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For an increasing number of women in the United States, a concern or preoccupation with body weight and size is a constant pressure. Female athletes, like most women in our society, are also often pressured to conform to certain ideal body sizes and shapes, as dictated by the entertainment and fashion industries. Female athletes, however, face a twofold pressure. They face the burden that our culture places on all women to be thin, but they also face the burden from coaches, parents, and other athletes to succeed in sports and look good doing so by maintaining an unrealistically low weight. When weight gain means removal from a team or elimination from competition, many female athletes turn to dangerous food restriction and excessive exercise. This pressure to achieve or maintain unrealistically low body weight underlies the development of a syndrome recently named the Female Athlete Triad. First identified by the American College of Sports Medicine in 1992, the Female Athlete Triad consists of three medical disorders commonly found in female athletes: disordered eating, amenorrhea, and osteoporosis. Alone each disorder is dangerous; in combination the triad disorders are potentially fatal.
Eating Disorders in Female AthletesBefore evaluating the available studies on the prevalence of disordered eating among female athletes, it is necessary to recognize the many limitations and problems that arise with such studies. First of all, there are a limited number of studies on this segment of females and their eating patterns. Also, many of these studies rely on self-reporting surveys, which inherently may be flawed due to the fact that many athletes may deny disordered eating behaviors on standard questionnaires. Finally, there is no true accepted consensus on the definition of disordered eating. This term refers to a wide range of abnormal behaviors, the extremes of which are anorexia nervosa and bulimia nervosa, but also includes limiting caloric intake, skipping meals, using diet pills, and many other pathogenic weight control behaviors. Having stated these limitations, there are a number of studies which do in fact indicate that female athletes struggle more with eating disorders than average females. Studies report that the rate of disordered eating among female athletes may be as high as 62% in certain sports (Yeager, Agostini, Nattiv, and Drinkwater, 1993). While a study of college female swimmers found 15.4% were affected, a study of college gymnasts showed that 62% of collegiate female athletes had seriously abnormal eating patterns. Smith (1996) found that disordered eating is most common among those in appearance sports, such as gymnastics, ballet, figure skating, equestrian sports, and diving. However, disordered eating behavior can be seen in other sports in which appearance is not as important, such as tennis, swimming, and running. Skolnick (1993) also notes that another study of 182 female athletes, who participated in a variety of college sports, found that 32% showed disordered eating patterns. Margot Putukian, MD (1998) reports in Clinics in Sports Medicine that a study of college athletes found 32% practiced some form of pathogenic weight control behavior, and 70% believed their behavior was harmless.
A study by Rush, Joy, Bainbridge, and Macintyre (1997) concluded that poor eating habits and characteristics of the Female Athlete Triad are common among dancers. In the study, a survey to identify risk factors for the triad was administered to experienced ballet dancers between the ages of 15 and 19. The study found that 4% of the ballet dancers had been diagnosed with disordered eating, 21% reported four or more characteristics of disordered eating (skipping meals, weighing oneself more frequently than biweekly, use of over the counter diet pills or laxatives or diuretics, fasting, vomiting, and excessive exercise). NONE of the women had adequate dietary intake of calcium and 53% reported avoiding meat, a sign of inadequate protein and iron consumption. Rush et al (1997) concluded that these female athletes were by far not meeting the nutritional needs for their age and activity level. While this study does provide insight into the eating behavior of dancers, it is limited in its subject scope by only examining one group of female athletes, who may or may not be representative of all female athletes.
In 1998, a study by Klungland and Sundgot-Borgen at the Norwegian University for Sport and Physical Education found similar results in a study screening young elite athletes for eating disorders, menstrual dysfunction, and bone health. The subjects included all of the female elite athletes who qualified for the junior or senior national team in 48 different sports. Matched controls were included. Results from the study showed that all athletes except seven had body mass indexes below or within optimal level, yet 57% of the female athletes had tried to reduce their weight at one or more times. 18% reported a history of eating disorders and 11% reported having disordered eating at the time of the survey.
Wiita and Stombaugh (1996) suggest that such disordered eating practices only worsen the longer a girl remains active in her sport. In a study of adolescent female runners, dietary analyses were twice performed in three years. The study found that the runners limited their consumption of beef, milk, and cheese, and their daily protein intake decreased significantly from 1.6 grams per kilogram of body weight to 1.1 grams of protein per kilogram of body weight, significantly lower than the recommended intake for endurance athletes. Wiita and Stombaugh (1996) also found that the runners’ mean daily energy intake decreased from 2,150 kcal to 1,647 over the three years. Given their average height, weight, and activity level they should have been consuming close to 2,500 kcal a day.
The medical complications associated with disordered eating are severe and should be understood by any athlete suspected of abnormal eating behaviors. These complications include depleted glycogen stores, decreased lean body mass, chronic fatigue, micronutrient deficiencies, dehydration, anemia, electrolyte and acid-base imbalances, gastrointestinal disorders, decreased bone density, and more. While disordered eating patterns can arise out of an athlete’s attempt to control her body weight or composition in order to positively affect her performance, the result may actually be a performance decrease as she falls victim to self-starvation in an extreme desire to be thin.
Amenorrhea in Female AthletesThe second feature of the Female Athlete Triad is the onset of amenorrhea – the absence of menses for at least three months as the result of hypothalamic dysfunction associated with starvation and weight loss. There are two forms of amenorrhea, primary and secondary amenorrhea. Primary amenorrhea is the absence of menstruation by the age of 16 in a girl with secondary sex characteristics. Secondary amenorrhea is the form usually associated with the Triad and it is the absence of three or more consecutive menstruation cycles. The causes of amenorrhea are many and may include low caloric intake, strenuous training, low body fat, low weight, genetic disposition, stress, or an eating disorder. Regardless, amenorrhea is abnormal and very unhealthy!
Skolnick (1993) reports that 2% - 5% of the average population in the U.S. has amenorrhea. In contrast, Skolnick states that several studies suggest that 3.4% - 66% of female athletes have either primary or secondary amenorrhea. Rush, Joy, Bainbridge, and Macintyre’s study of ballet dancers (1997) found that 16 out of the 47 dancers, or 34%, experienced menstrual dysfunction. The 1998 Norwegian University study of elite athletes found similar results: 37% of the female athletes reported menstrual dysfunction, with 11% having had less than six cycles in the last twelve months. Slavin (1984) reports that in a study comparing 128 recreational female athletes to 36 elite female cyclists, 33% of the elite cyclists experienced amenorrhea, compared to only 7% of the recreational athletes.
A reduction in the frequency of luteinizing hormone (LH) pulses from the pituitary gland is the direct cause of amenorrhea and subsequent ovarian suppression in physically active women. Reduction in LH pulse frequency is thought to be caused by a decrease in the frequency of gonadotrophic releasing hormone pulses secreted by the hypothalamus. Williams study (1995) on strenuous exercise with caloric restriction reported that LH pulsatility was suppressed after three days of exercise training, while dietary intake was reduced, but was not suppressed when dietary intake was supplemented. In another experiment LH pulse frequency was reduced both in non-exercising women when dietary intake was restricted and in exercising women when their dietary intake was not supplemented for the energy cost of exercise (Loucks, 1994). These studies reinforce the necessity of adequate nutrition both for female athletes and non-athletes and the importance of a healthy balance between energy intake and expenditure.
While the studies are mixed as to the long term effects on fertility from amenorrhea, there are studies which illustrate the dangerous effects of amenorrhea both on mother and child. Bulik (1999) conducted a study to examine the fertility and reproductive history in 66 women who had a history or anorexia nervosa (of which amenorrhea is a necessary symptom) and 98 randomly selected controls. The study found that women with anorexia had significantly more miscarriages and cesarean deliveries, and the offspring of women with anorexia were significantly more likely to be born prematurely and were of lower birth weight than offspring of controls.
The primary medical concern from amenorrhea is decreased bone density and premature osteoporosis. Amenorrhea is characterized by low blood estrogen levels, and estrogen plays an important role in calcium absorption, which in turn helps to ensure adequate calcium for bone growth and maintenance. A study by Dueck (1996) suggests that there is such a link between amenorrhea and bone loss. Duck shows lumbar bone mineral density is reduced by approximately 14% in athletes with amenorrhea compared with eumenorrheic athletes and by as much as 27% compared with normal menstrual cycle, sedentary women (Cann, 1984).
While these studies are a starting point in identifying the prevalence of amenorrhea in athletes, one of the main problems in identifying the abnormality among young female athletes is that many women do not see the loss of their menstrual cycle as abnormal, and they may even find it desirable. Some myths that athletes believe may be difficult to combat. For some, exercise-induced amenorrhea signals that they are training at an appropriate intensity, rather than indicating an unhealthy state.
Osteoporosis in Female AthletesClosely linked to amenorrhea in female athletes is osteoporosis, the third feature of the Female Athlete Triad. Low estrogen levels from amenorrhea can contribute to poor bone mineral density and premature osteoporosis in active young women. Healthy bones are important for all women, but hold special significance for the young athlete. Bone is a reservoir for calcium and phosphorus and protects the body’s vital organs. Bone also provides structure through which muscles act to provide movement. A decrease in bone mass contributes to the disease of osteoporosis. Osteoporosis in the female athlete refers to inadequate bone formation and premature bone loss, placing the woman at risk for stress fractures and broken bones. Rush, et al (1997) found that 32% of the ballet dancers surveyed reported bone or joint pain. The Norwegian study (1998) of athletes found 15% of female athletes reported stress fractures. As a result of these bone deficiencies, a woman may end up in her 20s with the bone density of a woman in her 50s.
The real danger associated with osteoporosis at such a young age is the fact that studies (Drinkwater, 1984) suggest that the bone mineral density lost as a result of amenorrhea may be completely or at least partly irreversible even with calcium supplementation, resumption of menses, and estrogen replacement therapy. Drinkwater’s study found that previously amenorrheic women who resume menses experience only a 6% increase in bone density 14 months after menstrual regularity resumes. This increase did not continue at that rate but dropped to 3% the following year then reached a plateau at a level well below normal bone mass for their age. Four years later, Drinkwater’s study showed that these women still did not have normal bone mass. In the International Journal of Eating Disorders, a study by Dr. Tony Towell’s from the University of Westminister in London, cites similar results. Towell studied 56 women with eating disorders, of whom 48 were anorexic. The study found that despite increases in body mass index 9-51 months after the initial evaluation, no significant changes in bone mass density were observed at the second evaluation. Thus, Towell made the same conclusion as Drinkwater: an increase in weight may not be sufficient in itself to increase bone mass density.
What do we know and what do we NEED to know about this disorder?
In the past twenty years female athletes have surpassed numerous hurtles to rise to new levels of achievement in women’s organized sports. For most of these women, participation in sports is a positive experience, providing female athletes with improved health and fitness and increased self-confidence and self-esteem. For a subset of this group of women, however, is the group of female athletes who adopt a dangerous win-at-all-cost attitude which drives them to obsess with appearance and with being thin, thinking the thinner she is the better she will perform and the better she will look while doing so. With this attitude comes a dangerous set of physical disorders which if left unchecked may prove deadly. The interrelated components of disordered eating, amenorrhea, and osteoporosis need to be recognized by coaches, parents, and other athletes in order to prevent, treat, and reduce the Triad’s risks.
The Female Athlete Triad is still a relatively new discovery, and more research is needed on its causes, prevalence, treatment, and consequences. While the cited studies do serve as a starting point to gain an understanding of this problem, further studies are needed in many areas related to the Triad. Future longitudinal studies will benefit by including athletes and active women from diverse activities, ages, sports, and backgrounds. When today’s female gymnast weighs almost 20 pounds less than her counterpart of twenty years ago, it is clear that female athletes have placed a heightened focus on thinness, and disordered eating and its complications have been the result. It is unlikely that the external and internal pressures on female athletes to be thin will diminish any time soon. Therefore, all those individuals involved in female athletics must be alert to signs and symptoms that suggest the presence of the potentially very serious disorders of the Female Athlete Triad.
Bulik, C.M. (1999). Fertility and reproduction in women with anorexia nervosa: a controlled study. Journal of Clinical Psychiatry, 60, 130 –135.
Cann, C.E., Mmartin, M.C., Genant, H.K., Jaffe, R.B. (1984). Decreased spinal mineral content in amenorrheic women. JAMA, 251, 626-629.
Dueck, C.A., Matt, K.S., Manore, M.M., Skinner, J.S., (1996). Treatment of athletic amenorrhea with a diet and training intervention program. International Journal of Sports Nutrition, 6, 24-40.
Klungland, M., Sundgot-Borgen, J. (1998). The female athlete triad in young elite athletes. The Norwegian University for Sport and Physical Education, 30, 181.
Loucks, A.B. (1994). Low energy availability alters luteinizing hormone pulsatility in regularly mennstruating, young exercising women. Endocrine Society Meeting.
Putukian, M. (1998). The female athlete triad. Clinics in Sports Medicine, 17, 675-696.
Rush, S.R., Joy, E.A., Bainbridge, C.N., Macintyre, J.G. (1997). Survey of female athlete triad traits in dancers. The Orthopedic Specialty Hospital and University of Utah, 29, 279.
Skolnick, A. (1993). ‘Female Athlete Triad’ risk for women. Journal of the American Medical Association, 270, 921-923.
Slavin, J. (1984). Amenorrhea in vegetarian athletes. Lancet, 8392, 1474-1475.
Smith, A. (1996). The female athlete triad. Physician and Sportsmedicine, 24, 67.
Weight gain does not increase bone density in women with eating disorders. (2000) International Journal of Eating Disorders, 27, 29-35.
Wiita, B.G., Stombaugh, I.A. (1996). Nutritional knowledge, eating practices, and health of adolescent female runners: a 3-year longitudinal study. International Journal of Sports Nutrition, 6, 414-425.
Williams, N.I., Young, J.C., McArthur, J.W., Bullen, B., Skrinar, G.S., Turnbull, B. (1995). Strenuous exercise with caloric restriction: effect on luteinizing hormone secretion. Medicine and Science in Sports and Exercise, 27, 1390-1398.
Yeager, K., Agostini, R., Nattiiv, A., and Drinkwater, B. (1993). The female athlete triad: Disordered eating, amenorrhea, osteoporosis. Medicine and Science in Sports and Exercise, 25, 775-777.
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