Female Athlete Triad

In 1992, the American College of Sports Medicine first recognized that girls and women in sports were particularly susceptible to three interrelated conditions – disordered eating, menstrual irregularity, and osteoporosis – that have come to be known as the "female athlete triad."

1. DISORDERED EATING

Contrary to popular belief, eating disorders are not limited to classic eating disorders (anorexia and bulimia), but occur on a spectrum ranging from calorie, protein and/or fat restriction and weight control measures (diet pills, laxatives, excessive, compulsive exercise in addition to normal training regimen, self-induced vomiting) to full-blown anorexia and bulimia.

Anorexia

Anorexia is a condition in which a girl's diet does not allow her to maintain her weight within 15% of the mean for girls her age and height. (Remember: daily requirements for calories, carbohydrates, and protein are greater for athletes).

Warning Signs:
- Sudden weight loss or gain
- Distorted body image
- Obsession with weighing oneself;
- Avoidance of social eating (i.e. a girl who likes to eat alone);
- Preoccupation with food and dieting/unreasonable fear of being fat (girls on severe diets in one Australian study were 18 times more likely to develop an eating disorder; moderate dieters were 5 times more likely than those who did not diet; Harvard researcher says 44% of high school girls and 15% of boys diet);
- Hair loss;
- Intolerance to cold
- Obsessive exercising

Bulimia

Bulimia is where a girl engages in "binge eating" (i.e. eating too much uncontrollably in one sitting) and then purging (vomiting, exercising intensely) to get rid of the food just eaten.

Warning Signs:
- frequent use of bathroom after eating
- Fluctuating weight
- Bloodshot eyes
- Swollen glands
- Swollen extremities
- Discolored teeth (i.e. eroded tooth enamel from frequent vomiting)
- Feelings of depression, guilt or shame about eating
- Suicide attempts
- Drug use
- Aches and pains
- Dramatic fluctuations in athletic performance

Serious Health Problems

Disordered eating results in serious health problems, some of which are potentially fatal (the mortality rate in severe cases can be as high as 10 to 15% from heart failure, hormonal imbalances or suicide), including:

heart problems such as irregular heart beat;
muscle weakness or fatigue;
fainting;
loss of concentration in school work and athletics;
irreversible bone loss;
decrease in athletic performance (decrease in endurance, strength, reaction time, speed);
depression
fluid and electrolyte imbalance [1]; and
suicide

Athletes at Risk

Though seen in all sports, those at greatest risk are those:

Playing single sport on a year-round basis;
Playing endurance sports (long distance running, swimming, cross-country skiing);
Engaged in sports demanding a thin physical appearance (gymnastics, ice skating, ballet dancing, diving);
Participating in sports with weight classifications (martial arts, rowing, wrestling);
Whose parents are perfectionists and put too much pressure on their athletic daughters to succeed no matter what the cost.

Chicken or Egg?

The problem is that the personality of an elite athlete and the personality of one prone to eating disorders have a lot in common: an additive/compulsive personality; a strong desire to do well/achieve perfection; a high desire to please other people, a desire to push oneself to the limit, and to work through pain without letting anyone know. In other words, disordered eating in athletes presents a classic "chicken or egg" question: do sports create eating disorders or do sports attract girls who are already prone to eating disorders in the first place?

Conflicting Cultural/Peer Messages

Girls are also sent conflicting messages by our culture and by their peers: that it is acceptable for them to participate in sports, but they also need to maintain the figure of a super model. The effect of societal pressure to be thin combined with similar pressures in sport may be a higher incidence of disordered eating behaviors and body shaping drug use (tobacco, diet pills, diuretics, laxatives, amphetamines and anabolic steroids) in athletic girls.

Reached Epidemic Levels

The number of athletes affected by eating disorders is staggering:

Depending on the survey, eating disorders are thought to affect anywhere from 15 to 62% of girls.
Among teens and younger children, disordered eating has reached "epidemic levels," according to researchers at the National Association of Anorexia Nervosa and Associated Disorders.
A 10-year study revealed that some 7 million U.S. females and 1 million males have eating disorders; that 10 percent reported that disorders began in elementary school, with some children as young as 7 or 8 preoccupied and dissatisfied with body image and weight.
Fully forty percent of 9-year-olds in one Harvard study reported dissatisfaction with body shape and as a remedy turned to dieting.
A 1996 study reported disordered eating in 100% of elite female gymnasts, and osteoporosis in more than half.

2. AMENORRHEA

Healthy weight is important for normal estrogen levels. When a female athlete's weight drops to an unhealthy level (i.e. when the percentage of body fat falls below 17 to 18%), either through disordered eating and/or intense training, menstruation may not start, may become irregular, or stop altogether. It is a myth that the absence of menses simply proves that a female athlete is training hard, and that amenorrhea is a positive adaptation of girls to exercise.

"Primary" and "Secondary" Amenorrhea

A girl is deemed to have "primary" amenorrhea if she has not begun to menstruate within 4.5 years after onset of breast development (menstruation usually begins between ages 12 and 15 for non-athletic females and 13 to 15 ½ for athletes). A girl who has not gotten her period for three to six months, menstruates irregularly or with very light flow, or at intervals longer than 35 days is considered to have "secondary" amenorrhea.

Affects All Female Athletes

Amenorrhea effects girls competing in all sports, but is most prevalent in competitive female gymnasts, ninety percent of whom get their periods a year or two late.

Because a female's body needs estrogen to absorb calcium for strong bones, not enough estrogen can cause bones to lose thickness and strength, resulting in a greater risk of stress fractures and osteoporosis. Research suggests that even minor forms of menstrual dysfunction may adversely effect bone density and lead to at least partially irreversible bone loss, although the silver lining to delayed menstruation is that it may lower a girl's risk of developing certain estrogen-related cancers.

3. OSTEOPOROSIS

A girl's teen years are a critical time for developing normal, strong bones as they are the years in which girls add half of their bone mass. Only ten percent of bone mass is added after age twenty. Too much exercise can cause effect bone mass and density, leaving a female athlete prone to increased risk of stress fractures if a girl is not having regular periods and does not have normal estrogen levels.

Prevention

Balanced Diet. First, and foremost, a proper balance of exercise, body weight, calcium intake, Vitamin D (400 IU's daily) and estrogen is critical to prevent osteoporosis (1500 mg. of calcium if irregular menses, 1200 mg. if regular periods, either via 3 to 4 dairy products a day or supplements). If necessary, you should take your daughter to a dietician or nutritionist who works with adolescent athletes.
Screening. To screen for the triad, make sure your daughter undergo a pre-participation physical evaluation. It is essential that, in taking the medical history, your daughter's pediatrician asks questions about nutrition, menstruation, evidence of bone mineral loss (stress fractures; Dual Energy X-Ray Absorptiometry scan), and body image . Because athletes tend to be more honest about menstrual history and are typically dishonest about eating patterns, an abnormal menstrual history is a red flag for eating disorders and psychological issues (this is why your daughter should keep track of her periods).
No Pressure. As a parent you should avoid pressuring your daughter to achieve an unrealistically low body weight, such as by comments about appearance, good or bad foods, dieting and nutrition (this advice holds true for your sons as well, particularly swimmers and wrestlers) You should be wary of coaches who conduct out-of-competition weigh ins or measurement of body fat, especially public ones which can highlight for teenage girls the already sensitive issue of their weight (one prominent Southern California swim club that counts among its alumni numerous Olympic gold medal winners labeled members with what it deemed too high a body fat ratio as members of the "Blub Club"). One eating disorder specialist theorizes that a relationship exists between eating disorders and girls going through the natural separation in adolescence of girls from their fathers because they are particularly vulnerable during this time to viewing their coach as a substitute father figure. Because girls tend to internalize criticism more than boys, if the coach is critical of her weight, he or she can have a negative effect on a female athlete's self-esteem.
No Secrets. Fourth, if you suspect that your daughter exhibits symptoms of one or more elements of the triad, let her know that you want to help but that you can't keep the matter a secret, nor can you solve the problem on your own. If she is found to have disordered eating, experts recommend a multidisciplinary treatment approach (doctor, nutritionist, mental health professional).

Above all, be patient. Don't engage your daughter in a test of wills.

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Female Athlete Triad

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