# Exercise as it relates to Disease/The female athlete triad - are elite athletes at risk

The components of the female athlete triad, as put forth by the 1997 ACSM positional stand, consisted of disordered eating, amenorrhea, and osteoporosis. It was noted that not all patients had to have 3 components of the triad. With increased data and research, it is being recognised that even having only 1 or 2 elements of the triad can greatly influence the chance of females’ long-term morbidity. More recent studies from the American College of Sports Medicine (2007) describe the female athlete triad as the interrelationship between energy availability, menstrual function and bone mineral density. This interrelationship ranges from healthy to diseased, however with the appropriate nutrition and exercise the three components should in turn exhibit a healthy and robust female athlete.

#### Three components of the Triad are as follows with a spectrum ranging from healthy to diseased

* Availability and use of energy through intake and expenditure -can range between optimal energy intake and use, to low available energy generally considered disorder eating in the female athlete triad.
* Bone mineral density varies from optimal healthy bone to osteoporosis
* Menstrual cycle and function can range from eumenorrhea to amenorrhea
Since defining the term ‘female athlete triad’ there has been significant research into understanding of the triad. In trying to understand the three concepts (disordered eating, osteoporosis and amenorrhea) one must understand that interrelated concepts are difficult to explain with out the influence of the other components.

## Prevalence

Due to the triad being made of up three inter-related elements it is difficult to diagnose and because the triad is so frequently denied, not recognised and underreported, screening for symptoms and risk factors has been recommended to properly recognise and report the triad. Articles suggest that all female athletes are at risk of developing the triad. However, athletes competing in sports that encourage lower/leaner body weight or include aesthetic aspects are said to be at an increased risk of developing the triad. The prevalence of eating disorders in young female athletes has been reported to be higher than in non-athletes. This is particularly prevalent in athletes competing in sports that emphasise leanness or a low body weight. Furthermore, it has been reported that amenorrhea is more prevalent in the athletic population (3– 66%) than in the general female population (2–5%). Few prevalence studies related to premature osteoporosis in young athletes and non athletes have been published. Two studies have reported a prevalence of osteoporosis of 10 –13% in small groups of amenorrheic distance runners, whereas two other studies did not find any females with osteoporosis in their samples. Furthermore another study conducted by the Norwegian University of Sport and Physical Education, Oslo used Eight athletes (4.3%) and five controls (3.4%) which met all the criteria for the Triad (disordered eating/eating disorder, menstrual dysfunction, and low BMD). Six of the athletes who met all the Triad criteria competed in leanness sports, and two in non-leanness sports. The evaluation included the presence of two or more components of the triad that showed the prevalence ranging from 5.4 to 26.9% in the athletes and from 12.4 to 15.2% in the controls. Therefore these results adhere to the assumption that a significant proportion of female athletes suffer from the female athlete Triad. In addition, the results found the female athlete triad to also be present among normal active females.

## Identification-signs and symptoms

The female athlete triad may be recognised and identified in many different ways. Current research suggests the easiest way to identify individuals at risk is through recognition of clinical correlation.

#### Symptoms may include

* Lanugo- a fine downy hair that grows due to lack of adipose tissue, in particularly found on the face (generally seen on those with a severe caloric deficit)
* Russell's sign- may be the presence of lacerations and callous on the hands due to repetitive contact with incisors from self induced vomiting.
* Oral complication- like enamel loss, salivary gland hypotrophy and periodontal disease.
* Menstrual history- to determine regulation, as well as helping to predict current bone health
Further tests may include and an eating disorder survey, the most commonly used, identified and tested is the Eating Disorder Inventory (EDI), the Eating Attitudes test (EAT) and the Eating Disorder Examination (EDE). All three of surveys have shown significant clinical utility in the diagnosis of eating disorders.

## Treatment/Management

The first step in treatment of the Triad is increasing energy availability, whether this is via an increase in energy intake, a decrease in exercise energy expenditure or a combination of the two. Through increasing energy availability, athletes can aim to restore menstrual cycling and increase in bone mass density. Not only this but as with any disease the best treatment is prevention. Education is clearly identified as a way to prevent and treat. Education and awareness helps not only the athletes but also the coaches. This in turn can contribute to a more open and non-threatening environment making treatment and acceptance easier to deal with.
Prevention and education of the triad and its components should be targeted towards all women involved in sport, particularly the elite in leanness sports. Furthermore management may include having recourses to help if further treatment is needed. Referrals should include a health care professional such as a psychologists/psychiatrists, nutritionists, and the primary care/team physician.

## Risk factors

Each of the three disorders of the Triad alone may result in serious medical health consequences. The appearance of all three disorders of the female athlete triad increases the potential for morbidity and even a higher rate of mortality. Providing guidelines for the coaching staff on proper communication with athletes regarding weight control and eating disorders will help to diagnose and treat the symptoms.

#### Risk Factors Include

* Disordered eating: Can lead to anorexia nervosa and or Bulimia. Both are characterised by severe disturbances in eating behaviour. Anorexia nervosa is generally characterised by the refusal to maintain a healthy body usually depicted by lack of calorie intake and excessive exercise. Bulimia is characterised by binge eating, generally followed through with self-induced purging, laxatives, fasting and excessive exercise.
* Bone mineral density: Can lead to osteoporosis. Osteoporosis, as defined by the ACSM, is a disease portrayed by low bone mass and deterioration of bone tissue, in turn leading to heightened skeletal brittleness and amplified risk of fractures.
* Menstural function: can lead to amenorrhea Amenorrhea simply stated is a lack of a menstrual cycle. Can be broken down into primary and secondary, primary being the late onset of menarche >16 years of age. Secondary is the absence of menstrual cycles lasting longer than three months.This delay of onset of absences can lead to severely low BMD as well as fertility issues.

## Limitations and Considerations

Studies into elite athletes found a lower BMI can increase the incidence of musculoskeletal injuries and chronic orthopaedic problems in amenorrheic athletes. Other more long-term effects may include amenorrhea or disordered eating patterns leading to major concerns such as osteoporosis. A decrease in the levels of estrogen can affect bone density as well as reproductive function.
Considerations for any athlete suffering with any component of the female triad should be a priority. They should be treated accordingly with time out to see specialist as well as increasing focus toward regain health and stamina through nutrition and appropriate amounts of exercise (not over exercising).

## Conclusion

Female athletes should be monitored continuously and examined for any signs or symptoms of the female triad. Early identification, treatment and intervention will support positive health outcomes and assist in a speedy recovery. If any one of the three components of the triad appear prevalent, the athlete should be tested for the other two, as there is a common link and often an intertwined association of the three components - as noted above. Results support the belief that a significant fraction of female athletes suffer from the components of the triad. In addition, the triad is also present in normal active females. Which in turn suggests the focus should be placed on all young girls and women who are physically active. Overall, the benefits of exercise to a female’s health far outweigh the risk of the negative health consequences associated with the Triad.

## Further reading

http://www.ausport.gov.au/ais/nutrition/factsheets/basics/female_athlete_triad
http://emedicine.medscape.com/article/89260-overview#showall

## References

* ↑ American College of Sports Medicine. The female athlete triad: disordered eating, amenorrhea, osteoporosis -- a call to action. Sports Med Bull. 1992;27:4.
* ↑ American College of Sports Medicine. The female athlete triad: disordered eating, amenorrhea, osteoporosis -- a call to action. Sports Med Bull. 1992;27:4.
* ↑ AIS Sports Nutrition, last updated December 2010. © Australian Sports Commission.
* ↑ AIS Sports Nutrition, last updated December 2010. © Australian Sports Commission.
* ↑ BYRNE, S., and N. MCLEAN. Eating disorders in athletes: a review of the literature. J. Sci. Med. Sport. 4:145–159, 2001
* ↑ BYRNE, S., and N. MCLEAN. Elite athletes: effects of the pressure to be thin. J. Sci. Med. Sport. 5:80 –94, 2002.
* ↑ SUNDGOT-BORGEN, J., and M. K. TORSTVEIT. Prevalence of eating disorders in elite athletes is higher than in the general population. Clin. J. Sport Med. 14:25–32, 2004.
* ↑ Klungland Torstveit, M and Sundgit-Borgen, J. The Female Athlete Triad: Are Elite Athletes at Increased Risk? The Norwegian University of Sport and Physical Education, Oslo, NORWAY; and 2 The Norwegian Olympic Training Centre, Oslo, NORWAY; Official Journal of the American College of Sports Medicine
* ↑ SUNDGOT-BORGEN, J., and M. K. TORSTVEIT. Prevalence of eating disorders in elite athletes is higher than in the general population. Clin. J. Sport Med. 14:25–32, 2004.
* ↑ 4. YOUNG, N., C. FORMICA, G. SZMUKLER, and E. SEEMAN. Bone density at weight-bearing and nonweight-bearing sites in ballet dancers: the effects of exercise, hypogonadism, and body weight. J. Clin. Endocrinol. Metab. 78:449 – 454, 1994.
* ↑ Klungland Torstveit, M and Sundgit-Borgen, J. The Female Athlete Triad: Are Elite Athletes at Increased Risk? The Norwegian University of Sport and Physical Education, Oslo, NORWAY; and 2 The Norwegian Olympic Training Centre, Oslo, NORWAY; Official Journal of the American College of Sports Medicine
* ↑ Klungland Torstveit, M and Sundgit-Borgen, J. The Female Athlete Triad: Are Elite Athletes at Increased Risk? The Norwegian University of Sport and Physical Education, Oslo, NORWAY; and 2 The Norwegian Olympic Training Centre, Oslo, NORWAY; Official Journal of the American College of Sports Medicine
* ↑ BEALS, K. A., and M. M. MANORE. Disorders of the female athlete triad among collegiate athletes. Int. J. Sport Nutr. Exerc. Metab. 12:281–293, 2002.
* ↑ Becker AE, Grinspoon SK, Klibanski A, et al. Current concepts: eating disorders. N Engl J Med 1999;340(14):1092–8
* ↑ Glorio R, Allevato M, De Pablo A, et al. Prevalence of cutaneous manifestations in 200 patients with eating disorders. Int J Dermatol 2000;39(5):348–53.
* ↑ Schwartz BK, Clendenning WE. A cutaneous sign of bulimia. J Am Acad Dermatol 1985;12(4):725–6.
* ↑ Brunet, M. Female Athlete Triad. Clinics in sports Medicine 24. 623-636, 2005.
* ↑ Garner DM, Olmsted MP, Bohr Y, et al. The Eating Attitudes Test: psychometric features and clinical correlates. Psychol Med 1982;12:871–8.
* ↑ Cooper Z, Fairburn C. The Eating Disorder Examination: a semi-structured interview for the assessment of the specific psychopathology of eating disorders. Int J Eat Disord 1987; 6:1–8
* ↑ Sports Medicine and Arthroscopy Review 10:23–32 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia
* ↑ Brunet, M. Female Athlete Triad. Clinics in sports Medicine 24. 623-636, 2005. USA
* ↑ Constance M. Lebrun, Jane S. Rumball, B.Sc. Female Athlete Triad. 10:23–32 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia
* ↑ Brunet, M. Female Athlete Triad. Clinics in sports Medicine 24. 623-636, 2005. USA.
* ↑ Constance M. Lebrun, Jane S. Rumball, B.Sc. Female Athlete Triad. 10:23–32 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia
* ↑ Brunet, M. Female Athlete Triad. Clinics in sports Medicine 24. 623-636, 2005. USA
* ↑ AIS Sports Nutrition, last updated December 2010. © Australian Sports Commission.
* ↑ Gottschlich, L. Female Athlete Triad. American collage of sports medicine. 2012.