Athletes involved in endurance activities and sports are at a higher risk for developing full blown eating disorders such as anorexia nervosa, bulimia nervosa, and the female athlete triad. The Female Athlete Triad is a condition that describes a combination of three interrelated disorders associated with athletic training: disordered eating, amenorrhea (without menstruation), and osteoporosis (bone weakening). This condition is most prevalent in females who participate in endurance sports, sports where appearance is judged, and sports with weight classes; however, any physically active female who under eats or over exercises, or both, is at risk.

Athletes frequently engage in disordered eating in an attempt to lose weight or to maintain their thin physique. Disordered eating (versus eating disorders) includes a broad scale of abnormal behaviors, which can include poor food choices and nutrition, meal skipping, and restrictive eating. Sometimes athletes unintentionally end up with an energy deficit by exerting more calories than they consume due to a rigorous training program.
Disordered eating, combined with high intensity exercise, leads to decreased caloric intake that can lead to deficiencies in various micronutrients including calcium. Because of the reduced intake of energy and nutrients, performances may decline and the female athlete can experience fatigue, decreased immunity, cognitive losses, decreased concentration, possible depression, as well as other psychological problems related to low self-esteem.

Disordered eating and intense exercise are precursors to amenorrhea, which means without menstruation. There are various kinds of amenorrhea; primary and secondary. Primary amenorrhea exists when a female doesn’t menstruate by the age of 16 or doesn't menstruate within two years after the onset of secondary sex characteristics, while secondary amenorrhea occurs when a woman who usually has regular menstrual periods misses three or more periods. In cases where the female athlete exercises very intensely and is extremely lean, athletic amenorrhea can develop (The Female Athlete Triad: Nutrition, Menstrual Disturbances, and Low Bone Mass). Athletes often view the absence of their periods as a benign side effect of training; however, amenorrhea as well as stress fractures which are closely connected, should raise an immediate red flag that the athlete is suffering from the Female Athlete Triad (1).

Extreme exercise and a deficit of calories contribute to the reduction in the levels of hormones that regulate a woman’s period and can interfere with a women’s ability to become pregnant in the future. Other factors can include the loss of too much body fat or the loss of specific fat stores such as on the hip, buttocks, and thighs. For the maintenance of normal menstrual cycles, you must maintain a body fat threshold that is typically 18 percent. Ceasing menstruation is the body’s way of protecting women from disordered eating and the restrictive caloric intake (2).

The condition when bones are brittle and weak is called osteoporosis, which can be linked to amenorrhea. Estrogen and progesterone are the two hormones that are important for female body health, with estrogen being vital for strong bones. Moderate exercise can protect against osteoporosis, however, intense exercise puts an enormous amount of stress on the weak bones caused by osteoporosis, which can lead to stress fractures. If the female athlete does not get enough calcium in her diet as she grows she might be at constant risk for breaking her bones and suffering from other soft tissue injuries. Athletes with the female athlete triad lose bone rapidly and often have the bone density of a 70 or 80 year-old woman. Two percent to six percent of bone mass can be lost per year; this bone loss is irreversible and makes the individual more susceptible to developing osteoporosis earlier in life (3).

In the next article of this series I will discuss the treatment for females that suffer from the Female Athlete Triad.

For additional information, please contact your Nutrition Coach.

References:
(1) Thrash, Lee E., et al. The Female Athlete Triad: Nutrition, Menstrual Disturbances, and Low Bone Mass. Nutrition Today. 2000; 168: 35.
(2) Girard Eberle, Suzanne. Endurance Sports Nutrition. Human Kinetics. 2000.
(3) Getz, Bruce. The Female Athlete Triad. Hughston Health Alert. Retrieved from http://www.hughston.com/hha/a_14_3_4.htm