Central Washington University Athletics

The Female Athlete Triad

By: Laura Hennig

For many female competitive athletes, success may be directly related to their weight. Athletes in these sports all have one thing in common - they are at higher risk to develop disordered eating, the first of three ‘stages’ of the female athlete triad. Discussed are characteristics of disordered eating, amenorrhea, and osteoporosis, along with what to do if you suspect someone may be falling into this devastating cycle.

Disordered eating: The spectrum of disordered eating may begin with restricting food and calories lightly, but may quickly develop into occasional bingeing and purging. Finally, if these events become an important part of an athletes life, anorexia (severe calorie restriction, excessive exercise, rapid weight loss) and bulimia (binge and purge) may occur. Disordered eating is as high as 62% in some sports. Behaviors that go along with disordered eating include the following:

preoccupation with food, calories and weight
high criticism of her body
wide fluctuations in weight over a short period
unwillingness to eat in front of others
baggy or layered clothing

A combination of voluntary starvation with a strict exercise regimen leads to behavior changes which can also lead to disordered eating. Also, stress from a job, school, friends, boyfriends, or family may play a role in the development. A common route is to first cut out sweets and fruit. But eventually, more and more food will become off-limits which may lead to either bingeing or starvation. In the case of bingeing and purging (through vomiting ,or laxatives) the individual may experience chest or throat pain, fatigue, abdominal pain, and constipation or diarrhea. Symptoms of starvation include intolerance to the cold, bloating, fatigue, constipation, lightheadedness, and a lack of concentration.

Amenorrhea: Nutritional deficiencies can be one of several stressors that can disturb the athletes hormonal imbalance. One result is amenorrhea - lack of a menstrual cycle for at least three months - which could be due to severe calorie restriction. To handle this problem, decreasing exercise intensity and increasing calorie intake is the key. Also, supplementing calcium and estrogen to prevent bone loss is very important. However, it may take several months to reestablish the cycle.

Osteoporosis: The last and most severe stage of the female athlete triad is osteoporosis. Premature bone loss relates to the incidence of bone stress and fracture. For young women athletes who partake in either disordered eating or have amennorhea, they may never reach the full potential for bone density. This can be devastating for the later years when building bone mass can no longer take place.

Prevention and treatment: The first step to prevent the triad from happening is to eliminate the notion that we can change our physical structure to resemble the body image of an extremely thin or small athlete. Also early education for parents and athletes regarding appropriate exercise and eating habits is necessary. Treatment involves increasing calorie consumption, decrease training, and taking Calcium supplements.

Approach: It is difficult to approach an athlete who is suspected of having an eating disorder, and careful steps must be taken. You must make sure you treat the athlete as a person, and not just a body. Here are some recommendations.
      Who: Typically, the individual who has the best rapport and the closest relationship with the athlete. In most cases, a teammate should not be the one to approach the athlete. The athlete typically will deny the existence of a problem or at least its seriousness. The person approaching the athlete should be prepared to get a negative response.
     When: As soon as an individual close to the athlete identifies a potential problem based on the presence of a number of identifying characteristics, not just one.
     How: The best strategy is to express concern for the individual gently but persistently, saying that you’re worried about their health (unhappiness, depression, etc.). Ask how he or she feels, both physically and psychologically, and ask if they want to talk about it. Do not be confrontational. They need to know that people care about them. Don’t discuss weight or eating habits; the issue and focus is their well-being.
One of the most detrimental errors a person can make in working to get a bulimic individual into treatment is following or watching her in an effort to catch her in the act of bingeing and purging.   However, this only puts more pressure on that individual to seek greater secrecy.   The process must be characterized by maximal sensitivity and minimal invasiveness. Remember, the athlete is being approached, not accused.

This is a very serious problem that most people cannot deal with on their own. They will need help from both family and a support group to get through this. The best treatment is a multidisciplinary team approach: with a physician who monitors her medical status and ability to participate safely in sports, a nutritionist who provides appropriate nutritional guidance, and a mental health professional who addresses any psychological issues. A key to prevention is to recognize the signs early talk with the person about getting help. If you or someone you know has an eating disorder, please contact the Sports Nutrition Center at 963-2094, and we can refer you to a dietitian for counseling. Please feel free to call anytime.

Source: ACSM’s Hot Topics and Fundamentals of
Sports Medicine Series: A Physician’s Guide