How to Manage the Transition From Compulsive Exercise to Healthy Activity and Sport with Young...
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How to Manage the Transition From Compulsive Exercise to Healthy Activity and Sport with Young People Affected by Eating DisordersMrs Claire Knight
Specialist Dietician, Eating Disorders Team, Child and Adolescent Mental Health Services, Nottinghamshire Healthcare NHS Trust, Nottingham, UK & Newbridge House Specialist Eating Disorders Unit, Sutton Coldfield, Birmingham, UK
Dr Damian Wood MBChB, DCH, MRCPCH
Consultant Paediatrician, Nottingham Children’s Hospital, Queen’s Medical Centre, Nottingham & Newbridge House, Specialist Eating Disorders Unit, Sutton Coldfield, Birmingham, UK
What’s in a word?
Physical Activity - Any bodily movement produced by skeletal muscles that requires energy expenditure
Exercise - Physical activity that is planned, structured and repetitive for the purpose of conditioning any part of the body. Used to sustain or improve health and fitness
Sport - An activity involving physical exertion and skill with an individual or team competes against another or others for entertainment
Terminology
Compulsive exercise
Anorexia athletica
Sports anorexia
Hypergymnasia
Eating disorders in athletes
DSM V Anorexia Nervosa
Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health) .
Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain (even though significantly low weight).
Disturbance in the way one's body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
Subtypes: Restricting type Binge-eating/purging type
Compulsive Exercise - Definition
Qualitative
To complete in workshop
Quantitative
T complete in workshop
Compulsive exercise
Physical activity that is associated with disordered eating attitudes and behaviours, and describes a condition characterised by an inability or unwillingness to cut down or stop exercising even though it is detrimental to health Dependence - Dysfunctional affect regulation Compulsivity - Extreme concerns about the perceived
negative consequences of stopping or reducing exercise Perfectionism - Rigid/inflexible exercise behaviour
Compulsive Exercise and ED
Longer duration of anorexia nervosa in those who exercise as part of their illness
Compulsive exercise often the last symptom to subside
Shorter time to relapse in those with anorexia nervosa who exercise compulisvely
Compulsive exercise predicts chronicity in those with anorexia nervosa
Longer IP stay or more IP stays for those who exercise
Rigid and routine
behaviour
Manage weight and shape
Inability to stop
Feelings of guilt at missing exercise
Associated with greater
anxiety levels
Exercise despite injury and
illness
Compulsive Exercise
Positive Reinforcement
Exercise - adaptive way of regulating affect Anxiolytic Anti-dpressive
Differentiates exercise from the other dysfunctional affect regulatory behaviours in that it may also positively reinforce the exercise behaviour.
“Dependence”
• affective withdrawal symptoms when they are unable to exercise (e.g. anxiety, depression, guilt, irritability, frustration, anger),
• avoidance of these adverse symptoms is a primary maintaining mechanism for the exercise behaviour (i.e., negative reinforcement).
• llittle to no empirical support for compulsive exercise actually being a type of physiological dependence/addiction,
• Similar symptoms
• Concept patients understand
Compulsivity
irrational yet pervasive fear that is grounded in false beliefs and dysfunctional assumptions (e.g. “muscle that is not used turns to fat” and/or “if I do not exercise I am a failure”).
fear is itself maintained by virtue of never being appropriately challenged
It is important to note that many of the fears will be focused around weight and shape issues, and/or emotional withdrawal symptoms.
Perfectionism
Rules - behavioural rigidity, especially in terms of dichotomous thinking operationalised as specific “rules‟ that the patient endeavours to follow.
These rules may also take the form of goals that are similarly rigid, extreme and inflexible.
Many compulsive exercisers follow rigidly structured and/or repetitive exercise routines and any deviation or failure to meet a specific goal leads to self-criticism which further reinforces the perfectionist strivings and behavioural rigidity.
Epidemiology
Compulsive exercise found in as many as 39% of Anorexia Nervosa and 23% Bulimia Nervosa admitted to an eating disorder clinic. (Cited by Goodwin et al, 2011)
Compulsive exercise test Validated Research and clinical use 24 item self report paper questionnaire 6 point Likert scale 5 subscales
Eating Disorders, Sport & Exercise
• Eating disorders are a major problem for sportsmen and women, and are often being overlooked.
• Research shows overall prevalence of eating disorders among sportsmen is 8% - 16 times the prevalence rate among non-athletic males.
• Overall prevalence of eating disorders among sportswomen is 20% –double that of female non-athletes.
Similarities
Good Athlete
Mental toughness
Commitment to training
Pursuit of excellence
Coachability
Unselfishness
Performance despite pain
Anorexic Individual
Asceticism
Excessive exercise
Perfectionism
Overcompliance
Selflessness
Denial of discomfort
Increased Risk of Developing an Eating Disorder
Desire to optimise performance
A belief that performance will be improved by weight or body fat loss (rightly or wrongly)
Involvement in sport that emphasises physical appearance, size or leanness for optimal performance
Increased body awareness, which may exacerbate body image concerns
High stakes associated with winning
Injury as a trigger for the onset of an eating disorder
Influence of parents, coaches and fellow athletes
Summary of Epidemiology/Psychopathology
Compulsive exercise is present in a significant number of young people with eating disorders
Presence of CE predicts a more severe/protracted course
Dependence, compulsivity, perfectionism are core traits
Similarities between traits which predispose to anorexia and those of elite athletes
Interventions
Medical assessment and exercise prescription Cardiac health Bone health and injuries
Nutritional assessment and advice Fuelling life Sports nutrition Fad diets
Psychological therapies LEAP FBT
Body Weight and Shape
An athlete is at greater risk if they are trying to achieve and/or maintain a weight or body composition that is physically difficult for them.
The affect of restriction on the athlete can have many different consequences including: Lack of hunger/fullness awareness Loss of connection to “normal eating.” Development of very rigid eating patterns & rules around food Obsessing about food, eating & body weight Physical consequences e.g. electrolyte imbalance, dehydration,
loss of bone mass density (BMD)
Eating Disorders vs Athletes
Healthy Eating – General population
Healthy Eating – Athletic population
Disordered Eating – Use of potentially harmful weight control measures
Eating Disorders
Figure Skating
20.5% of competitive skaters reported previous eating disorders
50% of these reported still having an eating disorder
Most – 62.5% reported symptoms of Anorexia Nervosa (Barkley 2001)
Taylor and Ste- Marie, 2001 found that 90% of figure skaters felt pressure to lose weight
Symptoms Associated with the Pressures of Skating
Weight loss was required for the sport
Needing to conform to
aesthetic ideals
Obtain better scores94% with previous eating
disorders100% with eating
disordersBarkley , 2001
Signs and Symptoms of Unhealthy or Unbalanced Exercise in Athletes (1)
Exercise is the individual’s primary means of coping
Exercise occurs despite injury
Withdrawal effects (i.e. Sleep and appetite disturbance, negative shift in mood, decreased concentration) occur when exercise is withheld
Overuse injuries
Stress fractures
Signs and Symptoms of Unhealthy or Unbalanced Exercise in Athletes (2) Menstrual irregularity in women or a decrease in
testosterone levels in men
Loss of bone density
Decreased immunity
Frequent colds or upper respiratory infections
Inflexibility of exercise schedule (i.e. Will not alter schedule, will not decrease exercise, will not not exercise)
Decrease in sports performance
Overtraining syndrome
Consequences
Disordered eating can lead to adverse effects on health and physical performance.
In some cases, the condition can be fatal.
Anorexia Nervosa has the highest rate of mortality for any psychiatric condition.
Compulsive Exercise Outcomes
Tasks of Adolescence – how affected compared to restricitve ED
Long term harms Physical – nutrition, bone health Psycholigical Social
Consequences
Consequences of disordered eating on health and performance will also depend on: the athlete’s immediate health status; the demands of sport-specific training; type, severity, and duration of the pathogenic weight
control or eating behaviours; the degree of nutrient deficiency
Decreased Performance
Results of severe energy restriction include: Reduced mental capacity or psychological fatigue Reduced muscle strength and endurance Premature muscle fatigue Decreased anaerobic performance Decreased aerobic capacity (endurance)
Female Athlete Triad
Disordered eating – low energy availability
Amenorrhoea
Reduced bone mineral density
International Olympic Committee Consensus Statement
Prevention
Sport - Education to sports coaches, encourage sport to fit body shape
Compulsive exercise in adolescence - Target individuals personality, motivation and general beliefs
Exercise Prescription
Type
Frequency
Duration
Intensity
ECG screening
Screening for athletes Specificity Sensitivity
Guidelines School College Elite
Nutrition for Adolescence
Appetite and energy intake will increase during a growth spurt
Under nutrition can inhibit bone development, lower peak bone mass, lower height increase velocity, leading to stunting
Energy requirements are higher in teenage boys (2755kcal/d) than girls (2110kcal/d)
Calcium, phosphorus and iron are higher for adolescents than adults
Adolescents conform more to peer pressure and less to their parents role modelling
Healthy Balanced Diet
http://www.nhs.uk/Livewell/Goodfood/Pages/eatwell-plate.aspx
Sports Nutrition in Adolescence
All athletes should adopt nutritional strategies for before, during and after training and competition
Physical training will increase nutrient requirements and may require individual assessment and advice to:
Meet energy requirements
Maximise nutritional intake
Optimise body size and composition
Sports Nutrition
Carbohydrate Basis of all meals and snacks Enough to fuel training programmes and replace carbohydrate
stores during recovery between training and competition
Protein Consumed in daily amounts grater than those recommended
for the general public Varied diet should achieve this Include food and snacks that contain high quality protein
throughout the day
Sports Nutrition
Low energy availability should be avoided
Dietiting in young athletes should be discouraged
Use of supplements does not compensate for poor food choices or an inadequate diet
Supplement use in young athletes must be discouraged
Focus on nutrient rich diet to promote growth and development and a healthy body composition
IOC 2010
Hydration
Athletes should be well hydrated before exercise and drink sufficient fluid during exercise to limit dehydration.
Sports Drinks
Designed to deliver a balanced amount of carbohydrate and fluid to allow an athlete to simultaneously rehydrate and refuel during exercise.
Should be within a compositional range of 4-8% (4-8 g/100 ml) carbohydrate and 23-69 mg/100mL (10-30 mmol/L) sodium (American College of Sports Medicine et al. 2007; American Dietetic Association et al. 2009)
The taste and temperature of sports drinks are also important factors in meeting hydration goals.
Nutrient Rich Snack Choices
200ml glass of semi skimmed milk
Low fat yogurt
Rice pudding
Smoothies made with low fat milk and fruit
Fruit – fresh or dried
Nuts
Cereal and milk
Cereal bars
Sandwich made with low fat cheese, lean meat and fish
Fruit bread
Biscuits: garibaldi, ginger, fig roll, Jaffa cakes
Timing of Meals and Snacks
Meal: 2-4 hours, Snack: 30-60 minutes
Allow time for the food to be digested before training or competing
This will depend on the size and content of the meal or snack eaten
The meal should be high in carbohydrate, low in fat and low to moderate in protein.
Too much protein or fat will slow down the movement of foods from the stomach, and will make you feel uncomfortable.
Refuelling
An essential part of sports nutrition is refuelling in recovery
Time frames;
As soon as possible, within 20 minutes
Within 2 hours for most effective muscle glycogen (energy stores) restoration
Recovery Snacks (1)
Amount of carbohydrate and protein content will depend on the weight of the athlete and the intensity of the session
Weight in kilos approximately equals minimum carbohydrate replacement requirement g/hr
Plus 10-20g of protein
Recovery Snacks (2)
Protein – 10g serving
50g nuts/seeds
330ml semi skimmed milk
200g yogurt
110g cereal bar
3 slices of bread
Carbohydrate -50g serving
200ml orange juice + 2 slices fruit bread
30g cornflakes (small serving) +200ml semi skimmed milk and a piece of fruit
35g jelly sweets + 150ml orange juice
2 slices of toast and jam + 200ml glass of semi skimmed milk
LEAP Programme
CBT
In-patient programme
Twice weekly one hour sessions
Taught and self directed learning
Homework
Exercisers and non-exercisers
LEAP Outcomes
First intervention designed to treat compulsive exercise in eating disorder patients
No research data
Used worldwide by 52 specialist services
Summary of prevention and intervention
Coaching advice
Sports nutrition advice
Exercise prescription simple and
Cardiac screening of athletes given the cardiac complications of eating disorders
LEAP Programme