To Your Health:

Female Athlete Triad

By Nancy DiMarco, Ph.D. and Johnna Kudlac

Several years ago, Sally was visiting the local health clinic on campus and was told by one of the nurses that she was “kind of chunky for a gymnast."

That unsolicited remark was enough to send this vulnerable young athlete into a torturous slide of disordered eating, followed by a loss of her menstrual cycle and finally a significant decrease of her bone mass. That's enough to cause an octogenarian to worry, let alone a 20-year-old athlete.

These interrelated, domino-effect factors of disordered eating, amenorrhea and osteoporosis are referred to as the Female Athlete Triad. The competitive nature of athletics, societal pressure to be lean and mean, plus the ever-present judging that accompanies many of the sports prone to disordered eating are all factors that contribute to the development of the female athlete triad.

In a NCAA survey conducted in 1992, 93 percent of collegiate programs reported eating disorders among women's sports. It is estimated that between 15 and 62 percent of women athletes in the United States have disordered eating, but there is no consensus on the definition of disordered eating and no validated screening tool.

The most current theory as to how the female athlete triad develops is called the "energy drain."

Reported daily caloric intakes of women athletes have varied from 1,272 calories per day to 2,400 calories per day. The average caloric intake of active women between ages 15 and 24 should be at least 2,200 calories per day — suggesting that a number of these young athletes are simply not taking in enough energy.

When this continues over several weeks to months while the athlete trains at the same level of intensity, the lack of calories to support the hormonal reproductive system results in amenorrhea, or lack of the regular menstrual cycle. Without adequate amounts of estrogen being secreted from the ovaries, calcium is withdrawn from the bones resulting in decreased bone mass.

It is not uncommon to perform a bone scan on a young woman with the female athlete triad and find that she has the bone density of a 60-year-old woman.

The Triad

Disordered eating was selected as the first component of the female athlete triad because athletes may not have symptoms that would meet the classic definitions of either anorexia nervosa or bulimia nervosa, but were practicing pathogenic weight control, nonetheless. Some of the unhealthy eating behaviors observed in these athletes included: decreased food intake; using appetite suppressants, laxatives or diuretics; and irregular episodes of bingeing followed by purging.

Amenorrhea is defined as having fewer than three menstrual cycles per year, or a cessation of menses for three months among women who had been previously menstruating. A loss of the menstrual period in previously menstruating women is not normal and should be brought to the attention of a physician quickly. Women athletes have a much higher prevalence of delayed onset of the menstrual cycle until 16 years of age compared to non-athletes.

Osteoporosis is the third component of the triad. It is defined as premature bone loss, inadequate bone formation or both, that results in low bone mass, microarchitectural deterioration, increased skeletal fragility and an increased risk of fracture. The severity of menstrual dysfunction is directly connected with the decrease in bone mass.

Parents, coaches and team physicians should be concerned because the athlete is at much higher risk for premature osteoporosis and stress fractures because of the low bone mass.

Typical Characteristics

These young women typically have very high goals for themselves, both academically and athletically, and tend to be perfectionists. On the other hand, these athletes are critical of themselves and often have low self-esteem. They have a distorted view of body image and emphasize maintaining an “ideal body weight” or optimal amount of body fat.

Three of the most serious myths that continue to pervade sports are that “thinner is better,” that “each sport has an ideal body weight” and that “you are training hard enough if you lose your menstrual cycle.”

The most prevalent misconception that has developed from these myths is that performance in sport will be enhanced if body weight or body fat is low. The truth is that no sport has any criteria for body composition that can be equated with optimal performance. Each athlete is an individual, and as such, should have an optimal body weight or percentage of body fat that is appropriate for her body.

Athletes whose body weight is too low cannot sustain the intensity required for strenuous training sessions and performance and risk serious injury or illness.

Fighting F.A.T.

One strategy to combat the female athlete triad is nutrition education provided by a sports dietitian who can separate fact from fiction. A sports dietitian can: address appropriate nutrient-dense food choices, teach athletes how to eat before, during, and after training and competition, teach how to use fluid replacement beverages wisely, demonstrate how to carbohydrate load prior to any long distance or endurance event, counsel about the use of ergogenic aids and supplements, and teach how to adjust food intake during training and off seasons.

In addition, the sports dietitian can counsel about appropriate body weight and percentage of body fat by giving a range of values for each person. There is no one number that an individual should try to achieve.

If you suspect someone you know or you yourself have the female athlete triad, it is imperative that help be sought as soon as possible. It is a health-threatening disorder that requires a multidisciplinary approach to treatment. Prevention involves education and good sports nutrition counseling.

Dr. Nancy DiMarco is a research professor in the Department of Nutrition and Food Sciences, the nutrition coordinator for the Institute for Women's Health and coordinator of the master's program in Exercise and Sports Nutrition at Texas Woman's University. She can be reached at . Johnna Kudlac, M.S., R.D., L.D. is practicum coordinator for the exercise and sports nutrition program at TWU and also is in private practice specializing in eating disorders and sports nutrition. She can be reached at ndimarco@twu.edu.

Common Characteristics And Behaviors Of Women Who Have The Female Athlete Triad

• Perfectionist personality

• High self expectations

• Competitive athlete

• Self-critical

• Low self-esteem

• Symptoms of depression

• Achieving or maintaining low body weight and low body fat percentage

• Unexplained weight loss or fluctuations

• Stress fractures without significant change in training

• Experience frequent unexplained injuries

• Multiple or recurrent stress fractures

• Menstrual irregularities

• Low bone mass

• Disordered eating including restriction of amount and kind of food eaten during hard training, eating differently from others, eating alone, hiding or hoarding food, moving food around the plate without eating it

• Frequent bathroom visits especially after meals

• Excessive exercise (more than an hour a day outside of regular training time)

• Shows a sudden change in academic achievement

For Further Information Contact:

Roy Kron
Director of News and Information
Tel: (940) 898-3456
e-mail: rkron@twu.edu