You may well be aware that nutrition plays a vital role in athletic performance, but what you might not know is the relationship of nutrition, or lack thereof, to two very serious disorders: amenorrhea (lack of menstruation), and osteoporosis. These three factors together combine to form a disorder known as the Female Athlete Triad. If you have a daughter who is physically active, or are the coach of young females, it is extremely important that you are familiar with this disorder, its risk factors and its symptoms. If not caught early, the health of those who have this disorder can be seriously jeopardized.
The Female Athlete Triad
The Female Athlete Triad occurs when there is energy drain on the body, either due to disordered eating or not eating enough to replace the energy used in training (1). If not corrected, this negative energy imbalance triggers amenorrhea, which in turn triggers low bone mineral density and places the athlete at risk for stress fractures and osteoporosis. Despite its name, not only athletes are at risk of the Triad. Any female who suffers from disordered eating can potentially be affected by the Triad. As a parent or coach, it is important that you educate yourself about the Triad and how to prevent it in your daughter or female athletes.
The first component of the Triad is dysfunctional eating, although this may not be the first observable symptom that something is wrong. Dysfunctional eating can range from dieting to fasting to full blown anorexia nervosa or bulimia. Dysfunctional eating can be intentional, as in the case of fasting, anorexia, etc, or it can be unintentional. For example, a highly active girl might not be intentionally trying to limit her caloric intake, but through her normal eating and exercise habits she may not be consuming enough calories to maintain energy balance, putting her in a state of negative energy balance. Although the unintentional disordered eating needs to be taken seriously, of most concern is intentional disordered eating.
Disordered eating is thought to result from a wide variety of factors. The American College of Sports Medicine (ACSM) lists the following as possible factors that contribute to disordered eating: social pressure to be thin, low self-esteem, family problems, abuse, repeated dieting, sport-related emphasis on body weight, perfectionism, and outside pressure to be a certain weight. Sports considered aesthetic sports, such as dance, figure skating, gymnastics, and diving are thought to contribute to disordered eating due to the emphasis on a lean physique (1). A Norwegian study found elite aesthetic sport participants to be at a significantly higher risk for the Triad than athletes participating in other sports and non-elite athletes (2). Other sport situations cited by the ACSM that potentially place a female athlete at risk of developing disordered eating, and subsequently the Triad, include participation in endurance sports (running, cycling, cross-country skiing) where a low body weight is thought to help performance, sports that require revealing clothing, sports with weight classes, and sports where the pre-pubertal body is considered advantageous for success, such as gymnastics or figure skating (1).
The importance of receiving proper nutrition should not be overlooked for any reason. The body requires adequate nutrition to sustain natural growth and maturation. Young athletes are growing and maturing in addition to placing a great deal of physical stress on their bodies, and this places them in a delicate situation. It is critical for parents and coaches to monitor eating habits and ensure that all children are getting adequate nutrition. Should an eating disorder develop, the consequences can be devastating. Lo, Herbert and McClean (3) list the following potential consequences of eating disorders: electrolyte imbalances, mental slowing, and decreased athletic ability . . . thermoregulatory problems, cardiac abnormalities, nutritional deficiencies, impaired immune systems, depression, and hypoestrogenism with resultant amenorrhea and musculoskeletal consequences (p. 2). If you suspect your child is beginning to develop bad eating habits, intervene right away. It is essential for you to set a good example for them in your own eating habits. Don’t talk about dieting around them or make comments about your own weight, much less theirs. The ACSM recommends avoiding placing pressure on your daughter to be a certain weight (1).
The second component in the Female Athlete Triad is amenorrhea. This funny word means simply that you are not menstruating. Primary amenorrhea refers to the condition where a girl has well passed the average age of 12.9 years (3) for the onset of menarche and has yet to have started menstruating. Secondary amenorrhea is the condition where a female experiences an absence of menstruation for three or more consecutive months. Amenorrhea may often be the best sign that an athlete is on her way toward developing the Triad (1). It should be taken seriously, as it has been linked with a greater risk for low bone mineral density, occurrence of stress fractures, scoliosis, and premature osteoporosis (3).
Amenorrhea is thought to occur in athletes primarily as a result of low energy availability, or energy drain. In athletes it is generally a signal that the athlete has been over training, but could also be a sign that one is not consuming enough calories. It is possible that amenorrhea occurs as the body’s way of saving energy (4). When it does occur, it results in low concentrations of ovarian hormones such as estrogen (1). Estrogen is needed for the body to absorb calcium and build bone mass. Are you beginning to see the connection to disordered eating and osteoporosis? The good news is there is a good chance that if changes are made in the diet and training program to create a positive energy balance, amenorrhea can be reversed. One study found that simply adding a day off and increasing the caloric intake of a female amenorrheic track athlete was enough to see a return of menstruation (5). The bottom line is amenorrhea is a serious problem, and if it should occur the best thing to do is to consult your doctor. If you let it go, it could result in stress fractures and even early onset osteoporosis.
The final component in the Female Athlete Triad is osteoporosis. You may be thinking this is a problem only frail old ladies need to worry about. The reality is that in the early teen years is when we deposit our bone mass, and between the ages of 25 to 30 is when we are at peak bone mass (3). Calcium and estrogen are two key components involved in building bones, and eating disorders and amenorrhea interfere with both of these components. Dysfunctional eating may result in insufficient consumption of calcium, while at the same time leading to amenorrhea, which results in low levels of estrogen. Estrogen is needed to absorb the calcium, and when both are low, bone mineral density will most likely be low as well. And while it is possible to reverse amenorrhea, it may not be possible to completely reverse the effects brought on by low estrogen and calcium deposition. Lo et al. (3) reported that “even after spontaneous resumption of normal menses, these women may never reach normal bone mass and are at a greater risk for premature osteoporosis” (p. 4). It should also be pointed out that amenorrhea does not immediately signal low bone mass. If it is short lived and nutrition was good before it occurred, it is possible that bone loss will not have yet occurred (1).
Strong bones and a healthy body are vital to a physically active lifestyle. Stress fractures or other problems caused by the triad can limit the activity that a person can do and potentially end a sports career. It is important that all girls are aware of how important it is to take good care of their bodies when they are in early adolescence and adolescence so that they may help ensure that they can stay active and live as a healthy, active adult. Parents and coaches need to be there to support their daughters or female athletes through a stressful and confusing time of their lives and not exacerbate the problem through well-meaning but misguided comments.
Prohibit yourself from making comments on appearance or weight. If your daughter brings up the subject, for example saying she’s fat, help guide her toward a different view of herself. Help her to see all of the good qualities she has to offer and concentrate on those. Not all of the risk factors for disordered eating, and in turn the Female Athlete Triad, can be so easily prevented, but working together with your daughter and being aware of what is going on in her life can help you to identify the problem before it starts.
Further Sources on the Triad From The Educated Sports Parent
(1) American College of Sports Medicine. (1997). The Female Athlete Triad. Medicine and Science in Sports and Exercise, 29, i-ix. Retrieved March, 2005 from http://www.xanedu.com.
(2) Sundgot-Borgen, J. (1994). Risk and trigger factors for the development of eating disorders in female elite athletes. Medicine and Science in Sports and Exercise, 26, 414-419. Retrieved March, 2005 from http://www.xanedu.com
(3) Lo, B. P., Hebert, C., & McClean, A. (2003). The female athlete triad: No pain, no gain? Clinical Pediatrics, 42, 573. Retrieved November 28, 2005 from ProQuest database.
(4) Eldridge, J. (2005). University of Texas of the Permian Basin Training and Conditioning Methods Course Notes: Module 3. Retrieved January, 2005 from http://uttc.blackboard.com.
(5) Dueck, C. A., Matt, K. S., Manroe, M. M., & Skinner, J. S. (1996). Treatment of athletic amenorrhea with a diet and training program. International Journal of Sport Nutrition, 6, 24-40. Retrieved March, 2005 from http://www.xandeu.com