In 1971, there were fewer than 300,000 girls participating in high school athletics, compared to 3.7 million boys. Title IX was passed in 1972, mandating nondiscrimination in all extracurricular activities and varsity athletics that received federal funding. In 2000, there were 2.7 million girls involved in high school sports compared to 3.8 million boys (30).
Menarche occurs approximately 1 year after peak height velocity, which ranges from 10.5-13.0 years for girls, compared to 12.5-15.0 years for boys (28).
Adult height is reached by age 17-19 years for girls and by age 20-22 for boys.
Skeletal maturity is completed by age 18-19 for girls and age 21-22 for boys.
[V with dot above]O2max averages around 50 mL · kg · min−1 in prepubescent children and changes little in boys throughout puberty, but decreases in girls with puberty secondary to a change in body composition and a decreased percentage of lean body mass.
After puberty, metabolically active muscle averages 40%-45% of total body weight in boys, but only 35%-38% in girls (16).
Girls develop smaller heart size, cardiac stroke volume, left ventricular mass, lung volume, aerobic capacity, and hemoglobin levels (13,21).
Women on average are shorter, weigh less, and have shorter limbs and smaller articular surfaces, narrower shoulders and smaller thoraces, and a wider pelvis in relation to their waist and shoulders than men. Women have less muscle mass per total body weight than equally trained and conditioned men. The average young adult female has approximately 20%-27% body fat, while the average young adult male has 12%-18% body fat (12,28).
The female athlete triad has three components: (a) low energy availability (with or without an eating disorder), (b) menstrual dysfunction, and (c) decreased bone mineral density (BMD) (23).
Eating disorders are characterized by disturbances in eating behavior, body image, emotions, and relationships. Tables 115.1, 115.2 and 115.3 exhibit diagnostic criteria of eating disorders.
Anorexia nervosa is an extreme version of restrictive eating behavior in which an individual continues to starve and feel fat, even though she (female athlete) is 15% or more below her ideal body weight.
Bulimia nervosa has cycles of recurrent binge eating with a feeling of loss of control followed by inappropriate compensatory behavior.
Eating disorder not otherwise specified (ED-NOS) is also included in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) and includes patients who have eating disorders but do not meet the exact diagnostic criteria of anorexia nervosa or bulimia nervosa.
Disordered eating includes the entire spectrum of abnormal eating behaviors that may not fit any of the DSM-IV criteria for eating disorders.
Disordered eating can have devastating effects on psychological well-being, skeletal health, and other physiologic problems such as dehydration, electrolyte disturbances, thermoregulatory and cardiac disturbances, loss of muscle mass, and decreased performance in addition to other medical complications.
Disordered eating can lead to an energy deficit that contributes to menstrual irregularity and an increased risk of stress fractures and decreased BMD.
Sports or activities that emphasize a lean physique or low body weight, such as gymnastics, swimming, or track and field, have a greater number of athletes who develop the female athlete triad.
Risk factors for disordered eating and the female athlete triad include the following:
Chronic dieting
Low self-esteem
Table 115.1 Diagnostic Criteria for Anorexia Nervosa
A.
Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight < 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight < 85% of that expected).
B.
Intense fear of gaining weight or becoming fat, even though underweight.
C.
Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
D.
In postmenarchal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)
Restricting Type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).
Binge-Eating/Purging Type: During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)
SOURCE: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Arlington (VA): American Psychiatric Association; 2000.
Table 115.2 Diagnostic Criteria for Bulimia Nervosa
A.
Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
a.
Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
b.
A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
B.
Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting; misuse of laxative, diuretics, enemas, or other medications; fasting; or excessive exercise.
C.
The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.
D.
Self-evaluation is unduly influenced by body shape and weight.
E.
The disturbance does not occur exclusively during episodes of anorexia nervosa.
Purging Type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
Nonpurging Type: During the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
SOURCE: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Arlington (VA): American Psychiatric Association; 2000.
Table 115.3 Eating Disorder Not Otherwise Specified
The eating disorder not otherwise specified category is for disorders of eating that do not meet the criteria for any specific eating disorder. Examples include the following:
1.
For females, all the criteria for anorexia nervosa are met except that the individual has regular menses.
2.
All the criteria for anorexia nervosa are met except that, despite significant weight loss, the individual’s current weight is in the normal range.
3.
All the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than 3 months.
4.
The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies).
5.
Repeatedly chewing and spitting out, but not swallowing, large amounts of food.
6.
Binge-eating disorder: Recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of bulimia nervosa.
SOURCE: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Arlington (VA): American Psychiatric Association; 2000.
Family dysfunction
Physical abuse
Biologic factors
Perfectionism
Lack of nutrition knowledge
An emphasis on body weight for performance or appearance
Pressure to lose weight from parents, coaches, judges, and peers
A drive to win at any cost
Self-identity as an athlete only (no identity outside of sports)
A sudden increase in training
Exercising through injury
Overtraining (especially when undernourished)
A traumatic event such as an injury or loss of a coach
Vulnerable times such as an adolescent growth spurt, entering college, retiring from athletics, and postpartum depression
Any athlete with one of the diagnostic criteria of the female athlete triad should be evaluated for the other two by a thorough history and a physical examination.
Laboratory tests that may be helpful include the following:
□ Complete blood count
□ Electrolytes, calcium, magnesium, phosphorus, blood urea nitrogen, creatinine, cholesterol, albumin, and total protein
□ Urinalysis
□ Pregnancy test
□ Follicle-stimulating hormone
□ Estradiol
□ Prolactin
□ Thyroid function tests
□ Erythrocyte sedimentation rate
An electrocardiogram may also be indicated because some patients may develop cardiac rhythm disturbances, including prolongation of the QTc.
Treatment for disordered eating requires a multidisciplinary team, including a physician or other health care provider, mental health counselor, and a nutritionist.
Treatment includes the following:
□ Recognition of the problem
□ Identification and resolution of psychosocial precipitants
□ Stabilization of medical and nutritional condition
□ Reestablishment of healthy patterns of eating
Indications for inpatient treatment for a patient with an eating disorder include the following:
Very low body weight (< 75% of expected body weight)
> 15% loss of initial body weight
Rapid (> 10% in 1-2 months) weight loss
Cardiac arrhythmiasRelated posts:
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