Download Female Athlete Triad - Jessica A. Daniels

THE
FEMALE
ATHLETE
TRIAD
By: Jessica Daniels
Defining the Triad
“The female athlete triad (Triad) refers to the
interrelationships among energy availability, menstrual
function, and bone mineral density, which may have clinical
manifestations including eating disorders, functional
hypothalamic amenorrhea, and osteoporosis.”1
Who is at Risk?
• According to Dunford, any female can be at risk, but the
most common athletes to experience low bone mineral
density, menstrual dysfunction, and low energy
availability are distance runners, ballet dancers,
swimmers, and rowers.2
• Hobart and Smucker found that most athletes do not meet
the criteria listed in the DSM-IV for anorexia nervosa and
bulemia, but they will exhibit disordered eating patterns
as part of the “triad syndrome”.3
At First Glance…
Criteria for Eating Disorders
Anorexia Nervosa
• Refusal to maintain body weight at
or above normal weight
• Fear of gaining weight when
underweight
• Denial of current weight or image,
disturbance in the way body image
or weight is portrayed
• Absensce of at least 3 menstrual
cycles
**Classified as either restrictive or
binge/purge.
Hobart and Smucker 3
Criteria for Eating Disorders
Bulemia
• Recurrent episodes of binge eating.
• Recurrent inappropriate
compensation to prevent weight
gain.
• Binge eating and compensatory
habits twice a week, lasting for at
least 3 months.
• Does not occur exclusively with
anorexia.
• Body weight and image influence
self evaluation.
**Classified as purging or non-purging
Hobart and Smucker 3
Eating Disorder Instruments
Further identification of eating disorders within
individuals can occur with the usage of additional
instruments.7
oEating disorder questionnaires
oEating disorder surveys
o Eating disorder inventory (EDI)
o Eating Attitudes Test (EAT)
o Eating Disorder Examination (EDE)
Amenorrhea
• Amenorrhea occurring in the athletic population can
result due to a change in the hypothalamus, causing levels
of estrogen to decrease.
• There are two types—primary and secondary.
• A history of amenorrhea is one of the easiest ways to
detect the female athlete triad.3
Amenorrhea
o Primary amenorrhea: Menses fails to occur by the
age of 16 years; if menses have not occurred by a time
period of 4.5 years after breast development9
o Secondary amenorrhea: loss of 3 to 6 menstrual
cycles consecutively for a female who has begun
menses9
o Menstrual dysfunction is more common in athletic
females when compared to the general population. 9
Osteoporosis
• Defined as ‘‘a skeletal disorder characterized by
compromised bone strength predisposing a person to an
increased risk of fracture”.1
• BMD levels reflect energy availability, menstrual status, and
factors related to nutrition, behavior, and environment.
• Low BMD pertains to a history of nutrition deficiencies,
stress fractures, hypoestrogenism, and secondary fracture
factors.
Osteoporosis
• Bone strength and fracture risk is dependent on the BMD
level.
• Bone mineral density (BMD) is used as a means of
screening and diagnosis for osteoporosis.
o Dual energy x-ray absorptiometry (DXA) testing can be used to
quantify density. 10
• According to von Schulthess and Zollikofer (2009), “the
Female Athlete Triad becomes a diagnostic consideration
for a radiologist when stress fractures and serous atrophy of
the bone marrow are identified on magnetic resonance
imagine (MRI).” 10
Signs and Symptoms
•
•
•
•
•
•
•
•
•
Weight loss
•
Fatigue
•
Amenorrhea
•
Stress fractures
•
Disordered eating habits
•
Frequent trips to the bathroom
Use of laxatives
Anemia
Depression
Frequent vomiting
Excessive exercise habits
Use of diet pills
Use of duretics
Excessive dieting for
weight loss
Treatment
• In most cases, treatment will involve multiple parties (physician,
dietitian, athletic trainer, exercise physiologist, coach, parents, friends,
athlete).
• Psychotherapy
• Counseling with Sports Dietitian
• Early intervention
• Hormone replacement therapy (debated)
• Alter participation by health level
• Nutrition journal and goals (ex: calcium intake of 1500 mg/day)
Who is Involved in Care?
• Physician
• Coach
• Psychiatrist/Psychologist
• Family
• Dietician
• Friends
• Certified Athletic Trainer
Coaches, family members, and friends can be a
great source of support!
Risk Factors and Prevention
• The following have been listed as risk factors: restricted
energy intake, excessive exercise, disordered eating behaviors,
frequent weigh-ins, punishment for weight gain, pressure to
succeed/win, over-controlling coaches or parents, social
isolation.3
• Prevention is seen as extremely important in this population, as
long-term effects of the triad are detrimental to self-esteem,
psychological state, and major body systems.
• Education is a key element in preventing the female athlete
triad. This can include athletes, parents, and coaches.
The “Triad” Illustrated
ACSM1
Proposed Expansion of FAT
• Now includes cardiovascular effects and sequalae11
• Has incorporated the recreationally active female
Example:
Case report:
16-year old female figure skater trains approximately 6 hours a week. She
begins to experience chronic knee pain that fails to improve with rehab and
treatment. When she is ordered to stop training she alters her diet out of fear
of gaining weight. After modifying her diet to eliminate foods such as
grains, salads, protein sources, and vegetables she loses weight over a period
of 3 weeks. She then begins to miss menstrual cycles. At this point she has
a much higher level of fatigue and chronic shin pain at night.8
Key points:
In further investigation it becomes apparent that this athlete may have
stopped formal training, but she continued off-ice training in addition to
rehab. In essence, she deprived her body of vital nutrients, increased overall
training, and added stress to her body.8
References
1. American College of Sports Medicine. (2007). The female athlete triad.
Medicine & Science in Sports & Exercise, 39 (10), 1867-1882.
2. Dunford, M. (2010). Fundamentals of sport and exercise nutrition.
Champaign, IL: Human Kinetics.
3. Hobart, J. A., Smucker, D. R. (2000). The female athlete triad. Retrieved
from http://www.aafp.org/afp/2000/0601/p3357.html.
4. Griffith, H. W., Moore, S., Yoder, K. (2006). Complete guide to symptoms,
illness & surgery (5th ed.). New York, NY: The Berkeley Publishing
Group.
5. France, R. C. (2011). Introduction to sports medicine and athletic training
(2nd ed.). Clifton Park, NJ: Delmar.
6. Manore, M. M., Meyer, N. L., Thompson, J. (2009). Sport nutrition for
health and performance. Champaign, IL: Human Kinetics.
References
7. Brunet, M. (2005). Female athlete triad. Clinical Sports Medicine, 24,
623-636.
8. Alleyne, J., CASM, C. (2004). Female athlete triad: The flip side of living.
The Canadian Journal of Diagnosis, 61-65.
9. American Academy of Pediatrics. (2000). Medical concerns in the female
athlete. Pediatrics, 106(3), 610-613.
10. von Schulthess, G.K., Zollikofer, C.L. (2009). Musculoskeletal diseases.
Segrate, Italy: Springer.
11. De Souza, M.J., Williams, N.I. (2004). Physiological aspects and clinical
sequelae of energy deficiency and hypoestrogenism in exercising
women. Human Reproduction Update, 10(5), 433-448.