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What you need to know about the female athlete triad

Kids need to be active! Portion control starts at an early age! Teach them healthy eating! That’s what we all keep hearing, right? And we all want to do right by our kids, but how much is too much, and how far do we take it?

These are all questions I find myself addressing with my patients and my parenting peers. Now don’t get me wrong, I preach about healthy eating and exercise, but there comes a time, especially with our girls, that we need to address what happens when these ideals are taken to extremes. For some girls, not balancing their bodies’ needs and their activity levels can have dire consequences. I am talking about the female athlete triad.

The triad is defined as a syndrome of disordered eating or low energy availability, menstrual disturbances or amenorrhea, and bone loss or osteoporosis. A female athlete can have one, two or all three of these to be at risk. For the sake of this discussion, I will use the word “athlete” but please keep in mind this can happen to any female that exercises not for sport as well.

Let’s break it down into the three components:

1. Disordered eating or low energy availability

Energy availability is described as the amount of energy that is available for your body after exercise; in other words, energy in minus energy out. Many active girls use more energy during sports or exercise than energy taken in by food. When this happens we refer to it as an energy deficit. When the deficit gets too large, the body doesn’t have enough energy to perform, normally resulting in abnormal menstrual cycles and even bone development.

Many times this starts out innocently enough. Our girls are often unaware of how much energy they are expending during sports or exercise and at the same time are under the constant peer pressure to maintain what they think is an ideal body weight. This can be especially worrisome in sports known to value a certain ideal body type such as ballet, figure skating, gymnastics and diving, or in sports in which athletes are classified by their weight such as rowing or martial arts. Girls are frequently under the impression that they need to lose weight and do so by fad diets, diet pills or laxatives, skipping meals, avoiding certain foods or drastically cutting calories. Combining this pressure to maintain an ideal body weight with the pressure to push themselves in sports or exercise can create an energy deficit of which they are completely unaware.

Disordered eating can range from simple dieting to clinical eating disorders such as anorexia nervosa and bulimia nervosa.

2. Menstrual disturbances or amenorrhea There are two types of amenorrhea: One is when a woman has been having her period and then stops menstruating for three or more months. The other is the delayed onset of menses, which can also be associated with a delay in the development of secondary sexual characteristics. Weight changes due to dietary restrictions or excessive exercise can lead to a decrease in estrogen released. Without the release of estrogen, the menstrual cycle is disrupted. Periods can become irregular or even stop.

You can see how this symptom of the triad goes hand in hand with low energy availability. What our young girls are not aware of is that in the long run, women with amenorrhea can even become infertile.

3. Bone loss or osteoporosis Osteoporosis is a condition in which the bones become fragile as a result of hormonal changes or deficiencies of calcium or vitamin D. We have already discussed what low estrogen can do to the menstrual cycle. Well, it can also lead to osteoporosis. Combine that with dietary deficiencies, and you have compounded the problem.

This is even more of an issue for girls who may have low energy availability and irregular periods as the peak ages for bone development are between puberty and early 20s. Although they are doing positive bone building exercise, they are actually failing to build the expected bone mass during this critical time, which can result in a lasting effect through adulthood, not to mention stress fractures and other injuries in the shorter term.

So, now that we understand the female athlete triad, let’s talk about what we need to look for. I’ll use a short story to illustrate.

Jill is an 8th-grader who just made the volleyball team. During uniform fittings a peer mentions that the bottoms look a little tight. Jill is embarrassed and thinks to herself that she’ll really watch her portions and try to lose a few pounds. Her parents notice she is leaving more food on her plate but brush it off as “typical” behavior for a teen. Meanwhile, Jill’s practices are longer and more intense than in the past and she is working really hard in hopes of making the starting lineup. Fast forward to the end of the volleyball season. Jill hasn’t noticed that her periods have stopped because she’s been so busy with school and volleyball. She also has been trying to rehab back from a stress fracture in her ankle.

Do you know anyone with a story like Jill’s? It is far more common than we think and easily overlooked until it is very far advanced. Besides weight loss, irregular periods, fractures and injuries, there are more signs, including:

  • Preoccupation with diet and exercises

  • Frequent bathroom trips after meals

  • Brittle hair or nails

  • Dental cavities

  • Low heart rate

  • Dry skin

  • Fatigue

  • Dizziness

  • Low blood pressure

  • Sensitivity to cold

  • Chest pain

I cannot stress enough that early detection is imperative. It is vital to recognize the symptoms and catch them before things get out of control. Female athletes need to be taught proper nutrition for their respective sport. They need to understand how to balance their diet to include the carbohydrates, proteins and fats that their bodies need.

Good food choices, the proper amount of exercise, and parents, peers and coaches who understand the risks will help female athletes reach their optimal performance while avoiding the triad syndrome.

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