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PREVALENCE OF FEMALE ATHLETE TRIAD COMPARED TO THE GENERAL POPULATION AND ITS EFFECT ON ATHLETES
April 25, 2011
Sports and exercise play a significant role in a balanced, healthy lifestyle. Exercise benefits every part of the body, including the mind, while competitive sports can instill a sense of accomplishment and self-confidence in a person. However, when training and diet become excessive, an athlete may potentially be hurting his or her performance, rather than improving it (Gavin, 2009). Female athletes that portray this type of behavior are at risk for the female athlete triad (FAT). It is a condition that combines disordered eating or energy deficit, amenorrhea, and osteoporosis. An athlete can suffer from all three components of the triad, or just one or two of the individual conditions (Gavin, 2009). FAT can occur in female athletes of all ages, beginning as early as junior high. Even at a young age, female athletes are oftentimes aware of the influence of body composition on athletic performance. Furthermore, they acknowledge that in some activities, an increase in body weight can decrease performance.
Pressure to lose weight to unrealistic levels contributes to the development of disordered eating habits. Consequently, restricting certain foods and excessive weight loss can lead to energy deficiency. The energy deficiency is the primary cause of the female athlete triad (Otis, Drinkwater, Johnson, Loucks, & Wilmore, 1997). With the increase of female participation in sports, the incidences of this athlete triad of disorders particular to women are also increasing. Furthermore, the female athlete triad can cause significant negative impacts on a woman’s health that can become life threatening. How prevalent is the female athlete triad in athletes compared to non-athletes based on its three components?
In the last few decades, female participation in athletics has increased dramatically. This increase can be attributed to Title IX legislation (Gottschlich & Young, 2008). This legislation, passed in 1972, stated, “No person in the U.S. shall, on the basis of sex be excluded from participation in, or denied the benefits of, or be subjected to discrimination under any educational program or activity receiving federal aid.” In other words, sex discrimination in schools, whether academics or athletics, was banned (Titleix).
Between 1972 and 2002, the participation in high school athletics increased from 3.7% to 40%. Similarly, the participation in college athletics rose from 2% to 43%. The American College of Sports Medicine (ACSM) first described the female athlete triad as a syndrome in 1993. In 1997, ACSM declared the components of the triad, consisting of disordered eating, amenorrhea, and osteoporosis. In 2007, ACSM emphasized that energy availability is the foundation from which the rest of the triad stems (Gottschlich & Young, 2008).
Components of the Triad & comparison to the general population:
Boys and girls experience puberty very differently. While boys gain muscle mass and are encouraged to gain weight to improve their performance, girls gain body fat and are encouraged to lose weight in order to improve their performance. Compared to boys, girls are more highly influenced by societal standards and peer pressure. This can cause an attempt to achieve unrealistic thinness. Girls may try to lose weight through a wide range of disordered eating practices. They may develop anorexia nervosa or bulimia nervosa, two extreme eating disorders that increase the risk of morbidity (Otis, Drinkwater, Johnson, Loucks, & Wilmore, 1997). According to the National Eating Disorder Association (2003), 5-10% of all women have some form of an eating disorder (Lim, 2008). However, are eating disorders more prevalent in athletes?
In 1994, Diane E. Taub and Elaine M. Bline did a study at Southern Illionois University at Carbondale focused on this question. The purpose of their correlational test was to determine whether certain groups of adolescent females were more vulnerable to disordered eating patterns. They obtained questionnaire responses from 605 high school females. Within these students, 302 were athletes, 89 were performance squad members, and 259 students were not engaged in these activities. Taub and Bline concluded that although the athletes emphasized body shape and control, participation in these activities did not increase their risk for developing disordered eating. Furthermore, one out of every five students submitted responses reflecting disordered eating habits (Taub & Blinde, 1994).
In another study, in 2000, Berry and Howe examined the eating disorders among female college athletes and non-athletes at a mid-size NCAA division II university. The correlational test observed 125 students, 60 female varsity athletes and 65 female non-athletes. The Eating Attitudes Test (EAT-26) was used to determine the presence or risk of developing eating disorders. This particular test is a widely used standardized self-report measure of symptoms and concerns related to disordered eating. It consists of 26 items and includes dieting, bulimia and food preoccupation, and oral control. Each item is rated from one (never) to six (always). The results showed significant differences between the athletes and non-athletes in terms of disordered eating habits. Furthermore, there were no differences related to self-esteem, social pressure, body image, or body mass index (Berry, 2000).
Amenorrhea is a condition defined by the absence of menstruation. There has always been a connection between short-term amenorrhea and physical training. Between 1% and 44% of athletic women of reproductive age who are not pregnant experience some form of amenorrhea at any given time. Exercise-associated amenorrhea (EAA) is the result of complex interplay of eating and exercise. Recent studies have shown that the crucial element resulting in amenorrhea is energy availability (Lim, 2000).
In 2005, Tomten and Hostmark did a study on the energy balance in weight stable athletes with and without menstrual disorders. They attempted to pinpoint a reason for energy deficiency causing the irregular menstrual function. They assessed the energy balance and nutritional adequacy in ten runners with irregular menstrual function and ten runners with normal menstrual function. Computerized records of three days of food intake were calculated, as were the content of energy and macronutrients. The daily total energy expenditure of both groups was found to be the same. However, the daily energy intake was found to be lower in the athletes with irregular menstrual function. The intakes of carbohydrates and protein were not significantly different in the two groups. The most important difference in macronutrient intake was found in dietary fat, which was significantly lower in the athletes with the irregular menstrual function. The experiment concluded that although both groups met the recommended intake of carbohydrates, protein, and fat in their diet fairly well, there was a small energy deficit observed in athletes with irregular menstrual function seemingly related to a lower dietary fat intake. (Tomten & Hostmark, 2005).
Osteoporosis is a disease characterized by the thinning of bone tissue and loss of bone density over time. In female athletes, osteoporosis refers to inadequate bone formation and premature bone loss. In the short term, this can cause amenorrheic athletes to have higher rates of injuries, specifically stress fractures. In the long run, these athletes are at risk for osteoporotic fractures. Studies have shown that bone mineral density (BMD) in amenorrheic athletes has been significantly lower than those with normal menstrual cycles (Lin, 2000).
In 2008, Christo did a study concerning bone metabolism in adolescent athletes with amenorrhea and athletes with eumenorrhea (normal menstrual cycles). The hypothesis was that, despite increased activity, bone density would be lower in athletes with amenorrhea, compared to athletes with eumenorrhea. The study also observed control subjects. The cross-sectional study examined 21 athletes with amenorrhea, 18 athletes with eumenorrhea, and 18 control subjects between the ages of 12 and 18 years. The study examined bone density of the spine, hip, and whole body and body composition. The results concluded that athletes with amenorrhea had lower bone-density at the spine and whole body, compared to athletes with eumenorrhea and control subjects. They also had lower bone-density in the hip compared to athletes with eumenorrhea. Furthermore, amenorrheic athletes had lower BMI scores than the other two groups. The study concluded that although there were no significant differences in lean mass between the three groups, amenorrheic athletes had lower bone density at the spine and whole body (Christo et al., 2008).
Prevalence of Female Athlete Triad in Female Athletes:
The previous studies have discussed the prevalence of the three components of the female athlete triad between athletes and non-athletes. Furthermore, how prevalent is the female athlete triad within the athletic community?
In 2006, Nichols did a study in order to estimate the prevalence of the female athlete triad among high school athletes. A cross-sectional study observed 170 female athletes representing eight different sports. Disordered eating and menstrual status were determined by interviewer-assisted questionnaires. A limitation for these questionnaires was the reliability of the subjects’ responses, especially with disordered eating. Bone mineral density was measured by dual-energy x-ray absorptiometry (DXA) of the hip, spine, and total body. Among all of the athletes, 18.2% met the criteria for disordered eating, 23.5% for menstrual irregularity, and 21.8% for low bone mass. Ten girls met the criteria for two components of the triad, while two girls met the criteria for all three components. The study concluded that although the prevalence of the full female athlete triad was low in their sample, a substantial percentage of the athletes might be at risk for long-term health consequences (Nichols, Rauh, Lawson, Ji, & Barkai, 2006).
In 2009, a similar study, by Schtscherbyna, observed the female athlete triad in elite swimmers in Brazil. The sample consisted of 78 athletes between the ages of 11 and 19 years. The presence of disordered eating was assessed through three different questionnaires: Eating Attitudes Test (EAT), Bulimic Investigatory Test, and Body Shape Questionnaire. The presence of menstrual dysfunctions was tested through a validated questionnaire, and the assessment of bone mineral density was found using dual x-ray absorptiometry. The results of this study found that 44.9% of the athletes met the criteria for disordered eating, 19.2% for menstrual irregularity, and 15.4% for low bone mass. Among the athletes, twelve met the criteria for two of the components, and one met all three criteria. Only 35.9% did not present with positive results for any of the components. The study concluded that although the prevalence of the female athlete triad was low, of all three components, a significant number of athletes presented with at least one of the components of the disorder (Schtscherbyna, Soares, Oliveira, 2009).
A third study, done in 2008 by Hoch and Papanek, examined the occurrence of disordered the female athlete triad in professional ballet dancers. The sample consisted of 22 dancers. The subjects completed a questionnaire in regards to disordered eating. Blood was drawn in order to determine hormonal, TSH, and prolactin levels. Bone mineral density and body composition was measured with a DXA. The results showed that 32% of the dancers had abnormal scores to the disordered eating questionnaire. Eighteen percent reported a history of amenorrhea and 27% reported a menstrual dysfunction. Thirty two percent of dancers had evidence of a low bone density. This study concluded that triad characteristics were common in the dancers. Eighteen percent had one component of the triad, 45% had two components, and 18% had all three components (Hoch et al., 2008).
Consequences of the Female Athlete Triad
It is evident that a large number of athletes suffer from at least one of the components of the female athlete triad. Further studies examine the impact of the female athlete triad and its consequences on athletes.
In 2010, Rauh did a study examining the relationships among injury and disordered eating, menstrual dysfunction, and low bone mineral density in high school athletes. This prospective cohort study consisted of 163 female athletes competing in eight interscholastic sports. Each participant was followed throughout her respective sport season for occurrence of musculoskeletal injuries. Data was collected through daily injury reports, disordered eating attitudes and behaviors through the Eating Disorder Questionnaire, bone mineral density and lean tissue mass using a DXA, and menstrual history and demographic characteristics through a questionnaire. The results found that 61 athletes (37.4%) incurred 90 musculoskeletal injuries. Furthermore, it was found that a history of amenorrhea, disordered eating, and low bone mineral density were associated with the occurrence of these injuries. This study concluded that disordered eating, low BMD, and amenorrhea were associated with musculoskeletal injuries in these female high school athletes (Rauh, Nichols, & Barrack, 2010).
The female athlete triad is a serious health problem in female athletes that is composed of three interrelated conditions: energy deficit/ disordered eating, amenorrhea, and osteoporosis. Through the studies, it is evident that there are clear associations between the three elements. The conditions can occur independent of the other two; however, it is likely than an athlete suffering from one condition is also suffering from the others. Although many athletes may not present with the extreme ends of the spectrum, many display progressing symptoms of one or more of the conditions. Oftentimes, these minor symptoms can go unnoticed, until the athlete’s health is detrimentally affected.
The first question posed focused on the prevalence of disordered eating, amenorrhea, and osteoporosis in athletes and non-athletes. For disordered eating, there was no significant difference in the disordered eating habits of athletes and non-athletes. Both groups experience similar peer pressure and societal standards that affect them in a similar way. Neither is influenced to a greater extent. However, when female athletes begin disordered eating habits, they are restricting the energy they need in order to perform. Long-term energy restriction in athletes can cause poor nutritional status, increased psychological stress, and put them at risk for a clinical eating disorder. Most importantly, disordered eating habits in female athletes lead to an energy deficiency that can cause exercise-induced amenorrhea and osteoporosis (Manore, 1999).
The prevalence of menstrual disorders in female athletes tends to be higher than the general female population. Menstrual disorders are oftentimes used in order to evaluate the presence of eating disorders. Amenhorrheic athletes that consume fewer calories than athletes with regular menstrual function may suggest a high incident of eating disorders in those athletes. The study by Tomten and Hostmark showed that compared to the general female population, female athletes need more than the average amount of nutrients in order to maintain the energy needed for training and performance. Without this energy, they can develop amenorrhea. There are athletes with menstrual disorders that maintain healthy eating habits and simply need to adjust their diet to meet different recommendations, while their body weights are healthy and stable (Manore, 1999). If not treated immediately, there are long-term effects of amenorrhea. Many women are unable to reverse the amenorrhea and are infertile. There is almost always an underlying cause of amenorrhea that can often be linked to energy deficiency from disordered eating that together can cause osteoporosis.
It is apparent that athletes with a history of menstrual dysfunctions are at a greater risk for developing osteoporosis. The occurrence of disordered eating habits and low calcium intake, combined with menstrual dysfunction, can cause bone loss. The development of premature osteoporosis is beginning in increasingly younger athletes. This puts the athletes at risk for stress fractures and osteoporotic fractures. Compression fractures of the spine have been documented in young women with anorexia nervosa. Although many female athletes may not meet the criteria for anorexia or bulimia nervosa, an inadequate caloric intake and poor nutrition combined with excessive exercise could put these athletes at risk for intense injuries and fractures (Otis et al. 1997).
Although the studies did not show that eating disorders are more prevalent in female athletes, it is evident that disordered eating habits in female athletes initiate the other two components that make up the female athlete triad. Athletes who partake in disordered eating habits increase their risk for amenorrhea, which consequently increases their risk for osteoporosis.
It’s difficult to compare the prevalence of the female athlete triad in athletes and non-athletes because there are no statistics of the triad in non-athletes. The only possible way to compare the two is two break them down into its three separate components. Through the studies it is evident that while there’s no difference in the prevalence of eating disorders between the two groups, amenorrhea and osteoporosis are more common in female athletes.
Energy deficiency is the primary cause of the female athlete triad. Restricting necessary nutrients initiates the triad of damaging conditions that make up the female athlete triad. The second question posed focuses on the prevalence of the female athlete triad in the athletic community. Although there are no exact statistics, it is evident that there is an increasingly large number of female athletes that suffer from at least one of the conditions of the triad.
There are many risks associated with the female athlete triad. The studies show that without normal menstruation, the level of estrogen may be lowered. Estrogen in the body keeps bones strong. Therefore, the bone density and strength will decrease. Consequently, this deterioration may cause stress fractures and recurrent musculoskeletal injuries.
The majority of the studies used in order to answer the posed questions were correlational studies. No experiments were used because altering one of the groups in attempt to prove the hypothesis would have been extremely unethical. In some of the correlational tests, control groups were used in order to compare the non-athletes to the athletes. In each study, the variables were measured using fairly accurate methods such as using the DXA in order to measure bone mineral density. Using questionnaires in order to assess disordered eating habits was one of the limiting methods in the studies because there was no way in detecting its accuracy. Another limiting factor in a few of the studies, such as the study observing the professional dancers, was the limited group of subjects. In order to prove both hypotheses accurately, I believe that a longitudinal cohort study is necessary. It is important to observe a large group of female athletes over a long period of time. This means, assessing prepubescent female athletes and observing them passed the college level. The results of this experiment would show the female athlete’s ability before and after puberty, and note any change in her performance due to any of the components of the female athlete triad.
The female athlete triad is an increasingly prevalent problem in females of all ages, although we cannot conclude exact statistics. Energy deficiency is the primary cause that drives its development. While disordered eating, amenorrhea, and osteoporosis occur may occur individually in both athletes and non-athletes, the combination of the three elements in female athletes is the focus of this growing problem. Education is the best tool in order to solve these detrimental conditions. Coaches need to push their athletes to improve in the healthiest ways possible. It is also essential that athletes be taught the ways in which they can succeed without damaging their bodies in the process. With a joint effort to maintain healthy habits by both the education from the coaches and the athletes themselves, athletes will be able to perform at their peak level and continue to benefit from these healthy habits later in life.
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