Consequences of Under-Eating as Eating Disorder

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Katherine Shone is an Advanced Sports Dietitian who consults at Olympic Park Sports Medicine Centre at AAMI Park. She has over 10 years of experience of working with all types of athletes, especially those who do endurance-based sports, such as triathletes, cyclists, swimmers, marathoners and ultra-marathoners. Her strong interest is in athletes with eating disorders and disordered eating. In this forum, Shone discussed the physical and psychological consequences of under-eating in a developed country.

• What is normal eating?

In the culture and time we live in, it is hard to know what normal eating is as disordered eating is prominent. We have the innate ability to control energy intake, hence we know when and how much to eat. An example of this is when children are permitted to decide when to eat and when to stop, they will only eat as much as they need. Hormones act as mechanisms that send signals to the brain so that we understand when we feel hungry (ghrelin) and adjust the concentration of blood when approaching fullness (leptin). However, disruptors, namely stress, drugs, alcohol, exercise, sleep deprivation and most importantly, dieting rules and beliefs, can interfere with our abilities to respond to these signals. Diet refers to the food usually consumed by a person, whereas a diet is anything that tells people what or how much to eat. Examples of diets include paleo, raw food, ketosis and carbohydrate loading. Sometimes, a diet such as carbohydrate loading may be needed by athletes, but essentially it teaches the body to disconnect. Instead of listening to internal cues, someone may be following external cues for how, what, when and how much to eat.

• Impacts of starvation

The physiological and psychological effects of severe and prolonged dietary starvation were discovered in a famous study done in the 1940s, called the Minnesota Starvation Experiment. The first phase of the experiment involved normalising the participants’ diet (normal amount of calories). The second step consisted of a calorie control diet (1500-1600 calories). Four critical changes in participants were noted:

Physical changes (weight loss, reduction in metabolic rate, slowed pulse, fatigue and pale skin).
Personality changes (increased depression, anxiety, tiredness and apathy; decreased concentration, mental alertness and ability to control emotions).
Food preoccupation (a tendency to take longer to eat, consume more tea/coffee and be more possessive of food, alongside an increased interest in food).
Social behaviour (an inability to see the humorous side of things and social withdrawal as food became the central topic of conversation).

• Impacts of Diets

According to Shone, dieting in the modern world is widely promoted and is offered as the solution to all sorts of problems, from self-esteem to happiness and health. However, dieting often has negative impacts on one’s life. The typical diet cycle starts with restriction, which may involve weight loss as people cut out certain foods or decrease calorie intake for a certain amount of time. Then, they tend to experience deprivation because some foods are cut out of the diet. They will begin to crave and eventually give in, as they start eating the previously restricted foods. The cycle begins again as their guilt leads to starting a new diet to fix the problem. The common symptoms of dieting include being moody, irritable, cold, constantly hungry and thirsty, hair loss, pale skin and constantly obsessing about food.

More importantly, dieting is the highest risk factor for gaining more weight in the long term. This statement was supported by a meta-analysis of US weight loss studies, where 95% of people who diet regain their lost weight, and more than 1 out of 3 people gained extra weight. An explanation of this is that calorie deprivation leads to changes in metabolism and hormones, where the body fights to restore the balance and protect the human against dying of starvation.

Dieting is therefore not the solution to improving health. Instead, people should engage in healthy behaviours/habits, such as exercising and eating more fruits and vegetables. It is crucial to recognize that the role of diet is significant, but it is only a part of many determinants of health.

Shone worked with Sally, a 35-year-old female athlete diagnosed with osteopenia who had not had a period in 7 years. She had dangerously low BMI, body fat and calorie intake compared to what she needed. Hence, she had low energy availability (LEA), meaning she did not have sufficient energy left for metabolism and human requirement (bone metabolism, reproductive function)

• Female Athlete Triad

The Female Athlete Triad was initially developed in the 1990s to explain observations found in female athletes with disordered eating, such as Sally. Later, it was discovered that irregular menstrual cycles, poor bone health and food intake occur along a continuum which an athlete can sit within (refer to Figure 1).

• Relative Energy Deficiency in Sport (RED-S)

In 2014, Triad was expanded to RED-S, a syndrome referring to impaired physiological functions as a result of the significant deficit between the energy required to support sport and health. RED-S model is more helpful than Triad as it can be applied to explain how all athletes can be affected by the physiological impacts of under-eating shown in Figure 2. It also shows the performance consequences which are crucial as this can raise their awareness of under-eating and its negative impacts (refer to Figure 3). Some underlying causes of RED-S involve poor cooking skills, lack of resources, being too busy and forgetful.

• Eating disorders (ED) in sport

Engagement in sport may be protective, but it can put someone at a higher risk of developing an eating disorder as stated by Shone. Almost half of all female athletes and one in five of male athletes meet the criteria for ED or disordered eating, with high risks in aesthetic, endurance running and weight-class athletes. Some factors that induce ED are genetics, personality traits (perfectionism, neuroticism) and environment/culture (media exposure, thin-ideal). Recently, experts have also suggested that brain structure may play a role in the development of eating disorders.

Conclusion

Shone argued that diets, although prominent in the modern world, are not biologically sustainable and can lead to weight regain, and may destroy one’s relationship with food and self. Instead, healthy behaviours are more important to obtain optimal health status. In athletes, under-eating has detrimental effects on their health and performances, thus they need to be healthy humans first to be better athletes. Finally, Shone notified that anybody should reach out for help if they are struggling with eating and food.

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