Disord, 1994. 15(2): p. 187-203.
4. West, R.V., The female athlete. The triad of disordered eating, amenorrhoea and osteoporosis. Sports Med, 1998. 26(2): p. 63-71.
5. J Am Diet Assoc, 1994. 94(8): p. 902-907.
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