Eating Disorders and Psychology

Transcription

1 England Athletics: Coaching the Female Endurance Athlete Seminar, 21 st January 2012 Eating Disorders and Psychology Carolyn Plateau National Centre for Eating Disorders in Sport Loughborough University

2 National Centre for Eating Disorders in Sport World class education, assessment and support for athletes and professionals Education Intervention Research Based on Loughborough University Campus in conjunction with Leicester Eating Disorders Service Centre co-ordinator: Dr Huw Goodwin

3 Background 800m runner, former GB Junior International Undergraduate degree in Psychology at Oxford University ( ) Masters Degree in Psychology Research at Loughborough University ( ) Currently working within the National Centre for Eating Disorders in Sport at Loughborough University. Conducting PhD research looking at eating disorders within athletes. Qualified Coaching Assistant, Leader in Running Fitness & working towards Coaching Award.

4 PhD Research Improve our understanding of the risk and trigger factors for eating disorder development amongst athletes Improve our understanding of the difficulties faced by coaches in identifying and managing athletes with unhealthy eating behaviours Use research findings to tailor educational programmes and intervention strategies employed by the National Centre for Eating Disorders in Sport

5 Outline: Eating Disorders and Psychology What are eating disorders? Definitions, prevalence and signs and symptoms Potential causes and risk factors Psychological co-morbidity Health and performance implications What can coaches do? Managing the training environment to minimise risks Recognising the early warning signs & managing symptomatic athletes

6 The Female Athlete Triad The interrelationships between energy availability, menstrual function, and bone mineral density. (Nattiv et al., 2007) Nattiv, A., Loucks, A.B., Manore, M.M., Sanborn, C.F., Sundgot-Borgen, J. & Warren, M.P. (2007) American College of Sports of Medicine Position Stand: The female athlete triad. Med Sci Sports Ex. 39 (10)

7 Female Athlete Triad Disordered Eating Low Energy Availability FEMALE ATHLETE TRIAD Osteoporosis Low Bone Mineral Density Amenorrhea Menstrual Dysfunction

8 Female Athlete Triad Continuum Athletes can be anywhere on the three spectrums. Their position is determined by their energy availability Figure from: Nattiv, A., Loucks, A.B., Manore, M.M., Sanborn, C.F., Sundgot-Borgen, J. & Warren, M.P. (2007) American College of Sports of Medicine Position Stand: The female athlete triad. Med Sci Sports Ex. 39 (10)

9 Energy Availability (EA) Definition: Energy availability is the amount of dietary energy remaining for other body functions after exercise & training. Needed for: - Cellular processes - Growth and repair - Maintaining body temperature - Reproduction - Immune system

10 Energy Availability Energy availability (EA) = dietary energy intake (EI) minus exercise energy expenditure (EEE) EA= EI-EEE (kg/ fat free mass) Therefore low energy availability may be a result of: Insufficient dietary intake and/or Increased energy expenditure through exercise. - A healthy athlete has an energy availability of 45 kcal/kg FFM - A normal resting metabolic rate requires 30kcal/kg FFM - Low energy availability is classified as below 30kcal/kg FFM.

11 Energy Availability: An example... A 60kg athlete (fat free mass 51kg, 15% body fat) has a daily dietary energy intake of 2000 kcal, expending 600kcal through exercise. EA=EI-EEE /kg FFM EA = ( )/51 = 27.5 kcal/kg FFM. Below the recommended 30kcal/kg FFM

12 What should her energy intake be? Energy Availability=Energy Intake Exercise Energy Expenditure /kg FFM (Healthy energy availability = 45 kcal/kg FFM) 45 = Energy Intake 600/51kg FFM. 45x51 = Energy Intake = Energy Intake = 2895 Kcal.

13 The consequences of low energy availability Cellular processes are maintained BUT less energy is available for other body functions... Disruption of temperature regulation feeling cold Impaired immune response increased vulnerability to illness Growth & repair processes will be slowed Less energy is available for reproductive processes Adaptation to training will be less effective.

14 When does low energy availability occur? 1. Inadvertent through... Poor nutrition knowledge: planning, food choices & balance, recovery & timing after exercise, insufficient intake Reduced appetite after prolonged exercise Increased training & no adjustment in food intake Increased energy required for growth (developing athletes) 2. Intentional weight loss for performance reasons 3. Psychological Abnormal eating behaviours (clinical/subclinical)

15 When does low energy availability occur? 1. Inadvertent through... Poor nutrition knowledge: planning, food choices & balance, recovery & timing after exercise, insufficient intake Reduced appetite after prolonged exercise Increased training & no adjustment in food intake Increased energy required for growth (developing athletes) 2. Intentional weight loss for performance reasons 3. Psychological motivations Abnormal eating behaviours (clinical/subclinical)

16 Female Athlete Triad Continuum Figure from: Nattiv, A., Loucks, A.B., Manore, M.M., Sanborn, C.F., Sundgot-Borgen, J. & Warren, M.P. (2007) American College of Sports of Medicine Position Stand: The female athlete triad. Med Sci Sports Ex. 39 (10)

17 Eating Disorders: What are they? Eating disorders are severe, psychological conditions that are characterised by disturbed attitudes towards food and abnormal eating behaviour.

18 Eating Disorders There are three main categories of clinical eating disorder: Anorexia Nervosa Bulimia Nervosa Eating Disorders Not Otherwise Specified (EDNOS)

19 Anorexia Nervosa 1. Refusal to maintain body weight at or above a minimally normal weight: 85% of what would be expected for age and height. 2. Intense fear of gaining weight or becoming fat, despite being underweight. 3. Disturbances in perception of body weight or shape. Body weight plays a principal role in self-evaluation & self-esteem. 4. Amenorrhea - the absence of at least three consecutive menstrual cycles.

20 Bulimia Nervosa 1.Recurrent episodes of binge eating. An episode of binge eating is characterized by: Eating an amount of food within a specific time frame that is much larger than most people would eat in a similar situation Lack of control over eating (e.g. feeling unable to stop or control what/how much they re eating) 2. Inappropriate compensatory behaviour to prevent weight gain e.g. self-induced vomiting, laxatives, diuretics, fasting or excessive exercise. Occurs at least twice a week for 3 months for clinical diagnosis 3. Self-evaluation is unduly influenced by body shape and weight.

21 Eating Disorders Not-Otherwise-Specified Atypical eating disorder manifestations: E.g. Meeting all other criteria for anorexia nervosa but weight is still in the normal range Failure to meet the frequency or duration criteria for binge-purge episodes in bulimia nervosa. Also: night eating syndrome, purging disorder and subthreshold binge-eating disorder. EDNOS is not an indicator of a reduced severity Up to 75% of all eating disorder cases receive a diagnosis of EDNOS

22 Signs and symptoms of eating disorders Do you know any of the signs and symptoms of eating disorders?

23 Symptoms: Anorexia Nervosa Physical and Medical symptoms Amenorrhea Fatigue in training (beyond expected) Muscle weaknesses Overuse injuries e.g. Stress fractures Gastrointestinal problems Dehydration Hyperactivity Weight loss Hypothermia (cold intolerance) Lanugo (fine hair on face and arms)

24 Symptoms: Anorexia Nervosa Psychological and behavioural symptoms Anxiety Avoidance of eating or eating situations Claims of feeling fat Depression Excessive exercise Insomnia Preoccupation with weight and eating Restlessness Social withdrawal Restrictive dieting Unusual weighing behaviour

25 Symptoms: Bulimia Nervosa Physical and Medical symptoms Dehydration Dental and gum problems Complaints of bloating Electrolyte abnormalities Frequent or extreme weight fluctuations Gastrointestinal problems Menstrual irregularity Muscle cramps, weakness Swollen glands Low weight despite eating large volumes of food.

26 Symptoms: Bulimia Nervosa Psychological / behavioural symptoms Binge eating Agitation if bingeing is interrupted Depression Evidence of vomiting unrelated to illness Disappearing after eating Excessive exercise Secretive eating Use of laxatives or diuretics unsanctioned by medical staff Stealing food

27 Co-morbidity of eating disorders Eating disorders often co-occur with other mental health conditions Low self esteem Anxiety disorders Depression Obsessive compulsive disorder Substance dependence Cause or consequence? Be on the look out for changes in mood, levels of anxiety and stress.

28 Disordered Eating to Eating Disorders: A Continuum Normal eating behaviour Mild dieting and body image concerns Disordered eating (subclinical) Clinical eating disorders

29 Disordered Eating Subclinical conditions Reduced severity, but may still engage in pathological behaviours & there may be significant distortion with regards to body image and weight perception. Anorexia Athletica Dieting and disordered eating behaviour is strongly predictive of subsequent clinical eating disorders Early intervention is important

30 Prevalence of eating disorders In the normal population: Anorexia Nervosa: ~1% (female) (0.3% male); Bulimia Nervosa: ~1.5% (female) (0.5% male), Amongst athletes: 20% female (8% male) elite athletes met the criteria for a clinical eating disorder (Sundgot-Borgen & Torstveit, 2004) Disordered eating: up to 47% of athletes competing in lean or endurance sports (Torstveit & Sundgot-Borgen, 2008) Athletes are at a significantly increased risk for eating disorders

31 Causes of Eating Disorders Why might athletes be at an increased risk of eating disorders?

32 Risk Factors for eating disorders Genetic vulnerability Sociocultural factors contributing to body dissatisfaction Media, celebrity role models Peers Family Thin people are more successful Personality factors Obsessive, compulsive High levels of anxiety Perfectionism

33 Sports specific risk factors Participation in sport itself does not increase ED risk; rather it is aspects of the sporting environment that are additional to those risks faced by the normal population. (Thompson & Sherman, 2010) Sports specific risk factors: Revealing sports attire Contagion Effect Competitive Thinness Trigger factors - Traumatic life events (e.g. injury) - Sudden increase in training volume. - Frequent weight fluctuations, dieting.

34 Difficulties with identification Presumption of good health with good athletic performance Sport stereotypes expectations that distance runners will be slim Secretive nature of the eating disorders Similarities between anorexic traits and desired characteristics for sport: High levels of mental toughness and self control; High commitment to training and exercise regimes; Perfectionism; Overcompliance and willingness to obey; Selflessness and continuing despite pain or discomfort

35 Hungry for Gold (International Olympic Committee)

36 Role of the Coach: Managing the training environment 1. Nutrition education and input Healthy eating (junior and beginner athletes) Sports nutrition, pre and post training fuel. 2. Motivation, self esteem and support Well-being Psychological support, monitoring mental health 3. Weight for performance Factors to consider

37 Nutrition education and input Prevention of low energy availability: Recovery strategies encourage athletes to bring food with them tuck shop of food for after training Nutrition talks or advice for parents at your club Pre and post exercise nutrition UCoach nutrition booklets and materials that can be distributed

38 Motivation, well-being & support Person oriented versus performance oriented coaching style. Motivation Athletes with higher levels of intrinsic motivation perceived their coaches to provide high levels of positive & informationally based feedback & low frequencies of negative feedback. (Amorose & Horn, 2000) Biesecker & Martz (1999) performance centred coaching with regards to weight may have a negative influence on body image anxiety & dieting behaviour in some cases. Self esteem is it tied very closely to their athletic performance? Low self-esteem is a risk factor for disordered eating Keep an eye out for changes in mood, stress, and sociability

39 Depression in Sport The Hidden Side of Sport

40 Depression in sport 1 in 10 athletes may suffer from depression could be as high as 20%. Changes to look out for: Depressed mood Diminished interest or pleasure in activities Significant weight loss or gain; change in appetite Sleep disturbances Fatigue or loss of energy Feelings of worthlessness Poor concentration Suicidal ideation

41 Weight for performance Is weight loss or modification appropriate? Factors to take into account: Age Training history Level of competition Performance vs. body dissatisfaction?

42 Adjusting body weight for performance Modifications to weight and body composition should take place gradually. 1. Guided nutritional input 2. Appropriate & realistic targets that are monitored 3. Appropriate time frame 4. Encourage a focus on healthy habits and making good food choices 5. Monitor progress by measuring changes in performance and energy levels, injuries & illness and menstrual function. 6. Help athletes to develop lifestyle changes to maintain a healthy weight. Concern over non-performance related dieting or unusual eating behaviours.

43 Scenario of Sarah (Scenario 1) Sarah is a talented 18 year old female at your club. She works extremely hard both at her university course and in athletics, and has recently expressed a desire to do additional training beyond her current schedule. She says she wants to succeed and will do whatever it takes. Her performances on the track have been good and she has a chance of being selected to compete for the GB Junior Team this year. You notice that Sarah has lost weight in the last few weeks and that she has become more rigid about her diet, excluding most carbohydrates. In groups, discuss the scenario and decide on the actions that you might take as Sarah s coach.

44 Scenario of Alice (Scenario 2) Alice is a 16 year old high jumper at your club. She trains three times a week and has made good progress in the last year. She has grown a lot in the last six months and her performances have improved as a result. However, Alice has been complaining of pain in her foot for the last 3-4 weeks, and it doesn t seem to be improving even with reduced training. When you ask Alice about her menstrual cycle, she tells you that she hasn t started her periods yet. In groups, discuss the scenario and decide on the actions that you would take as Alice s coach.

45 IOC MC guidelines/decision trees Produced by the IOC to provide guidance on how to deal with athletes presenting with symptoms of the Female Athlete Triad. Advice with regards to training and people who might be useful to involve at various stages e.g. Sports medic, Eating Disorder Specialist, Nutritionist or Dietician.

46 From the International Olympic Committee Medical Commission: Position Stand on the Female Athlete Triad

47 From the International Olympic Committee Medical Commission: Position Stand on the Female Athlete Triad National Centre for Eating Disorders in Sport

48 Any Questions? Advice, support & assessment Interested in taking part in research?