Female Athlete Triad. Shea Teresi. SUNY Oneonta

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1 1 Female Athlete Triad Shea Teresi SUNY Oneonta

2 2 Physical activity, along with eating nutritiously, are a very important and essential aspect in maintaining a healthy lifestyle for both men and women. Eating adequately before, during and after exercise is a huge component for a high level of performance and recovery for athletes. Unfortunately for some young women, being involved in regular exercise or sports has brought on some negative behaviors. The Female athlete triad syndrome was defined by the American College of Sports Medicine (ACSM) in 1992 after certain negative behaviors in young female athletes were observed with high prevalence (Lebrun, 2007, p.397). The triad syndrome originally included these 3 distinct components: disordered eating, amenorrhea, and osteoporosis/ osteopenia. These components were believed to be too broad and are now recognized as: disordered eating, menstrual dysfunction, and altered bone mineral density (BMD). This syndrome is seen in female athletes of all ages but it is mostly seen in young female athletes, both in high school and collegiate level sports. Although the participation in sports is a benefit for the health of the athletes and their body image, select populations of these athletes fall under the pressure of certain body image and aesthetics standards of the sport. Also, sports that place an emphasis on leanness and low body weight, such as gymnastics, wrestling, lightweight rowing, horse racing, figure skating, body building and distance running (Alters & Schiff, 2011, p.46)can also cause females to develop the triad behaviors because low body weight is seen advantageous for performance. Acquiring one or more of the three components over a period of time will cause short term as well as long term consequences on the health of the female, especially if she starts as a still developing adolescent. It is important to inform parents, coaches and athletes of the female athlete triad syndrome and the consequences

3 3 these behaviors have on the body of the athletes as a means of prevention and to intervene with treatments if an athlete displays one or more of these behaviors. Most factors that put an athlete at risk for developing disordered eating are personal and self-induced. Personal factors that may create risk for an athlete include: inaccurate belief that lower body weight will improve performance, imbalance between energy input and output resulting in weight loss, low self-esteem, or self-appraisal, dysfunctional interpersonal relationships, a genetic history of eating disorders/ addiction, chronic dieting, history of sexual or physical abuse, peer and cultural pressures to be thin, coaches who only focus on success and performance rather than on the athlete as a whole person, and performance anxiety or a fear of failure (Matsumato, 2010, p.5). When these risks trigger eating disorders weight loss results but this weight loss can actually be detrimental to performance despite the athlete s belief. When energy input is lower than energy output (under eating), the body actually starts to break down muscle mass for fuel which, in the long run, weakens performance. Prevention methods, which will be discussed later, are essential for decreasing the risk of athletes obtaining one or more of the triad. When a young female athlete begins to believe that she needs to lose weight, either for aesthetic reasons or performance benefits, she usually begins changing her energy availability. Energy availability is defined as energy intake minus energy expenditure (Thein-Nissenbaum, Carr, 2011, p ). This relationship, determines whether the body can regulate normally and properly or abnormally in a negative energy state. Methods that reduce energy availability, recognized as disordered eating, include: restricting food intake, fasting, self-induced vomiting,

4 4 diet pills, laxatives, diuretics, and excessive exercise (Lebrun, 2007, p.399), while in more severe cases some athletes obtain serious eating disorders such as anorexia nervosa and bulimia nervosa. Although the prevalence of disordered eating is not exactly known, studies have reported disordered eating in up to 62% in female athletes (Matsumato, 2010, p.7). Females that adopt these unhealthy behaviors are usually young high school athletes because most have negative thoughts and attitudes towards their changing and maturing bodies so they are most vulnerable and tempted to try anything to achieve their ideal body. These young girls see quick results shortly after they begin these risky techniques. But, what these young athletes don t know is that restricting energy availability through disordered eating over a long period of time can cause hormonal and nutrient changes that affect their performance and most importantly, their growth and development. Hormones are made in the body to stimulate reactions in the body. Menstruation is one of the most important cycles in females that is directly affected by certain levels of specific hormones. Amenorrhea, which is defined as the absence of menstruation, is diagnosed as either primary or secondary. Primary amenorrhea is defined as the lack of menstruation by age 15 while secondary amenorrhea is the cessation of menstruation for 3 consecutive months in the adolescent/ adult who has started menstruation (Thein-Nissenbaum, Carr, 2011, p.109).although the prevalence is not exactly known, Menstrual abnormalities are estimated to affect 20% of exercising females and studies in the adolescent athletic population have estimated the prevalence of MI (menstrual irregularities) to range from 20% to 54 % (Thein- Nissenbaum, Carr, 2011, p.109). Secondary amenorrhea is said to be triggered when caloric intake is 30 % less than the energy the body requires in accordance to the individual s level of

5 5 activity (Brown, 2011, p.75). Weight loss as a result of restricted energy intake can lead to an inadequate level of body fat (BMI <18.5) for normal body functions and a loss that exceeds approximately 10-15% of usual weight decreases estrogen, Luteinizing Hormone (LH) and FSH concentrations (Brown, 2011, p.58). According to Lebrun s The Female Athlete Triad, the onset of menstrual cycle irregularities is caused by the decreased secretion of the luteinizing hormone (LH) and gonadotrophic releasing hormone (GnRH) (p.120). The decrease in LH and GnRH directly affects the level of estrogen and progesterone circulating in the blood. A drop in estrogen levels causes bone mineral density alterations which can lead to stress fractures and in severe cases broken bones as well as permanent and irreversible damage to the bones. If left untreated, the cessation of menstruation can have dire consequences on the state of fertility of the female individual as well as bone mineral density alterations that not only affects the risk of injury but the chances of osteopenia/ osteoporosis. Moderate physical activity (about 40 minutes/day) is actually very beneficial for the bone health of developing adolescents. Weight bearing activities such as gymnastics, strength training, hiking, walking, etc., places a constant stress on the bones and muscles which is beneficial in achieving peak bone mass during the adolescent years. On the contrary, when hormones such as estrogen decrease along with intake of important nutrients such as calcium and vitamin D, the risk of premature loss of bone mineral density is increased and may lead to irreversible damage. When a female doesn t allow herself to achieve peak bone mass, which accrues before age 30 according to Lebrun (2206, p.120), the chances of developing osteopenia (Low bone mineral density that precedes osteoporosis) and osteoporosis prematurely, is heightened. Serious injuries such as stress fractures and broken bones are more likely to occur

6 6 as well because with bone demineralization comes more fragility. A recent study on the relationship between triad components and other conditions such as musculoskeletal injuries, performed by M.J Rauh, determined that athletes reporting disordered eating were over 2 times more likely to incur a musculoskeletal injury than female athletes who reported normal eating behaviors (Thein-Nissenbaum, Carr, 2011, p.113). The danger lies mostly within the knowledge of the athlete. Many women may not realize or know that the cessation of their menstrual cycle for an extended period of time is detrimental for their future health. What most females do not know is that those that become amenorrheic or menopausal increase BMD loss up to 2% each year instead of.3% each year in a premenopausal, non-amenorrheic state (Lebrun, 2007, p.399). This means that those who don t seek medical guidance or treatment immediately after the cessation of menstruation, potentially risk losing 7 times as much bone mineral density or risk a much higher level of decreased bone formation each year than if they were not hypoestrogenic. The female triad is a complex and under-recognized syndrome that needs the involvement of parents, coaches and health professional s for prevention measures as well as treatment. Prevention measures should focus on informing and educating parents, coaches and athletes about the triad, the consequences it has on the athlete, how to recognize behavioral warning signs of developing disordered eating and how to prevent the triad. Young female athletes are especially vulnerable to the societal norms and stereotypes placed on the body image of certain sports (such as aesthetic sports), so one of the most important ways to help prevent athletes from thinking you have to be thin to win is not emphasizing weight as component of performance quality. Instead coaches and parents should encourage the athletes

7 7 to use emotional skills such as goal setting, imagery, positive thoughts and self-motivation to enhance their training and competition (Sherman & Thompson, 2012, p.42). This allows the athlete to build up their confidence so they train better with healthier methods and strengthen the team as a whole. Coaches, parents and even medical professionals can talk to the athletes about the importance of an adequate diet. But it is essential that the nutrition education is based on the concept of energy in relation to performance, not weight. This avoids the possibility of girls adopting disordered eating based on anxieties they form to fit a certain image. Because girls are ultra-sensitive to weight gain, coaches should avoid frequent weigh-ins as they cause girls to give themselves unhealthy consequences such as limiting calorie intake or excess exercising, for any weight gain they see (Matsumato, 2010, p.5). Athletes most at risk to the triad are usually high achievers, perfectionistic, and goal-orientated, with the need to be in control (Lebrun, 2006, p. 120)as well as those who have low self-esteem, few friends, and identify thin physiques with ideal body shape (Alters & Schiff, 2011, p.46). Recognizing behavioral risks helps coaches and parents from making inadvertent comments about the athlete s weight and therefore avoids a situation which could cause the at risk athlete s psychological balance to tip. Educating coaches, players and parents about the triad is the best prevention method that can help athletes create and carry healthier lifestyles and ways of thinking for the rest of their lives. Screenings and evaluations are productive measures in detecting disordered eating in athletes that can help determine if an athlete needs professional help and treatment. Preparticipation Physical Evaluations (PPE) are given to athletes who present any one component of the female athlete triad and need to be evaluated for the presence of the other

8 8 two components (Lebrun, 2006, p.121). This evaluation offers an opportunity for physicians to screen for problems in a way that doesn t threaten the athlete. Menstrual history, a brief nutritional screening and questions that regard perceived body image, in a non-threatening manner, as well as health history questions, diet behaviors and issues of control are things commonly asked on PPEs. An athlete can also be evaluated for stress fractures, recurrent illness or injuries, menstrual changes, cardiac arrhythmias and depression (Lebrun, 2007, p.402). If the physicians deduce that an athlete presents one or more of the triad, treatment and help can be administered immediately. Based on the severity, athletes exhibiting one or more of the triads can receive behavioral/ psychological interventions as well as nutritional and supplemental/ medicinal intervention if needed. An athlete may initially exhibit denial that she has a problem, but once a nurse or physician informs the athlete of the triad and its consequences, the athlete may accept her problem. Once she accepts and realizes she needs to change her ways she will be able to receive and fully accept nutritional intervention, supplemental intervention if needed and even psychological intervention. Nutritional intervention is administered to help restore the body s strength by improving energy balance ( Prevention, 2012). Working with Registered Dieticians is highly recommended so the athlete can receive proper nutrition education and help make a personalized diet plan for herself. If the athlete exhibits any type of amenorrhea, supplemental or medicinal intervention must be used if menstruation does not resume after calorie intake increases and proper weight gain is achieved. Before administering or prescribing any medicine, physicians must test to see if the problem lies in other medical issues, such as hypothyroidism. Hormonal therapy such as oral contraception can be used for hormone

9 9 replacement to protect BMD and if a prolonged and untreated span of amenorrhea resulted in low BMD, physicians advise specific calcium supplementation for treatment (Lebrun, 2007, p.401). Extensive psychological and nutritional intervention must be put forth for athletes that proved to have eating disorders such as anorexia nervosa and bulimia nervosa. Eating disorders have a range of short term and long term consequences: dehydration, severe electrolyte imbalance, anemia, infertility, cardiovascular and gastrointestinal issues (Lebrun, 2010, p.401). The goal of eating disorder treatment is to address underlying feelings the female has towards eating so she can begin to normalize her eating behaviors (Matsumato, 2010, p.26). Changing her perceived thought about food and the effects it has on her body in a positive manner makes the process of normalizing eating behavior easier. By giving young female athletes with eating disorders the time, patients and resources to change their thoughts, behaviors and actions towards eating, many may make an amazing recovery and continue playing in a healthier state of mind and body. Weight and body image has always been an incredibly sensitive subject for most females. The Female Athlete Triad is a highly interconnected syndrome between disordered eating, menstrual dysfunction and altered BMD that usually begins from the over emphasized connection between weight and performance seen in many sports. Treatment and intervention should always be implemented and encouraged to save and improve the female s state of health. Educating young female athletes as well as their coaches and parents is one of the best measures put forth to prevent and treat components of the triad. Athletes must be aware that changing their energy input in order to fit a body image can have dire and permanent damage on their overall health. The injuries, health and behavioral issues not only affect the player but

10 10 their team as a whole. Learning about the triad is in no way a reason for athletes to consider not playing a sport in fear that they may develop these behavioral and physiological problems. In fact, it s actually a great way for females to learn and implement more healthy behaviors in combination with exercise to improve the state of their health and their perception of nutrition for the rest of their lives.

Eating Disorders in Athletes: Women and Men

Eating Disorders in Athletes: Women and Men Eating Disorders in : Women and Men Barbara J Long MD MPH Associate Clinical Professor Division of Adolescent Medicine University of California, San Francisco Why discuss eating disorders and the athlete?