The female athlete triad (or “the Triad” for short) is a The Female Athlete Triad is a syndrome of three interrelated conditions that exist on a continuum of severity. These three conditions have traditionally included:
Disordered Eating
Amenorrhea
Osteoporosis
According to a report published by the Medical Commission of the International Olympic Committee (IOMC), although any one of these problems can occur in isolation, inadequate nutrition in a female athlete may lead to all three occurring in sequence. Thus, the syndrome is referred to by the term the “female athlete triad.” More recently, however, the definition of the Triad has expanded to include other menstrual disorders, low energy levels, and low bone mineral density.
As many as two-thirds of female athletes are affected by symptoms of the Triad (Eating Disorders Review, Vol. 19/No. 5). Unfortunately, however, only a small percentage of females with the Triad receive treatment.
Those at greatest risk for developing the Triad are women who participate in aesthetic sports (e.g., gymnastics, diving, cheerleading) and endurance sports (e.g., swimming, rowing, running), and “weight-class” sports (e.g., body building, karate). Although the occurrence of the Triad is highest in elite athletes, it can occur at any age or athletic skill level (Shepphird, 2008).
Signs and Symptoms of the Triad include:
weight loss
no periods or irregular periods
fatigue and decreased ability to concentrate
stress fractures (fractures that occur even if a person hasn’t had a significant injury)
muscle injuries
Girls with female athlete triad often have signs and symptoms of eating disorders, such as:
continued dieting in spite of weight loss
preoccupation with food and weight
frequent trips to the bathroom during and after meals
using laxatives
brittle hair or nails
dental cavities because in girls with bulimia tooth enamel is worn away by frequent vomiting
sensitivity to cold
low heart rate and blood pressure
heart irregularities and chest pain
The American College of Sports Medicine recommends that early intervention and education as important priorities for reducing the risk of the Triad in female athletes. Among their recommendation are:
Athletes should be assessed for the Triad at the pre-participation physical and/or annual screening (Download Screening History for the Female Athlete Triad), and whenever an athlete presents with any of the Triad’s clinical conditions.
The first aim of treatment for any Triad disorder is to increase energy availability by increasing energy intake and/or reducing energy expenditure.
Athletes with eating disorders should be required to meet established criteria to continue exercising, and their training and competition may need to be modified.
The effects of the Triad on a young female can be devastating. Resulting bone loss leads to an increase risk of fractures, and the bone loss may indeed be permanent. Currently, there is no pharmacologic agent adequately restores the bone loss that can result from the Triad. While hormone replacement therapy No published longitudinal studies are available on the long-term benefits of hormone replacement therapy will treat amenorrhea, the American Academy of Family Physicians reports that no published longitudinal studies are available on the long-term benefits of hormone replacement therapy to slow or reverse the loss of bone mineral density in these young women. (To read a Q&A about the Triad from the AAFP, click here).
Of course, prevention of the Triad is an important effort. Colleges and Universities have thankfully joined in this important work. For example, Boston College has developed an “Eating Awareness Team”, providing education and information to its student community. Among their recommendations are these “tips”:
“Choose an activity that complements your natural body strengths and suits you as an individual.
Realize your health is more important than competitive success. Taking health risks for a perceived competitive edge will make you lose in the long run.
Be wary of those who value your competitive success over your well being. Frequent weigh-ins, weight comments and punitive consequences for weight gain may increase an athlete’s risk for the Triad.
Appreciate your own healthy, active body. Don’t compare yourself to others, especially those portrayed in the media. Optimal weight for health AND performance is different for everyone.
Realize the thinnest athletes are not necessarily the fastest or the strongest.
Think of fuel as the ultimate performance enhancer!
Don’t starve your bones. Part of your fuel mix should include several servings a day of good calcium sources like milk, yogurt, cheese, calcium-fortified juices and soy products. If you are lactose-intolerant, try some of the no-lactose dairy products available. Green leafy vegetables, almonds and beans also have some calcium.
Be a role model with both your words and actions. Speak up when you hear others making negative comments about weight or body shape. Compliment friends and teammates on their talents and personality, not their looks. Take a positive attitude about fueling yourself and enjoying foods.”
In addition, the NCAA Coaches Handbook now, gratefully, addresses the issues of prevention and education regarding eating disorders and the risk of females athletes developing the Triad. For more information about the Triad, visit The BodySense Program, “a positive body image initiative for athletes” that began as an outreach in Canada and features a very informative website.