The American College of Sports Medicine’s “The Female Athlete Triad” (2007) examines a well documented medical condition observed in physically active girls. The Female Athlete Triad (Triad) involves three interrelated components: eating disorders which result in low energy availability; amenorrhoea (loss of menstrual fuction); and decreased bone mineral density, which can lead to osteoporosis. The paper outlines the current state of knowledge of the disorder, examines the three components, identifies risk factors and health consequences, and offers clinical recommendations for the prevention, recognition and treatment for those who work with athletically active females.
Risk factors for Triad include restricted those who restrict their caloric intake, exercise for prolonged periods, are vegetarian, and limit the types of food they eat. The eating disorders anorexia nervosa and bulimia are often associated with the Triad, but it can exist without them. Triad can be intentional, inadvertent or a psychological disorder. Athletes need higher than average caloric intake, protein, and water. However, some athletes erroneously believe that maintaining extremely low body fat will increase their performance. Triad occurs most often in sports that emphasize lean body mass and low body fat, such as cross country running or ballet (Nattiv et. al, 2007). To lose weight while training, they often resort to “tricks” and extreme weight loss methods. including restricted caloric intake, self-induced vomiting, and the abuse of appetite suppressants, stimulant diet pills, diuretics and laxatives. Without adequate nutrition, patients with Triad can suffer a cascade of health related problems.
Energy availability is defined as “dietary energy intake minus exercise energy expenditure” (Nattiv, et. al, 2007, p. 1868). Chronic energy deficit, where caloric intake is lower than energy expenditure, forces the body to compensate by reducing the amount of energy used for cell maintenance, temperature regulation, growth, and reproduction. This is a form of “survival mode” that restores energy but impairs health. Symptoms of the Triad include menstrual cycle irregularities, which can lead to infertility, and low bone mineral density (BMD), linked to osteoporosis. Other long term effects can include psychological problems, cardiovascular disease, and an increased risk of suicide. Severe under-nutrition compromises hormonal and bone health, increasing the likelihood of broken bones. Statistics from a number of studies are cited to reinforce that patients with Triad are at risk of death or serious long term health consequences. Treatment for eating disorders include increased caloric intake, decreased activity, nutritional counseling, individual psychotherapy, and the use of antidepressants
According to the authors, Triad is a dangerous, complex and interrelated condition. However, they largely focus on the medical condition itself, instead of the psychological or environmental causes. Young athletes may believe they are simply being disciplined, and motivated to win or contribute to their team, when in reality they are hurting their own health. Sports and exercise should be part of a balanced, healthy lifestyle. Studies have shown that people who play sports are physically and psychologically healthier, get better grades, and are less likely to use alcohol, cigarettes, or drugs. Sports can increase self-esteem, social skills, and help promote long term health (Boyd & Hrycaiko, 1997). However, when too much training or exercise is mixed with a restricted diet, it becomes extremely unhealthy. The menstrual irregularities, estrogen imbalance and decreased bone density can be lifelong ailments. The syndrome is often seen in “perfectionists,” motivated by a intense desire to get results in sports, or to be seen as fashionably thin, which may be a result of exposure to media, peer pressure or competition. The portrayal of females in the media often shows unrealistically low body weight as the norm, and female athletes are often scrutinized and celebrated for their looks, instead of their talent and performance. As a result, some young women believe being thin is more important than being healthy, which can have drastic lifelong consequences. Overall, this position paper offers detailed medical information on the condition, and valuable insights into recognizing Triad, allowing health care workers, couches, and nutritionists to understand and identify a condition that takes exercise - a healthy and wholesome activity - and turns it into something dangerous and debilitating.
Boyd, Karin R., and Dennis W. Hrycaiko. "The effect of a physical activity intervention package on the self-esteem of pre-adolescent and adolescent females." Adolescence 32.127 (1997): 693.
Nattiv, A, Loucks, A, Manore, M, Sanborn, C, Sundgot-Borgen, J, and Warren, M. American College of Sports Medicine position stand: The female athlete triad. Med Sci Sports Exerc 39: 1867–1882, 2007