The Female Athlete Triad

Female athletes are often nutritionally vulnerable as they strive for thinness and a lean physique in the belief that this will make them faster & stronger and lead to an overall improvement in their sporting performance.

 

The female athlete triad was first defined in 1992 by the American College of Sports Medicine (ACSM) and described the interrelationship between disordered eating, amenorrhoea (cessation of menstruation) and osteoporosis; an updated position was released in 2007 that modified the components of the triad to energy availability, menstrual function and bone mineral density (BMD) (George et al., 2011).

Low energy intakes and disordered eating affects body fat levels and menstrual function, leading to amenorrhea, which, in-turn leads to the development of impaired bone health and subsequent development of osteoporosis.  Adolescents and women training for sports in which low body weight is emphasised for athletic activity or appearance are at greatest risk (Nattiv et al., 2007, George et al., 2011).

A simplistic view of the triad
www.femaleathletetriad.org

It is important, at this point, to distinguish the difference between the terms “disordered eating” and “eating disorder”; disordered eating refers to unhealthy and harmful eating behaviours that are used to achieve low body weight and leanness, whereas an eating disorder refers to one of the three clinical conditions, anorexia nervosa, bulimia nervosa or eating disorder not otherwise specified (EDNOS), each diagnosable by a set of clinical criteria (Burke & Deakin 2010).

Low or restricted energy intakes will ultimately lead to both macro-nutrient (protein/fat & carbohydrate), micro-nutrient (vitamin & mineral) deficiencies and low intakes of the essential fatty acids, omega 3 & 6, leaving the individual susceptible to fatigue, illness, infection and possible risk of injury.   As body fat is reduced, hormonal imbalances are created and as levels of oestrogen, follicle-stimulating hormone (FSH) and luteinising hormone (LH) decline, menstruation may then cease; according to Frisch (2002) “a girl does not have her menstrual period until she has a predictable minimum amount of body fat, and a grown woman requires a larger minimum amount of fat to maintain ovulation and regular menstrual cycles”.  Oestrogen suppresses osteoclast (cells that break down bone tissue) activity and therefore loss of endogenous oestrogen leads to accelerated bone loss.

 

An athlete's condition moves along each spectrum at a different rate,
in one direction of the other, according to her diet and exercise habits
(American College of Sports Medicine)

 

On a more positive note, if energy intake is increased to compensate and accommodate for increased energy expenditure, hormonal balance and menstrual function will usually return to normal; strenuous training alone is not enough to disrupt menstrual function unless it is accompanied by dietary restriction (George et al., 2011).  However, as the number of missed menstrual cycles accumulates, the loss of BMD may not be fully reversible and may compromise the achievement of peak bone mass (the highest level of bone mass achieved as a result of normal growth) (Thomas & Bishop 2007). “Studies conducted with female athletes have shown that premature osteoporosis may occur as a result of menstrual dysfunction and may be partially irreversible” (Burke & Deakin 2010); low BMD also increases the risk of injury and stress fractures. 

Nutrition is pivotal to an athlete’s performance and the female athlete triad demonstrates how severe under-nutrition can impair not only overall health but also reproductive and skeletal health; “existence of one or more components of the triad, alone or in combination, poses a health risk for the physically active and athletic female” (Lanham-New et al., 2011).

Prevention, recognition and early intervention of the triad should be a priority for all those who work with female athletes and education should be at the forefront to ensure that all women are able to enjoy the benefits of regular exercise & physical activity throughout the whole of their lives. 

 

“I am building a fire, and every day I train, I add more fuel.   At just the right moment, I light the match.” – Mia Hamm (Olympic gold medalist in women’s football)

 

Burke, L., Deakin, V. (2010) Clinical Sports Nutrition, 4^th Edition, Australia, McGraw-Hill Education (Australia) Pty Ltd

Frisch, R.E. (2002) Female Fertility and the Body Fat Connection, London, The University of Chicago Press Ltd

George, C.A., Leonard, J.P., Hutchinson, M.R. (2011) The female athlete triad: a current concepts review. South African Journal of Sports Medicine, Vol 23, No.2, pp. 50-56

Lanham-New, A.A., Stear, S.J., Shirreffs, S.M., Collins, A.L. (2011) Sport & Exercise Nutrition, West Sussex, John Wiley & Sons Ltd

Nattiv, A., Loucks, A.B., Manore, M.M., Sanborn, C.F., Sundgot-Borgen, J., Warren, M.P. (2007). The Female Athlete Triad.  American College of Sports Medicine, Position Stand, pp. 1867-1877

Thomas, B., Bishop, J. (2007) Manual of Dietetic Practice, 4^th Edition, Oxford, Blackwell Publishing Ltd

Feeding Young Minds

I conducted a series of nutrition workshops last Sunday on behalf of Satellites of Macclesfield Swimming Club; the day was organised by Head Coach, Lisa Atkinson, and involved a busy day of activities, including swimming and yoga, for talented young swimmers aged 10-12 years from the North Midlands.  Lisa asked if I would attend to provide some sports nutrition workshops and healthy eating messages for the young swimmers in order to convey the importance of nutrition in helping prepare them for their formative, forthcoming years in swimming.

The day was a great success and I enjoyed it immensely; the young swimmers were fabulous, interacting and getting involved in the activities and quizzes I’d prepared for them; unfortunately we didn’t have access to power-point, but the slides were easily printed out and adhered to a flip chart.  Lisa had organised the groups into no more than ten at a time, so the four separate groups, spread throughout the day, all contributed something different to each session; working with young people involved in sport is so inspiring, they are so dedicated to their activity, rising early morning to train and often attending classes & events late into the evening - real dedication which obviously means that their nutrition is of paramount importance to ensure they stay well, healthy and free from injury.

I began by talking to them about energy and the importance of carbohydrates and we then moved onto protein, and the constituent building blocks of amino acids, before moving onto fat.  I think it so important to emphasise to young people that all fat is not bad; there is so much hype about fat being the demon macromolecule, but without it we couldn’t absorb the fat soluble vitamins, ADE & K and for athletes it is a valuable source of energy - furthermore, all fat is not equal!  Most of the young swimmers were aware of saturated fat and although I hadn’t planned on talking about the monounsaturated and polyunsaturated varieties, the final group of the day were eager to learn more and so I briefly touched upon these and their importance in our diets, emphasising that for athletes, when time is short and energy often needed quickly and in large amounts, high energy rather than nutrient-dense snacks are absolutely vital.

I then talked about the vitamins, minerals & antioxidants and the importance of eating lots of fruits & vegetables; we discussed how many portions of F&V they thought we should all eat on a daily basis; fortunately most were aware of the 5 a day message, but I was very pleased that some thought it should be 5+ and this is indeed the answer we agreed upon.  It made me smile, when one of the young swimmers asked me “do you eat 5 a day?” -  honesty is definitely the right policy and so I said that yes, on the whole I tried very hard to make sure I achieved that goal but there were busy days when this was impossible; however, it was important not to beat myself up about it, but rather get back on track and make up for the shortfall as soon as I possibly could.

We then talked about fuelling up prior to training and the importance of refuelling afterwards and the optimum time-frames for doing so; we brainstormed ideas for snacks to have beforehand and discussed those containing both carbohydrate and protein to have within the hour after training and devised healthy meal options to ensure their “fuel tanks” were full to prepare them for the next busy day and to enable them to train and perform again at their best.

It’s such a privilege and so very refreshing to work with young people; to be able to try to make a difference and to provide them with sound, scientific knowledge about nutrition, before they begin to perhaps be influenced by messages that are based upon the latest fads or trends.  I’ve inserted below my final messages to the young swimmers, which I hope they will remember!

 

It is very important to remember that as an athlete you expect a great deal from your body, therefore you need a huge amount of energy to perform all your day to day activities, i.e. going to school, doing your homework, meeting with your friends etc. and lots more energy besides to train & compete.

Your diet needs to contain a wide variety of foods - carbohydrates to give you energy, protein to repair and recover and lots of fruit and vegetables to provide you with your vitamins & minerals.

BUT … this does not mean that foods such as cakes, crisps, chocolate and sweets are all BAD, it is ok to have them now and then, they will give you lots of energy as well, but just don’t have too many of them, choose healthier snacks instead such as toast & jam, a peanut butter sandwich, cereal with milk, yogurt, lots of fruit, a cereal bar or a milk shake.

Don’t be a fussy eater; athletes need a wide variety of foods to ensure they obtain all their vitamins & minerals; be prepared to try new foods and even if you don’t like a vegetable such as broccoli very much, try to think like an athlete and eat like an athlete, and try just a small amount.

The Eatwell Plate - a visual representation of the types and proportions
of foods needed for a healthy & well-balanced diet

Eat well, stay well

 

Cathy x