Course:KIN366/ConceptLibrary/AnorexiaAthletica

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Movement Experiences for Children
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KIN 366
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Instructor: Dr. Shannon S.D. Bredin
Email: shannon.bredin@ubc.ca
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Anorexia Athletica involves maintaining high physical performance while depriving one’s caloric intake as well as having a low body mass (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Anorexia athletica is not classified as an eating disorder because although many of the characteristics of an individual with anorexia athletica are similar to those of other eating disorders, it does not completely match the criteria for eating disorders (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Anorexia athletica is therefore classified as disordered eating or being subclinical, which is also called EDNOS (eating disorders not otherwise specified) (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Disordered eating can be defined as ranging from anorexia athletica and EDNOS, and their associated abnormal eating behaviours, to clinical eating disorders, including anorexia and bulimia (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004).

Characteristics

Criteria of anorexia athletica include weight loss, restriction of caloric intake, and the fear of becoming obese (Herbrich, Pfeiffer, Lehmkuhl & Schneider, 2011). There are certain characteristics of anorexia athletica that clearly distinguish it from an eating disorder (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Compared to individuals with eating disorders who reduce their body mass for appearance reasons, someone with anorexia athletica does so in order to perform at a higher level (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). As well, dieting and excessive exercise is often pushed upon athletes by coaches, trainers, or the athletes themselves to perform more optimally. (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). It is not as common for people with anorexia athletica to be concerned about their body shape, however, there are more athlete- to-athlete comparisons made. (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004).

Another characteristic of anorexia athletica is that weight loss and gain is commonly temporary. This weight cycling can be attributed to sports having off-seasons, where the volume of intensity of training for athletes may be lower than during the training and performance times for their sport (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Therefore, the risk for developing a clinical eating disorder is increased when athletes maintain this extremely low body weight all year round (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). The final characteristic of anorexia athletica is when the athletes career is over, any abnormal behaviours should no longer be prevalent (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004).

Prevalence

Eating disorders and subclinical eating disorders are seen at higher rates in athletes compared to non-athletes (Herbrich, Pfeiffer, Lehmkuhl & Schneider, 2011). In contrast to athletes who participate in physical activity and sports for a variety reasons, elite athletes face the pressure of improving performance and therefore are more susceptible to developing anorexia athletica (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Oftentimes athletes try and reduce their weight to be an ideal body weight for their sport and this in turn can cause athletes, particularly female athletes, to become increasingly worried about their body and can result in the development of disordered eating behaviours (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Disordered eating behaviours and body weight concerns are seen more commonly in females who participate in esthetic sports, such as gymnastics and ballet, rather than those athletes participating in endurance and team sports (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). A study comparing adolescent ballet dancers to a control group of high school students found that 11 of the ballet dancers met the criteria for anorexia athletica, while only one student in the control group met the criteria for anorexia athletica, further confirming the notion that females in esthetic sports are at an increased risk of developing anorexia athletica and patterns of disordered eating (Herbrich, Pfeiffer, Lehmkuhl & Schneider, 2011). Esthetic sports however are not the only sports at risk for anorexia athletica. One way to differentiate against typical eating disorders and anorexia athletica is that anorexia athletica is more common in elite sports where weight can aid in performance (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004) Therefore, it is usually diagnosed in both esthetic sports such as dance and gynmanstics or other sports that have advantages to anorexia athletica features, such as track (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004).

In current society, anorexia athletica is becoming more prevalent in male athletes as well. According to Hatmaker (2005)’s study, anorexia athletica is more common in leaner, weight dependent sports such as wrestling, running, and bodybuilding. Similar to female athletes, they over use exercise and decrease caloric intake to provide an athletic advantage to their sport.

Diagnosis

At this time there are minimal scientifically-based tools to identify and diagnose athletes with anorexia athletica (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). However a recent exercise-based instrument, the Exercise Orientation Questionnaire, has been implemented as a tool to identify individuals that are at risk for eating disorders (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). The primary use of the questionnaire is to distinguish between eating disorder patients and controls without eating disorders, both groups having a similar low body mass index (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Most athletes already obtain a lower body weight than the average human, therefore this questionnaire is helpful in properly diagnosing anorexia athletica (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004).

Issues with Diagnosis

An issue with the diagnosis of anorexia athletica is that body measurements, such as height, weight, and waist, hip, and chest circumference, as well as total body fat percentage vary greatly between athletes in different sports. These measurements do not take into account the athletes, who at the specific time of the measurements have normal body fat and mass, but are actively engaging in weight loss behaviours in order to compete in a different weight class in their specific sport or to improve overall performance (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). As well, all of the issues with the current diagnosis of anorexia in athletes clearly outline the need for the development of new tools for the diagnosis of this condition which do not take into account the athletes body measurements and specific sport body types (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Diagnosing anorexia athletica can be difficult because some of the characteristics of someone with anorexia athletica will often overlap with the criteria for other more serious clinical eating disorders). In addition, it is not known whether athletes who develop anorexia athletica and disordered eating behaviours have an underlying eating disorder that is manifesting itself in the specific sport setting, or whether the cause of this condition is strictly a result of competing in sports at an elite level (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Some evidence surrounding the development of anorexia however can confirm that specific sports do have increased prevalence of this condition, such as female ballet dancers (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004).

Health Consequences

Research regarding specific health consequences of anorexia athletica and its effects on the movement experiences of children is lacking as anorexia athletica is a particularly new concept, which was introduced in the 1990s (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). However as anorexia athletica is classified as a subclinical eating disorder, the health consequences of anorexia athletica are similar to the problems for children associated with clinical eating disorders such as anorexia nervosa and bulimia.

As previously mentioned, one of the criteria for anorexia athletica is restriction of caloric intake, and therefore children and adolescents with eating disorders will likely be suffering from nutritional deprivation (Herbrich, Pfeiffer, Lehmkuhl & Schneider, 2011). The specific health consequences of nutritional deprivation varies from individual to individual, as the effects depend on the length, severity, number of episodes of restriction, as well as the timing of these deprivation episodes with respect to the child’s normal periods of growth and physical development (Rome, Ammerman, Rosen, Keller, Lock, Mammel, O’Toole & Rees, 2003). Malnutrition in both acute and severe forms can have an affect on all of the organs of the body (Rome, Ammerman, Rosen, Keller, Lock, Mammel, O’Toole & Rees, 2003). Often times the damage to the brain and bone tissue associated with malnutrition can never be completely restored even when proper nutrition is attained (Rome, Ammerman, Rosen, Keller, Lock, Mammel, O’Toole & Rees, 2003). Malnutrition is often associated with deficiencies in specific nutrients; but oftentimes the main limiting factor to normal functioning of the body is the lack of energy, because even if the body has all of the vital building blocks it needs, if it is lacking energy, tissue maintenance and synthesis cannot occur (Rome, Ammerman, Rosen, Keller, Lock, Mammel, O’Toole & Rees, 2003). That being said, disordered eating and malnutrition often do result in serious nutritional deficiencies (Rome, Ammerman, Rosen, Keller, Lock, Mammel, O’Toole & Rees, 2003).

Young athletes often display energy and nutritional inadequacies as well as purging methods and this combination can lead to restrictive eating behaviours being normal at a young age (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Long –term dieting affects the body in a number of ways including affecting body composition, increasing the risk for cardiovascular disease, inducing changes in the metabolic and neuroendocrine systems, as well as leading to the development of abnormalities in the endocrine system, which is associated with reproductive function (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Along with the large amount of fat loss associated with anorexia comes the decrease in endocrine hormones related to fat mass, such as leptin, which is closely linked to the regulation of energy intake and expenditure (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). These adaptations and changes can help to explain why some athletes can perform at such high levels on very low-calorie diets (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Calorie deprived athletes may also still be able to compete at a high level as there is an associated decrease in resting metabolic rate associated with anorexia athletica (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004).


Female Athlete Triad

Of particular concern for female athletes with anorexia athletica and reduced weight is a delay in the onset of menarche, irregular menstruation, as well as a decrease in the formation of bone; all of which make up the Female Athlete Triad (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). In addition there is also higher than normal rate of injuries in those athletes with anorexia athletica (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). As the name suggests the Female Athlete Triad is a condition affecting women who display disordered eating, amenorrhea, and osteoporosis (Kazis & Iglesias, 2003). This syndrome is becoming more prevalent as there are an increasing number of women participating in elite level sports (Kazis & Iglesias, 2003). The mechanism by which this syndrome works is through dysregulation of the hypothalamic-pituitarian-ovarian (HPO) axis caused by high levels of intense exercise or disordered eating behavious, which results in amenorrhea (Kazis & Iglesias, 2003).

Primary amenorrhea occurs when a female by age 16 who has developed normally and has sexual characteristics has not yet had their first period, or when a 14 year old female without developed secondary sexual characteristics has not had their first period (Heiman, 2009). Secondary amenorrhea is more common and can be defined as when a female who has previously had a normal menstruation cycle has not had their period for 3 months, or for 9 months in a female who previously had oligomenorrhea, or infrequent menstruation (Heiman, 2009). The development of amenorrhea is associated with osteoporosis and increased risk for fracture (Kazis & Iglesias, 2003). The main concern associated with adolescents developing the Female Athlete Triad is that they are at a particularly critical time in development and as a result may not reach their peak bone mass (Kazis & Iglesias, 2003).

Other complications associated with the Female Athlete Triad along with not reaching peak bone mass, include a decreased final bone density, scoliosis, and stress fractures, all which are going to have an effect on how females will be able to move freely throughout their life (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004).

Treatment

It is crucial that those suffering from anorexia athletica get treatment as soon as possible due to the severe effects it can have on the body (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). It is of particular importance for young athletes to restore energy levels, as adequate energy is needed maintain growth and development of tissues as well as to meet the energy demands for competing at high levels of athletics (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). As with most conditions, the success of recovery is increased with early detection and early intervention (Rome, Ammerman, Rosen, Keller, Lock, Mammel, O’Toole & Rees, 2003). Treating eating disorders in children involves an interdisciplinary team of doctors, nurses, dieticians, and mental health professionals (Robin, Gilroy & Dennis, 1998).

The main goals for all aspects of treatment for children with eating disorders are to ensure weight gain and restoration of physical health, return to normal eating habits and meeting all the nutritional requirements for their age and developmental status (Robin, Gilroy & Dennis, 1998). Mentally eliminating distorted thoughts, body and self-image problems, as well as any associated mental conditions such as an underlying anxiety disorder are equally important (Robin, Gilroy & Dennis, 1998). Finally, having family therapy to maintain the family relationship and any parent-child conflict that may exist is important for long-term maintenance (Robin, Gilroy & Dennis, 1998). Many treatment techniques can be used in order to reach all the goals of treatment including individual dynamic therapy, family therapy, behaviour modification, and cognitive-behavioural therapy (Robin, Gilroy & Dennis, 1998). However, there is a lack of evidence on the best treatments for treating eating disorders in children and adolescence, but most likely some combination of treatments would yield the best possible outcomes (Robin, Gilroy & Dennis, 1998).

Practical Applications

Although attaining a certain low body weight is advantageous in many sports, especially at the elite level, this can lead to the development of disordered eating behaviours and anorexia athletica in very young athletes (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). The importance of early detection and diagnosis cannot be stressed enough in children with eating disorders as there are permanent effects that a reduced body weight and disordered eating can have on their physical growth and development (Rome, Ammerman, Rosen, Keller, Lock, Mammel, O’Toole & Rees, 2003). With this information parents and coaches of children who play sports, especially those of children who are competing at high levels, should be constantly on the lookout for children who are displaying characteristics of anorexia athletica so that treatment can be implemented.

Advice for Parents

Recognizing that your child has an eating disorder is the first step that parents can take in the recovery process (Natenshon, A.H., 1999). Anorexia athletica, compared to other eating disorders, is often more difficult to notice warning signs, as their behaviours may appear healthy (Natenshon, A.H., 1999). For a parent it is helpful to remember that disorders such as anorexia athletica progress gradually, and every case is different, as symptoms vary for each child (Natenshon, A.H., 1999). Therefore, as Natenshon (1999) mentions, there are now diagnostic questionnaires for parents and families to fill out if they are unsure that their child has a problem.

Parents should also note that family support and involvement is completely necessary for the recovery of their child with an eating disorder (Robin, Gilroy & Dennis, 1998). It has been proven that in the long-run family therapy is more effective in restoring the individual’s weight than individual therapy (Robin, Gilroy & Dennis, 1998). Parents need to be understanding and accepting that their child is suffering from anorexia athletica, despite guilt and other feelings they may have towards the situation, and be 100% committed to helping their child reach a full recovery. As well, parents may be pushing their child to compete at higher and higher levels in their sport and this is not recommended as it may lead the child to feel extreme pressure to succeed and could potentially lead to the development of anorexia athletica in an effort to improve their performance.

Advice for Coaches

Coaches working with children competing at elite levels should understand the necessary energy requirements that their athletes need in order to not only develop normally but also to compete at a high level (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). If an athlete needs to reduce their weight this should be done during the off-season and energy intake should be modified so that the athlete is still getting the required amount of carbohydrates and proteins (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Weight changes should not occur when the athlete is in a period of high intensity volume and training, as sufficient energy is needed to maintain body weight, replenish glycogen stores, and provide enough protein for tissue growth and repair (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Coaches should also be working closely with a sport dietician to ensure that proper nutrition is attained when weight reduction is occurring and in addition should also be working with health professionals to determine a normal body weight and fat percentage for a child of a certain age and gender (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004). Coaches should only recommend safe weight reduction mechanisms to their athletes that will not affect their physical health or performance (Sudi, Ottl, Payerl, Baumgartl, Tauschmann & Muller, 2004).

Finally, it is important to remember the power that is held by a coach or trainer. An athlete is constantly trying to appease their coach, and studies are showing that coaches are constantly increasing pressure on their athletes performance/appearance, which in turn is causing these anorexia athletica behaviours from the athletes (Hatmaker, G., 2005). Being able to use a coach’s power in a positive way like being a good role model, and being aware of the symptoms of anorexia athletica is in the best interest of both the athlete and the coach’s future.

References

Hatmaker, G. (2005). Boys With Eating Disorders. The Journal of school nursing, 21(6), 329.

Heiman, D. L. (2009). Amenorrhea . Primary Care: Clinics in Office Practice, 36(1), 1-17. doi: http://dx.doi.org.ezproxy.library.ubc.ca/10.1016/j.pop.2008.10.005

Herbrich, L., Pfeiffer, E., Lehmkuhl, U., & Schneider, N. (2011). Anorexia athletica in pre-professional ballet dancers. Journal of Sports Sciences, 29(11), 1115-1123. doi: 10.1080/02640414.2011.578147

Kazis, K., & Iglesias, E. (2003). The female athlete triad. Adolescent Medicine, 14, 87.

Natenshon, A. H. (1999). When your child has an eating disorder. Iossey-Bass Publishers, San Francisco.

Robin, A. L., Gilroy, M., & Dennis, A. B. (1998). Treatment of eating disorders in children and adolescents. Clinical Psychology Review, 18(4), 421-446. doi: http://dx.doi.org.ezproxy.library.ubc.ca/10.1016/S0272-7358(98)00013-0

Rome, E. S., Ammerman, S., Rosen, D. S., Keller, R. J., Lock, J., Mammel, K. A., O’Toole, J., & Rees, J. M. (2003). Children and adolescents with eating disorders: The state of the art. Pediatrics, 111(1), 98-108. doi: 10.1542/peds.111.1.e98

Sudi, K., Ottl, K., Payerl, D., Baumgartl, P., Tauschmann, K., & Muller, W. (2004). Anorexia athletica.Nutrition, 20(7-8), 657-661. doi: http://dx.doi.org.ezproxy.library.ubc.ca/10.1016/j.nut.2004.04.019