Case Studies on Relative Energy Deficiency in Sport

Case #1

Patient Background:
The patient is a 13-year-old female with no significant past medical history. She is a competitive lacrosse player who practices six days a week for two hours each session. On her off day, she runs five miles by herself. She is currently experiencing puberty, which would typically result in weight gain. However, she has instead experienced a five-pound weight loss in the last year. She has only had one period, which was over one year ago. Upon further questioning, the patient reported feeling self-conscious about her body and feeling like she needed to lose weight to improve her performance in lacrosse. She had started to restrict her food intake and had become more fixated on counting calories and avoiding certain foods, such as carbohydrates and fats. She also reported feeling guilty when she ate and would compensate by exercising excessively.
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Physical Examination by Pediatrician:
The patient was found to be slightly underweight with a BMI of 17.2 kg/m2 (normal range is between 18.5-24.9 kg/m2). She had no obvious signs of malnutrition, such as hair loss, dry skin or brittle nails. However, she had lost some muscle mass and her body fat percentage was lower than expected for her age and activity level.
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Diagnostic Workup:
The diagnostic workup included various lab tests to rule out any underlying medical conditions that could cause the patient's weight loss. The complete blood count, comprehensive metabolic panel, and thyroid studies were all normal. However, the magnesium levels were slightly increased, while the phosphorus levels were normal. The erythrocyte sedimentation rate was also normal.
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Diagnosis:
After the diagnostic workup, the patient was diagnosed with disordered eating due to her increasingly restrictive diet and body image concerns. The patient did not yet meet the criteria for an eating disorder, but she was at high risk for developing this in the future which emphasized the need for prompt intervention. The patient's young age and multiple unsuccessful attempts at weight gain by the outpatient pediatrician led to her referral to adolescent medicine for treatment.
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Treatment:
The patient was referred to a team of specialists in adolescent medicine, including a physician, a dietitian, and a therapist. She underwent a comprehensive assessment of her medical and psychological needs and was provided with a personalized treatment plan.
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The treatment plan included:

• Nutritional counseling: The dietitian worked with the patient to develop a meal plan that met her nutritional needs and supported weight gain. The focus was on increasing her calorie and protein intake to help her build muscle mass and improve her athletic performance.
• Cognitive-behavioral therapy: The therapist worked with the patient to address her distorted thinking patterns and negative beliefs about her body. She also learned coping strategies to deal with stress and anxiety without turning to food or exercise.
• Family-based therapy: The patient's family was involved in her treatment to provide support and guidance. They were educated about the disorder and learned ways to help their daughter with meal planning and reducing anxiety around food.

After several months of treatment, the patient was able to restore her weight to a healthy level and improve her physical and emotional health. She was able to return to lacrosse and was offered an athletic scholarship to play in college. She continued to receive follow-up care from her treatment team to ensure her ongoing success in recovery.
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Case #2

Patient Background:
The patient is a 16-year-old male who presented to his outpatient pediatrician with a history of five-pound weight loss and fatigue. He is a cross country runner for his local high school. He mentions that his running times have been increasing by a noticeable amount in the past year. Upon further questioning, it appears that the patient is not consuming adequate calories to meet the demands of his cross-country training. The patient has no disordered eating behaviors and denies attempting to lose weight.
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Diagnostic Workup:
The diagnostic workup included various lab tests to rule out any underlying medical conditions that could cause the patient's weight loss. Complete blood count was normal, but ferritin (measurement of iron storage in the body) was very low. Thyroid studies were normal. Complete metabolic panel was normal.
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Diagnosis:
Based on the patient’s workup, it seems that the patient's weight loss and fatigue were likely due to inadequate nutrition, specifically low iron levels. The fact that the patient is a cross country runner who is not consuming enough calories to meet the demands of his training suggests that he may need more guidance in terms of his diet and nutrient intake.
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Treatment:
In addition to iron supplementation, the patient was referred to a registered dietitian who worked with him to create a balanced meal plan that met his increased caloric needs for cross country training. The dietitian emphasized the importance of including iron-rich foods such as red meats, lentils, tofu, and spinach in his diet. The patient was also encouraged to consume foods high in vitamin C, such as citrus fruits and bell peppers, to aid in the absorption of iron.
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After implementing these dietary changes and receiving iron supplementation, the patient's fatigue resolved and his running times improved. He continued to follow a balanced diet and was able to maintain a healthy weight while meeting the demands of his cross-country training. The patient and his family were counseled on the importance of monitoring nutrient intake and seeking medical attention if any further symptoms or concerns arose.
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Case #3

Patient Background:
Patient is a 16 year old female with no significant past medical history. She presented to her outpatient pediatriciain for her annual well child visit with a 15 pound weight loss in one year. She has not had her period in multiple months. She has reported frequent dizziness recently. She plays soccer for her local high school and her competitive club team. She has had severe challenges with endurance on the field lately. Upon further questioning, the patient revealed that she had been restricting her diet due to body image concerns and fear of gaining weight. The pediatrician noted that the patient appeared thin and had a low body mass index (BMI) for her age and height.
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Physical Exam:
During the physical exam, the patient's heart rate was noted to be slow and her blood pressure decreased when she stood up from a sitting position. These findings suggested that the patient may be experiencing orthostatic hypotension, which can be a result of dehydration and inadequate calorie intake.

Diagnostic Workup:
The diagnostic workup included various lab tests to rule out any underlying medical conditions that could cause the patient's weight loss. The complete blood count was normal. Thyroid studies were normal. The complete metabolic panel was normal, including magnesium and phosphorus levels. The vitamin D level was also normal. Hormone levels, including testosterone, estradiol, follicle-stimulating hormone, and luteinizing hormone, were within normal ranges. An electrocardiogram (EKG) showed sinus bradycardia, which is a slow heart rate, but no other abnormalities such as arrhythmias were detected.
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Diagnosis:
After ruling out other medical causes for her weight loss, the patient was diagnosed with anorexia nervosa, a type of eating disorder characterized by an intense fear of gaining weight, a distorted body image, and restrictive eating behaviors.
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Treatment:
She was referred to a specialized eating disorder treatment team including a registered dietitian, therapist, and psychiatrist. She was admitted to a partial hospitalization program for intensive treatment. The patient's treatment plan included individual therapy, family therapy, and group therapy, in addition to nutritional counseling and medical monitoring. The patient's weight and vital signs were monitored regularly, and she was given a meal plan that gradually increased her calorie intake to a healthy level. The patient worked with her treatment team to challenge her negative thoughts and beliefs about food, weight, and body image. As she progressed in treatment and began to achieve weight restoration and behavioral improvements, she transitioned to an outpatient treatment program. The patient continued to receive ongoing medical monitoring, therapy, and nutritional counseling, as well as support from her family and treatment team. With consistent and comprehensive treatment, the patient was able to successfully recover from anorexia nervosa and maintain a healthy weight and lifestyle. As a result, she regained the weight she had lost and her menstrual cycle returned. She also reported an improvement in her energy levels and was able to perform well on the soccer field without experiencing endurance challenges or dizziness.
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