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The Female Athlete Triad

In the new millennium, sports participation by girls and women is growing quickly. New opportunities in both amateur and professional sports once closed to women are now open. Research has proven that physical activity - including participation in physically demanding sports - is not only healthy, but the exercise and increased strength associated with training for such activity is linked to decreased mortality and an improved psychological outlook.

Gymnasts, figure skaters, runners and female athletes in sports wherein body composition is perceived to play an integral role in performance are under ever-increasing pressure to maintain specific weight and body fat percentages. Many female athletes are inappropriately encouraged by trainers, coaches and peers to follow a “less-is-more” fitness prescription.

“In the early 1980s, I began to see women athletes at UCLA who came in and told me that they were vomiting, and they stated they had a lot of body dissatisfaction,” recalls Los Angeles-based sports medicine physician Carol Otis, a former UCLA team physician, chairperson on the women’s health initiative and the lead author of the 1992 American College of Sports Medicine (ACSM) Position Stand on Female Athlete Triad.

“We didn’t even know about bulimia then, but these women were talking about their experiences with weight loss techniques for the purpose of enhancing their performance. In reality, they were conveying symptoms associated with bulimia, depression, eating disorders and other weight-related problems,” says Otis.

In the early 1990s, researchers at the National Institutes of Health (NIH) and the American College of Sports Medicine (ACSM) made research efforts directed at uncovering the relationship between the prevalence of disordered eating and menstrual irregularities that occur in female athletes. It was revealed that there are three interrelated components. When they occur in tandem, irregular menstrual cycles and eating disorders are associated with premature bone loss and osteoporosis. Together, this has become known as the female athlete triad, which is a potentially serious condition occurring in many physically active girls and women. The position statement concludes that the syndrome is triggered by eating disorders coupled with overtraining that is characteristic in many sports but especially in the “appearance” sports, or those sports that encourage the athlete to look and be thin. Gymnastics, figure skating, dancing and distance running have a higher percentage of athletes with eating disorders, according to the ACSM position stand.

Triad Factor #1: Disordered Eating

What can begin as a harmless diet may develop into a clinically defined disordered eating pattern. Disordered eating can range from moderate restriction of food intake to binge eating and purging, to severe food restrictions. However, it is important to understand the difference between clinically defined eating disorders, such as anorexia nervosa or bulimia nervosa, and “disordered” eating patterns, defined as unsafe and flawed practices used to lose weight fast. The Diagnostic and Statistical Manual of the American Psychiatric Association describes self-induced vomiting, the use of laxatives and short-term, self-induced starvation as part of a large and assorted category of disordered eating patterns termed, "Eating Disorder Not Otherwise Specified" or “EDNOS.”

The use of diuretics, self-induced vomiting, fad diets, fasting and attempts to sweat weight off are examples of techniques used for weight loss that are part of ENDOS. When athletes want to lose weight and it does not come off quickly enough, they may embrace these techniques. Once started, athletes may experiment with these techniques occasionally or as frequently as several times a day. These practices can be classified as harmful eating behaviors that do not result in true weight loss. One of the first signs of the triad is evidence that at least one of these practices is being used by a female athlete to lose weight.

Triad Factor #2: Amenorrhea

Menstrual dysfunction is widely recognized in female athletes and is typically seen in females associated with sports that emphasize low body weight or low body fat. Some females who participate intensely in sports from a young age may never get their first menstrual period because they have been training so intensely for so long. This is referred to as delayed menarche. Primary amenorrhea (pronounced ay-meh-nuh-ree-uh) is a situation in which a female reaches the age of 16 without starting a regular menstrual cycle. Oligomenorrhea is a condition where the athlete experiences scant menstrual flow. Unfortunately, the athlete does not see missing her period as an issue, but neither does she relate missed periods to future damage to her body.

When an athlete is developing symptoms of the triad, she is typically exercising intensely while simultaneously reducing her weight. When the menstrual cycles have ceased without reasonable cause (such as pregnancy), become irregular or stopped for at least three consecutive periods, and she is increasing her training and changing eating habits, the research literature refers to this as athletic amenorrhea or secondary amenorrhea. The prevalence of amenorrhea among the general population is between two and five percent, but among female athletes, it has been reported in the ranges of three percent to 66 percent.

Triad Factor #3: Osteopenia to Osteoporosis

Bone mineral disorders are recognized as a serious consequence of menstrual dysfunction because estrogen is necessary for proper bone density development and skeletal construction. Even though bone mineral density may increase with the resumption of normal menses, the amount of bone that is regained is limited and will remain well below normal levels. Low estrogen levels and poor nutritional intake can lead to osteopenia, a milder form of osteoporosis, which is one of the most common and serious bone diseases. Evidence to date suggests that between the ages of 15 and 30, women usually form 30 percent of their bone density. “Without the appropriate requisite bone matrix formed during this particular period, bones do not progress to their fullest density, and this becomes an irreversible problem,” says Otis.

Female athletes are at an increased risk for injuries such as stress fractures and other long term, acute and chronic soft tissue damage. Because the female athlete’s bone mineral density is diminished, weakened bones that are exercised repeatedly and excessively will eventually fail. Repeated or frequent stress fractures are a strong indication that disordered eating patterns and diminished or absent menstrual flow is occurring.

Body Image and the Media

Despite the overall interest in healthy exercise and sport-related performance training, mixed messages abound. Women with the skinny appearance of an ectomorph are almost always shown in the mass media and on popular magazine covers, as well as fitness/sport-related publications, and this body image has become the ideal. Eating disorders seem to be most prevalent among elite female athletes. It is important to establish weight standards that maximize performance but minimize the risk of initiating an eating disorder.

“Since the majority of recreational, competitive and elite athletes are in middle and high school, this poses a very real threat to the health of our nation’s young, athletic women,” said former Iowa State University associate professor Deborah Rhea, in a 1996 interview. “Today’s healthy look is thin, according to society’s current definition,” Rhea observed.

Unfortunately, very unhealthy behaviors are associated with this slender appearance. Eating disorders are generally considered to be psychological disorders and are extremely difficult to treat. It is Rhea’s opinion that the most desired body image for a young female athlete is slim with very small, almost androgynous hips combined with voluptuous breasts - unattainable by most. Eating disorders among female athletes are among the most serious problems facing this population and parallels the seriousness of anabolic steroid use in male athletes, claims Rhea.

The Role of Health Professionals

According to a paper published through the University of Nebraska Extension Office, it may be easy for girls with symptoms of the triad to keep such information a secret because information about their menstrual periods and any damage done to bones usually isn’t visible to friends, teammates, coaches and family members. For these reasons alone, females found to have one component of the triad should be screened for the other two.

As an example, if a female is found to have irregular menstrual cycles or regular cycles have ceased, the athlete should be questioned by team physicians, coaches and/or parents about her eating patterns, weight loss history and whether she is prone to stress fractures. Alternatively, if she has repeated stress fractures, she should be screened to see if she experiences irregularities in her eating patterns or if she is having irregular menstrual cycles. The repeated presence of stress fractures is a more visible triad symptom.

The Triad on a Continuum

The ACSM position stand warns that the female athlete triad occurs not only in elite athletes but also in physically active girls and women participating in a wide range of physical activities. The three components appear in a wide range and differ in how they affect athletes and fitness enthusiasts. Fitness industry professionals such as personal trainers do not often think the triad applies to them or their clients, but in these populations, the triad can have a strong presence. Otis reminds us that “although 20 years ago, we were initially talking about the triad being described in female adolescents and young women, we are now beginning to see that this problem is occurring in the Baby Boomers,” she says. Although a 30-something female fitness enthusiast may not actively be perusing a competitive sport, she may be using disordered eating habits such as self-induced vomiting or starvation techniques in addition to excessive amounts of exercise to control her weight. The term “anerexercise” can be used to describe the concept of planning an exercise session for the purpose of caloric expenditure that matches recent caloric intake. In this situation, the fitness participant may expect the exercise session to “burn off” the specific calories that have been recently consumed. For example, a fitness participant may have consumed an extra 300 calories greater than normal earlier that day. She then exercises to burn off that extra 300 calories in a later exercise session. The personal fitness trainer is in a unique position to effectively educate the client about this unproductive weight loss technique.

What Else Can Fitness Professionals Do?

Fitness professionals are in a great position to make a positive impact on the triad and its related disordered patterns. “Fitness industry people do not think it applies to them, but it definitely does. This is for your 'regular' clients – recreational athletes or fitness enthusiasts, not just for thin celebrities and elite athletes who work with personal trainers and coaches” states Otis.

Some important ways in which a personal trainer can positively affect a client athlete in one or more of the components of the triad:

  1. Be honest about what you as the trainer observe. If you are noticing that statements made by the athlete or client are negative and degrading, ask her about them. Bring to her attention that she is using negative self-talk. Ask if her feelings about body dissatisfaction are affecting other parts of her life.
  2. Don’t be judgmental. State observations made in “I” statements.
  3. Follow up with honest and direct observations and offer appropriate professional referrals. For example, if the trainer suspects body image distortion because the client is thin and lean and complaining that she feels fat and unhealthy, refer her to her primary care physician. It may also be worth mentioning a sports psychologist as another type of referral. This type of psychologist is often perceived as less threatening than a clinical psychologist to an exercising female or an athlete. For one reason, they teach visualization and relaxation techniques to optimize performance. If seeing a sports psychologist helps the client get the help she needs, then it is worth the extra research. Be aware of treading on “scope of practice” issues. The typical personal trainer, although probably knowledgeable in a variety of areas, is usually not a physician, a registered licensed dietitian or a licensed psychologist. Stay away from “prescribing” based on statements or behaviors that are observed in the client. Make notes and always refer out.

Although individuals with components of the triad (disordered eating or amenorrhea) may deny any nutritional or health problems, it is important that medical attention is sought. If the client athlete is reminded that proper nutrition and appropriate medical care may enhance performance, she may be more likely to get the help she needs. Also, if the risk factors are described to the client athlete in a non-judgmental way, she may in turn be more likely to get the medical help she needs.

Treatment of the triad often requires intervention through a team approach. A medical professional aligned with a psychologist, nutritionist, parents and coaches can create a healthy and full-range approach. More research continues in many areas related to the triad. Monitoring young women to avert and treat the female athlete triad is the best way to prevent the disastrous outcomes.


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