Athletes and eating disorder

By Danielle Taddeo, Paediatrician, CHU Ste-Justine

It may seem obvious that athletes are more at risk for developing an eating disorder. It’s also interesting to try to understand why. It is clear that many of the qualities that allow them to become a competitive athlete are those that you also quite often find, in people suffering from eating disorders. Indeed, these two groups show proof of willpower, of determination, demonstrating a certain denial of the physical discomfort and in even feeling a certain pride in it and they have a tendency to be perfectionists. There’s a widespread belief that the best performance is achieved at the lowest weight (“thinner is better”) and with the lowest possible percentage of body fat. This is a reason why eating disorders occur more often in sports where a lower weight is desired as in dance, gymnastics, and long distance running. Sports that are classified by weight encourage a lighter weight. But at what point is this emphasis on low body weight a real asset for these sports? The question arises. The women who are most at risk are those who take part in sports that put an emphasis on a thin figure or consist of a subjective evaluation of the appearance (figure skating, gymnastics, ballet). Weighing themselves frequently and the pressure from parents and coaches could increase the risk of developing an eating disorder in the youngest athletes. Also, performance anxiety exists among numerous athletes and some could be tempted to manage it by means of an eating disorder.

Male athletes also have behaviours that could be considered symptoms of eating disorders, like binge eating, diuretic use and/or steam baths (such as saunas) to lose weight. They could take substances aimed at changing their figures (ie. anabolic steroids aimed at increasing their muscle mass) and at enhancing their performance (ie. protein diets). An unusual aspect of these behaviours is that, linked with excessive exercise, they’re often valued socially.

Here, we’re going to elaborate more on the female athlete triad. It was first defined in 1993 by Yeager, Agostini, Nativ and Drinkwater, then, in a position taken by the American College of Sports Medicine in 1997, as a combination of an eating disorder, amenorrhea and osteoporosis. The key component to understanding this entity is that the caloric intake is insufficient compared to the energy burned. It’s not restricted to elite athletes because it’s been observed more and more among recreational athletes.

An eating disorder could include the whole spectrum of abnormal behaviours surrounding food and weight: it could involve restriction, starvation, binge eating, self-induced vomiting, laxatives use, the consumption of diet products and an excessive preoccupation with food, exercise or body image. It’s not limited to anorexia or bulimia.

Eating disorders could lead to the following consequences: a chronic fatigue, deficiencies in micronutrients, dehydration, anemia, electrolyte imbalances, heart and gastrointestinal problems. These problems could not only alter the performance, but also increase the risk of injuries and even death

The changes that are being produced in the level of hormones vary from oligomenorrhea (less frequent periods) to amenorrhea (absence of periods for more than 3 menstrual cycles). They originate from a number of factors. The main hypothesis is that the lack of energy, in combination with the physical and psychological stress endured by the athlete, affects the hypothalomo-hypophyso-ovarian axis, whose appropriate functioning results in the secretion of estrogens by the ovaries, the hormone that plays an important role in the health of bones

A low level of estrogens is one of the causes of osteoporosis found among numerous female athletes. Osteoporosis consists of a deterioration of bone density resulting in brittle bones and an increased risk of breaks. A poor state of nutrition, especially with deficiency in calcium and vitamin D is another important factor. Genetics has once again, its place here, certain people having been predisposed to this problem through heredity. However, the type of physical activities may equally influence bone health. Indeed physical activities implicating an impact or loading may help with the gain of bone mass. It must be understood that more than 50% of bone mass and 15% of adult height are acquired during adolescence. Peak bone density is reached between 18 and 25 years of age, after which there is a loss of 0.3 to 0.5 % a year until menopause accelerates this pace. Here is why it is essential to detect and to take charge of this problem especially if it shows up in adolescence.

It’s important to suspect this problem in an athlete who shows for example, an excessive performance anxiety, dissatisfaction with their body, restrictive food habits and/or takes substances to improve their performance. Once the problem is identified, the solution can be found in the reduction of the intensity of training, an increase in caloric intake, adequate intake of calcium and vitamin D. On the hormonal side, there is still controversy and the decision whether or not to take hormones like those found in contraceptive pills or only substitutes must be decided on an individual basis.

In the course of recovery, certain individuals discover that the sport they practised made them excessively anxious or, sometimes for the children or adolescents, that they tried to please their parents rather than themselves. This process of self discovery could sometimes be very difficult to go through; especially if the training started at a very young age with the hope of becoming an elite athlete. A multidisciplinary approach may sometimes be necessary and beneficial, including medical, dietary, psychological and /or family support, especially if it is really an eating disorder. So do not hesitate to consult, in case of doubt, because it may be difficult to distinguish between an athlete who’s paying attention, who wishes to eat and train himself in the best way from one who does it in an exaggerated way, to the detriment of their physical and psychological health.