The Female Athlete Triad October 1 st 2011

Transcription

1 England Athletics South Area Coaching Conference Lee Valley Athletics Centre. The Female Athlete Triad October 1 st 2011 Carolyn Plateau National Centre for Eating Disorders in Sport Loughborough University

2 National Centre for Eating Disorders in Sport World class education, assessment and support for athletes and professionals Education Intervention Research Based on Loughborough University Campus in conjunction with Leicester Eating Disorders Service Centre co-ordinator: Dr Huw Goodwin

3 Background 800m runner, former GB Junior International Undergraduate degree in Psychology at Oxford University ( ) Masters Degree in Psychology Research at Loughborough University ( ) Currently working within the National Centre for Eating Disorders in Sport at Loughborough University. Conducting PhD research looking at eating disorders within athletes. Qualified Coaching Assistant, Leader in Running Fitness & working towards Coaching Award.

4 PhD Research Improve our understanding of the risk and trigger factors for eating disorder development amongst athletes Improve our understanding of the difficulties faced by coaches in identifying and managing athletes with unhealthy eating behaviours Use research findings to tailor educational programmes and intervention strategies employed by the National Centre for Eating Disorders in Sport

5 Outline: The Female Athlete Triad What is the Female Athlete Triad? Components, symptoms and physiological effects Potential causes Risk factors and long term implications The role of the coach Managing the training environment to minimise risks Recognising the early warning signs & managing symptomatic athletes

6 Definition The Female Athlete Triad The interrelationships between energy availability, menstrual function, and bone mineral density. (Nattiv et al., 2007) Nattiv, A.,Loucks, A.B., Manore, M.M., Sanborn, C.F., Sundgot-Borgen, J. & Warren, M.P. (2007) American College of Sports of Medicine Position Stand: The female athlete triad. Med Sci Sports Ex. 39 (10)

7 A Triad? Disordered Eating Low Energy Availability FEMALE ATHLETE TRIAD Osteoporosis Low Bone Mineral Density Amenorrhea Menstrual Dysfunction

8 Clinical Significance of the Triad Clinical manifestations Eating disorders Amenorrhea Osteoporosis With proper nutrition, the relationship between the three factors promotes robust health. Energy availability is the key.

9 Female Athlete Triad Continuum Athletes can be anywhere on the three spectrums. Their position is determined by their energy availability Figure from: Nattiv, A.,Loucks, A.B., Manore, M.M., Sanborn, C.F., Sundgot-Borgen, J. & Warren, M.P. (2007) American College of Sports of Medicine Position Stand: The female athlete triad. Med Sci Sports Ex. 39 (10)

10 Female Athlete Triad Model Increased training Increased energy expenditure Insufficient nutritional intake Prioritising of essential bodily functions Reduction in Energy (kcal) Insufficient energy for... Deficiencies in calcium, Vit D & other important nutrients Reduced oestrogen, LH & other hormone production Hormonal changes Hormones necessary for bone production Functional Hypothalamic Amenorrhea Bone modelling and repair

11 How common is the triad? Few studies have considered the presence of all 3 components. Estimates range from 1.2% - 16%. Triad often narrowly defined Point prevalence versus longitudinal studies Sample size & athlete group investigated Individually: Disordered eating: up to 47% of athletes in lean or endurance sports (Torstveit & Sundgot-Borgen, 2008) Menstrual dysfunction: up to 65% secondary amenorrhea in elite long distance runners (Dusek, 2001); primary amenorrhea up to 22% in some aesthetic sports (Beals & Manore, 2002) Low bone mineral density: up to 22% amongst high school female athletes. (Nichols et al, 2006)

12 Relationship between triad components Measured BMD, menstrual status, eating behaviour and training volume in 44 UK elite female endurance runners (Pollock et al, 2010) Low BMD noted in 34.2% in the lower back; 33% presented with osteoporosis in the wrist. Menstrual dysfunction, disordered eating and low BMD co-existed in 16% of athletes. Longitudinally, a positive association existed between training volume & BMD reduction in the spine. Pollock, N., Grogan, C., Perry, M., Pedlar, C., Cooke, K., Morrissey, D. & Dimitriou, L. (2010) Bone-Mineral Density and other features of the female athlete triad in elite endurance runners: a longitudinal and cross-sectional observational study. Int J Sport Nutr. Exer. Metabolism 20,

13 Correlation between training volume & bone mineral density (Pollock et al, 2010)

14 Correlation between training volume & bone mineral density (Pollock et al, 2010) Negative correlation between training volume & bone mineral density in elite female distance runners

15 Relationship with injury risk Prospective cohort study with 163 female athletes competing across a range of school sports. Injury reports, eating behaviours, BMD and menstrual function were measured. A history of amenorrhea during the past 12 months were associated with an increased risk of musculoskeletal injury. Disordered eating, menstrual dysfunction and low BMD were associated with an increased risk of musculoskeletal injury. Rauh, M.J., Nichols, J.F., Barrack, M.T. (2010) Relationships among injury and disordered eating, menstrual dysfunction and low bone mineral density in high school athletes: a prospective study. Journal of Athletic Training, 45 (3)

16 Injury risk relationship with bone density, eating behaviour and menstrual dysfunction. (Rauh et al, 2010)

17 Injury risk relationship with bone density, eating behaviour and menstrual dysfunction. (Rauh et al, 2010) Athletes with disordered eating, menstrual irregularity and lowered bone mineral density were significantly more likely to have a major injury compared to those that with normal eating, menstrual patterns and bone density.

18 Female Athlete Triad Model Increased training Increased energy expenditure Insufficient nutritional intake Prioritising of essential bodily functions Reduction in Energy (kcal) Insufficient energy for... Deficiencies in calcium, Vit D & other important nutrients Reduced oestrogen, LH & other hormone production Hormonal changes Hormones necessary for bone production Functional Hypothalamic Amenorrhea Bone modelling and repair

19 Energy Availability (EA) Definition: Energy availability is the amount of dietary energy remaining for other body functions after exercise & training. - Cellular processes - Growth and repair - Maintaining body temperature - Reproduction - Immune system

20 Energy Availability Energy availability = dietary energy intake (EI) minus exercise energy expenditure (EEE) EA=EI-EEE (Measured in Kcal per kg of fat-free mass) - A healthy athlete has an energy availability of 45 kcal/kg FFM - A normal resting metabolic rate requires 30kcal/kg FFM - Low energy availability is classified as below 30kcal/kg FFM.

21 Energy Availability: An example... A 60kg athlete (fat free mass 51kg, 15% body fat) has a daily dietary energy intake of 2000 kcal, expending 600kcal through exercise. EA=EI-EEE /kg FFM EA = ( )/51 = 27.5 kcal/kg FFM. Below the recommended 30kcal/kg FFM

22 What should her energy intake be? Energy Availability=Energy Intake Exercise Energy Expenditure /kg FFM (Healthy energy availability = 45 kcal/kg FFM) 45 = Energy Intake 600/51kg FFM. 45x51 = Energy Intake = Energy Intake = 2895 Kcal. Can you think of an example of one of your own athletes?

23 Your own athlete Approximate body weight Body fat: 14-25% (healthy range) Energy expenditure: approx. 90kcal/mile; 1 hour of vigorous activity uses around 600kcal. Healthy energy availability = 45kcal/kg FFM. EA= EI-EEE/kg FFM

24 Low Energy Availability Why? What might cause low energy availability?

25 When does low energy availability occur? 1. Inadvertent through... Poor nutrition knowledge: planning, food choices & balance, recovery & timing after exercise, insufficient intake Reduced appetite after prolonged exercise Increased training & no adjustment in food intake Increased energy required for growth (developing athletes) 2. Intentional weight loss for performance reasons 3. Psychological - disordered eating patterns, dissatisfaction with body image.

26 Female Athlete Triad Model Increased training Increased energy expenditure Insufficient nutritional intake Prioritising of essential bodily functions Reduction in Energy (kcal) Insufficient energy for... Deficiencies in calcium, Vit D & other important nutrients Reduced oestrogen, LH & other hormone production Hormonal changes Hormones necessary for bone production Functional Hypothalamic Amenorrhea Bone modelling and repair

27 Insufficient nutritional intake 1. Energy requirements not met for volume of training 2. Poor diet and food choices 3. Increased energy requirements for growth

28 Macronutrients: Carbohydrate, Protein & Fat intake Carbohydrate Protein Fat - CHO should account for ~60% daily intake. - Protein intake should constitute around 15% (slightly higher in strength or speed athletes than in endurance athletes). - Fat intake should constitute around 25% e.g. A 50kg female training at a moderate level will need g of carbohydrate per day. Training Level Regular levels of activity (3-5 hours/week) 4-5 Moderate duration, & low intensity (1-2hours/day) 5-7 Moderate to heavy training (2-4hours/day) 7-12 Carbohydrate g/kg/d Extreme exercise programme From: Fuelling fitness for sports performance (Dr Samantha Steer, 2004)

29 Iron deficiency One of the most prevalent nutrient deficiencies in the female athlete: up to 60% female athletes have poor iron stores (compared to 20-30% of the normal population) Could be a result of: Poor nutritional intake, avoidance of iron-rich foods, vegetarian diets (bio-availability of iron is low) Energy restriction Loss of iron (sweat, menstruation)

30 Energy requirements for developing athletes 1. Greater protein needs per kilogram of body weight to satisfy growth requirements 2. Greater calcium needs to support bone accretion 3. Higher metabolic cost of movement per kilogram of body mass (less metabolically efficient) 4. Relatively more fat use during exercise 5. Sweat electrolyte losses differ between children, adolescents and adults 6. Dehydration is more detrimental to young athletes than to adults. (Bar-Or, 2001)

31 Calorie & protein needs for normal growth & development (before exercise) Age Calories (kcal/kg) (female) (male) (female) (male) Protein (g/kg) Recommended dietary allowances NRC 1989

32 Calorie & protein needs for normal growth & development (before exercise) Age Calories (kcal/kg) Protein (g/kg) (female) (male) (female) (male) Recommended dietary allowances NRC 1989 e.g. A 12 year old female athlete weighing 40kg would require 2200 kcal & 40g of protein for basic everyday activities before her requirements for training and exercise.

33 The consequences of low energy availability Cellular processes are maintained BUT less energy is available for other body functions... Disruption of temperature regulation feeling cold Impaired immune response increased vulnerability to illness Growth & repair processes will be slowed Less energy is available for reproductive processes Adaptation to training will be less effective.

34 When does low energy availability occur? 1. Inadvertent through... Poor nutrition knowledge: planning, food choices & balance, recovery & timing after exercise, insufficient intake. Reduced appetite after prolonged exercise Increased training & no adjustment in food intake Increased energy required for growth (developing athletes) 2. Intentional weight loss for performance reasons 3. Psychological - disordered eating patterns, dissatisfaction with body image.

35 Female Athlete Triad Model Increased training Increased energy expenditure Insufficient nutritional intake Prioritising of essential bodily functions Reduction in Energy (kcal) Insufficient energy for... Deficiencies in calcium, Vit D & other important nutrients Reduced oestrogen, LH & other hormone production Hormonal changes Hormones necessary for bone production Functional Hypothalamic Amenorrhea Bone modelling and repair

36 Performance (2) Intentional weight loss for performance Relationship between weight and performance Sherman, Thompson & Rose (1996) study of elite gymnasts & world championship performances. Body Mass Index Sherman, R.T., Thompson, R.A., & Rose, J.S. (1996) Body mass index and athletic performance in elite female gymnasts. Journal of Sport Behavior, 19,

37 Adjusting body weight for performance Modifications to weight and body composition should take place gradually to avoid negative effects of the female athlete triad. 1. Guided nutritional input 2. Appropriate & realistic targets that are monitored 3. Appropriate time frame 4. Encourage a focus on healthy habits and making good food choices 5. Monitor progress by measuring changes in performance and energy levels, injuries & illness and menstrual function. 6. Help athletes to develop lifestyle changes to maintain a healthy weight. Concern over non-performance related dieting or unusual eating behaviours.

38 When does low energy availability occur? 1. Inadvertent through... Poor nutrition knowledge: planning, food choices & balance, recovery & timing after exercise, insufficient intake. Reduced appetite after prolonged exercise Increased training & no adjustment in food intake Increased energy required for growth (developing athletes) 2. Intentional weight loss for performance reasons 3. Psychological - disordered eating patterns; dissatisfaction with body image.

39 (3) Low Energy Availability: Disordered Eating and Eating Disorders Low energy availability can be indicative of a more serious problem with eating behaviour. Definition Eating disorders are severe, psychological conditions that are characterised by disturbed attitudes towards food and abnormal eating behaviour. Normal eating behaviour Mild dieting and body concerns Disordered eating (subclinical) Clinical eating disorders

40 Anorexia Nervosa 1. Refusal to maintain body weight at or above a minimally normal weight: 85% of what would be expected for age and height. 2. Intense fear of gaining weight or becoming fat, despite being underweight. 3. Disturbances in perception of body weight or shape. Body weight plays a principal role in self-evaluation & self-esteem. 4. Amenorrhea - the absence of at least three consecutive menstrual cycles.

41 Bulimia Nervosa 1.Recurrent episodes of binge eating. An episode of binge eating is characterized by: Eating an amount of food within a specific time frame that is much larger than most people would eat in a similar situation Lack of control over eating (e.g. feeling unable to stop or control what/how much they re eating) 2. Inappropriate compensatory behaviour to prevent weight gain e.g. self-induced vomiting, laxatives, diuretics, fasting or excessive exercise. Occurs at least twice a week for 3 months for clinical diagnosis 3. Self-evaluation is unduly influenced by body shape and weight.

42 Disordered Eating Subclinical conditions Eating Disorders Not Otherwise Specified (EDNOS) Anorexia Athletica Binge Eating Disorder Range in severity BUT dieting and disordered eating behaviour is strongly predictive of clinical eating disorders

43 Symptoms of Eating Disorders Do you know any of the signs and symptoms of eating disorders?

44 Symptoms: Anorexia Nervosa Physical/Medical symptoms Amenorrhea Fatigue in training (beyond expected) Muscle weaknesses Overuse injuries e.g. Stress fractures Gastrointestinal problems Dehydration Hyperactivity Weight loss Hypothermia (cold intolerance) Lanugo (fine hair on face and arms) Psychological/behavioural symptoms Anxiety Avoidance of eating/eating situation Claims of feeling fat Depression Excessive exercise Insomnia Preoccupation with weight and eating Restlessness Social withdrawal Restrictive dieting Unusual weighing behaviour

45 Symptoms: Bulimia Nervosa Physical/Medical symptoms Dehydration Dental and gum problems Complaints of bloating Electrolyte abnormalities Frequent or extreme weight fluctuations Gastrointestinal problems Menstrual irregularity Muscle cramps, weakness Swollen glands Low weight despite eating large volumes of food. Psychological / behavioural symptoms Binge eating Agitation if bingeing is interrupted Depression Evidence of vomiting unrelated to illness Disappearing after eating Excessive exercise Complaints of bloating Secretive eating Use of laxatives or diuretics unsanctioned by medical staff Stealing food

46 Difficulties with identification Presumption of good health with good athletic performance Sport stereotypes expectation that distance runners or high jumpers are slim Secretive nature of the eating disorders makes identification challenging. Symptoms versus desired characteristics in sport - sport ethic.

47 Causes of Eating Disorders What factors might be related to an increased risk of eating disorders amongst athletes?

48 Risk Factors for Eating Disorders Genetic vulnerability Sociocultural factors contributing to body dissatisfaction Media, celebrity role models Peers Family Thin people are more successful Personality factors Obsessive, compulsive High levels of anxiety Perfectionism

49 Risk Factors for Eating Disorders Participation in sport itself does not increase ED risk; rather it is aspects of the sporting environment that are additional to those risks faced by the normal population. (Thompson & Sherman, 2010) Sports specific risk factors: Revealing sports attire Contagion Effect Competitive Thinness Trigger factors - Traumatic life events (e.g. injury) - Sudden increase in training volume. - Frequent weight fluctuations, dieting.

50 Female Athlete Triad Model Increased training Increased energy expenditure Insufficient nutritional intake Prioritising of essential bodily functions Reduction in Energy (kcal) Insufficient energy for... Deficiencies in calcium, Vit D & other important nutrients Reduced oestrogen, LH & other hormone production Hormonal changes Hormones necessary for bone production Functional Hypothalamic Amenorrhea Bone modelling and repair

51 Amenorrhea or menstrual dysfunction Definition The absence of menstrual cycle (considered clinical if occurs for longer than 3 months) Primary (not occurred by age 15) Secondary (cessation after onset) Oligomenorrhea lengthened cycle (>35 days apart) A cause for concern! Amenorrhea is NOT normal for athletes and should always be investigated by a medical professional.

52 Causes & Consequences of Amenorrhea Lots of medical causes other than the low Energy Availability of the Female Athlete Triad. E.g. pregnancy, medication, thyroid dysfunction, high levels of anxiety or stress etc. Amenorrhea should be investigated by a medical professional for alternative causes. Long term consequences of Functional Hypothalamic Amenorrhea: Lowered bone density & increased risk of fracture Long term implications for fertility

53 Relationship between weight & menstrual function Female athletes with low energy availability (EI<30kcal/kg FFM) are more likely to be amenorrheic. (Manore et al 2002) Onset of puberty and the maintenance of regular menstruation depends on reaching a critical body weight & body fat levels(suggested to be around 47kg & 17%). Loss of 10 15% of body weight, commonly results in amenorrhea. This is especially likely when weight loss occurs rapidly.

54 Female Athlete Triad Model Increased training Increased energy expenditure Insufficient nutritional intake Prioritising of essential bodily functions Reduction in Energy (kcal) Insufficient energy for... Deficiencies in calcium, Vit D & other important nutrients Reduced oestrogen, LH & other hormone production Hormonal changes Hormones necessary for bone production Functional Hypothalamic Amenorrhea Bone modelling and repair

55 Osteoporosis & Low Bone Mineral Density Definition a systemic skeletal disease characterised by low bone mass and microarchitectural alterations associated with increased fragility and susceptibility to fracture. (World Health Organisation, 1993) Normal Bone Mineral Density Osteopenia Osteoporosis

56 Osteoporosis: Bones become more porous

57 Causes of low Bone Mineral Density Bone mass doubles during adolescence. Peak bone mass is determined to an extent by genetics, but nutrition and physical activity also play a key role. Up to 90% of peak bone bass is achieved by the age of 18 in females; adolescence is a crucial period for building bone Key determinants of peak bone mass & bone loss From: The ESHRE Capri Workshop Group, (2010) Human Reproduction Update, Vol 16 (6)

58 Consequences of low Bone Mineral Density Increased risk of fracture & significant injury Increased likelihood of osteoporosis in later life. Bone Density changes over age in women Line 1: Athlete with good nutritional intake, normal menstruation and undergoing an intense training regime in her 20 s. Line 2: Normal female Line 3: Athlete of low body weight with prolonged amenorrhea & poor bone accumulation in her 20 s. Undergoing an intense training regime. Wolman R L BMJ 1994;309:400

59 Treatment of the Triad If one element of the triad exists then athletes should be investigated for the presence of the other two by a medical professional. 1. Energy availability assessment - minimum criteria of >30kcal/kg FMM 2. Increased energy availability will aid bone remodelling processes & hormone production. 3. DEXA scans can be used to assess body composition and bone density. 4. Beware of the oral contraceptive may mask an underlying problem & doesn t correct metabolic abnormalities. 5. Eating disorders can be very serious, early detection is important. If you have concerns about an athlete, the National Centre for Eating Disorders in Sport can provide you with advice, assessment and support where required. 6. Prevention of bone loss is crucial - peak bone mass may not be achieved if bone remodelling processes are interrupted. 7. Amenorrhea should always be investigated for other possible causes.

60 Role of the Coach: Managing the training environment 1. Nutrition education and input Healthy eating (junior and beginner athletes) Sports nutrition, pre and post training fuel. 2. Motivation, self esteem and support Well-being Psychological support 3. Weight for performance Factors to consider

61 Nutrition education and coach input What strategies have you got in place at the moment? Have you any other ideas?

62 Nutrition education and input Recovery strategies encourage athletes to bring food with them tuck shop of food for after training Nutrition talks or advice for parents at your club Pre and post exercise nutrition UCoach nutrition booklets and materials that can be distributed NB: If you are concerned about an athlete s eating behaviour, always investigate it further - early detection is crucial

63 Motivation, well-being & support Person oriented versus performance oriented coaching style. Motivation Athletes with higher levels of intrinsic motivation perceived their coaches to provide high levels of positive & informationally based feedback & low frequencies of negative feedback. (Amorose & Horn, 2000) Biesecker & Martz (1999) performance centred coaching with regards to weight may have a negative influence on body image anxiety & dieting behaviour in some cases. Self esteem is it tied very closely to their athletic performance? Low self-esteem is a risk factor for disordered eating

64 Weight for performance Is weight loss or modification appropriate? Factors to take into account: Age Training history Level of competition Performance vs. body dissatisfaction? Guided nutritional input Appropriate targets that are monitored Appropriate time frame

65 Scenario of Sarah (Scenario 1) Sarah is a talented 18 year old female at your club. She works extremely hard both at her university course and in athletics, and has recently expressed a desire to do additional training beyond her current schedule. She says she wants to succeed and will do whatever it takes. Her performances on the track have been good and she has a chance of being selected to compete for the GB Junior Team this year. You notice that Sarah has lost weight in the last few weeks and that she has become more rigid about her diet, excluding most carbohydrates. In groups, discuss the scenario and decide on the actions that you might take as Sarah s coach.

66 Scenario of Alice (Scenario 2) Alice is a 16 year old high jumper at your club. She trains three times a week and has made good progress in the last year. She has grown a lot in the last six months and her performances have improved as a result. However, Alice has been complaining of pain in her foot for the last 3-4 weeks, and it doesn t seem to be improving even with reduced training. When you ask Alice about her menstrual cycle, she tells you that she hasn t started her periods yet. In groups, discuss the scenario and decide on the actions that you would take as Alice s coach.

67 IOC MC guidelines/decision trees Produced by the IOC to provide guidance on how to deal with athletes presenting with symptoms of the Female Athlete Triad. Advice with regards to training and people who might be useful to involve at various stages e.g. Sports medic, Eating Disorder Specialist, Nutritionist or Dietician.

68 From the International Olympic Committee Medical Commission: Position Stand on the Female Athlete Triad

69 From the International Olympic Committee Medical Commission: Position Stand on the Female Athlete Triad National Centre for Eating Disorders in Sport

70 From the International Olympic Committee Medical Commission: Position Stand on the Female Athlete Triad

71 From the International Olympic Committee Medical Commission: Position Stand on the Female Athlete Triad

72 Any Questions? Advice, support & assessment Interested in taking part in research?