Mary Anne Clairmont, RD

The term “female athlete triad” refers to a newly acknowledged triad of potentially life-threatening symptoms that affects not only female athletes but also very thin women.

The three components of the triad, in order of their appearance, are disordered eating, amenorrhea, and osteoporosis. The disordered eating pattern, along with undernourishment and a high activity level, leads to amenorrhea. The accompanying decrease in estrogen levels causes more rapid absorption of bone tissue by the body and a decrease in bone density, setting the stage for the development of osteoporosis.

This syndrome is not well studied. Each of the individual components has been researched, but the syndrome, or the interplay of the three components, remains mysterious. For instance, little is known about its prevalence. The lack of answers to basic questions complicates identification, treatment, and prevention.

Whether the syndrome is new, or merely newly acknowledged, is not clear. Evidence suggests that it is a relatively recent development. The first appearance of the term “female athlete triad” occurred at an American College of Sports Medicine conference in Washington, DC, in June 1992 (1). However, the association between low bone density and amenorrhea in women athletes became apparent in the 1980s. Menstrual dysfunction associated with inadequate energy intake was evident even earlier, coinciding with an emphasis on extreme thinness for athletes, which began with the “thin is in” culture of the 1970s.

Participation in diverse activities, including sports, increased for women during this period. Although women were encouraged to excel in sports, they were just as strongly encouraged to pursue an unrealistically thin body shape, two goals that do not necessarily complement one another.

Athletes in sports with a predominant emphasis on thinness are more at risk than athletes in other sports, providing support for the hypothesis that extreme thinness influences the development and progression of the triad. Thinness may be emphasized for appearance (as in judged sports such as gymnastics, diving, and figure skating) or for perceived performance enhancement (as in running and cross-country skiing).

Dancers are often left out of discussions of the triad, perhaps because they are seen as part of the arts community rather than the sports world. Yet, ballet dancers are noted to have one of the lowest body fat rates of active females, suggesting significant risk for the triad (2).

The consequences of the female athlete triad can be tragic. These symptoms may lead not only to an increased risk of fracture and irreversible bone loss but to permanent damage to the kidneys, heart, and skeleton. Because of women’s widespread participation in sports activities and the potentially grave consequences of this triad, primary care providers, sports medicine practitioners, gynecology clinicians, and registered dietitians should all be keenly alert to the potential for this syndrome in their female patients. Furthermore, they should educate all of their female athlete patients, particularly those who evidence disordered eating patterns, about the risks, symptoms, and preventive strategies of each component of the female athlete triad.

Disordered eating

Disordered eating is the first element of the triad. Estimates of the prevalence of eating disorders among female athletes range from 15 to 62 percent.3,4 The majority of studies use screening surveys based on self-report, so these estimates indicate only that individuals are at risk for an eating disorder. They are not confirmed diagnoses, nor do they indicate the prevalence of the triad.

Disordered eating behaviors occur along a continuum from minimal restriction of eating, to intermittent bingeing and purging, to the extreme calorie restriction and frequent bingeing and purging of anorexia and bulimia nervosa. Many practices of disordered eating—fasting, diet pills, laxatives, diuretics, and vomiting, as well as chronic undereating—starve the body of nutrients needed for optimal performance and health. The behavioral, physical, and psychological signs and symptoms of disordered eating appear in patients with the triad. The impact of the disordered eating on the other components of the triad depends on its severity in relation to the overall health status of the individual. Diarrhea, constipation, electrolyte imbalance, dehydration, and malnutrition are some of the potential consequences of disordered eating.

There are a variety of screening tools to assess disordered eating behaviors, such as the EAT-26.5 Nutrition assessment of the athlete should minimally include the key areas specified in Table 1. Table 2 lists issues to consider in developing an individualized nutrition care plan to meet the needs of each patient. Specific guidelines for disordered eating, amenorrhea, and osteoporosis are provided, although it is recommended that counselling integrate advice on all three components.

Amenorrhea

Criteria for a diagnosis of amenorrhea vary. Primary amenorrhea generally refers to the absence of menses in a woman 16 years of age or older who has never experienced menses. Secondary amenorrhea refers to the cessation of menses, defined as the loss of menses for 3 or 6 months, or the occurrence of less than three menses per year.

The prevalence of amenorrhea among women of reproductive age is 2 to 4 percent. The prevalence in athletes is 40 percent or higher.6 The risk may be higher for vegetarian than nonvegetarian athletes (7). All too often amenorrhea is viewed as a normal consequence of athletic training by athletes and athletic professionals. But amenorrhea can have serious consequences, such as reduced bone density and increased risk for osteoporosis. Actual bone density in women is related to the number of menstrual cycles they have had (6).

Therapy for female athletes should include discussion of menstrual function and menstrual history. The absence of menstruation or the existence of menstrual irregularities triggers the need to screen for disordered eating behaviors. It also indicates the need to educate patients about the detrimental consequences of amenorrhea, reassure them that amenorrhea can be treated, and recommend that they seek the care of a gynecologist for a thorough physical examination to rule out other possible causes of amenorrhea.

From a nutrition perspective, amenorrhea is the least understood element of the female athlete triad. It was widely believed that body fat content influenced hormonal production, and restoration of body fat was traditionally the goal of nutrition therapy. It has since been ascertained that calorie intake, not body fat content, is the influential factor in hormonal production. Sufficient calories are required for adequate hormonal function, although the specific mechanism of this relationship is not understood.

This revised view steers nutrition therapy toward strategies to increase the patients’ intake of total calories, not necessarily fat calories. This recommendation may cause less anxiety in patients with disordered eating and therefore may be more acceptable and promote a speedier restoration of menstrual function and overall progress in recovery. An increase in body fat remains an essential treatment goal in certain situations.

Osteoporosis

Discovery of amenorrhea and, to a lesser extent, disordered eating may indicate to clinicians that a bone density assessment is necessary. Typically, concerns about bone density are raised only after an athlete sustains an injury. Stress fractures or fractures that appear severe compared to the actual injury should arouse suspicion. Athletes need comprehensive assessment after an orthopedic injury to determine contributing factors.

Ideally, bone density studies employing dual energy x-ray absorptiometry (DEXA), quantitated computed tomography, or single energy x-ray absorptiometry should be used to assess the patient’s bone density. DEXA is the most commonly used procedure.

The prevalence of osteoporosis among athletes has not been determined. Screening has revealed bone loss in athletes who experience none of the symptoms of the triad. In one study, groups of runners and gymnasts with equal rates of menstrual irregularities were tested for bone density. The gymnasts had more bone mass than both the runners and a control group. The runners had the lowest bone density. These results suggest that bone density is greatly influenced by levels of specific weight-bearing activities.8 Theoretically, swimmers also are at higher risk for low bone density because they do not bear their weight for much of their training.

Table 1. Nutrition assessment for female athlete triad

Nutrition assessment issues common to disordered eating, amenorrhea, and osteoporosis:
- Nutrition history and intake records with an emphasis on calcium foods
- Menstrual status
- Eating disorder screening Activity patterns
- Family osteoporosis history Medications used
- Supplements used
- Nutrition-related medical conditions
Additional topics for assessment of disordered eating:
- Patient’s beliefs about:
  - How the body uses food Calorie and protein foods Relationship of exercise to food and body size
  - Good foods/bad foods
- Usual intake vs optimal intake
- Food cravings and/or bingeing
- Food restrictions
- Purging behaviors
- Body image issues
- Bloating

Table 2. Nutrition objectives in treating the female athlete triad

We apologize that this chart could not be included.

Osteoporosis cannot be treated successfully in the absence of treatment for the other components of the triad. Supplementation with calcium and vitamin D cannot replenish bone without adequate hormonal activity to permit absorption of the minerals. Hormone replacement therapy, which provides protection of bone, is essential to maintaining bone density and treating menstrual difficulties. Adequate calorie intake is also crucial in the treatment of both osteoporosis and the other elements of the triad.

Integrate treatment

It is recommended that treatment of each element of the female athlete triad be integrated into the nutrition therapy program. Nutrition intervention should be integrated into the overall treatment program and coordinated with the other members of the treatment team.

When considering the female athlete triad as a whole, general guidelines for therapy include enabling the patient to:
- Increase calories gradually with a goal of 300 additional calories daily,
- Increase weight slowly with a goal of a 3 percent weight gain,
- Increase calcium intake to 1,500 mg daily, and
- Decrease training level by 10 to 20 percent.

Awareness and education efforts need to send the dual message that the triad has dire consequences for the female athlete and that it can be successfully treated without compromising the athlete’s performance.

Mary Anne Clairmont, RD, is the nutritionist at the Student Health Service, University of Pennsylvania, Philadelphia, and owner of Take Two Nutrition, a nutrition consulting company in Plymouth Meeting, PA. She is also editorial advisor for Today’s Dietitian and a freelance writer.

References

1. American College of Sports Medicine. Position stand on the female athlete triad. Med Sci Sports Exerc 1997; 29:i–ix.
2. Houtkooper LB, Going SB. Body composition: how should it be measured? Does it affect sports performance? Sports Science Exchange 1994; 52:5–6.
3. Dummer GM, Rosen LW, Heusner WW, et al. Pathogenic weight-control behaviors of young competitive swimmers. Phys Sportsmed 1987; 15:75–86.
4. Rosen LW, Hough DO. Pathogenic weight-control behaviors of female college gymnasts. Phys Sportsmed 1988; 16:141–146.
5. Garner DM, Olmstead MA, Polivy J. Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. Int J Eat Disord 1983; 2:15–34.
6. Eichner ER, Loucks AB, Johnson M, Steen SN. The female athlete triad. Gatorade Sports Roundtable 1997; 27:5–6.
7. Loosli AR, Ruud JS. Meatless diets in female athletes: a red flag. Phys Sportsmed 1998; 26:45–48, 55.
8. Robinson TL, Snow-Harter C, Taaffe DR, et al. Gymnasts exhibit higher bone mass than runners despite similar prevalence of amenorrhea and oligomenorrhea. J Bone Miner Res 1995; 10:26–35.

This article is from the Healthy Weight Journal (Health at Every Size Journal) and can be cited as Mary Anne Clairmont, RD, “Female Athlete Triad: Challenges in Nutrition Practice,” from Health At Every Size 14:4 (July/August 2000).