There is a lot of talk of menstrual cycles in female athletes. Why? Menstruation is an easy marker to follow for possible signs of insufficient energy intake. A female athlete with low energy availability may develop irregular or absent menstrual cycles. While there is no direct equivalent marker in male athletes, insufficient fueling can impact hormone levels in male athletes, in particular testosterone.
Energy deficiency in male athletes has been much less discussed both in the scientific literature and in the athletic world in general. Since the term “female athlete triad” was coined in the 1990s, much of the focus has centered on the health consequences of insufficient energy intake in female athletes, namely as it relates to menstrual dysfunction and bone health. (1) Recognizing that male athletes can suffer health and performance consequences due to low energy availability, the International Olympic Committee (IOC) published a consensus statement in 2014 to broaden the term “female athlete triad” to “relative energy deficiency in sport” (RED-S).
Myth 4: Bradycardia, or slow heart rate, is always a sign of good fitness in a female athlete.
Truth: The medical definition of bradycardia is a heart rate less than 60 beats per minute. While an athlete’s heart rate may slow some as they gain fitness, a very low heart rate at rest (especially under 50) may be a clue that there is more to the story. Excluding other serious causes of bradycardia, there are two scenarios that are the most common to explain a slow heart rate in an athlete– an athlete’s heart vs a starving heart.
Myth 3: The only medical problems that can be found in athletes with low energy intake are amenorrhea and bone density loss.
Truth: In the 1990s the ACSM coined the term female athlete triad. (4) This term describes the relationship between low energy intake in athletes, loss of menstrual cycle, and low bone density. The scope of the problem of low energy intake as it relates to the female body is actually broader than amenorrhea and low bone density…
Myth 2: Oral contraceptive pills (OCPs) can be used to maintain bone health in athletes with amenorrhea and should be used to “jump start” periods.
Truth: It seems logical that if the low estrogen found in those with amenorrhea is part of the reason why bone density decreases then if we give an athlete hormone pills with estrogen then the bones would be protected. Unfortunately…
Myth 1: Amenorrhea in a female athlete is an expected consequence of sport participation and is nothing to be concerned about.
Gastroparesis is felt to be nearly universal in those who have restricted calories resulting in significant weight loss (generally 10-20% of body weight). (1) It is worth emphasizing that gastroparesis can occur in those of all body shapes and sizes and one does not need to be clinically underweight to develop gastroparesis. (2) The most common symptoms are early satiety (meaning feeling very full even after just a small amount of food) and bloating. For those with an eating disorder, specifically those who have body image concerns that focus on the appearance of their abdomen, a distended and bloated stomach can certainly challenge even the most recovery motivated person.
It was OCD Awareness Week last week. It was timely that the Sunday, October 7th evening broadcast of “60 Minutes” featured an interview with John Green, author of The Fault in Our Stars. Before the interview, I only knew that he was a good writer, and that he has a great sense of humor. What I didn’t know, before this interview, was that he suffers from OCD as does approximately two percent of the population. Often, when we think of OCD, we imagine an individual who is incessantly washing hands due to contamination fears or flipping a light switch eight times to ward off a disaster of some type. However, there are many ways OCD can show up and affect a person’s life.
Now let’s focus on some of those myths.
Myth 1: It is normal for an athlete to stop menstruating during periods of heavy training.
It is NEVER normal for an athlete to stop menstruating. Yes, you read that right. Amenorrhea should never be considered an acceptable consequence of any level of athletic or fitness training. Amenorrhea is a red flag that the body is not functioning to its full potential. Amenorrhea again can be due to exercising too much for your body, under-fueling, high stress, or a combination of these factors.
Myth 2: Amenorrhea in athletes is unique to only endurance or high-level athletes.
Amenorrhea can be seen in females from any sport and at any level from recreational to elite. Even those without sport specific goals and that exercise for health/fitness/enjoyment can develop amenorrhea. It is likely true that higher intensity and frequency of exercise might make someone more prone to FHA than those who exercise at a lower intensity, frequency.
Iron deficiency is common in athletes. Nearly half of females who exercise may experience iron deficiency.1 While females are at higher risk for iron deficiency due to monthly loss of blood with menstruation, male athletes can also suffer from it. The International Olympic Committee 2009 Consensus Statement on periodic health evaluation of elite athletes even recommended routine screening for iron deficiency.2 Please note, unless otherwise specified, the term iron deficiency in this article solely refers to low iron and not resultant anemia, or low red blood cells. This article is also focused on adult athletes and the information discussed may not apply to children.
Stress…we all have it. There is beneficial stress (eustress), which often brings positive results, and then there is distress, which can take its toll. A few examples of good stress are: exercise, enjoying a scary movie, riding a rollercoaster (if you like it), buying a new home, etc. Some examples of distress are: loss, financial trouble, negative work environment, partner problems, etc. Eustress generally produces a good feeling while distress produces an unpleasant feeling. And then there are combinations such as the eustress experienced by buying the new home and the distress experienced by the associated expenses and move.
Many of you may be familiar with the term Female Athlete Triad. This term was first coined in the 1990s by a task force of the American College of Sports Medicine (ACSM) in order to describe three interrelated conditions that lead to negative health outcomes in female athletes1. The three prongs of the Female Athlete Triad…
Eating healthy is valued and increasingly emphasized by many groups in our culture. For example, athletes attempt to enhance performance with diet, or individuals receiving a concerning health-related diagnosis may receive recommendations or might be advised to make dietary changes to improve health outcomes. Making important dietary changes can be beneficial or even lifesaving for many individuals and alone do not create a disorder. However, when the changes become obsessive and fixated the potential for developing disordered eating and potential medical compromise increases. Often, in these cases, significant weight loss and/or nutritional deficiency first comes to the attention of a medical professional.
Here is a list of six aspects of outpatient medical care that you can advocate for in the primary care office, if you have an eating disorder. There are many medical problems that can emerge from eating disorders—some measurable, some not so much. Despite this fact, most medical practitioners get almost no training about eating disorders, size stigma, or other important social justice themes having to do with bodies. I didn’t!
I’m an internal medicine physician who cares for patients with eating disorders and disordered eating, of all shapes and sizes, all genders, and all ages, in my outpatient clinic. I’m struck by how common it is for my patients to confide in me that they don’t feel they are “sick enough” to warrant their friends’ and family’s worry, their need to have a multi-disciplinary team, or to change their behaviors. That feeling of not being “sick enough” is part of the mental illness. People with the most remarkable insight about just about everything else can utterly lack (or distort) insight into the medical and psychological issues that arise from their eating disorder.
One of the key elements of recovery from an eating disorder is nutritional rehabilitation. That means consuming enough calories at regular intervals to accommodate the needs of the body and allow it to heal. People of all genders, ages, shapes, and sizes can have eating disorders and disordered eating; you can’t tell whether someone is healthy or sick just from looking at them. In this article, we will discuss the role of supplemental feeding in the treatment of eating disorders, from oral nutritional supplements like Ensure or Boost, to the use of various types of feeding tubes.
I entered this field and worked for eight years in a medical hospital setting, caring for highly medically compromised adults with anorexia nervosa. In retrospect, practically every interaction I had with patients took place in a totally controlled environment. They were patients who, for their clinical teams at home and loved ones, were in fearsome danger of death. Their vital signs, laboratory values, nutritional intake, and bodies were all as unsafe as could be imagined. And yet, once they were admitted to the program I had helped run on a daily basis for so long, I knew they would be okay. Enveloped by expert professionals, introduced to carefully designed clinical care pathways, guaranteed to be monitored and nourished, my hospital patients were safe. Can’t get out of bed on her own due to weakness? There’s a nurse’s aide by her side all night long so she doesn’t fall. Overcome by anxiety? Their psychologist who sees them daily will be here this afternoon.
On numerous occasions over the 14 years that I have helped my clients with their psychological challenges, I have had many arrive at intake confused by what has been suggested as the problem area by well-meaning family, friends and other professionals. This has been especially true when symptoms overlap in multiple problem areas, looking like one thing and being quite another.
In my last blog post, we started to consider how one’s brain responds to starvation, aka caloric restriction. In case you didn’t catch that one, I consider our cave person brain to be the part of our brain that keeps our body running on a day-to-day basis, operating separately from our thinking brain. And as a Cliff’s Notes version to that blog, by way of introducing today’s topic, is when your cave person brain doesn’t get adequate nutrition, it shifts into calorie conservation mode, reducing your metabolic rate (the calories needed neither to lose nor gain weight). These blogs on the cave person brain go into further details about how exactly your body achieves its goal of slowing metabolism. Remember: humans only exist today because our ancestors developed multiple mechanisms to survive famine. When food resources were scarce, humans became extraordinarily efficient at surviving and functioning. I’m always struck by the magnificence of our bodies’ innate functioning…vastly more responsive to our environments and scientifically and beautifully set up to keep us going than our own coarse attempts to over-control food and exercise.
There are so many medical complications that can occur in eating disorders and in the caloric restriction that can come with disordered eating. Let’s simplify our understanding and take a 30,000-foot view. To illustrate this concept, I’m going to use the concept of the “cave person brain.” From a not-very-neuroanatomical perspective, the “cave person brain” is the part of your brain that manages all the aspects of your body that you’re not consciously aware of. I call it the “cave person brain,” because it has kept us alive as a species through millennia of evolution. This first of two posts will review how the cave person brain affects certain vital signs.