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The Female Athlete Triad

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What is the Female Athlete Triad?

The Female Athlete Triad is a condition usually seen in active young women and girls, particularly those who compete in sports. It is made up of three separate but interrelated conditions: 1. Low energy availability – A condition where not enough energy (calories) are taken in to balance the body’s needs.

The Female Athlete Triad

2. Amenorrhea – Absent or irregular menstrual periods.

3. Osteoporosis/Osteopenia – Conditions of low bone mass and density.

The Female Athlete Triad can have serious complications both in the short and long term.

This learning module is intended to share information about the Female Athlete Triad so that you may better understand the causes, warning signs, and treatment options for these conditions.

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Who is affected by the Female Athlete Triad?

The Female Athlete Triad can affect any woman, but it’s much more common in very active and competitive athletes. Those who participate in sports with weight classes where performance is partially tied to leanness or that emphasize aesthetics are at the greatest risk.

• TRACK/CROSS COUNTRY • DANCE • DIVING, SWIMMING • CHEERLEADING

Up to 16% of female athletes suffer from all three conditions, and 60% have one of them1.

Since the 3 conditions are related, having one increases your risk of developing another.

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(#1) Energy Availability Low energy status refers to using more energy (calories) than you take in. Under consuming calories while engaging in rigorous activity leaves our bodies scrambling for more energy at the risk of compromising some functions; such as the menstrual cycle and bone health.

Your calorie needs are based on a number of things, like: • GENETICS • AGE • BODY SIZE • MUSCLE MASS • EXERCISE

Any time exercise frequency, intensity and/ or duration increases, so should your food intake. The more energy you expend, the more you will need to take in to remain in balance, even if you’re trying to change your weight or body composition.

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Energy and Athletes It is not uncommon for athletes to be energy deficient:

1. High-energy demands due to intense practices, conditioning and games can be a challenge to keep up with, and can affect your desire to eat.

2. Performance may be tied to leanness or bodyweight in some sports; falsely leading athletes to assume they must under consume calories to stay or become thin.

3. Athletes are held to high body standards perpetuated by the media, especially those who wear more revealing uniforms.

4. Women in particular face strong societal pressure to be thin for acceptance both on and off the playing field.

Energy deficits are a significant and widespread problem among collegiate female athletes. A recent study found that only 9% were meeting their energy needs and 25% were taking in adequate carbohydrates2.

The energy deficit was found to be intentional for many of the athletes, as 1/3 reported a desire to lose weight.

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Know your Energy Needs It is helpful to be aware of your energy (calorie) requirements to determine if you are providing your body with enough fuel.

Your school’s sports dietitian will be able to provide you with an estimate of your energy expenditure and help you develop a meal plan or eating pattern that meets your needs.

SYMPTOMS OF LOW ENERGY STATUS

• Absence of menses or change in menstrual pattern • Frequent injuries, especially stress fractures • Fatigue

• Poor concentration

• Decreased strength

• A decline in performance • Frequent illnesses • Irritability

• Depression

• Weight loss 6

Disordered Eating Disordered eating refers to unhealthy eating habits that could contribute to low energy status and the Female Athlete Triad.

Disordered eating is not necessarily a clinical eating disorder, but it may increase your risk of developing one. It can even be accidental, if you unintentionally take in less food than required for your body size and activity level.

DISORDERED EATING WARNING SIGNS

• Preoccupation with food, weight, calories, body image • A focus on eating only “healthy foods” like fruits, vegetables and protein while restricting fats and starches • Avoidance of meals, secretive eating

• Excessive weight fluctuations, rapid weight loss • Fatigue/lack of energy

• Excessive exercise to burn calories

• Depression and anxiety may be connected to disordered eating 7

Eating Disorders: Help and Assistance If you suspect you may be struggling with disordered eating or an eating disorder, please speak to someone about it as soon as possible, like a therapist, dietitian or medical provider.

Duke has a team of providers who are trained to give you comprehensive assistance and help you on your path to recovery. Contact Student Health or Counseling and Psychological Services (CAPS) directly or tell your athletic trainer who will know where to connect you.

Duke Nutrition Services If you suspect you have an eating disorder, click here; https://studentaffairs.duke.edu/studenthealth/nutrition/disordered-eatingeating-disorder-information for more information.

Take our Screening Tool http://screening.mentalhealthscreening.org/dukeED to determine if you are at risk for disordered eating practices.

Duke Counseling and Psychological Services (CAPS) https://studentaffairs.duke.edu/caps

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(#2) Amenorrhea Amenorrhea refers to an irregular or nonexistent menstrual cycle, diagnosed with at least three consecutive months without a period, or >35 days between periods. *This may be a normal pattern for some.

Amenorrhea can be brought about by low energy status or malnutrition. Lack of a menstrual cycle, changes in flow or irregular cycles are more common among young female athletes, but may not be normal or healthy.

Lack of a period can cause abnormal hormone fluctuations and reduce estrogen, a key regulator of many body processes. These hormonal changes can negatively impact your mood, performance and bone density.

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Prevention and Treatment of Amenorrhea Amenorrhea related to the Female Athlete Triad is a symptom of low energy status.

Increasing calories and/or decreasing training may help correct the problem.

An energy deficit of just 200-300 calories per day can disrupt your menstrual cycle.

Examples of 200-300 calorie food options • Small peanut butter and jelly sandwich • Greek yogurt with nuts and granola • Slice of pizza with vegetables • Pretzels and hummus • Apple and string cheese

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(#3) Osteoporosis / Osteopenia Osteoporosis or Osteopenia are conditions of decreased bone mass. More commonly known as a disease of older adults, osteoporosis can be caused by hormonal changes, especially fluctuations in estrogen. Your skeleton becomes fragile and susceptible to fractures.

Osteopenia is not only associated with an increased risk for stress fractures and muscle injuries, but it extends the amount of practice and playing time missed during recovery3.

Osteoporosis before your mid 20s could compromise your peak bone mass development, predisposing you to severe and chronic bone disorders later in life. A 20-year-old female athlete suffering from the Female Athlete Triad could have the skeleton of an 80-year-old.

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Prevention and Treatment of Osteoporosis / Osteopenia Maintaining adequate energy levels and a regular menstrual cycle can prevent osteoporosis from occurring. If you suffer from frequent stress fractures you may want to consider getting evaluated by a professional for the Female Athlete Triad.

Adequate calcium and vitamin D levels also may help prevent osteoporosis from occurring. Females with amenorrhea have an increased daily calcium requirement4. Include both calcium and vitamin D rich foods in your diet.

*Because of the hormonal changes associated with amenorrhea, calcium and vitamin D alone will not prevent or treat osteoporosis, but they may slow its progression.

HIGH CALCIUM FOODS

VITAMIN D FOODS

• Leafy greens and broccoli

• Eggs

• Dairy foods

• Fortified cereal (Total, Raisin Bran)

• Fortified juices and milk alternatives

• Fish

• Dairy

• Fortified juice and milk substitutes

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Symptoms and Diagnosis The Female Athlete Triad is difficult to diagnose due to the nonspecific nature of its symptoms. Menstrual dysfunction can be easily identified, however, a professional must diagnose osteoporosis and low energy status. This makes it even more important to understand the potential warning signs and when to seek help.

Consult your medical provider or dietitian for an evaluation if you suffer from several of the symptoms previously described for low energy status and/or disordered eating, have menstrual irregularity and/or suspect energy deficiency.

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Methods for Prevention and Treatment Preventing and treating the Female Athlete Triad requires awareness of the problem and its causes. Treatment begins by determining the contributing factors and correcting them.

Due to the many potential causes treatment requires a diverse team of health professionals.

This would ideally include a medical provider, a sports dietitian, an athletic trainer and a sports or clinical psychologist5. They will ensure you are physically and mentally healthy, assess and modify your training program and help you develop proper eating strategies.

Treatment of the Female Athlete Triad does not mean you will not be able to participate in your sport, rather it will improve your health and performance. If caught early enough, most suffering from the Female Athlete Triad can expect a full recovery in a short period of time.

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Wrap-up The Female Athlete is a condition that typically affects female athletes. It caused by low energy status due to increased calorie needs and disordered eating, and can lead to amenorrhea and osteoporosis. It is important to remember the main causes and warning signs of the Female Athlete Triad to know when to seek help.

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Links for more Information:

ACSM Information on the Female Athlete Triad https://www.acsm.org/docs/brochures/the-female-athletetriad.pdf SCAN/CPSDA Energy Availability Fact Sheet http://www.ncaa.org/sites/default/files/Energy%20Availability%20Fact%20Sheet%20WEB.pdf

NCAA Managing the Female Athlete Triad https://www.ncaa.org/sites/default/files/Female%20Athlete%20Triad.pdf 15

References 1. Gibbs, J., Williams, N., De Souza, M. (2013). Prevalence of individual and combined components of the female athlete triad. Med Sci Sports Exerc. 45(5):985-996 2. Shriver, L., Betts, N., Wollenberg, G. (2013). Dietary intakes and eating habits of college athletes: are female college athletes following the current sports nutrition standards? J Am Coll Health.

61(1):10-6 3. Rauh, M., Nichols, J., Barrack, M. (2010). Relationships among injury and disordered eating, menstrual dysfunction and low bone mineral density in high school athletes: a prospective study.

J Athl Train. 45(3):243-52.

4. ACSM Information on the Female Athlete Triad. (2011). American College of Sports Medicine. https://www.acsm.org/docs/brochures/the-female-athlete-triad.pdf

5. Mountjoy, M. et al. (2014). The IOC relative energy deficiency in sport clinical assessment tool (RED-S CAT). Br J Sports Med. 0:1-3.

6. Slide 10 Bone picture: http://www.webmd.com/osteoporosis/ss/slideshow-osteoporosis-overview

Š 2015 Duke University/Student Health Nutrition Services

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