The road to health for undernourished athletes.

This article is the second of two parts.

though the far more widespread crisis of overweight among American children continues to deserve the lion's share of our attention, body-image issues and unrealistic or obsessive performance goals can contribute to a different set of problems in many athletic programs. As student athletes, parents, teachers and physicians, it behooves us to explore these issues.

Nutrition and women

In the Female Athlete Triad (see Mar/Apr 2004, page one), a deficit of calories causes deteriorating performance, an inability to menstruate (amenorrhea) and a heightened risk of stress fracture. A recent review in The Canadian Journal of Applied Physiology looked at the existing theory and evidence surrounding energy expenditure and reproductive function, as well as treatment strategies for these athletes.

The review found that regular menstrual cycles are determined to a large extent by adequate energy availability, and that by far the most dramatic consequence of menstrual irregularity is its impact on bone health. When young women suffer bone density loss in adolescence, they are candidates for not only stress fracture but for the early onset of osteoporosis. Furthermore, once menstruation resumes for these patients, bone density does not entirely normalize with that of their age-matched peers. Most alarmingly, despite the known, permanent impact of amenorrhea on bone health, this condition alone seldom causes these young athletes to correct their nutritional deficit.

What advice can we offer clinicians and athletes? Studies show that athletes can increase caloric intake without significantly altering their training regimens and restore proper menstrual function in a matter of a few months. At least one study published that, at the end of a 15-week treatment involving an increase of 360 kcal/day and a reduction to six from seven days training per week, the athlete gained about five pounds and achieved "several personal best performances." In this case the athlete even remained on the treatment program after the study concluded. How do athletes and their parents, physicians and trainers overcome the psychological hurdles that can impede nutritional reform?

Behavior contracting for athletes

To determine how to best support an athlete's climb back to health, we should examine five basic principles of behavior contracting. When the contract is grounded in something specific and quantifiable like weight gain, it can keep athletes participating while holding them accountable for meeting energy requirements.

* Allow sufficient time to develop a therapeutic relationship. It's imperative first of all that the athlete perceives a need to change eating behavior. Forcing someone to agree to reforms in writing will do nothing if they don't see the genuine need for reform in the first place. This takes time.

* Involve the athlete in contract development. There is the risk of alienating by playing on an already-likely impression of being out of control. Listening to the athlete's input every step of the way establishes cooperation and trust. The contract must be issued jointly.

* Where expectations are concerned, get specific. Give incremental behavioral goals: e.g., "Add one tablespoon of peanut butter to lunch each day."

* Monitoring progress is a must. This promotes discussion and accountability. Set aside time to follow up, and stick to it. Be aware that athletes know creative ways to add weight, such as wearing extra clothing or consuming water just prior to weighing in.

* Carry out consequences. If weight goals are not met, participation must be restricted, unequivocally. Without firm limits and clearly defined outcomes, the contract is useless. Parents, coaches and doctors must present a unified front.

Body image and men

Are the media and other aspects of American culture to blame for adolescents' and young adults' newfound bodily dissatisfaction? This argument does not hold up against the numbers: American males are fatter than ever and doing little about it. (See Part One of this article in Mar/Apr 2004.) Yet it's worth noting that if the latest G.I. Joe doll were life-sized, he would have a 48-inch chest, a 32-inch waist and 32-inch biceps.

An obsessive dissatisfaction with one's body represents a concern in a portion of the young adult male demographic. Called muscle dysmorphia, it constitutes a falsely perceived underdevelopment of muscle mass and tone, and tends to manifest in athletes.

These men and adolescent boys compulsively weight train, monitoring minute changes in their body composition on the scale and in the mirror. Steroid use is common among them. According to the CDC's 2001 Youth Risk Behavior Survey, 6% of American male high school students have used illegal steroids. Muscle dysmorphia is a subset of body dysmorphia, the category of eating disorders once almost exclusively affecting women, including anorexia and bulimia.

Recognizing a problem

Doctors and trainers point out that males don't take body-image disorders seriously. There is a cone of silence around physical abnormality, no matter its cause or course. To help spot muscle dysmorphia, parents, coaches and teachers should listen to a student's frequent references to how fat or out of shape he is, despite obvious external appearance. Look for patterns of compulsive exercise, regardless of injury or seasonal heat--as well as a refusal to partake in physically revealing activities like swimming. Is there an unusual relationship with mirrors, either seeking out or avoiding? Perhaps a teen excessively reads about a single body part.

Try to encourage young athletes to view food as fuel; remind them that "fat" is not a feeling. Better terms to discuss feelings might be "inadequate" or "imperfect." And finally, reiterate that too much weight loss means stamina, strength and concentration loss--not infinitely faster race times or better performance. If someone you know may have an eating disorder, talk to a health professional or visit the Academy of Eating Disorders at www.aedweb.org or the National Eating Disorders Screening Program at www.mentalhealthscreening.org/eat/eat-fact.htm for more information.

(Can. J. Appl. Phys., 2004, Vol. 29, No. 1, pp. 48-58; Phys. & Sportsmed., 2003, Vol. 31, No. 9, pp. 15-18, 26; ACE FitnessMatters, 2003, Vol. 9, No. 5, pp. 7-9; CDC 2001 Youth Risk Behavior Survey, www.cdc.gov/mmwr/PDF/SS/SS5104.pdf)