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