including ergogenic agents. While it is beyond the scope of this chapter to describe the details of dietary ma- nipulation, meal plans generally progress from specific (referring to dosing of food as medicine based on amount and timing) to more general, with the end goal of establishing an adequate nutrient intake and bal- ance among food groups and variety of foods. Te type of eating plan depends on the type and severity of the disorder as well as the individual patient needs. Most patients express a desire to return to normal eat- ing, characterized by mindfulness and intuition. Retraining the patient to eat in response to internal cues, utilizing mindfulness or an approach termed intuitive eating, would generally follow weight restoration and requires that the patient be at a place where she or he can integrate interoceptive awareness (ability to per- ceive physical, bodily sensations) with emotional regulation and respond to her or his own needs in a timely manner. One principle of intuitive eating is unconditional permission to eat. Keeping in mind food ad- diction theory, implementation of all the principles of mindful or intuitive eating may need to be delayed or may never be effective or appropriate.104


As previously described, the RDN may apply an assortment of


psychological therapy techniques as part of MNT. We find that athletes generally understand, at least cog- nitively, the need for carbohydrate-rich foods as fuel for the brain, power for muscles, and a vehicle for fiber and phytochemicals. Tey also relate to the necessity of adequate protein as a bridge supporting satiety sig- nals, as well as a connector for building muscle and producing neurotransmitters.91


may apply to any of the macronutrients, fear of body fat oſten translates into fear of food fat. Athletes are not immune to nutrition myths, and they are aware that weight loss may result in an initial


performance improvement. What they have a difficult time understanding is the transience of this bene- fit. Te first impression is lasting, and even aſter continued efforts to lose weight through dietary restriction that result in nutritional deficits, fatigue, loss of strength, impaired immunity, and illness, the initial success may propel the athlete and, through contagion, teammates or others watching to move along the same path toward developing a clinical ED, including purging by vomiting, use of diuretics or laxatives, or excessive ex- ercise.6


Te devastation of a poor performance due to injury or illness pales in comparison to the potential


for a life-threatening cardiac event due to hypoglycemia, dehydration, or electrolyte imbalance. RDNs are uniquely qualified to educate athletes and coaches on the critical role of nutrition to health and performance. When a semistarved person is identified (eg, an athlete identified with LEA), a thorough nutritional


and medical assessment, with ongoing monitoring, is warranted. Rapid restoration of nutrition, especially among adults, can be life threatening when it results in a rapid shiſt of phosphorus from the serum into the cells. Low serum phosphorus can cause muscle breakdown (eg, rhabdomyolysis), blood cell dysfunction, respiratory failure, seizure, and cardiac arrest.53 Te term refeeding may refer to either (1) the process of restoring nutrition or (2) the potentially


life-threatening condition that results from improved energy intake (especially from carbohydrate), known as refeeding syndrome. It is important to know that theoretically any patient could experience refeeding syndrome in the process of increasing nutritional intake. While no single indicator exists to precisely iden- tify who will develop refeeding syndrome, the National Institute for Health and Care Excellence guideline 32 provides criteria for identifying those at higher risk (Table 18.3).105 Traditionally, the strategy toward restoring nutrition has been to “start low, go slow” in terms of ca-


loric intake. However, recent research suggests that refeeding risk varies depending on the degree of malnutrition, the age of the patient or client, and the ratio of carbohydrate to fat and protein.54


Initially,


carbohydrate intake may be less than 50% of calories in an attempt to reduce risk of refeeding syndrome. Tis lower percentage of carbohydrate goes against conventional wisdom of sports nutrition and is met with resistance among some athletes and sometimes their family members and coaching or training staff. Te restoration of energy intake is incrementally increased, by 100 to 200 kcal daily or by up to 400 kcal every 3 days with close medical supervision. Caloric needs for a person who is severely energy restrict- ed defy typical calculations and may be upward of 3,000 to 4,000 kcals/d, even at low physical activity and concurrent with indicators of downregulation of metabolism. Research suggests that the thermic effect of food may be elevated from between 14% and 30% among those with AN by psychological state (eg, anx- iety and depression related to eating) and hormonal response to stress.106,107


More research is needed to 410 SECTION 3: PRINCIPLES IN PRACTICE


While the fears of eating


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