Female Athlete Triad

You may well be aware that nutrition plays a vital role in athletic performance, but
what you might not know is the relationship of nutrition, or lack thereof, to two very
serious disorders: amenorrhea (lack of menstruation), and osteoporosis. These three
factors together combine to form a disorder known as the Female Athlete Triad. If
you have a daughter who is physically active, or are the coach of young females, it is
extremely important that you are familiar with this disorder, its risk factors and its
symptoms. If not caught early, the health of those who have this disorder can be
seriously jeopardized.

The Female Athlete Triad occurs when there is energy drain on the body, either due to
disordered eating or not eating enough to replace the energy used in training (1). If
not corrected, this negative energy imbalance triggers amenorrhea, which in turn
triggers low bone mineral density and places the athlete at risk for stress fractures and
osteoporosis. Despite its name, not only athletes are at risk of the Triad. Any female
who suffers from disordered eating can potentially be affected by the Triad. As a
parent or coach, it is important that you educate yourself about the Triad and how to
prevent it in your daughter or female athletes.

Dysfunctional Eating

The first component of the Triad is dysfunctional eating, although this may not be the
first observable symptom that something is wrong. Dysfunctional eating can range
from dieting to fasting to full blown anorexia nervosa or bulimia. Dysfunctional eating
can be intentional, as in the case of fasting, anorexia, etc, or it can be unintentional.
For example, a highly active girl might not be intentionally trying to limit her caloric
intake, but through her normal eating and exercise habits she may not be consuming
enough calories to maintain energy balance, putting her in a state of negative energy
balance. Although the unintentional disordered eating needs to be taken seriously, of
most concern is intentional disordered eating.

Disordered eating is thought to result from a wide variety of factors. The American
College of Sports Medicine (ACSM) lists the following as possible factors that contribute
to disordered eating: social pressure to be thin, low self-esteem, family problems,
abuse, repeated dieting, sport-related emphasis on body weight, perfectionism, and
outside pressure to be a certain weight. Sports considered aesthetic sports, such as
dance, figure skating, gymnastics, and diving are thought to contribute to disordered
eating due to the emphasis on a lean physique (1). A Norwegian study found elite
aesthetic sport participants to be at a significantly higher risk for the Triad than
athletes participating in other sports and non-elite athletes (2). Other sport situations
cited by the ACSM that potentially place a female athlete at risk of developing
disordered eating, and subsequently the Triad, include participation in endurance
sports (running, cycling, cross-country skiing) where a low body weight is thought to
help performance, sports that require revealing clothing, sports with weight classes,
and sports where the pre-pubertal body is considered advantageous for success, such
as gymnastics or figure skating (1).

The importance of receiving proper nutrition should not be overlooked for any
reason. The body requires adequate nutrition to sustain natural growth and
maturation. Young athletes are growing and maturing in addition to placing a great
deal of physical stress on their bodies, and this places them in a delicate situation. It is
critical for parents and coaches to monitor eating habits and ensure that all children
are getting adequate nutrition. Should an eating disorder develop, the consequences
can be devastating. Lo, Herbert and McClean (3) list the following potential
consequences of eating disorders:
electrolyte imbalances, mental slowing, and decreased athletic ability . . .
thermoregulatory problems, cardiac abnormalities, nutritional deficiencies, impaired
immune systems, depression, and hypoestrogenism with resultant amenorrhea and
musculoskeletal consequences (p. 2).
If you suspect your child is beginning to develop bad eating habits, intervene right
away. It is essential for you to set a good example for them in your own eating
habits. Don’t talk about dieting around them or make comments about your own
weight, much less theirs. The ACSM recommends avoiding placing pressure on your
daughter to be a certain weight (1).

Amenorrhea

The second component in the Female Athlete Triad is amenorrhea. This funny word
means simply that you are not menstruating. Primary amenorrhea refers to the
condition where a girl has well passed the average age of 12.9 years (3) for the onset
of menarche and has yet to have started menstruating. Secondary amenorrhea is
the condition where a female experiences an absence of menstruation for three or
more consecutive months. Amenorrhea may often be the best sign that an athlete is
on her way toward developing the Triad (1). It should be taken seriously, as it has
been linked with a greater risk for low bone mineral density, occurrence of stress
fractures, scoliosis, and premature osteoporosis (3).

Amenorrhea is thought to occur in athletes primarily as a result of low energy
availability, or energy drain. In athletes it is generally a signal that the athlete has been
over training, but could also be a sign that one is not consuming enough calories. It is
possible that amenorrhea occurs as the body’s way of saving energy (4). When it
does occur, it results in low concentrations of ovarian hormones such as estrogen
(1). Estrogen is needed for the body to absorb calcium and build bone mass. Are
you beginning to see the connection to disordered eating and osteoporosis? The
good news is there is a good chance that if changes are made in the diet and training
program to create a positive energy balance, amenorrhea can be reversed. One
study found that simply adding a day off and increasing the caloric intake of a female
amenorrheic track athlete was enough to see a return of menstruation (5). The
bottom line is amenorrhea is a serious problem, and if it should occur the best thing to
do is to consult your doctor. If you let it go, it could result in stress fractures and
even early onset osteoporosis.

Osteoporosis

The final component in the Female Athlete Triad is osteoporosis. You may be thinking
this is a problem only frail old ladies need to worry about. The reality is that in the
early teen years is when we deposit our bone mass, and between the ages of 25 to 30
is when we are at peak bone mass (3). Calcium and estrogen are two key
components involved in building bones, and eating disorders and amenorrhea interfere
with both of these components. Dysfunctional eating may result in insufficient
consumption of calcium, while at the same time leading to amenorrhea, which results
in low levels of estrogen. Estrogen is needed to absorb the calcium, and when both
are low, bone mineral density will most likely be low as well. And while it is possible to
reverse amenorrhea, it may not be possible to completely reverse the effects brought
on by low estrogen and calcium deposition. Lo et al. (3) reported that “even after
spontaneous resumption of normal menses, these women may never reach normal
bone mass and are at a greater risk for premature osteoporosis” (p. 4). It should also
be pointed out that amenorrhea does not immediately signal low bone mass. If it is
short lived and nutrition was good before it occurred, it is possible that bone loss will
not have yet occurred (1).

Strong bones and a healthy body are vital to a physically active lifestyle. Stress
fractures or other problems caused by the triad can limit the activity that a person can
do and potentially end a sports career. It is important that all girls are aware of how
important it is to take good care of their bodies when they are in early adolescence
and adolescence so that they may help ensure that they can stay active and live as a
healthy, active adult. Parents and coaches need to be there to support their
daughters or female athletes through a stressful and confusing time of their lives and
not exacerbate the problem through well-meaning but misguided comments.

Prohibit yourself from making comments on appearance or weight. If your daughter
brings up the subject, for example saying she’s fat, help guide her toward a different
view of herself. Help her to see all of the good qualities she has to offer and
concentrate on those. Not all of the risk factors for disordered eating, and in turn the
Female Athlete Triad, can be so easily prevented, but working together with your
daughter and being aware of what is going on in her life can help you to identify the
problem before it starts.

Further Sources on the Triad From The Educated Sports Parent

Female Athlete Triad - ppt.

References

(1) American College of Sports Medicine. (1997). The Female Athlete Triad. Medicine
and Science in Sports and Exercise, 29, i-ix. Retrieved March, 2005 from http://www.
xanedu.com.

(2) Sundgot-Borgen, J. (1994). Risk and trigger factors for the development of eating
disorders in female elite athletes. Medicine and Science in Sports and Exercise, 26, 414-
419. Retrieved March, 2005 from http://www.xanedu.com

(3) Lo, B. P., Hebert, C., & McClean, A. (2003). The female athlete triad: No pain, no
gain? Clinical Pediatrics, 42, 573. Retrieved November 28, 2005 from ProQuest
database.

(4) Eldridge, J. (2005). University of Texas of the Permian Basin Training and
Conditioning Methods Course Notes: Module 3. Retrieved January, 2005 from http:
//uttc.blackboard.com.

(5) Dueck, C. A., Matt, K. S., Manroe, M. M., & Skinner, J. S. (1996). Treatment of
athletic amenorrhea with a diet and training program. International Journal of Sport
Nutrition, 6, 24-40. Retrieved March, 2005 from http://www.xandeu.com