Understanding The Female Athlete Triad
Components of the triad not only affect female athletes, but also fitness enthusiasts.
With Olympic gold in her sights, gymnast Christy Henrich trained over several years with a goal of achieving contender status on the U.S. Olympic Women’s Gymnastics Team. But then a judge at a national competition told the 95-pound Henrich that if she expected to win Olympic gold, she would have to lose weight—“advice” that eventually proved fatal for the 15-year-old.
Although Henrich believed that her intense training and disciplined diet would contribute significantly to her success, she developed the severe eating disorders known as bulimia and anorexia nervosa. She struggled with these eating disorders for 6 years before dying in 1994, weighing only 47 pounds. Henrich has been called a “poster child” for the syndrome that has become known as the female athlete triad (Porter 2000).
Gymnasts, figure skaters, runners and female athletes in other sports wherein body composition is perceived to play an integral role in performance, are under ever-increasing pressure to maintain specific weight and body fat percentage. Many female athletes are encouraged by coaches to be unrealistically thin. “In the early 1980s, I began to see women athletes at UCLA who came in and told me that they were vomiting, and they stated they had a lot of body dissatisfaction,” recalls Los Angeles-based sports medicine physician Carol Otis, a former UCLA team physician, chairperson on the women’s health initiative and the lead author of the 1992 American College of Sports Medicine (ACSM) “Position Stand on Female Athlete Triad.”
“We didn’t even know about bulimia then, but these women were talking about their experiences and conveying symptoms associated with bulimia, depression, eating disorders and other weight-related problems. We thought we’d better get a group together and talk about how we would deal with this issue moving forward,” she explained recently.
In the early 1990s, researchers at the National Institutes of Health (NIH) and ACSM had a consensus conference simply to talk about the problem. Following the conference, research efforts were directed at uncovering the relationship between the prevalence of disordered eating and menstrual irregularities that occur in female athletes. It was revealed that when they occur in tandem, irregular menstrual cycles and eating disorders are associated with premature bone loss and osteoporosis. Together, disordered eating, menstrual dysfunction and decreased bone mineral density became known as the female athlete triad.
According to the 1992 ACSM position statement, it is important for coaches and parents to tell female athletes about the female athlete triad syndrome. “There are three interrelated components to the triad,” Otis explains. “Disordered eating—poor nutritional habits that are less severe than anorexia or bulimia—which 8 leads to amenorrhea, or the loss of regular menstrual cycles, and, finally, the early onset of bone mineral density or osteoporosis, a condition that is irreversible for women between the ages of 18 and 30.”
This is a potentially serious condition occurring in many physically active girls and women. The position statement concludes that the syndrome is triggered by eating disorders coupled with overtraining that is characteristic in many sports, but especially in the “appearance” sports, or those sports that encourage the athlete to look and be thin. Gymnastics, figure skating, dancing and distance running have a higher percentage of athletes with eating disorders, according to ACSM’s position.
What can begin with a harmless diet may develop into a clinically defined disordered eating pattern. Disordered eating can range from moderate restriction of food intake to binge eating and purging to severe food restrictions. However it is important to understand the difference between clinically defined eating disorders, such as anorexia nervosa or bulimia nervosa, and “disordered” eating patterns, defined as unsafe and flawed practices used to lose weight fast.
The use of diuretics, self-induced vomiting, fad diets, fasting and attempts to sweat off weight are examples of techniques used for weight loss that are part of disordered eating patterns. One of the first signs of the triad is the use of these practices to lose weight. Female athletes may experiment with these techniques occasionally, or as frequently as several times a day. When female athletes want to lose weight and it does not come off quickly enough, they may embrace these techniques. These practices can be classified as harmful eating behaviors that do not result in true weight loss (Corsini & Reitz 2003).
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders describes self-induced vomiting, the use of laxatives and short-term, self-induced starvation as part of a large and assorted category of disordered eating patterns termed eating disorder, not otherwise specified (EDNOS) (1994). EDNOS is a category reserved for individuals with clinically significant disordered eating patterns who fail to meet all of the diagnostic criteria for anorexia nervosa or bulimia nervosa.
However, EDNOS as a term may understate the significance of these practices, and they may mistakenly be perceived as less important. Despite the differences in classification, females in either category share at least one common feature of the disordered eating behaviors, which is the measure of body weight as a self-assessment.
When an athlete is developing symptoms of the triad, she is typically exercising intensely while simultaneously reducing her weight. Some athletes do not see missing their periods as an issue, but neither do they relate missed periods to future damage to their bodies.
Primary amenorrhea (pronounced ay-meh-nuh-ree-uh) is defined as a female reaching the age of 16 without starting a regular menstrual cycle. If menstrual cycles cease without reasonable cause (such as pregnancy) for at least three consecutive periods, and the athlete is increasing her training and changing eating habits, this is secondary amenorrhea (Otis & Goldingay 2000; Boeckner 1998).
Estrogen levels are typically low during amenorrhea and decreased estrogen levels lead to decreased bone mass and increased cardiac risk (Otis & Goldingay 2000). The prevalence of amenorrhea among the general population is between two and five percent. But among female athletes it has been reported in the ranges of three percent to 66 percent (Otis & Goldingay 2000).
Estrogen is necessary for proper bone density development and skeletal construction. Low estrogen levels and poor nutritional intake can lead to osteopenia, a milder form of osteoporosis, which is one of the most common and serious bone diseases (Thibodeau & Patton 1997).
“If estrogen levels are low and calcium intake is reduced because of food restrictions, there is a strong possibility that bones will be weakened. One needs a certain amount of calcium in order to grow requisite bone mass, especially athletes who participate in sports,” said Malhar Gore, team physician at Iowa State University in a 1996 interview. “Female athletes are at an increased risk for injuries such as stress fractures because their bone mineral density is diminished. Weakened bones that are exercised repeatedly and excessively will eventually fail.
“Athletic women who combine low body fat levels with overexercise and an inadequate diet stop experiencing regular menstrual cycles. At this point their estrogen levels tend to drop below normal levels to maintain healthy bone, which may lead to a catastrophic event. A minimum of 1,500 mg of calcium per day is needed to build and maintain bone, and most female athletes don’t get that much,” Gore said.
Evidence to date suggests that between the ages of 15 and 30 women form 30 percent of their bone density. “Without the appropriate requisite bone matrix formed during this particular period, bones do not progress to their fullest density, and this becomes an irreversible problem,” Otis adds.
In the new millennium, sports participation by girls and women is growing quickly. New opportunities in both amateur and professional sports once closed to women are now open. Research has proven that physical activity, including participation in physically demanding sports and activities, is not only healthy, but the exercise and increased strength associated with training for such activity is linked to decreased mortality and an improved psychological outlook (Smith 1996).
Despite the interest in healthy exercise, mixed messages abound. “The media can have such a negative influence. Women with the skinny appearance of an ectomorph are almost always shown on magazine covers, and this has become the ideal body image,” Otis observes. “It is important for consumers to understand that genetics plays such an important role in physical development and how one will appear as an adult.”
“Those at greatest risk for these negative body influences are children,” said former Iowa State University associate professor Deborah Rhea, in a 1996 interview. Rhea has concentrated her research efforts on eating disorders among high school and college athletes.
A study performed by the American Association of University Women found the self-esteem of pre-adolescent (middle school) and adolescent girls plummets as much as 30 percent from the self-esteem of girls in elementary school. “Since the majority of recreational, competitive and elite athletes are in middle and high school, this poses a very real threat to the health of our nation’s young, athletic women,” Rhea said.
With the constant attention given to achieving and maintaining a prescribed weight goal, the female athlete is at a very real risk to experience lifelong health problems. “Today’s healthy look is thin, according to society’s current definition,” Rhea observed. Unfortunately very unhealthy behaviors are associated with this slender appearance. “Eating disorders are generally considered to be psychological disorders and are extremely difficult to treat. The most desired body image for a young, female athlete is slim, with very small, almost androgynous hips combined with voluptuous breasts—unattainable by most. Eating disorders among female athletes are among the most serious problems facing this population and parallels the seriousness of anabolic steroid use in male athletes,” Rhea said.
Although the number of gymnasts affected by the triad is unclear at present, USA Gymnastics has created a task force to examine its response to the female athlete triad. With more than 50,000 mostly adolescent female athletes registered with USA Gymnastics, the organization is “attempting to actively pursue policies that will provide a healthy environment in which gymnasts can pursue their goals as athletes, yet maintain a healthy body image.” The organization created a task force, which developed a position stand, to cope with the effects of the triad on its athletes (USA Gymnastics 1995).
According to a paper published through the University of Nebraska Extension Office, it may be easy for girls with symptoms of the triad to keep such information a secret because information about their menstrual periods and any damage done to bones usually isn’t visible to friends, teammates, coaches and family members. For these reasons alone, females found to have one component of the triad should be screened for the other two.
As an example, if a female is found to 8 have irregular menstrual cycles, or regular cycles have ceased, the athlete should be questioned by team physicians, coaches and/or parents about her eating patterns, weight loss history and whether she is prone to stress fractures. Alternatively, if she has repeated stress fractures, she should be screened to see if she experiences irregularities in her eating patterns or if she is having regular menstrual cycles. The repeated presence of stress fractures is a more visible triad symptom (Boeckner 1998).
Otis reminds us that the components of the triad affect not only female athletes but also fitness enthusiasts of a variety of ages. “Although 20 years ago we were initially talking about the triad being described in female adolescents and young women, we are now beginning to see that this problem is occurring in Baby Boomers,” she says. “Fitness industry professionals such as personal trainers do not think the triad applies to them or their clients.”
She adds that in these populations, “The triad can tend to run on a continuum.” The three components have a wide range of how they appear and affect people in a variety of ways.”
Although Otis admits there are no long-term studies on the triad, she says that development of the triad will result in compromised bone mineral development. “A personal trainer can use several techniques to screen for components of the triad such as asking specific questions that include ‘I’ statements. Repeated or frequent stress fractures are also a tip-off.”
Contrary to the stand and the consensus of the NIH, Judy Mahle-Lutter, co-author of The Bodywise Woman and co-founder and president of the Melpomene Institute in St. Paul, Minnesota, disagrees with the level of severity with which the female athlete triad has become associated. “It’s easy for coaches and the press to latch onto a name like the female athlete triad, making it look more deadly than it is—to play on people’s fears,” she says. “It’s good to have a name so coaches and parents can be aware of the potential damage of this situation—the fact that it could be an issue for elite-level athletes. But the naming of this condition is often overstated. The data does not support the prevalence of the triad among the general exercising population, and I don’t think it would be accurate to state that it is something of this level of severity.”
The Melpomene Institute performs research devoted to health issues affecting physically active women and attempts to educate women in a variety of ways including providing educational resources. “We did not see a high number of female athletes with this condition. It is more of an elite athlete that we are dealing with,” Mahle-Lutter observes. Further, to synthesize the words of Carol Oglesby, a member of the Melpomene’s advisory board, “the [number of] women suffering from the female athlete triad is miniscule compared to the number of women who are not participating in exercise.”
Mahle-Lutter concluded by stating that the research is still not conclusive. The big picture is that coaches do not know enough about it, but at least they bring it up, and they may be able to refer the female athletes who exhibit these symptoms to appropriate treatment without the panic that all exercising females will experience this problem.
The ACSM position stand warns that female athlete triad occurs not only in elite athletes, but also in physically active girls and women participating in a wide range of physical activities. Otis reminds us that fitness professionals are in a great position to make a positive impact on this condition. “Fitness industry people do not think that it applies to them, but it definitely does. This is for your clients, not just for thin celebrities and elite athletes who work with personal trainers and coaches.”
How can you deal with such situations? Be honest about what you observe. If you notice that statements made by the client are negative and degrading, ask her about them. Bring to her attention that she is using negative self-talk. Ask if her feelings about body dissatisfaction are affecting other parts of her life. If she agrees that they are, refer her to her primary physician or other health professional.
Although individuals with components of the triad (disordered eating or amenorrhea) may deny any nutritional or health problems, it is important that medical attention is sought. If the client is reminded that proper nutrition and appropriate medical care may enhance performance, she may be more likely to get the help she needs. Also, if the risk factors are described to the athlete in a non-judgmental way, she may in turn be more likely to get the medical help she needs.
Treatment of the triad often requires intervention through a team approach. A medical professional aligned with a psychologist, a nutritionist, parents and coaches can create a healthy and full-range approach.
More research continues in many areas related to the triad. Monitoring young women to avert and treat the female athlete triad is the best way to prevent the disastrous outcomes.
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- preoccupation with food and weight
- excessive leanness or rapid weight loss
- expressed concern with being too fat
- frequent eating alone
- use of laxatives
- trips to the bathroom during or immediately following a meal
- increased criticism of self
- continual drinking of no-calorie beverages
- many dental cavities, foul breath (from self-induced vomiting)
- depression, low self esteem
- daily vigorous exercise in addition to regular training
- chipmunk-like cheeks from swollen parotid glands (self-induced vomiting)
- undue fatigue
- erosion of dental enamel from frequent vomiting
- abdominal pain and bloating
- dry skin
- sore throat
- decreased ability to concentrate
- cold intolerance
- chest pain
- cold and discolored hands and feet
- irregular or loss of menstrual cycles
- lanugo (fine, downy hair covering the body)
- stress fractures (micro fractures of bones that may progress to complete bone breakage)
The following are excerpts from the ACSM “Position Stand on Female Athlete Triad” as presented by the American Family Physician in a clinical brief.
- The female athlete triad occurs not only in elite athletes, but also in physically active girls and women participating in a wide variety of sports and other physical activities. The triad can result in waning overall physical performance, as well as physical and psychological illness, and even death.
- The triad is often denied by athletes, not recognized by parents, coaches or health care professionals and, as a result, is underreported. Health care profes- sionals need to be aware of the interrelated components of the triad and be able to recognize, diagnose and treat or refer women when at least one component of the triad is identified.
- Women with at least one component of the triad identified should be screened for the other two components of the triad. Frequently occurring stress fractures, recent or sporadic weight loss and missed periods should be discussed openly without judgment. This can be done at the pre-participation physical exam and during routine clinical evaluations.
- All sports medicine professionals should learn the symptoms and risks of the triad. They should have basic nutrition information and should have access to referral sources for nutritional counseling and medical and mental health evaluation.
- Education for physically active girls and women, coaches, fitness professionals working with women, and parents is key to prevention of the triad. These individuals should be aware of basic proper nutrition, safe training practices and the warning signs of the risk of the triad.
It is believed that early identification of an eating disorder can lead to earlier treatment thereby reducing serious physical and psychological complications or even death (Boeckner 1998). The Eating Attitudes Test (EAT-26) is a screening test primarily used for early identification of an eating disorder and is designed to assess concerns and attitudes common in those with eating disorders. Only a qualified professional in a formal psychological evaluation can diagnose an eating disorder, but EAT-26 is probably the most widely used standardized measure of symptoms and concerns characteristic of eating disorders.
Certifications: ACE, ACSM, AEA, AFAA and NSCA
Education provider for: ACE and AFAA less
American Family Physician. 1997. Clinical brief: Position stand on female athlete triad, 56 (6), 1676-77.
Boeckner, L. 1998. The female athlete triad. University of Nebraska, Lincoln Facts Nebraska Cooperative Extension, Institute of Agricultural and Natural Resources, NF98-361. University of Nebraska, Lincoln. Retrieved December 23, 2003 from www.ianr.unl.edu/pubs/foods/nf361.htm.
Corsini, M., & Reitz, J. 2003. The prevalence of risk factors for the female athlete triad in college level female athletes at the University of South Dakota. Retrieved December 23, 2003 from www.med.usa.edu/
Diagnostic and Statistical Manual of Mental Disorders (4th ed.). 1994. Washington, D.C.: American Psychiatric Association.
Garner, D.M., et al. 1982. The eating attitudes test: Psychometric features and clinical correlates. Psychological Medicine, 12 871-8.
Garner, D.M. 1997. Psychoeducational principles in treatment. In D.M. Garner & P.E. Garfinkel (Eds.), Handbook of Treatment for Eating Disorders. New York: Guilford Press.
Hobart, J.A., & Smucker, D.R. 2000. The female athlete triad. American Family Physician, 61 (11), 3357-70.
Otis, C.L., & Goldingay, R. 2000. The Athletic Woman’s Survival Guide. Champaign, IL: Human Kinetics Publishers.
Porter, Y. 2000. Tumbling down: Eating disorders and the female athlete triad. The Village Voice, April, 19-24.
Smith, A.D. 1996. The female athlete triad: Causes, diagnosis, and treatment. The Physician and Sports Medicine, 24 (7), 67-72.
Thibodeau G.A., & Patton, K.T. 1997. The Human Body in Health and Disease, 3rd ed. St. Louis: Mosby.
USA Gymnastics Online. 1995. Technique: Task force on USA gymnastics response to the female athlete triad preliminary report. Retrieved December 23, 2003 from www.usa-gymnastics.org/publications/technique/
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