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2000 Third Web Report
The Female Athlete Triad is defined as the combination of the three distinct, but interrelated conditions of disordered eating, amenorrhea, and osteoporosis, which are associated with athletic training in females (2). The Triad has become a particularly salient issue in more recent years because of the passage and enforcement of Title IX and the success of women's sports teams in international events. Female athletes have become more visible in society, and participation, especially among girls and young women, in sports and other athletic activities has increased. However, in a culture that propagates unrealistic standards for body image for females, many of these girls and young women may be at an increased risk to develop one or more of the conditions of the Triad. Although the internal psychological and external social pressures placed on girls and women to achieve or maintain unrealistically low body weight underlie the development of this disorder (8), the possible physical consequences can be especially devastating. As the components of this disorder are often unrecognized and/or overlooked because of the misconception that they are harmless, there is a pressing need to inform and prevent, as well as detect and treat the disorders among female athletes. Moreover, in order to promote and facilitate physical, mental and social well being and a better self-image, the greater social influences affecting the female athlete, and more importantly, the female, should be addressed.
In an attempt to excel at their sport and to attain the body image that society has set for them, many girls and young women have taken on unhealthy nutritional habits such as calorie restriction, bingeing and purging. Eating disorders among female athletes have been found to range from 16 to 72% (Brooks-Gunn 1987; Burckes-Miller 1988; Rosen 1988) while in the general population they have been found to range from 5 to 10% (9). Moreover, females appear to be at much greater risk than are their male counterparts for disordered eating, and there are a number of studies that indicate that female athletes struggle more with eating disorders than women in the non-athletic population (8).
In a study done at Ball State University by Katherine Beals and at Arizona State University by Melinda Manore, it was discovered that athletic women were eating significantly less than non-athletic women (1). This is significant because "disordered eating" or "sub-clinical eating disorders" may explain why women have 75% more sports injuries than do their male counterparts (1).
Skolnick (1993) found in a study of 182 female athletes, who participated in a variety of college sports, that 32% showed disordered eating patterns (4). Putukian (1998) also reported that a study of college athletes found that 32% practiced some form of pathogenic weight control behavior, and 70% believed their behavior was harmless (4). In addition, studies have reported disordered eating behavior in 15 to 62% of female college students (5).
Eating disorders are complex disorders that have social, cultural, psychological, behavioral and physiological components. They usually begin during adolescence "with a mean age of onset ranging from 14 to 20 years of age, which is also the primary age range for athletic training and participation (Woodside 1992)" (9). However, the area of disordered eating in the female athlete is not well defined. Because many athletes do not meet the strict criteria for anorexia or bulimia that are listed in the Diagnostic and Statistical Manual of Mental Disorders (5), the eating disorders of these athletes are often overlooked. They may instead engage in regular caloric restriction and fail to meet the caloric and nutritional requirements of their activity (2). In response to pressure to lose weight, they may also practice "unhealthy weight-control methods, including...self-induced vomiting, consumption of appetite suppressants and diet pills, use of laxatives and compounds..." (6). This may not seem overtly dangerous, however these practices in poor nutrition often cause tiredness, performance plateaus or declines, burnout, and repeated injuries. Moreover, in the Female Athlete Triad, disordered eating may cause amenorrhea and in the long run, osteoporosis.
Amenorrhea is a menstrual abnormality that may be caused by low caloric intake, strenuous training, low body fat, low weight, or an eating disorder, (4) and it is more common among female athletes than in the general female population. Skolnick (1993) reports that 2-5% of women in the general population in the U.S. have amenorrhea, while 3.4%-66% of female athletes have amenorrhea (4).
Over the years, this menstrual dysfunction has been associated with high levels of physical activity (2) in competitive female athletes, many times with the incorrect assumption that it is a normal consequence of training because it is so common. Indeed, there has been little concern with this phenomenon because it has been observed that once the activity levels of the female athletes decreased, normal menstrual cycles returned without apparent harm to the athlete (2).
Secondary amenorrhea is the loss of menstruation for three or more consecutive cycles (2) in a female with previously regular menses and is the amenorrhea most commonly associated with the Female Athlete Triad. It is also known as hypothalamic amenorrhea.
Normal menstrual function relies upon the delicate balance of the hypothalamic-pituitary-ovarian axis (8). The functioning of this system depends on the secretion of gonadotrophin-releasing hormone (GnRH) from the hypothalamus (9), which in turn stimulates the production of luteinizing hormone (LH) (4). In amenorrheic athletic females, the secretion of GnRH appears to be lower than in normal females, leading to decreased production of LH, which then leads to a decreased production of estrogen (4). It is believed that the decreased estrogen levels associated with hypothalamic amenorrhea may lead to the premature osteoporosis found in female athletes affected by the Female Athlete Triad (3) because estrogen is needed for proper bone construction (7). Estrogen plays an important role in calcium absorption, which helps to ensure adequate calcium for bone growth and maintenance (4). Thus, the rigorous physical training and caloric restriction practiced by some female athletes may place them at greater risk for amenorrhea and the related risk of osteoporosis (2).
Osteoporosis is a disease characterized by low bone mass and "microarchitectural deterioration" (6), which leads to bone fragility, and the subsequent increased risk of nontraumatic fractures (8). Osteoporosis in the female athlete specifically refers to inadequate bone formation and premature bone loss (4). Although this disease is commonly thought of as a disease striking postmenopausal women, it is seen in young amenorrheic women as well.
Although healthy bones are important for all women, they hold special significance for athletes. Premature osteoporosis in the short run may cause amenorrheic athletes to have higher rates of injury, particularly stress fractures (2). In the long run the consequences are more severe, as those with premature osteoporosis are at increased risk for osteoporotic fractures and "their incumbent morbidity at a younger age" (2).
Recent studies indicate that peak bone mass occurs at a younger age than previously thought. Several studies have shown that the average peak bone mass occurs closer to the ages of 18 to 25 than the age of 30 (5). Following this time, both men and women lose bone mass at an extremely slow rate throughout life. However, women with menopause develop a ten-fold increase in the rate of bone loss due to estrogen deficiency, and postmenopausal women lose most of their bone mass and density in the first four to six years after menopause (8). If this is true of amenorrheic athletes, intervention is needed before bone mass is irreversibly lost (5).
However, in 1984, both Cann et al. and Drinkwater et al. noted that the bone mineral density in amenorrheic athletes was significantly lower than in their peers with normal menstrual cycles. Moreover, in 1986, Drinkwater noted that the bone mineral density in these amenorrheic athletes did not catch up to that of their peers. These studies as well as others suggest that the bone mineral density lost as a result of amenorrhea may be completely or at least partly irreversible (2) even with calcium supplementation, resumption of menses, and estrogen replacement therapy (4).
Implications & Discussion
Thus, there need to be efforts in early prevention, early detection, and early treatment because these interrelated conditions have long-term consequences. Education efforts should be focused on junior high and early high school girls because of the rapid bone formation that occurs during puberty (2). Moreover, this is also the age during which many girls both get involved in sports and begin to worry about their body image.
The Triad is often denied, not recognized, and under reported. Some components of the female athlete triad are often undetected because of the spectrum and hence, lack of definition for disordered eating, as well as the commonly held belief that amenorrhea is a normal consequence of training (5). These common misconceptions associated with the Female Athlete Triad need to be dispelled not only within the female athlete population, but also within society for the conditions to be properly addressed, detected and treated.
As for treatment of the Triad, reduced training intensity and nutritional counseling should be implemented because they are interconnected. Both should be regulated in order to help ensure good health for the athlete (3). Proper nutritional practices should also be taught in general as a means of early prevention, as well. In addition, women with one component should be screened for other components. Preservation of bone mineral density is one of the many reasons to screen female athletes and diagnose the triad early on (5), as the potential damage of osteoporosis may be irreversible.
Furthermore, although the Female Athlete Triad is specifically termed for diagnosis among female athletes, girls and women participating in a wide range of physical activities are at risk (8). This is an issue that is not limited in significance to just female athletes, but one that can be extended to the general female population because most females face societal pressure to be thin at some point in their lives.
A young woman or girl who wants to be thinner to enhance performance may attempt to do so through dieting and excessive exercise. Societal perpetuation of the ideal body image may intensify the desire for a "better" body. Sports, such as figure skating, gymnastics, ballet, distance running, diving and swimming that emphasize appearance can even increase the risk of developing the female athlete triad (5).
However, education and treatment efforts about the Triad and its possible devastating consequences should not be limited to females or female athletes themselves, but also to their parents, coaches, and peers. While aiming to restore the affected individuals' physical and mental health, these efforts should also explore the deeper social influences being placed on the individual. Family, peers, and coaches all play key roles in contributing to the risk factors associated with eating disorders, however well meaning they may be.
By attempting to prevent eating disorders, however, our cultural obsession with being thin as a physical, psychological, and moral issue, must also be addressed. In addition, there is a need to focus on the development of the young female's self-esteem and self-respect apart from appearance issues. There is a very distorted meaning of both femininity and masculinity in today's society that often emphasizes appearance and body size. While athletic involvement is related to physical appearance and general self-esteem, it is also related to greater self-concept (Jackson 1986) (9). Thus, the key is to promote balanced physical, mental and social well being for good health.
2) The Female Athlete Triad , article in Uconn Health Center Sports Medicine
3) Nutrition for Female Athletes , article in obgyn.net
4) What is the relationship between the 3 elements of the Female Athlete Triad: Disordered Eating, Amenorrhea, and Osteoporosis? , article by Sophie Kennedy in Health Psychology Home Page of Vanderbilt University
5) The Female Athlete Triad - June 1, 2000 , article in American Academy of Family Physicians
6) The Female Athlete Triad / The NCAA News: News & Features article in sports science newsletter
7) The Female Athlete Triad, NF98-361
8) The Female Athlete: An Update , article in hypermedic.com
9) The Female Athlete Triad from a Social Ecological Perspective
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