The Female Athlete Triad

For many athletes, participation in exercise is a healthy pursuit.  Unfortunately, for a significant proportion, exercise can lead to, or exacerbate one or all of the trio of conditions which constitute what is termed the Female Athlete Triad.  This blog looks at the triad, highlights why it should be of concern to female athletes and their coaches, and suggests some interventions to prevent or treat the conditions of the triad.

The condition comprises the following:

1. Disordered eating or an eating disorder 
2. Low bone mineral density, usually in the form of osteopenia (less severe) or osteoporosis (more severe) 
3. Absent or irregular menstrual cycles (olgiomenorrhoea or amenorrhoea)

According to the American College of Sports Medicine (ACSM), the triad is interrelated in aetiology (causes), pathogenesis (symptoms), and consequences.  The triad can result in long-term medical and psychological illness, as well as in short-term declines in physical performance.

Stress fractures, related to declined oestrogen levels, an insufficient diet and subsequently reduced bone mineral density are a major concern for athletes, and anything that increases osteoporosis, a highly debilitating disease which increases with age, is of major concern to society. 

 

Body composition, eating disorders and disordered eating

Body mass and body composition can be a major obsession of athletes in certain sports, particularly those related to those which are subjectively scored (figure skating, diving, synchronised swimming, body building and gymnastics), those where a lean body mass and low can help performance (high jump), endurance sports associated with low body mass (distance running, cross country skiing), weight-restricted sports (lightweight rowing, boxing and some martial arts, horse racing), and sports which require reviling clothing during performance (cheerleading, diving, swimming, beach volleyball and gymnastics).  Athletes in these sports are particularly susceptible to disordered eating and eating disorders.

A low percent body fat can directly lead to menstrual dysfunction, and low bone mineral density.  Practices, such as restricted or unhealthy eating practices, insufficient calorie intake, insufficient mineral intake, obsessive exercising and eating disorders, which lead to low body mass, can have additional indirect effects on menstrual health, and bone mineral density.

Eating disorders in themselves can lead to severe morbidity, and even death.  Anorexia nervosa and bulimia nervosa are severe psychological illnesses, and require early diagnosis and treatment to limit the long-term effects of the sufferer.  Individuals who develop an eating disorder enter a downward spiral of self-destruction and denial and obsessive behaviour, and the longer it goes untreated, the more difficult it is to break out of the situation.

Anorexia nervosa can be caused by a number of reasons, and suffers will require professional treatment relevant to the source of their illness.  Though clinical eating disorders may not be much more prevalent in sport than in the general population, a range of sub-clinical form of eating issues, known collectively as disordered eating, or anorexia athletic, are extremely prevalent in sports people.  Suffers often intentionally attempt to reduce their weight because they perceive it to be important in their sport, and engage in unhealthy practices to do so.   Disordered eating can lead to menstrual dysfunction, low bone mineral density, impaired performance and a range of other illnesses, and injury risks.

Some warning signs include:

• Excessive concern about body size or shape
• Noticeable fluctuations in weight
• Changes in ‘normal’ eating behaviours
• Obsession with food
• Eating alone
• Excessive exercising
• Depressed mood, low self-esteem
• Use of diet pills, laxatives
• Going to the bathroom frequently after meals
• Fear about gaining weight or becoming fat
• Bloodshot eyes, smell of vomit

Amenorrhoea and menstrual dysfunction

Amenorrhoea, i.e. prolonged absence of menstrual bleeding, is probably the most recognisable and easily assessed of the three component parts of the triad.  Sports participation, with or without the co-existence of disordered eating, is shown to be higher in female athletes than their sedentary counterparts.  Low body mass, inadequate energy intake and physical and psychological stress and training history are just some of the proposed contributing factors.  Prolonged menstrual dysfunction, and the associated reduction in oestrogen levels, can have prolonged detrimental affects on bone mineral density.

Bone mineral density, osteopenia and osteoporosis

Bone mineral density, which generally increases in response to impact exercise, can actually be compromised in response to sudden, sever increases in training volume, low oestrogen levels, insufficient nutrient intake and low body mass.  Low bone mineral density is significant, not only because of the long-term risk of osteoporosis, but also because of the short-term injury risk for the athlete.  Stress fractures have been shown to be higher in athletes with low bone mineral density, and take longer to heal in those with contributing risk factors.

Treatment

Treatment is often difficult, as athletes will likely resist increasing body weight and decreasing training loads.  Athletes also find it difficult to admit to menstrual problems and eating problems, particularly if they have spiraled deep into the circle if self-destruction and denial.  Early diagnosis is important.  Treatment of eating disorders, which should be undertaken by qualified staff, is paramount.

Menstrual disturbance should be medically assessed to ensure that it’s not pathological.  The return of menses, which should occur after a reduction in training volume and a return to a healthy body weight is ideal.  A reduction in training volume of around 10% is recommended, though this does vary from one individual to the next.  Energy intake should be increased gradually.

The contraceptive pill and other hormonal medications are prescribed in many cases, but don’t cure the underlying causes.  Bone mineral density has been shown to increase after the resumption of menses, but bone mineral density may never return to normal levels, even after years of regular menses and hormonal use.

Further information

• There is lots of useful information relating to the Triad on the Female Athlete Triad Colation website.
• Some useful information relating to eating disorders can be found on the B-eat website (uk) and on Bodywhys (Ireland).
• The Eating Disorders in Sport research group at Loughborough University also have good information on their website, and look for research participants from time to time.
• UK Sport produced a good downloadable booklet entitled Eating Disorders in Sport which is specifically designed for practitioners and coaches working with high performance athletes.

A number of good books are available for those suffering from eating disorders as well as those supporting those suffering from anorexia and bulima.  These are just some of the options available:

Eating disorders are not exclusive to women, and there is an increasing rate of disordered eating, body
dismorphic disorder and biogrexia among male exercisers. This book highlights some of the issues:

 

Here are some good general books looking at issues faced by female athletes:

 

Striking a balance

Last week I delivered a workshop to a group of sports scholarship students at the University of East London.  The session specifically looked how a student-athlete can set about creating a balance in their lives, an environment which will both help them in their sport and facilitate their development as a human being.  Some interesting discussion followed.  Here is a summary of the key points:

No man is an island

Athletes, like everyone else, live in an ever changing environment, and have to interact with many different people, and balance many different aspects in their lives.  These are just some of the many things that athletes (and particularly student-athletes), need to be good at:

• Managing budgets
• Selling themselves (to funders and potential sponsors)
• Dealing with the media
• Managing their time
• Organising and planning
• Coping with setbacks (bouncebackability)
• Managing relationships (with coaches, teammates, fans, sponsors)
• Coping with pressure (from the press, fans, teammates, self, parents)
• Decision making
• Accepting the uncontrollable
• Negociating
• Striking a balance
• Setting goals

All these skills are required in addition to the physical and mental attributes required for their sport, and more than a good measure of hardwork.  The above factors are just some of the elements which make up the ‘athlete lifestyle’

Getting a balance

The best story that I heard of to demonstrate balance, is the one where the university professor gets two pint glasses, and demonstrates to a group of university students how they can go about getting a balance in their lives.  He takes the first glass and fills it to the brim with water (signifying alcohol or a social life).  Filled to the top, there is no room left in the glass to for anything else; place a stone or pebble in it, and some of the water will flow over the edge.  He takes the second glass, and fills it to the top with stones.  The glass takes 5 or 6 medium sized stones and can take no more.  The glass, it could be said, is full of stones.  With the stones, however, there is still some room of other things.  The professor takes some small stones, and puts as many of them as he can in the glass.  He fits a large handful in.  A handful of pebbles follow, and then a small handful of sand.  Just as the audience think that the glass can hold no more, the professor takes a beaker of water, and manages to fit some into the glass.

The glass can be taken as a metaphor for the student-athlete’s life.  Think of the larger stones as the training sessions, the smaller ones as the lectures and coursework, the pebbles as all the little chores of life like shopping, cooking, and eating, the sand as sleep, and the water as relaxing and social time.  This way around, there is plenty of time to fit everything in.

A good route to striking a balance, can be broken into 5 processes:

1. Set goals

Deciding what you want to achieve, and what you want to get from life will help focus your balance.  Some of the questions that you might want to ask yourself include: what do you want to achieve?  What do you need to do to achieve those goals?  Are  the goals realistic?  Do you have goals in multiple areas of your life (sport, academic, career, other hobbies, life)?  What can be done to ensure that those goals fit together?  Are you following your goals for the right reasons (i.e. are they your goals, or are the goals you think others expect you to achieve).

2. Make a plan

Plans can be set on a daily, weekly, termly, seasonal, or yearly basis.  Some specific forms of planning are included in the timemanagement blog below.  Use the tools and planning process that work best for you.  Constantly consider your goals when planning.  Do your plans work towards your goals?  Review your plans to ensure that you are realistic in what you can achieve on a daily basis.  Identify where you are losing time, or being inefficient (are you spending two hours travelling each day, when the journey would be quicker to cycle? Did you spend time travelling because you failed to pack everything you needed for the day before you left the house in the morning?).

3. Make any important decisions

Student athletes constantly need to make decisions as they attempt to strike a balance in their lives, and often make decisions on a daily basis which they don’t even realise that they are making.  At certain times, however, important decisions which affect one’s goals and plans, need to be made.  Procrastination over making decisions can be an additional source of stress for an athlete, and delaying making the decision can result in missed opportunities.  Athletes should develop sound decision-making skills.  The following task, helps to highlight some of the processes involved in making decisions:

• Pick an important decision that you need to make now, or in the near future
• Consider what happens if you don’t make a decision, or delay making the decision
• List all your available options (include at least one ‘dream’ option i.e. in an ideal world what would you do?)
• List where you can find further information to help you make your decision
• List all the people that you can seek advice from (don’t just include people who will tell you what you want to hear)
• List any factors that you will use to help you make your decision (e.g. your goals, values, abilities, time, financial or family situation, location, things that you will/won’t compromise on)
• Consider what sort of things stop you from making decisions
• After seeking further information and advice, and considering any factors that your decision will be influenced by, choose 2 or 3 viable options from your initial list
• List the positive and negatives for each option
• It will be a lot easier to make a decision once you know what exactly your options are.  Imagine yourself in different situations.

In many cases, there are no right or wrong decisions, just decisions that cause stress because they haven’t been make.

4. Build in relaxation or recover time

Planned recovery time can be far more rewarding and beneficial than ad hoc down time.  Consider how you are going to relax and recover each day, week or season and use recover to refresh and revitalise the mind as well as the body.  Use down-time at the end of the season to cross things off your bucket list that you don’t get to do during the season.

5. See everything as a choice, not a sacrifice

Sport for most is a hobby, and the choices you make to achieve your goals should never be seen as sacrifices.  Choose to be successful.

Hay Fever and Sport

With hay fever season well and truly here, I thought it appropriate to share some advice on the illness.  I, like many others it seems this year, am relatively new to the illness, and am beginning to realise that summer time is not all sunshine so to speak!

Firstly, all high performance athletes who suffer from hay fever, should check that any medication that they take complies with anti-doping regulations.  While there are many over-the-counter and prescription treatments which are permitted, some are not, especially intra-muscular injections with are sometimes prescribed to treat the condition, and products containing pseudoephedrine which is prohibited in competition (e.g. Zirtex Plus Decongestant Prolonged Release Tablets).  Athletes should check the status of any medication (intra-muscular, oral, nasal or otherwise) that they take on their national drug database - www.globaldro.com for medications purchased in UK, including Northern Ireland, USA and Canada and www.eirpharm.com for products purchased in the Republic of Ireland.

Any athlete who is prescribed a prohibited cortiosteriod intra-muscular injection will need to take additional measures, including obtaining documentation to show that such a treatment was necessary, over and above the permitted medications available.  Athletes who are part of their national testing pool (i.e. subject to out-of-competition testing) will need to obtain a Therapeutic Use Exemption (TUE) prior to use, and other high performance athletes will need to obtain and provide TUE permission after testing.

Further information can be obtained here (for athletes in the UK) and here  (for athletes in Ireland).

As well as the potential of failing a drug test, taking hay fever medication can result in drowsiness; not ideal when you're trying to compete at the top of your game!  Any steps that you can take to avoid the symptoms may be better than taking medication.  Simple things like wearing wrap-around sunglasses can help prevent pollen getting the eyes, and can therefor reduce at least one of the symptoms of hay fever.

This article provides useful basic information on hay fever.  Remember though you should always seek medical advice for any condition that you suffer from, and check all medications, even if they have been prescribed by a doctor.