Female Athlete Triad

By: Vance "Action" Jackson

With dreams of Olympic trials and college scholarships in her mind, Hannah joined the track team her freshman year and trained hard to become a lean, strong sprinter. When her coach told her losing a few pounds would improve her performance, she didn't hesitate to start counting calories and increasing the duration of her workouts. She was too busy with practices and meets to notice that her period had stopped - she was more worried about the stress fracture in her ankle slowing her down.

Although Hannah thinks her intense training and disciplined diet are helping her performance, they may actually be hurting her - and her health

There's no doubt about it - playing sports and exercise are part of a balanced, healthy lifestyle. Girls who play sports are healthier; get better grades; are less likely to experience depression; and use alcohol, cigarettes, and drugs less frequently. But for some girls, not balancing the needs of their bodies and their sports can have major consequences.

More girls and women participate in sport than ever before. The opportunities created by Title IX have increased female participation at the scholastic and collegiate level. The successes of American women at the 1996 Atlanta Olympic Games and the 1999 Women's World Cup of Soccer were covered more extensively by major media outlets than any other women's sporting events in history. Women's professional leagues now operate successfully in the sports marketplace and draw significant numbers of fans and network television coverage.

The majority of women in sport certainly derive significant health and social benefits from running, jumping, throwing, and swimming -being on the team. Yet everyday, thousands of women may be at risk of significant harm from their participation in sport. Girls and women who may consider themselves at the peak of health may, in fact, be in danger of severe injury, illness, or even death. The cause of this risk: the Female Athlete Triad.

Definitions and Prevalence

The female athlete triad is a combination of three interrelated conditions that are associated with athletic training: disordered eating, amenorrhea and osteoporosis. FAT(s) with disordered eating may engage in a wide range of harmful behaviors, from food restriction to bingeing and purging, to lose weight or maintain a thin physique. Many athletes do not meet the strict criteria for anorexia nervosa or bulimia nervosa, but will manifest similar disordered eating behaviors as part of the triad syndrome

Anorexia nervosa

A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85 percent of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85 percent of that expected).

B. Intense fear of gaining weight or becoming fat, even though underweight.

C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

Specify type:
Restricting type: during the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics or enemas)
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Binge-eating/purging type: during the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics or enemas)

Bulimia nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is characterized

by both of the following:

1) Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances

2) A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas or other medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Specify type:
Purging type: during the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas Nonpurging type: during the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas

Eating disorder not otherwise specified

The eating disorder not otherwise specified category is for disorders of eating that do not meet the criteria for any specific eating disorder

Amenorrhea that is related to athletic training and weight fluctuation is caused by changes in the hypothalamus. These changes result in decreased levels of estrogen. Amenorrhea in the female athlete triad may be classified as primary or secondary. In patients with primary amenorrhea, there is no spontaneous uterine bleeding in the following situations: (1) by the age of 14 years without the development of secondary sexual characteristics, or (2) by the age of 16 years with otherwise normal development. Secondary amenorrhea is defined as the six-month absence of menstrual bleeding in a woman with primary regular menses or a 12-month absence with previous oligomenorrhea.

Osteoporosis

Low estrogen levels and poor nutrition can also lead to osteoporosis, the third aspect of the triad. Osteoporosis is a weakening of the bones due to the loss of bone density and improper bone formation. This condition can ruin a female athlete's career because it may lead to stress fractures and other injuries due to weakened bones. Because of poor nutrition, a girl's body may not be able to repair the injuries efficiently.

Usually, the teen years are a time when girls should be building up their bone mass to their highest levels - called peak bone mass. Female athlete triad can lead to a lower level of peak bone mass and a lot of time on the sidelines. After she becomes an adult, a girl may also develop health problems related to osteoporosis at an earlier age than she would have otherwise

Functional Anatomy 

Stress fractures and lower-extremity, pelvic, and vertebral fractures are most typical in the osteoporotic bone observed in those with the female athlete triad. These fractures are most likely due the increased stress sustained by these bones in the course of physical activity. In this respect, athletes with the triad are not unlike their healthy counterparts. However, those who have the triad or portions of it are more susceptible to multiple fractures, and they are more likely to sustain fractures in larger, less commonly affected bones (eg, femoral neck, pelvis, vertebra).

Sport Specific Biomechanics 

No particular sport is known for having a larger portion of its participants with the triad, but some generalizations can be made. Sports in which body type or weight seem important puts women at risk for the triad. Gymnastics, track and field, dance, and cheerleading have a higher percentage of women with the female athlete triad, as opposed to softball or weight lifting. Whether these sports cause the athletes to develop triad-related behavior or whether women with predispositions toward the female athlete triad are drawn to those sports as a way to hide their behavior is not known. Female swimmers with the female athlete triad may be at even greater risk for osteoporosis. These athletes lack the bone-preserving effect of weight-bearing exercise that may attenuate bone loss due to hormonal causes.

Although the exact prevalence of the female athlete triad is unknown, studies have reported disordered eating behavior in 15 to 62 percent of female college athletes. Amenorrhea occurs in 3.4 to 66 percent of female athletes, compared with only 2 to 5 percent of women in the general population. Some components of the female athlete triad are often undetected because of the secretive nature of disordered eating behavior and the commonly held belief that amenorrhea is a normal consequence of training.

Management Personal Viewpoint

Communicating with and educating athletes, coaches, parents, medical staff, judges and officials, and administrators about the Triad are the most important aspects of prevention. Coaches must take the lead in ensuring that everyone involved in a sports program is aware of the risks and signs associated with the Triad; educational programs, team meetings, and informational materials ought to be built into every seasonal plan.

Educational programs should include⁴:

• Giving athletes the message that sports participation is about having fun and being physically and mentally healthy
• The message that "winning at all costs" is not a program philosophy
• Nutrition education
• Emphasizing strength and fitness over thinness and body weight
• Information about normal maturation and development processes
• Encouraging athletes to discuss eating, maturation and menstruation, and personal issues with a confidential contact person

It is never too soon to start educating athletes and parents about the Triad.

Because disordered eating is a disease related to issues surrounding control and body image, coaches should foster independence in athletes from an early age. Teaching young athletes to assume responsibility for their training, nutrition, performance, and other issues helps them develop a sense of intrinsic control over various aspects of their sport and lives. This sense of control can make sport more fun because independent athletes must examine their reasons for participating; athletes who participate because "I want to are at less risk than athletes who do so because "coach or mom/dad says so".

Coaches must examine their own beliefs regarding weight and body size, and how these characteristics affect performance. Weight gain and body changes are a normal process in

Growing children and adolescents. Coaches should never conduct public or team wiegh0ins or single out athletes for weigh-ins. There is a lack of research to support a relationship between being thin and improved performance. In fact, weight loss can lead to dehydration, fatigue, poor concentration, and injury.Evaluating skills and fitness is far superior to weight and body fat measurements in determining performance outcomes. Weight management issue should be discussed with a health care professional.Every athlete should have a pre-participation medical screening and be encouraged to develop an on-going relationship with a health care provider they trust.

Personal Viewpoint

The following remark is how I will approach the following subject with concerns about the female athlete triad. There is always a good chance as a personal fitness trainer that I will work with a female athlete, also since I want to eventually get into the education field. Education has to be the key. At all levels, but especially when young women are starting to get serious about a possible sporting or dance career, sports professionals have a great responsibility to ensure these young people’s goals are compatible with their basic body type. To continue to push athletes to strive for the genetically impossible will set them up for long-term injury. It is also crucial to promote a healthy, nutritionally complete diet, supplemented if necessary to take account of the specific demands of the sport.

The female athlete triad needs to be caught and confronted early; management will probably require the collaboration of a multi-disciplinary team of nutritionists, doctors, psychologists and physiotherapists.

Simple steps can be:

• Reduce training activity by 10- 20%, but couple this with an increase in resistance training. This is important for two reasons: psychologically the athlete still feels that they are progressing in their hard-fought fitness and development; and the resistance training may also help to stimulate the bone metabolism.
• Assess dietary patterns and start a gradual increase in calorific intake.
• Agree an increase in body weight over a set time period.
• Introduce multivitamins and minerals into the diet, especially calcium.
• Educate the athlete and her family.
• Assess the pressures being placed on the athlete to succeed and remove some of those pressures, eg sponsors.

It is important to remember that the female triad has complex triggers: it is not just the athlete’s problem alone. To overcome this condition, you will need to examine and advise changes to the lifestyle both of the athlete and also her family and friends. The sports professionals dealing with the athlete, including the coach, must reassess their training methods and style to ensure that you are not unwittingly encouraging, or at least offering an excuse for the athlete to stick to her unhealthy pattern of behaviour.

The female athlete triad does have long-term consequences for the health of women. Failure to develop strong well-mineralised bones at an early age can lead to osteoporotic fractures, which will not just cause a premature end to their athletic careers but will also have implications for their future lifestyle, fertility and health into old age.