Female Triad

By Candace Chemtob, B.S. and M.S. in Human Nurtition

There is enormous pressure on competitive athletes to have the “ideal” body size and composition for their sports. This pressure can come from coaches, parents, teammates, or the players themselves in pursuit of achieving peak performance. This pressure is compounded, especially for females, to conform with society’s view of the ideal body. For women of all ages, the adage “you can never be too rich or too thin” prevails. According to ABC news, the average body mass index (BMI) for a female model is 16 (average height 5’9” and 110 pounds), which by medical standards is considered to represent severe malnutrition (per World Health Organization BMI < 16 is severe malnutrition). For an athlete, It would be impossible to perform at their best in a severely malnourished state.

The pressures to attain the “ideal” body for their sports, coupled with society’s distorted and unhealthy version of the “ideal” female body, are escalated for the female athlete. The result can be a condition called the Female Athlete Triad. The components of the Female Athlete Triad are the interrelated problems of disordered eating, amenorrhea (lack of or loss of menstruation), and osteoporosis. To cover this topic, we will discuss each component and how they relate to each other.

Screen Shot 2014-11-14 at 12.43.51 PMDisordered eating is on the spectrum of eating disorders. Disordered eating is a classification (within DSM-IV-TR, used in the health-care field) to describe a wide range of irregular eating behaviors that do meet the criteria of a diagnosis of a specific eating disorder such as anorexia nervosa or bulimia nervosa. Disordered eating starts with a “diet” to lose weight. Or some females may not admit to the desire to lose weight, but instead will choose self-imposed restrictions such as becoming a “vegetarian”. A teenage or college age female choosing to become vegetarian is often a red flag for the beginnings of self restriction—dieting—with their “hidden agenda” being to lose weight. The act of intentional self restriction of food can progress into chronic restrained eating, compulsive eating, and habitual dieting with irregular, chaotic eating patterns, which are the hallmarks of disordered eating.

Do not underestimate the prevalence of disordered eating and eating disorders in American teenagers and young adults. Over one half of teenage girls and one third of teenage boys admitted to unhealthy weight control methods such as skipping meals, fasting, smoking cigarettes, vomiting or taking laxatives (Neumark-Sztainer, 2005). One quarter of female college students report engaging in bingeing and purging as a “weight management technique” (American J of Psychiatry, Vol 152, 1995). The rate of self-reported disordered eating in female athletes is as stunningly high as 70% with those participating in “aesthetic” sports or sports with weight divisions most at risk (Katch and Katch, 2009).

Amenorrhea is the loss of menstruation. Primary amenorrhea is diagnosed when a female has not experienced her first menstrual period by the age of 15 years old. Secondary amenorrhea is missing three or more consecutive menstrual periods. Amenorrhea can be caused by several pathologic conditions such as pituitary and hormonal imbalances, pregnancy, and anabolic steroid use. However, without the presence of other causes, the most common cause of amenorrhea is prolonged energy restriction. Initially, it was thought that amenorrhea was triggered by a loss of body fat below a critical level. However, the current theory focuses on the gap between energy required (total daily energy expenditure, last month’s article defines this) and energy intake. This makes identifying the Female Athlete Triad more difficult, for a normal weight female athlete can be afflicted. Additionally, in a sport with high energy/calorie demands, such as squash, the energy “gap” may be difficult to detect. The energy demands of squash can be upwards of 1,000 calories per day, so an energy deficit diet in a squash player may be seemingly adequate to the untrained observer. A significant energy deficit over a long period of time will eventually cause the body to shut down “non-essential” functions. The hypothalamus, which is essentially the control center for some non-voluntary functions of the body, like body temperature regulation, turns off the menstrual cycle to conserve energy for other functions necessary to stay alive.

Over time, amenorrhea increases the risk for bone loss which can lead to osteoporosis. During prolonged energy restriction (dieting), the hypothalamus “down regulates” estrogen. This drop in estrogen levels causes bone loss. In fact, an amenorrheic female can lose enough bone mass (as what happens in post-menopausal women) to increase the risk of bone fracture and stress fractures in young women at a time when they should be building bone mass.

The same traits that make an athlete excel in sports may also put them at risk for developing disordered eating and eventually the Female Athlete Triad, such as compulsive, competitive, and perfectionist behaviors, looking for approval, and self motivation (Katch and Katch, 2009). From my own personal observations, these traits can describe many elite female junior/college squash players. The NCAA and American College of Sports Medicine has taken this problem seriously. In a handbook published by the NCAA, it is recommended that “the focus in working with the student-athlete who is affected by disordered eating or has other symptoms of the Triad should be more on her health and nutrition, and less on her weight…nothing is more important than the athlete’s physical and mental health.” Coaches, it is important that you educate yourselves and your athletes on the Triad. If you suspect the Triad in your teammate, child, or athlete, please start by contacting a mental health professional who specializes (such as a member of the National Eating Disorder Network, or NEDA) in disordered eating and eating disorder spectrum.