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The Female Athlete Triad and its Relevancy to Today’s Female Athlete
April 30, 2009
"Feminism is about freedom: the individual and collective liberty to make decisions. Sports have freed women, and continue to free women, from restrictive dress, behaviors, laws and customs-and from the belief that women can't or shouldn't achieve or compete or win" (Nelson, 1998, p. xi). While the higher than ever achievements of today’s women athletes suggest freedom, this freedom does not always come without a cost. In a study by Johnson, Powers, and Dick (1999), the mean fat content desired by 341 female student athletes was 13%. The ideal fat content for the age range of these athletes is 19- 23% and thus this is indicative of the female athletes’ desire of “an abnormally low fat content”. From where does this desire for an abnormally low fat content stem? Perhaps it is from coaches, parents, other athletes, the sport, the athlete herself, or even a combination of such. No matter where it stems from, the bottom line remains the same. For today’s women athletes, the desire of an abnormally low fat content, either independently or as part of the Female Athlete Triad, is a serious problem that may have lasting health ramifications.
What is the Female Athlete Triad?
The Female Athlete Triad, recognized by the American College of Sports Medicine in 1992, is a medical condition affecting female athletes. Three distinct components; low energy availability, amenorrhea, and osteoporosis distinguish the condition. While each individual component poses a severe threat to health, the interplay of all three components poses an even greater threat, including the increased likelihood of death (Nattiv, Loucks, Manore, Sanborn, Sundgot-Borgen, and Warren, 2007).
Component One: Low Energy Availability
During normal function, the body takes in energy via food consumption and uses up energy through daily expenditures and exercise. Energy availability is computed as the difference resulting from food consumption (dietary energy intake) minus energy used up (exercise energy expenditure). In the case of the Female Athlete Triad, energy availability is very low. In some affected individuals this low energy availability may coincide with a defined eating disorder such as anorexia nervosa or bulimia nervosa. However, a defined eating disorder is not a stipulation of the Female Athlete Triad and the majority of affected individuals do not in fact meet the diagnostic criteria for such. Alternatively, they show signs of disordered eating habits that may include, but are not limited to, fasting, binging, purging, laxative use, diuretic use, enemas, and diet pills (Nattiv, Loucks, Manore, Sanborn, Sundgot-Borgen, and Warren, 2007).
When individuals engage in such habits, or either decrease or fail to increase dietary energy intake during increased exercise energy expenditure, low energy availability begins to pose a severe threat to health. There is too little energy for the body to draw upon and thus normal functions, such as cellular maintenance, thermoregulation, growth (bone maintenance), and reproduction (the menstrual cycle) are compromised in order to “restore energy balance and promote survival”. It is this very compromise that poses such a severe threat to health (Nattiv, Loucks, Manore, Sanborn, Sundgot-Borgen, and Warren, 2007).
A small number of studies on the disordered eating habits of female athletes have been conducted and caution should be taken when evaluating the accuracy of the information. Individuals who are affected by disordered eating habits rarely seek professional help and the few who do are often times guarded with the information that they reveal. As a fixed definition of disordered eating is lacking and most methods of study include self- reports and interviews, it is very easy for affected individuals to conceal or even deny disordered eating habits. Even after acknowledging these problems, studies still suggest that a number of female athletes display disordered eating habits.
The position stand of the American College of Sports Medicine cites only two large, well- controlled studies as having obtained “unbiased and reliable estimates of the prevalence of eating disorders in elite female athletes in different types of sports”. In the first of these studies, Bryne and McLean (2000) looked at the prevalence of eating disorders among 263 Australian elite athletes from an assortment of ten sports (108 male and 155 female) and a matched control group of 263 non- athletes. The ten sports were categorized as either a “thin- build” sport, which emphasizes leanness or a low body weight, or a “normal- build” sport, which does not emphasize leanness or a low body weight. Study methods included the Composite International Diagnostic Interview and a range of self- report questionnaires, which were utilized over two phases.
In the first phase, the Composite International Diagnostic Interview was conducted so as to identify those who met the criteria for anorexia nervosa, bulimia nervosa, or EDNOS as set forth in the DSM-IV. In addition, subjects used a 0 to 10 rating scale to indicate the intensity of the perceived pressure to be thin or lean, either in their particular sport (in the case of athletes), or in their social group (in the case of non-athletes). Subjects participating in thin-build sports perceived the most pressure to be thin or lean, followed by subjects participating in normal-build sports, and then non-athlete controls. Overall, females perceived more pressure to be thin or lean than did males. 15% of female subjects participating in thin-build sports, 2% of female subjects participating in normal- build sports, and 1% of the female non-athletes met the criteria for anorexia nervosa or bulimia nervosa. 16% of female subjects participating in thin- build sports, 7% of female subjects participating in normal-build sports, and 5% of female non-athletes met the diagnostic criteria for EDNOS.
In the second phase, a range of self- report questionnaires including the drive for thinness, bulimia, and body dissatisfaction subscales of the Eating Disorders Inventory II, the Bulimia Test-Revised, and the restraint subscale of the Three Factor Eating Questionnaire. The BMI of each subject was also recording during this phase. Three main comparisons were drawn from the resulting data. With regard to both female and male athletes and non- athletes, athletes reported significantly higher scores on all self- report questionnaires except the body dissatisfaction subscale of the Eating Disorders Inventory II. When comparing both females and males participating in thin- build and normal- build sports, subjects participating in thin- build sports reported significantly higher scores on all self- report questionnaires except the body dissatisfaction scale of the Eating Disorders Inventory II. Overall, females reported significantly higher scores on all self- report questionnaires. Regarding BMI, both females and males participating in thin-build sports had significantly lower BMI scores than either subjects participating in normal-build sports or controls. There were no differences in BMI between females participating in normal-build sports and non-athletes but the mean BMI of females participating in thin-build sports fell into the underweight category whereas the mean BMI scores for the other groups were within the healthy range.
From this study, one can conclude that not only do subjects participating in thin- build sports, but also females, overall and within in each group, perceive the most pressure to be thin or lean. In accordance with this conclusion, subjects who perceived themselves to be susceptible to increased pressure to achieve a lean body shape demonstrated higher rates of eating problems.
In the second study of similar design, Sundgot-Borgen and Torstveit (2004) looked at the prevalence of eating disorders in the entire population of Norwegian male and female elite athletes. 1620 athletes and 1696 controls underwent self- report questionnaires and clinical interviews. An initial screening by a detailed questionnaire, which included subscales of the Eating Disorder Inventory, was used to identify athletes and controls at risk for eating disorders. Athletes and controls who were identified as at- risk, as well as a representative sample of athletes and controls not classified as at- risk then underwent a detailed standardized clinical interview in order to determine the number of at-risk athletes and controls who met the DSM-IV criteria for anorexia nervosa, bulimia nervosa, EDNOS, or anorexia athletica. The interview was performed by an eating disorders specialist and followed the format of the Eating Disorder Examination. Sport-specific questions and questions on possible contributing factors to the development of eating disorders were also included in the interview. Overall, 20% of females and 8% of males met the criteria. 13.5% of athletes met the diagnostic criteria for subclinical and clinical eating disorders while only 4.6% of controls met the same criteria. In addition, the prevalence was significantly higher among athletes competing in sports that emphasize leanness and weight when compared with athletes competing in other sports and controls.
With respect to the Female Athlete Triad, it is necessary to study not only the prevalence of defined eating disorders, but also the prevalence of subclinical eating disorders and dangerous eating and weight control behaviors. In a study by Petrie and Stoever (1993), 218 female gymnasts from a total of 21 NCAA Division I universities completed a 36- item objective self- report known as the Bulimia- Test Revised. 28 of the items were used to determine the prevalence of bulimia nervosa and the remaining 8 were used to determine the prevalence of pathogenic eating and weight control behaviors. 4.1% of the gymnasts were found to meet the criteria for bulimia nervosa and 32.6% reported binge eating at least once a week. Regarding pathogenic eating and weight control behaviors, 57.3% reported exercising for two or more hours per day, 28.4% reported fasting or dieting four or more times in the past year, 6% reported vomiting two to three times per month, 0.5% reported using diuretics at least once per week, and 2.4% reported using laxatives at least once per week. Thus one can conclude that even though relatively few gymnasts were affected by bulimia nervosa, a large number implement dangerous eating and weight control behaviors “that have been associated with psychological and attitudinal disturbances, such as body dissatisfaction and low self- esteem”. Consequently, this indicates that although many female athletes do not meet the diagnostic criteria for a defined eating disorder, they still suffer from severe disordered eating habits. Furthermore, athletes should be screened for these habits and interventions should be conducted in order to “prevent the possibility of more severe eating pathologies”.
In a collaborative study with the NCAA, Johnson, Powers, and Dick (1999) administered a 133-item survey to 1,445 athletes. The survey was comprised of questions regarding demographics, the nature and extent of athletic involvement, eating-related behaviors such as dieting, binge eating, and purging, drug and alcohol behavior, and attitudes concerning body image and weight-related issues. 1.1% of the females met DSM-IV criteria for bulimia nervosa, 9.2% of the females were identified as having clinically significant problems with bulimia, 2.85% of the females were identified as having a clinically significant problem with anorexia nervosa, 10.85% of the females reported binge eating on a weekly or greater basis, and 5.52% of the females reported purging behavior (vomiting, laxatives, diuretics) on a weekly or greater basis.
Other studies have found the prevalence of disordered eating behaviors to be as high as 62% (Yeager, Agostini, Nattiv, and Drinkwater, 1993) and the practice of pathogenic weight control behaviors to be as high as 32% (Rosen 1986). In any case, a significant number of female athletes, especially those participating in sports that emphasize leanness or low body weight, are affected by defined eating disorders or disordered eating habits. Not only does this severely limit an athlete’s energy availability, it may also inhibit normal functions, such as the menstrual cycle, and thus contribute to another component of the Female Athlete Triad, amenorrhea.
Component Two: Amenorrhea
The second component of the Female Athlete Triad is amenorrhea or cessation of the menstrual cycle for more than three months. There are two varieties of amenorrhea. Primary amenorrhea is typical of a delayed menarche, or first menstrual cycle and may overlap with a delayed development of secondary sex characteristics. The second variety, known as secondary amenorrhea, is typical of the cessation of the menstrual cycle for more than three months in a woman who has experienced menarche (Nattiv, Loucks, Manore, Sanborn, Sundgot-Borgen, and Warren, 2007).
In the functioning of a normal menstrual cycle, estrogen release is the governing factor. The release of estrogen, however, is dependent on gonadotropic hormones, which “stimulate growth of the gonads and the secretion of sex hormone (e.g. gonadotropin-releasing hormone, lutenizing hormone and follicle stimulating hormone)”. The hypothalamus is responsible for the production of these gonadotropic hormones and when weight begins to fluctuate as a result of the disordered eating habits or increased energy expenditure its production is disrupted and thus the entire menstrual cycle is also disrupted (http://en.wikipedia.org/w/index.php?title=Female_athlete_triad&oldid=280765976).
In a study by Dušek (2001), the effect of intensive training on the menstrual cycles of 72 female athletes and 96 controls was examined. The method of study was a two- part questionnaire in which the questions were directed towards personal menstrual cycle characteristics and personal involvement in the participant’s respective sport. A greater number of athletes, as opposed to the controls, reported both primary and secondary amenorrhea. The prevalence of secondary amenorrhea was found to be three times greater in athletes than in the control group and its prevalence was further examined with respect to participant’s specific sports. 11 out of 17 long- distance runners reported secondary amenorrhea while only one basketball player reported such. Thus from this study, one can conclude that different types of training correspond highly with a greater prevalence of secondary amenorrhea.
In their study, Brooks- Gunn, Warren, and Hamilton (1987) gathered supporting evidence for the relationship between disordered eating habits and amenorrhea. In a survey of 55 dancers, 56% reported a delayed menarche and 19% were currently amenorrheic. Of those reporting amenorrhea, 50% also reported suffering from anorexia nervosa. Hence disordered eating habits, in addition to different types of training, may influence the onset of amenorrhea.
Regardless of influence, amenorrhea is a component of the Female Athlete Triad that must be taken into serious consideration. Many athletes may misperceive amenorrhea as being indicative of the intense training required in their respective sports. While this may be true in theory, the consequences of amenorrhea, most notably osteoporosis, the third component of the Female Triad, must be acknowledged.
Component Three: Osteoporosis
The third and final component of the Female Athlete Triad is osteoporosis, which the National Institute of Health defines as “a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture”. During amenorrhea, estrogen levels are low and it is due to this hypoestrogenmia that osteoporosis occurs. When estrogen levels are low, the osteoclasts live longer and are able to absorb more bone. In response to the increased bone resorption, there is increased bone formation and a high-turnover state develops which leads to
Image from: http://www.walgreens.com/library/graphics/images/en/17285.jpg bone loss and perforation of the trabecular plates. As the osteoclasts break down the bone, there is a loss of bone mineral density and thus bones become more brittle. In addition, disordered eating habits that are characteristic of the Female Athlete Triad may lead to insufficiencies of certain vitamins and minerals that assist in maintaining bone mineral density (e.g. vitamin D or calcium). As bone mineral density diminishes, athletes are then susceptible to fractures as much mechanical stress is endured during athletic activity (http://en.wikipedia.org/w/index.php?title=Female_athlete_triad&oldid=280765976).
In a study by Barrow and Saha (1988), the relationship between menstrual history and stress fractures was examined in 240 collegiate female long-distance runners. The runners were grouped into three categories based upon their number of menstrual cycles per year and any reports of stress fractures were recorded. The categories were as follows: very irregular (0 to 5 menses/year), irregular (6 to 9 menses/year), and regular (10 to 13 menses/ year). 49% of the very irregular runners reported stress fractures, as did 39% of the irregular runners and 29% of the regular runners. In a second part of the study, runners experiencing amenorrhea were removed from the very irregular group and disordered eating habits were examined in all four groups. 47% of the amenorrheal group, 20% of the very irregular group, 10% of the irregular group, and 7% of the regular group admitted to an eating behavior disorder. From this, one can clearly see the interplay of the three components of the Female Athlete Triad as disordered eating habits inhibit the normal functioning of the menstrual cycle and prolonged absence of the menstrual cycle correlates strongly with stress fractures (which are related to reduced bone mineral density and consequently osteoporosis).
Even with restoration to a normal, healthy lifestyle, some athletes are never able to recover the bone mineral density that is lost due to the influence of amenorrhea and/ or disordered eating habits. In a study by Towell, Baker, and Roberts (1999), 56 women affected by eating disorders underwent a scan to determine bone mineral density. 9-51 months during which the women’s body mass indices increased passed and then a second scan was performed. Comparisons were drawn between the first and second scans but no significant changes in bone mineral density were observed. Therefore increasing BMI may not be sufficient enough to recover the bone mineral density that is lost. In fact, the loss may be irreversible.
What are the Effects of the Female Athlete Triad?
For individuals suffering from any component of the Female Athlete Triad, there are multiple short- term effects and, if left untreated, serious long- term effects as well.
Short- Term Effects
Short- term effects include increased susceptibility to stress fractures, muscle weakness, and reduced physical performance. Disordered eating habits may also lead to depression, anxiety, and low self- esteem. For those experiencing amenorrhea, infertility must be considered, as there is no ovarian follicular development, ovulation, or luteal function. If the menstrual cycle is restored, unforeseen pregnancies may result, as ovulation will precede the restoration. In addition, amenorrhea leads to damaged “endothelium- dependent arterial vasodilation, which reduces the perfusion of working muscle, impaired skeletal muscle oxidative metabolism, elevated low- density lipoprotein cholesterol levels, and vaginal dryness” (Nattiv, Loucks, Manore, Sanborn, Sundgot-Borgen, and Warren, 2007).
Long- Term Effects
Most long- term effects are extensions of short- term effects. The psychological problems associated with the disordered eating habits may intensify and anorexia nervosa presents a sixfold increase in standard mortality rates compared to the general population with one study reporting suicide attempts by 5.4% of athletes. With regard to amenorrhea, each missed menstrual cycle not only increases the chances of permanent infertility, but also reduces bone mineral density (as do the nutritional deficits associated with disordered eating habits). This reduction is most often irreversible and puts the athlete at a greater risk for stress fractures and life- long osteoporosis (Nattiv, Loucks, Manore, Sanborn, Sundgot-Borgen, and Warren, 2007).
Prevalence of the Female Athlete Triad Among Female Athletes
According to Picard (1999), surveys estimate that between I% and 2% of college women have anorexia nervosa, 6% to 8% suffer from bulimia, and up to 50% display a variety of abnormal eating behaviors. Although anyone may be susceptible to developing an eating disorder, athletes have an increased risk. Athletes tend to exemplify several personality characteristics commonly seen in individuals with eating disorders such as high self-expectations, competitiveness, perfectionism, compulsiveness, drive, self-motivation, a “win at all costs” attitude, and the intense pressure to be slim and perform. For athletes participating in sports that emphasize leanness as beneficial to appearance or performance, there is an even higher risk as the athlete conforms to the emphasis. These sports may include, but are not limited to, long- distance running, gymnastics, swimming, and skating (http://www.femaleathletetriad.org/for-athletes-coaches/risk-factors/).
Evaluation, Treatment, and Prevention of the Female Athlete Triad
Pre-participation examinations and yearly check- ups may be the best time to screen for the Female Athlete Triad and during the screening, physicians will focus on the athlete’s past history. Physicians should inquire about menstrual cycles and eating habits and also be concerned with any athlete with a history of stress fractures. Screening for the Female Athlete Triad will generally follow the following format of TABLE 2.
Screening History for the Female Athlete Triad
Age at menarche
Frequency and duration of menstrual cycles
Longest period of time without menstruation
Last menstrual period
Physical signs of ovulation, such as cervical mucus change or menstrual cramps
Hormonal therapy taken previously and currently
What was eaten in the past 24 hours
List of any forbidden foods
Highest/lowest weight since menarche
Happiness with current weight
Ideal weight according to the patient
Disordered eating practices: bingeing and purging
Use of laxatives, diuretics or diet pills
Exercise patterns/training intensity for the sport (hours per day, days per week)
Additional exercise outside of required training
History of previous fractures
History of overuse injuries
If the patient is experiencing any symptoms such as anemia, depression, fatigue, or electrolyte imbalances the physician may warrant further testing as these symptoms are commonly associated with disordered eating habits. Unfortunately, amenorrhea cannot be diagnosed with testing and is rather diagnosed by exclusion. In the case of prolonged amenorrhea, the physician may require a DEXA scan in order to evaluate bone mineral density loss (Hobart and Smucker, 2000).
If after undergoing a physician’s evaluation, an athlete is identified with any of the three components of the Female Athlete Triad she must pursue treatment. Treatment generally includes the involvement of a variety of medical specialists, as well as those who have close relations with the athlete. Physicians, counselors, and nutritionists are most often involved with treating low energy availability. They, along with the athlete, will collaborate on a suitable goal weight and measures will then be taken to reach the goal weight.
In reaching the goal weight, the physician may limit the athlete’s exercise activity by 10 to 20 percent. Nutritionists may work with the athlete to devise a proper diet that is in accord with the athlete’s individual needs and the demands of the athlete’s particular sport. This diet will frequently consist of a balance of healthy foods such as fruits, dairy products, vegetables, iron, breads, and protein (such as chicken, fish, and beans). Counselors may often work in conjunction with nutritionists in order to address the behaviors and action associated with the athlete’s disordered eating habits. Together, these three medical specialists will help the athlete to acknowledge disordered eating habits for it is only after the athlete acknowledges this fact that they may learn to manage the habits through appropriate exercise and nutrition. Additionally, medication may be prescribed in order to treat the disordered eating habits, amenorrhea, and bone mineral density loss that is associated with osteoporosis (Hobart and Smucker, 2000).
For the disordered eating habits, medication that alleviates related symptoms such as depression, vomiting, and irregular heartbeat may be prescribed. Besides selective serotonin reuptake inhibitors, which are used in the treatment of depression, physicians advocate the use of benzodiazepines for the treatment of the anxiety that some athletes experience when eating. As the treatment of the disordered eating habits usually results in restoration of the menstrual cycle, additional measures are not normally taken to treat amenorrhea. However, hormone replacement therapy in the form of oral contraceptives and cyclic estrogen/ progesterone has been successful in treating not only amenorrhea but also increasing bone mineral density and preventing stress fractures. For example, Cumming (1997) conducted a study of amenorrheic runners in which he compared hormonal therapy with placebo over 24 to 30 months. Treatment consisted of either conjugated estrogen in a dosage of 0.625 mg per day or an estradiol transdermal patch in a dosage of 50 µg per day. Both treatments were given in combination with medroxyprogesterone in a dosage of 10 mg per day for 14 days per month. Those treated with hormonal therapy displayed a significant increase in bone mineral density, while those treated with placebo displayed no significant decreases of less than 2.5 percent (Hobart and Smucker, 2000).
The Female Athlete Triad Coalition, an international consortium, lays emphasis on the education of not only athletes, but also coaches and parents, as the principal method of preventing the Female Athlete Triad. This education should consist of what the Female Athlete Triad is, how to identify it, and how to actively set about preventing it. Together, coaches and parents should stress how essential eating, health, and a good body image, as opposed to body weight, are to favorable training and performance. They should provide support, whether it be emotional or in external resources such as athletic trainers, physicians, counselors, and nutritionists. Emotional support should be provided at all times and not solely during training and performances. Athletes should seek this emotional support from not only coaches and parents, but also from teammates (http://www.femaleathletetriad.org/for-athletes-coaches/prevention/).
Additionally, athletes should employ a form of tracking their menstrual cycles and utilize the external resources in order to hamper any potential components of the Female Athlete Triad. For example, a nutritionist should be utilized in order to determine a diet that is suitable for a sport and the athlete’s individual energy necessities, a physician should be utilized if any disruptions in the menstrual cycle occur or if any frequent injuries or stress fractures are sustained, and a counselor should be utilized if there is any distress regarding body image, in particular the desire to be thinner (http://www.femaleathletetriad.org/for-athletes-coaches/prevention/).
The Female Athlete Triad is a rather new, but serious medical condition affecting more and more female athletes. Further research on the Triad, in particular its prevalence, effects, and treatment is needed but studies do suggest that while very few athletes are affected by all three components of the Female Athlete Triad, each individual component has lasting health consequences. In a society that is motivated by success, it is doubtful that the high risk personality characteristics of athletes or the emphasis that some sports place on leanness or low body weight will disappear any time soon. Thus the Female Athlete Triad, if not evaluated, treated and prevented, is likely to continue to affect more and more of today’s female athletes.
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