The female triad.
In addition to women who train at a competitive level, many non-competitive women exercise vigorously as well. It is not just that they train at high intensities but that their ambition to train surpasses that of individuals who are more moderate in their exercise programs. This mindset is such that training becomes a lifestyle philosophy as well as a passion. While this is generally an admirable trait, it is not without significant risk. For example, "over training" injuries in the form of muscular strain, tendonitis and stress fractures will likely occur to many individuals who overprioritize their workouts at the expense of sufficient recovery and nutrition. Specifically for young women, there is an even greater health concern that far outweighs typical "overuse syndrome"--the female triad. If not dealt with appropriately, the female triad can damage women's wellness throughout their lives.
Defining the Female Triad
The female triad is a combination of three coexistent conditions associated with exercise training: disordered eating, amenorrhea and osteoporosis (Hobart and Smucker 2000). Originally termed "female athlete triad," the name was derived at a meeting led by members of the American College of Sports Medicine in the early 1990s (Yeager et al. 1993). Papanek (2003) reports that the meeting was called in response to the alarming increase in stress fracture rates, documented decreases in bone mineral density and menstrual dysfunction in otherwise healthy female athletes. Furthermore, the depiction of the triad as a triangle was developed to demonstrate the interrelationship between the three disorders normally considered independent medical conditions.
Over the last decade, the triad's definition has evolved to be more precise about the involvement of related clinical conditions. Anorexia nervosa (AN) and bulimia nervosa (BN) are the most common clinical disorders. A third category for eating disorders not otherwise specified (EDNOS) was created in an effort to expand treatment access for patients at high risk for an eating disorder (Papanck 2003). In other words, an athlete who falls short in meeting the criteria for AN or BN could still be recognized as needing treatment by being placed in the EDNOS category. See Table 1.
However, not all restrictive eating behaviors necessarily reach the clinical level (Beals and Manore 2000). Even with the addition of the EDNOS category, female athletes with the triad display a wide range of food-related pathologies. Therefore, the term "eating disorder" was found to be too restrictive and replaced by "disordered eating" to include the various forms of aberrant eating behaviors that disrupt caloric balance (Papanek 2003). Common disordered eating patterns exhibited by female athletes include food restriction, prolonged fasting as well as abuse of diet pills, diuretics and laxatives (Donaldson 2003).
Eumenorrheic or regular menstrual cycles are defined as regular flow occurring every 21 to 45 days, with 10 to 13 cycles per year, and oligomenorrhea refers to three to six cycles occurring per year (Rome 2003). Marshal (1994) classifies amenorrhea as primary or secondary and defines them as follows: primary amenorrhea or delayed menarche is defined as not having experienced a single menstrual cycle by the age of 16 and secondary amenorrhea is the absence of menses for six months or a length of time equivalent to at least three of the woman's previous menstrual cycle lengths. The main difference is that in secondary amenorrhea, at least one menstrual period has occurred. Physiologically, this means all parts of the reproductive axis (i.e., hypothalamus, pituitary, ovaries and uterus) worked together once, but for some reason, this integrative function has changed (Papanek 20O3).
Osteoporosis is a systemic, skeletal disease characterized by low bone density and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and fracture susceptibility (O'brien 2001). To clarify, the term osteoporosis, as referred to in this writing, is actually secondary osteoporosis because it is caused or exacerbated by other disorders (Stein and Shane 2003). Additionally, osteopenia, which is abnormally low bone density and believed to be an osteoporosis precursor (Nelson 2000), has also been included when identifying the female triad syndrome. Amenorrheic adolescent athletes do not acquire proper bone mass and, thus, will be osteopenic in their early adult years (Elford and Spence 2002).
Society has done a great disservice to adolescent females by perpetuating the "ideal" body image. For young women, this can intensify the pursuit of a thin physique at a time when nutrition plays a key role in proper growth and development. According to a 1997 Youth Risk Behavior Surveillance Survey, 34 percent of adolescent females were likely to consider themselves "too fat" and, therefore, limited their dietary intake (Kann et al. 1998). Hobart and Smucker (2000) add that many factors may create poor self-image and pathogenic weight-control behaviors in female athletes. Likewise, frequent weigh-ins, punitive consequences for weight gain, pressure to "win at all costs," an overly controlling parent or coach and social isolation caused by intensive sports involvement may increase a female athlete's risk of disordered eating behavior.
Disordered eating occurs in 5 percent of the general population (Donaldson 2003), but affects as many as two thirds of young female athletes (Nativ et al. 1994). According to Gidwani and Rome (1997), 32 percent of female athletes, at all levels of competition, practice pathogenic behavior for weight control. Rosen and Hough (1988) reported disordered eating behavior in 15 to 62 percent of female college athletes. Even before the triad was officially recognized as a distinct syndrome, Calabrese (1985) performed a study with collegiate gymnasts and discovered 62 percent displayed stone type of disordered eating--26 percent vomited on a daily basis, 24 percent used diet pills, 12 percent fasted and 75 percent had been told by their coaches that they weighed too much. Disordered eating behavior is believed to contribute to a disruption in the hypothalamic-gonadal axis, resulting in amenorrhea (Donaldson 2003).
The Interrelationship of the Triad
The three components of the female triad--disordered eating, amenorrhea and osteoporosis--pose serious health concerns for young athletic women. Shafer and Irwin (1991) state that the adolescent growth spurt accounts for approximately 25 percent of adult height and 50 percent of adult weight. Additionally, girls develop reproductive capacity during this time and dieting behaviors and nutrition can have an enormous impact on their gynecologic health (Seidenfeld and Rickert 2001).
While they can all occur independently, the interrelationship between the three parts of the triad is such that one component will affect another. In order to understand the physiological beginning of this syndrome, one must first realize that, in addition to the calories required for basal metabolic rate and physical activity, calories are required for menstruation, building and repairing muscle, healing and, in younger athletes, growth (Papanek 2003). The pathophysiology of the triad can be explained by a caloric deficit which disrupts the release of gonadotropin-releasing hormone, resulting in low levels of gonadotropins and secondarily reduced levels of estrogen and progesterone, leading to amenorrhea and osteopenia (Elford and Spence 2002).
Disordered eating behavior affects the number of calories available for normal life function. Manore (1999) states that any athlete, regardless of size, who consumes less than 1,800 calories per day is unable to meet caloric and nutrient requirements. Furthermore, a female athlete exercising 10 to 20 hours per week requires at least 2,200 to 2,500 calories per day to maintain body weight.
Negative Caloric Balance and Amenorrhea
Dueck, et al., (1996) reported that the average difference between amenorrheic and eumenorrheic athletes was only a caloric balance deficit of 250 calories per day. Many athletes do not realize the nutritional demands of their sports and, thus, it is this disordered eating that causes a negative caloric balance leading to amenorrhea (Papanek 2003). Even as early as 1981, Frisch, et al., found that amenorrheic competitive runners had an average intake of 1,700 calories per day, whereas eumenorrheic runners consumed 2,200 calories per day.
In addition to a caloric deficit due to disordered eating, physical training intensity plays an important role in the triad syndrome. Even if caloric deprivation does not occur through disordered eating, negative caloric imbalance can result from failing to support the training regimen with adequate recovery. Primary and secondary amenorrhea can occur in the context of eating disorders or intense athletics (Rome 2003). DiPietro and Stachenfeld support this by adding that a chronic negative energy balance, being underweight and exercise stress are important elements in the pathway to amenorrhea (1997). Cobb, et al., (2003) write that female athletes with disordered eating may limit their calorie and/or fat intakes but maintain high training levels, often resulting in a state of chronic energy deficit. Athletic amenorrhea occurs more frequently in activities such as running, ballet and gymnastics, in which intense physical training is combined with the desire to maintain a lean build (Warren 1980).
Osteoporosis and Negative Caloric Balance
Bones require a normal level of systemic hormones, adequate caloric intake (including protein, calcium and vitamin D, in particular) and regular, weight-bearing exercise throughout life (O'brien 2001). Exercise's effects on the growing skeleton are complex and influenced by many factors, including the nature and intensity of the activity, skeleton area primarily involved, body weight and dietary calcium intake (Stein and Shane 2003). Although moderate exercise protects against osteoporosis, too little or excessive exercise may actually cause it (O'brien 2001).
The minimum daily calcium requirement is 1,300 milligrams for people ages 11 to 23. Unfortunately, 85 percent of adolescent females do not consume this amount (National Institutes of Health and Child Development Publication 2001). Attitudes about their bodies during puberty can contribute to the dietary changes adolescent females make. This can lead to possible chronic dieting disorders, resulting in low bone mass and a risk for osteoporotic fractures later in life (All and Siktberg 1996).
Osteoporosis is a prevalent AN complication. In fact, the duration of AN is a predictor of low bone mineral density because the longer the illness lasts, the greater bone mineral density is reduced (Mehler 2003). For example, more than 50 percent of female patients with AN develop osteoporosis (Treasure and Surpell 2001). Miller and Klibanski (1999) add that the lack of nutrition is so severe in anorexics that an increased osteoporosis risk may exist due to associated endocrine abnormalities, including estrogen deficiency.
Amenorrhea and Osteoporosis
Continuing the triad syndrome's assault oil the female athlete's wellness is the relationship between the absence of menses and bone deterioration. Some athletes see amenorrhea as a sign of appropriate training levels, while others regard it as a great solution to a monthly inconvenience (National Institutes of Health 2003). There is a prevailing myth in women's athletics that equates a disrupted menstrual cycle with the appropriate level of elite training (Papanek 2003). Mickelsfield, et al., (1995) state that amenorrheic/oligomenorrheic athletes on average have lower bone mineral density than eumenorrheic controls. Stein and Shane (2003) agree that low bone mineral density is a consequence of exercise-induced amenorrhea. Osteopenia or significantly reduced bone mass occurring with prolonged loss of menses has been associated with an increased risk of stress fractures (Mansfield and Emans 1993).
The female triad is a unique phenomenon that does not occur overnight but rather appears to gradually infiltrate female adolescents' lifestyle. Under intense pressure from parents, coaches teammates and often themselves, many young women begin to fall into patterns of disordered eating and/or overintense calorie expenditure without the support of adequate rest and nutrition. The triad is especially troubling due to the fact that, while each affliction can occur independently, they often are interrelated by a chain reaction. Amenorrhea/oligomenorrhea is likely to follow the caloric imbalance, which leads to osteopenia and ultimately osteoporosis. This downward spiral can result in termination of an athletic career as well as a chronically unhealthy adult life.
Identification of the triad can be difficult. When confronted by family, friends, coaches and physicians about their eating behavior, athletes can be anywhere from elusive in their explanation to perfectly convincing that nothing is wrong. Although it is more common to find this syndrome affecting athletic women, it is certainly not exclusive to this population. In general, women struggle with the perception of the "perfect body image" society has unfairly placed upon them. Regardless of the circumstances, we as health care providers, coaches and parents are ultimately responsible for protecting the wellness of the young women in our care. Therefore, we must provide a proper wellness environment by nurturing sound physical training and nutritional habits.
Table 1. Diagnostic criteria and warning signs for eating disorders Anorexia Nervosa (AN) DIAGNOSTIC CRITERIA WARNING SIGNS AND SYMPTOMS 1. Refusal to maintain body 1. Fat and muscle atrophy weight at or above 85 percent of normal weight for age and height 2. Dry hair and skin 2. Intense fear of gaining weight 3. Cold, discolored hands and feet or becoming fat, even though underweight 4. Decreased body temperature 3. Disturbance in the way in 5. Lightheadedness which one's body weight or shape is experienced, undue influence 6. Decreased ability to concentrate of body weight or shape on self-evaluation or denial of the 7. Bradycardia (i.e., slowness of seriousness of current low body the heartbeat, so that the pulse weight rate us less than 60 per minute) 4. Amenorrhea 8. Past history of physical or sexual abuse Bulimia Nervosa (BN) DIAGNOSTIC CRITERIA WARNING SIGNS AND SYMPTOMS 1. Recurrent episodes of binge 1. Swollen parotid glands eating 2. Chest pain, sore throat 2. Sense of lack of control over eating during the episode (e.g., 3. Fatigue, abdominal pain feeling that one cannot stop eating or control what or how 4. Diarrhea or constipation much one is eating) 5. Menstrual irregularities 3. Recurrent inappropriate compensatory behavior to prevent 6. Callous formation or scars weight gain (e.g., diuretics, knuckles enemas, self-induced vomiting, misuse of laxatives or other medications, fasting or excessive exercise) 4. The binge eating and inappropriate compensatory behaviors occur, on average, at least twice a week for three months 5. Self-evaluation is unduly influenced by body shape and weight 6. The disturbance does not occur exclusively during episodes of anorexia nervosa Eating Disorder Not Otherwise Specified (EDNOS) DIAGNOSTIC CRITERIA 1. For females, all of the criteria for AN are met except the individual has regular menses 2. All criteria for AN are met except that, despite significant weight loss, the person's current weight is in the normal range 3. All the criteria for BN are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than two per week for a duration of less than three months 4. Regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after consumption of two cookies) 5. Repeatedly chewing, but not swallowing, and spitting out large amounts of food 6. Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of BN
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Cobb, K.L., et al. "Disordered eating, menstrual irregularity, and bone mineral density in female runners." Med. Sci. Sports Exerc., 2003, 35 (5), 711-9.
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Donaldson, M.C. "The female athlete triad: A growing health concern." Orthop. Nuts., 2003, 22 (5), 322-3.
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QUESTIONS: "The Female Triad"
1. The female triad is a combination of three coexistent conditions: disordered eating, amenorrhea and --.
2. A third category of eating disorders, --, was created to expand access to treatment for high-risk patients.
A. polymyalgia rheumatica
B. anorexia nervosa (AN)
C. bulimia nervosa (BN)
D. eating disorder not otherwise specified (EDNOS).
3. The term, "eating disorder," was found to be too restrictive and replaced by--to include the various forms of aberrant eating behaviors that disrupt caloric balance.
A. disordered eating
D. None of the above.
4. The occurrence of three to six menstrual cycles per year is referred to as --.
D. secondary amenorrhea
5. -- is defined as not having experienced a single menstrual cycle by the age of 16.
A. Primary amenorrhea
B. Delayed menarche
C. Secondary amenorrhea
D. A and B.
6. -- is a systemic skeletal disease characterized by low bone density and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility and fracture susceptibility.
A. Osteoporosis B. Amenorrhea
D. None of the above.
7. -- is abnormally low bone density and has been included when identifying the female triad syndrome.
D. None of the above.
8. A female athlete participating in 10 to 20 hours of exercise per week requires at least -- calories per day to maintain body weight.
A. 1,600 to 2,200
B. 1,900 to 2,500
C. 2,200 to 2,500
D. 2,500 to 2,900
9. In addition to the calories required for basal metabolic rate and physical activity, calories are required for --.
B. building and repairing muscle
C. healing and growth
D. All of the above.
10. Dueck, et al. (1996) reported that the average difference between amenorrheic and eumenorrheic athletes was only a caloric balance deficit of -- calories per day.
11. In addition to a caloric deficit due to disordered eating, physical training intensity plays an important role in the triad syndrome. Even if calorie deprivation does not occur through disordered eating, negative caloric imbalance can result from failing to support the training regimen with adequate --.
D. All of the above.
12. Bones require a normal level of -- throughout life.
A. systemic hormones
B. adequate nutrition
C. regular, weight-bearing exercise
D. All of the above.
13. The minimum daily calcium requirement for females ages 11 to 23 is --.
A. 500 milligrams
B. 1,000 milligrams
C. 1,300 milligrams
D. 1,600 milligrams
14. Attitudes about their bodies during puberty can contribute to the dietary changes adolescent females make. This can lead to possible chronic dieting disorders, resulting in -- and a risk for osteoporotic fractures later in life.
A. low bone mass
B. high calcium content
C. high mineral content
D. None of the above.
15. Some athletes see amenorrhea as both a sign of -- levels of training as well as a great answer to a monthly inconvenience.
D. None of the above.
Lola Ramos is pursuing her bachelor's degree in kinesiology and health promotion at California State University, Fullerton. She has recently completed an academic internship through the SpeciFit Foundation.
Gregory L. Welch, M.S., is an exercise physiologist and president of SpeciFit, An Agency of Wellness and Competitive Performance Enhancement, located in Seal Beach, California. He is also founder and CEO of the SpeciFit Foundation, a non-profit entity providing wellness concepts for adolescent women. Welch has published several articles regarding wellness of older adults and through his foundation has added adolescent women to the category of special populations. He can be reached at (562) 431-5208 and www.specifit.com.
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|Author:||Ramos, Lola; Welch, Gregory L.|
|Date:||May 1, 2004|
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