The Female Athlete Triad
Laura Lawler, Senior Dietetics and Exercise Science Student, Iowa State University
The female athlete triad is a combination of disordered eating, amenorrhea and osteoporosis resulting from intense athletic training.
The athlete triad typically begins with disordered eating, which the National Eating Disorder Information Center defines as irregular, chaotic eating patterns from eating disorders to compulsive eating to habitual dieting (1). Many athletes turn to dieting to lose weight exposing them to factors of eating disorders. Athletes have added pressure to perform at high standards, acquire unrealistic weight and/or body fat goals, and achieve perfection. Perfection is a state of being, it cannot be "set", it can be interpreted, judged, etc. by coaches, family, peers or the athlete herself. Some sports pose a higher risk for developing eating disorders, especially those which perceive thinness provides the greatest performance; for example running, gymnastics, and dance. To attain peak performance, it is easy for female athletes to become preoccupied with food, caloric intake and body weight, which can lead to a distorted body image and disordered eating to set the female athlete triad into motion. (2)
Over decades, women have gained major ground in societal hierarchy. Yet, with all of these advances, feminism still holds a connotation of a slender body frame. Holding such an image can depress many individuals own body image. For many women, body image is the main triggering factor to developing an eating disorder. Body image is comprised of perception, attitude and behavior toward one's own body. When the attitude toward the body contrasts with an individual's personal view, body distortion develops because the mind does not see reality. A preoccupation with one's own body image can become pathologic, a compulsion, and simple food restrictions can develop into a wide spectrum of restrictions of foods, caloric intake or enjoyable daily activities.
Restricting behavior is a warning sign for eating disorder development. There are two types of factors involved in the development of eating disorders; predisposing and precipitating factors. Predisposing factors, which enhance the onset on eating disorders, are conflicts within families, a cultural ideology of thinness and/or obsession with perfection. Precipitating or contributing factors to eating disorders are chronic dieting, being a victim of bullying based on weight or the death of a loved one. The most commonly diagnosed eating disorders are Anorexia nervosa, Bulimia nervosa, Binge eating and Eating disorders not otherwise specified. Anorexia nervosa is categorized when there is severe weight loss from self-starvation and/or persistent behavior that interferes with weight gain. Within Anorexia nervosa, athletes can be diagnosed with Anorexia athletica; excessive fears of becoming obese, restrict calories, have severe weight loss and gastrointestinal dysfunction. Also, the athlete must show at least one of the following: body image disturbance, compulsive exercising, binge eating, purging, delayed puberty or menstrual dysfunction (although, amenorrhea is no longer a requirement for diagnosis). 4 Warning signs include amenorrhea, muscle loss, dry hair and skin, bradycardia, and minimal subcutaneous fat.
Bulimia nervosa, also, is composed of a drive for thinness and distorted body image but, the individual's body weight is usually normal or above normal because of the binge eating followed by a method of purging (vomiting, laxatives, diuretics, fasting, excessive exercise) at least once weekly. Warning signs of bulimia include erosion of tooth enamel, calluses on the back of the hand, preoccupation with quantities of food and/or calories, and eating alone.
Binge eating is when an individual has recurring bouts of significant caloric intake in a short amount of time than most people would under similar circumstances because of a lack of self-control. Many have a feeling of guilt, embarrassment of disgust, which can cause distress. Binge eating disorder is diagnosed when the average of binges is at least once a week over the last 3 months. (4)
In a Norwegian study, 20% of elite female athletes met the criteria for having an eating disorder, compared to 9% of female athletes who were not considered "elite."1 Although, most female athletes do not meet the strict criteria for these disorders, athletes often have many of the characteristics, putting them into classification of Eating Disorders not otherwise specified (EDNOS). (2,3) This classification of eating disorders is usually disordered eating through excessive exercise and inadequate caloric intake in excess or deficiency.
An athlete who has an eating disorder needs to be treated for complete recovery. Eating disorders should be treated nutritionally, psychologically and behaviorally. An undiagnosed eating disorder can decrease an athletes performance level, which can add more pressure, worsening the disordered eating habits. If eating disorders are not treated, complications can occur such as improper functioning of the cardiovascular, hormonal and gastrointestinal systems, imbalance in fluids and electrolytes, the onset of depression and even death. (2)
An imbalance in hormonal secretion can affect the menstrual cycle causing amenorrhea. The menstrual cycle is dependent on hormone levels in response to gonadotropins released from the hypothalamus in the brain. A normal menstrual cycle lasts 23-35 days, but any alteration in the hormonal secretion of gonadotropins will affect the menstrual cycle because these hormones regulate normal growth, sexual development and reproductive function. There are two types of amenorrhea: primary and secondary. Primary amenorrhea is when a female athlete has not started menarche (first menstrual cycle) after the age of 16. Secondary amenorrhea is the absence of a period for at least three to six consecutive months. Athletes have a higher incidence rate of amenorrhea because of the many factors that impact the menstrual cycle: weight, body composition, fat distribution, eating behavior and exercise. (2)
It has been proven that athletes with as low as four percent body fat can still have a regular menstrual cycle, but it is not uncommon for athletes to stop having regular menstrual cycles during their competitive season and return to a normal cycle during the off-season. When there is a lack of caloric intake, amenorrhea can occur because the gonadotropin, luteinizing hormone, a hormone that affects menstrual regulation, is not signaled. Luteinizing hormone depends on the energy available within the body. Since there is a lack of caloric intake, amenorrhea is the body's way of conserving energy. Amenorrhea has been related to decreased bone density, reproductive dysfunction, decreased estrogen levels and risk for cardiovascular disease. A decreased bone density can lead to stress fractures and early development of osteoporosis. Amenorrhea is completely reversible by decreasing the amount and intensity of training and/or increasing caloric intake if calories are deficient. (2)
When amenorrhea occurs, the body is deficient in the production of estrogen, the hormone that regulates bone density leading to osteoporosis. During the adolescent years and up until the age of 18, most women reach 95% of their peak bone mass. Once peak bone mass is reached, women lose about 1% of bone mass per year until menopause. Athletes who develop amenorrhea have more bone mass loss than those who have regular menstrual cycles. The exact rate of bone mass loss varies because of other factors such as age of menarche, timing and duration of amenorrhea and caloric intake. Osteoporosis is when an individual's bone mineral density is greater than 2.5 standard deviations below the mean of a normal young female, according to the World Health Organization. Many athletes participate in weight-bearing exercises, which does increase bone density. For example, speed skaters, gymnasts and soccer players have higher bone mass densities because of the high weight bearing loads and quick, spontaneous movements. Although, most athletes participate in weight-bearing exercises, these exercises may not be enough to offset the effects of the high intensity training. Therefore, athletes who are amenorrheic or are prone to low levels of iron should have their bone mass density monitored regularly through pre-physical exams. (2)
Beginning with disordered eating, leading to amenorrhea and osteoporosis, the female athlete triad can be prevented through education of the athlete, coaches, parents and teammates. Theoretically, any female can fall into the triad but it typically appears in female athletes because of societal pressures to be thin in order to achieve athletic perfection. It is important to take care of oneself emotionally, physically and spiritually which will improve body image and boost self-esteem. By suppressing disordered eating, the body's regular functioning of hormones allows for menstruation to completely cycle and reduces the rate of osteoporosis. If you or you know someone who falls into the female athlete triad, seek help as the long-term consequences of the condition are life threatening.
For questions, contact: Carrie J. Leiran, MS, RD, LD, The Nutrition Centre at UnityPoint Health - Des Moines, 515.241.8686, Carrie.Leiran@unitypoint.org
1 Bear, M. National Eating Disorder Information Center. Web. 20 Jun 2013. <http://www.nedic.ca/index.shtml>
2 Lebrun, Constance M M.D., M.P.E., C.C.F.P. and Rumball, Jane S. B.Sc., "The Female Athlete Triad." Sports Medicine and Arthroscopy Review. (2002) 10.1: 23-32.
3 Hobart, Julie A. M.D., and Smucker, Douglas R. M.D., M.P.H. "The Female Athlete Triad." American Family Physician. (2000) Jun 1;61(11): 3357-3364. < http://www.aafp.org/afp/2000/0601/p3357.html>
4 Grohol, John M. PSY.D.. "DSM-5 Changes: Feeding and Eating Disorders." PsychCenteral. (2013) May 28. <http://pro.psychcentral.com/2013/dsm-5-changes-feeding-eating-disorders/004412.html>