05 September 2012

The female athlete triad: a hidden epidemic

As more women compete in sport, the incidence of eating disorders, amenorrhoea and osteoporosis continues to rise. How can athletes 'make weight' without compromising their health?


Female athletes often ask me what they can do to combat what is called "The Female Athlete Triad". The direct answer is of course, "eat a balanced diet that meets your high energy needs instead of starving yourself of energy and thus of most other nutrients".

In practice, however, it is not so easy for young women who have dedicated their lives to a specific sport or athletic discipline to achieve a balance between the sometimes unrealistic demands of their sport and the physiological demands of their bodies and of good health.

These athletes are often in a Catch 22 situation - should they starve themselves to achieve a desired weight or body size required for pursuits such as athletics or ballet or should they choose the safe route of eating a balanced diet including adequate kilojoules only to fail to "make weight"?

To a certain extent, the conundrum these female athletes face, is like that of top athletes who turn to banned substances to enhance their performance. "To eat or not to eat", therefore, becomes the same kind of choice as "to dope or not to dope".

What does the triad consist of?

According to official definitions that were formulated in 1997 by the American College of Sports Medicine (ACSM), and then later refined in 2007, the Female Athlete Triad consists of the following three disruptions in normal behaviour and/or physiology:

  • "Disordered eating" or as it has more recently been reworded "low energy availability with or without an eating disorder" - this encompasses low to very low energy intakes some of which may even border on starvation combined with eating disorders such as anorexia nervosa or bulimia or orthorexia
  • "Amenorrhoea" or a series of derangements in menstrual function ranging from "eumenorrhoea"   (normal menstruation) to "functional hypothalamic amenorrhoea" (absence of normal menstruation due to malfunction in the hypothalamus which controls ovulation, caused by very low energy intakes)
  • "Osteoporosis" which has been replaced with a broader range of conditions relating to bone health including "optimal bone health" all the way to "osteoporosis"

(Gottschlich et al, 2012)

It has been suggested that excessive energy restriction and associated poor nutrition which so many young athletes suffer from, may also have a negative effect on the function of the endothelium (lining of the blood vessels), which may increase the risk of heart disease in later years. Research into this aspect may well prove that the Female Athlete Triad is actually a Female Athlete Tetrad instead (Gottschlich et al, 2012).

Prevalence of the triad

As more and more girls and women participate in sport, the incidence of these three morbidities continues to rise. So although it is often difficult to pinpoint which athletes are suffering from which aspect of the Triad because these young women are adept at concealing their problems,  Prof Laura Gottschlich and her team (2012), report the following prevalences:

  • Disordered eating has been recorded in up to 62% of the female athletic population and the incidence of anorexia and bulimia varies between 4-39%. Associated psychological conditions such as anxiety, depression, or obsessive, compulsive disorder make the tendency to ingest far too little energy for the strenuous demands of the athlete’s sport, even more pronounced. 
  • Menstrual dysfunction may range from as low as 6% to as high as 79%.
  • Low bone mineral density (BMD) with associated stress fractures, osteopenia (low BMD which may be a precursor of osteoporosis), and outright osteoporosis can occur in up to 50% of female athletes compared to 12% of women who are not athletes.

What can be done to prevent the triad?

In view of the startlingly high prevalence of the three manifestations of the triad, and the long-term negative effects they can have on the future health of the affected women, it is vital that female athletes of all ages should be warned not to restrict their energy intakes excessively and to ensure that they eat a balanced diet at all times. This is easier said, than done.

Anyone who watched the London Olympics, will realise that athletes of both sexes will do practically anything to achieve their ultimate goal of being the very best and winning gold. Probably the only way to prevent young women who are dedicated to sacrificing themselves on the altar of the games from starving themselves into ill health is by means of education.

Nutrition education should be provided for everyone who is involved with young female athletes - this includes the parents, teachers, coaches, trainers, and of course also the athlete herself.

Prof Gottschlich and her coauthors (2012) suggest that by alerting as many individuals associated with a young athlete as possible about the dangers of the triad (stress fractures, outright osteoporosis, inability to ever catch up the bone deficit in later years, full-blown eating disorders, possible cardiovascular complications and lack of ovulation which may affect conception in adulthood), significant long-term morbidity can be avoided.

Dietary needs of female athletes

According to Mahan and her coauthors (2011), an athlete suffering from the Female Athlete Triad with one or more symptoms (amenorrhoea, low mineral bone density, eating disorder), needs to increase her energy intake to the level that will sustain her physical activity. Gottschlich et al (2012), state that "Energy availability is the cornerstone on which the other 2 components of the triad rest. Without correction of this key component, full recovery from the female athlete triad is not possible".

If you are an athlete or a parent or a coach are unsure as to how many kilojoules the young female athlete under your care requires on a daily basis to prevent the triad, consult a registered dietician who will calculate the energy requirements for the athlete in question. 

In addition to adequate energy intakes, female athletes of all ages generally require additional calcium, vitamin D and magnesium (Mahan et al, 2011).

The best sources of readily available calcium and high quality protein, are low-fat milk and dairy products. Vegetarian athletes can use calcium-fortified soy milk and tofu made with calcium sulphate to ensure adequate calcium intakes. Blood tests can determine if you require additional vitamin D and magnesium, so ask the team doctor to arrange for such tests. Exposure of the skin to sunlight for 30 or more minutes a day, should help to boost vitamin D levels, while magnesium is found in seeds, nuts, legumes, dark green vegetables and wholegrains.  If necessary female athletes may need to take calcium, magnesium and vitamin D supplements such as MenaCal.7 (which contains calcium, vitamin D and vitamin K) and Magnesite (magnesium granules).

If you are a young female athlete or if you are responsible for such an athlete, it is important that you are aware of the Female Athlete Triad, its associated risks and how it can be avoided.

 (References: Gottschlich L et al (2012). Female Athlete Triad.; Mahan LK et al, 2011. Krause’s Food and the Nutrition Care Process. 13th Edition. Elsevier Saunders, USA)

 - (Dr IV van Heerden, DietDoc, September 2012)

(Photo of young female athlete from Shutterstock)

Any questions? Ask DietDoc

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