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THE FEMALE ATHLETE TRIAD UKA Event Group Coaching Qualifications
THE FEMALE ATHLETE TRIAD UKA Event Group Coaching Qualifications
www.eatingdisordersinsport.com
Eating Disorders in Sport Loughborough University Centre for Research into Eating Disorders
World class education, assessment and support for athletes and professionals
The Female Athlete Triad
Definition
The Female Athlete Triad
The interrelationships between energy
availability, menstrual function, and bone mineral density. (Nattiv et al., 2007)
Nattiv, A.,Loucks, A.B., Manore, M.M., Sanborn, C.F., Sundgot-Borgen, J. & Warren, M.P. (2007) American College of Sports of Medicine Position Stand: The female athlete triad. Med Sci Sports Ex. 39 (10) 1867-82
Osteoporosis Low Bone Mineral Density
Amenorrhea Menstrual Dysfunction
Disordered Eating Low Energy Availability
FEMALE ATHLETE
TRIAD
A Triad?
Clinical Significance of the Triad
Clinical manifestations:
– Eating disorders – Amenorrhea – Osteoporosis
With proper nutrition, the relationship between the three factors promotes robust health.
Energy availability is the key.
Female Athlete Triad Continuum
- Athletes can be anywhere on the three spectrums.
- Their position is determined by their energy availability
Figure adapted from: Nattiv, A.,Loucks, A.B., Manore, M.M., Sanborn, C.F., Sundgot-Borgen, J. & Warren, M.P. (2007) American College of Sports of Medicine Position Stand: The female athlete triad. Med Sci Sports Ex. 39 (10) 1867-82
Female Athlete Triad Model
Hormonal changes
Reduction in Energy (kcal)
Reduced oestrogen, LH & other hormone
production
Bone modelling and repair
Increased training Insufficient nutritional intake
Insufficient energy for... Prioritising of essential
bodily functions
Hormones necessary for bone production
Deficiencies in calcium, Vit D & other important nutrients
Increased energy expenditure
Functional Hypothalamic Amenorrhea
How common is the triad? Few studies have considered the presence of all 3 components.
Estimates range from 1.2% - 16%. • Triad often narrowly defined • Point prevalence versus longitudinal studies • Sample size & athlete group investigated
Individually: – Disordered eating: up to 47% of athletes in lean or endurance sports (Torstveit &
Sundgot-Borgen, 2008)
– Menstrual dysfunction: up to 65% secondary amenorrhea in elite long distance runners (Dusek, 2001); primary amenorrhea up to 22% in some aesthetic sports (Beals & Manore, 2002)
– Low bone mineral density: up to 22% amongst high school female athletes. (Nichols et al, 2006)
• Prospective cohort study with 163 female athletes competing across a range of school sports.
• Injury reports, eating behaviours, BMD and menstrual function were measured.
• A history of amenorrhea during the past 12 months were associated with an increased risk of musculoskeletal injury.
• Disordered eating, menstrual dysfunction and low BMD were associated with an increased risk of musculoskeletal injury.
Relationship with injury risk
Rauh, M.J., Nichols, J.F., Barrack, M.T. (2010) Relationships among injury and disordered eating, menstrual dysfunction and low bone mineral density in high school athletes: a prospective study. Journal of Athletic Training, 45 (3) 243-252.
Injury risk – relationship with bone density, eating behaviour and menstrual dysfunction. (Rauh et al, 2010) Athletes with disordered eating, menstrual irregularity and reduced BMD were
significantly more likely to have a major injury
Figure adapted from Rauh et al., 2010
Energy Availability (EA) Definition: Energy availability is the amount of dietary energy remaining
for other body functions after exercise & training.
- Cellular processes - Growth and repair - Maintaining body temperature - Reproduction - Immune system
Energy Availability
Energy availability = dietary energy intake (EI) minus exercise energy expenditure (EEE)
EA=EI-EEE
(Measured in Kcal per kg of fat-free mass)
- A healthy athlete has an energy availability of 45 kcal/kg FFM
- A normal resting metabolic rate requires 30kcal/kg FFM
- Low energy availability is classified as below 30kcal/kg FFM.
Energy Availability: An example...
A 60kg athlete (fat free mass 51kg, 15% body fat) has a daily dietary energy intake of 2000 kcal, expending 600kcal through exercise.
EA=EI-EEE /kg FFM
EA = (2000 - 600)/51 = 27.5 kcal/kg FFM.
Below the recommended 30kcal/kg FFM
What should her energy intake be? Energy Availability=Energy Intake – Exercise Energy Expenditure
/kg FFM
(Healthy energy availability = 45 kcal/kg FFM) • 45 = Energy Intake – 600/51kg FFM. • 45x51 = Energy Intake – 600 • 2295+600 = Energy Intake
= 2895 Kcal.
Can you think of an example of one of your own athletes?
When does low energy availability occur?
1. Inadvertent through...
– Poor nutrition knowledge: planning, food choices & balance, recovery & timing after exercise, insufficient intake
– Reduced appetite after prolonged exercise – Increased training & no adjustment in food intake – Increased energy required for growth (developing athletes)
2. Intentional weight loss for performance reasons
3. Psychological - disordered eating patterns, dissatisfaction with body image.
Insufficient nutritional intake
1. Energy requirements not met for volume of training
2. Poor diet and food choices 3. Increased energy requirements for growth
Energy requirements for developing athletes 1. Greater protein needs per kilogram of body weight to satisfy growth
requirements 2. Greater calcium needs to support bone accretion
3. Higher metabolic cost of movement per kilogram of body mass (less metabolically efficient)
4. Relatively more fat use during exercise 5. Sweat electrolyte losses differ between children, adolescents and adults 6. Dehydration is more detrimental to young athletes than to adults.
(Bar-Or, 2001)
Age Calories (kcal/kg)
Protein (g/kg)
11-14 (female) 55 1.0
11-14 (male) 47 1.0
15-18 (female) 40 0.9
15-18 (male) 45 0.9
Calorie & protein needs for normal growth & development (before exercise)
Recommended dietary allowances NRC 1989
e.g. A 12 year old female athlete weighing 40kg would require 2200 kcal & 40g of protein for basic everyday activities before her requirements for training and exercise.
The consequences of low energy availability
– Cellular processes are maintained
BUT less energy is available for other body functions...
– Disruption of temperature regulation – feeling cold – Impaired immune response – increased vulnerability to illness – Growth & repair processes will be slowed – Less energy is available for reproductive processes
Adaptation to training will be less effective.
• Modifications to weight and body composition should take place gradually to avoid negative effects of the female athlete triad. 1. Guided nutritional input 2. Appropriate & realistic targets that are monitored 3. Appropriate time frame 4. Encourage a focus on healthy habits and making good food choices 5. Monitor progress by measuring changes in performance and energy
levels, injuries & illness and menstrual function. 6. Help athletes to develop lifestyle changes to maintain a healthy
weight.
• Concern over non-performance related dieting or unusual eating behaviours.
Adjusting body weight for performance
Eating Disorders: What are they? Eating disorders are severe, psychological conditions that are characterised by disturbed attitudes towards
food and abnormal eating behaviour.
Eating Disorders
There are three main categories of clinical eating disorder:
– Anorexia Nervosa – Bulimia Nervosa – Eating Disorders Not Otherwise Specified (EDNOS)
Anorexia Nervosa 1. Refusal to maintain body weight at or above a
minimally normal weight: 85% of what would be expected for age and height.
2. Intense fear of gaining weight or becoming fat, despite being underweight.
3. Disturbances in perception of body weight or shape. Body weight plays a principal role in self-evaluation & self-esteem.
4. Amenorrhea - the absence of at least three consecutive menstrual cycles.
1. Recurrent episodes of binge eating. An episode of binge eating is characterized by:
• Eating an amount of food within a specific time frame that is much larger than most people would eat in a similar situation
• Lack of control over eating (e.g. feeling unable to stop or control what/how much they’re eating)
2. Inappropriate compensatory behaviour to prevent weight gain – e.g. self-induced vomiting, laxatives, diuretics, fasting or excessive exercise. • Occurs at least twice a week for 3 months for clinical diagnosis
3. Self-evaluation is unduly influenced by body shape and weight.
Bulimia Nervosa
Eating Disorders Not-Otherwise-Specified
• Atypical eating disorder manifestations: – E.g. Meeting all other criteria for anorexia nervosa but weight is
still in the normal range – Failure to meet the frequency or duration criteria for binge-purge
episodes in bulimia nervosa. – Also: night eating syndrome, purging disorder and subthreshold
binge-eating disorder. – EDNOS is not an indicator of a reduced severity
• Up to 75% of all eating disorder cases receive a diagnosis of EDNOS
Symptoms: Anorexia Nervosa
Physical and Medical symptoms
§ Amenorrhea § Fatigue in training (beyond expected) § Muscle weaknesses § Overuse injuries – e.g. Stress fractures § Gastrointestinal problems § Dehydration § Hyperactivity § Weight loss § Hypothermia (cold intolerance) § Lanugo (fine hair on face and arms)
Psychological and behavioural symptoms
• Anxiety • Avoidance of eating or eating situations • Claims of feeling fat • Depression • Excessive exercise • Insomnia • Preoccupation with weight and eating • Restlessness • Social withdrawal • Restrictive dieting • Unusual weighing behaviour
Symptoms: Anorexia Nervosa
Symptoms: Bulimia Nervosa Physical and Medical symptoms
• Dehydration • Dental and gum problems • Complaints of bloating • Electrolyte abnormalities • Frequent or extreme weight fluctuations • Gastrointestinal problems • Menstrual irregularity • Muscle cramps, weakness • Swollen glands • Low weight despite eating large volumes of food.
Psychological / behavioural symptoms
• Binge eating • Agitation if bingeing is interrupted • Depression • Evidence of vomiting unrelated to illness • ‘Disappearing’ after eating • Excessive exercise • Secretive eating • Use of laxatives or diuretics unsanctioned by
medical staff • Stealing food
Symptoms: Bulimia Nervosa
Co-morbidity of eating disorders
• Eating disorders often co-occur with other mental health conditions – Low self esteem – Anxiety disorders – Depression – Obsessive compulsive disorder – Substance dependence
• Cause or consequence?
• Be on the look out for changes in mood, levels of anxiety and stress.
Disordered Eating to Eating Disorders: A Continuum
Normal eating behaviour
Mild dieting and body image concerns
Disordered eating (subclinical)
Clinical eating disorders
Disordered Eating
• Subclinical conditions – Reduced severity, but may still engage in pathological behaviours
& there may be significant distortion with regards to body image and weight perception.
– Anorexia Athletica
Dieting and disordered eating behaviour is strongly predictive of subsequent clinical eating disorders –
Early intervention is important
Prevalence of eating disorders In the normal population:
– Anorexia Nervosa: ~1% (female) (0.3% male); – Bulimia Nervosa: ~1.5% (female) (0.5% male),
Amongst athletes: – 20% female (8% male) elite athletes met the criteria for a clinical eating
disorder (Sundgot-Borgen & Torstveit, 2004)
– Disordered eating: up to 47% of athletes competing in lean or endurance sports (Torstveit & Sundgot-Borgen, 2008)
Athletes are at a significantly increased risk for eating disorders
Sports specific risk factors Participation in sport itself does not increase ED risk; rather it is aspects of the sporting environment that are additional to those
risks faced by the normal population. (Thompson & Sherman, 2010)
Sports specific risk factors:
• Revealing sports attire • Contagion Effect • Competitive Thinness • Trigger factors
- Traumatic life events (e.g. injury) - Sudden increase in training volume. - Frequent weight fluctuations, dieting.
Difficulties with identification
• Presumption of good health with good athletic performance
• Sport stereotypes • Secretive nature of the eating disorders
• Similarities between ‘anorexic traits’ and desired characteristics for sport:
– High levels of mental toughness and self control; – High commitment to training and exercise regimes; – Perfectionism; – Overcompliance and willingness to obey; – Selflessness and continuing despite pain or discomfort
Amenorrhea or menstrual dysfunction Definition…
The absence of menstrual cycle (considered clinical if occurs for longer than 3 months)
• Primary (not occurred by age 15) • Secondary (cessation after onset) • Oligomenorrhea – lengthened cycle (>35 days apart)
A cause for concern! – Amenorrhea is NOT normal for athletes and should always be
investigated by a medical professional.
Causes & Consequences of Amenorrhea
• Lots of medical causes other than the low Energy Availability of the Female Athlete Triad. – E.g. pregnancy, medication, thyroid dysfunction, high levels of
anxiety or stress etc.
• Amenorrhea should be investigated by a medical professional for alternative causes.
• Long term consequences of Functional Hypothalamic Amenorrhea: – Lowered bone density & increased risk of fracture – Long term implications for fertility
Relationship between weight & menstrual function
• Female athletes with low energy availability (EI<30kcal/kg FFM) are more likely to be amenorrheic. (Manore et al 2002)
• Onset of puberty and the maintenance of regular menstruation depends on reaching a critical body weight & body fat levels(suggested to be around 47kg & 17%).
• Loss of 10 – 15% of body weight, commonly results in amenorrhea. This is especially likely when weight loss occurs rapidly.
Osteoporosis & Low Bone Mineral Density Definition
…a systemic skeletal disease characterised by low bone mass and microarchitectural alterations associated with increased fragility and susceptibility to fracture. (World Health Organisation, 1993)
Normal Bone
Mineral Density
Osteopenia Osteoporosis
Osteoporosis: Bones become more ‘porous’
Causes of low Bone Mineral Density • Bone mass doubles during
adolescence.
• Peak bone mass is determined to an extent by genetics, but nutrition and physical activity also play a key role.
• Up to 90% of peak bone bass is achieved by the age of 18 in females; adolescence is a crucial period for building bone
Key determinants of peak bone mass & bone loss
From: The ESHRE Capri Workshop Group, (2010) Human Reproduction Update, Vol 16 (6) 761-773
Bone Density changes over age in women
Figure adapted from Wolman, R.L. BMJ 1994;309:400
Consequences of low Bone Mineral Density • Increased risk of fracture &
significant injury • Increased likelihood of osteoporosis
in later life.
Line 1: Athlete with good nutritional intake, normal menstruation and undergoing an intense training regime in her 20’s.
Line 2: Normal female
Line 3: Athlete of low body weight with prolonged amenorrhea & poor bone accumulation in her 20’s. Undergoing an intense training regime.
Treatment of the Triad
If one element of the triad exists then athletes should be investigated for the presence of the other two by a medical professional.
1. Energy availability assessment - minimum criteria of >30kcal/kg FMM
2. Increased energy availability will aid bone remodelling processes & hormone production.
3. DEXA scans can be used to assess body composition and bone density.
4. Beware of the oral contraceptive – may mask an underlying problem & doesn’t correct metabolic abnormalities.
5. Eating disorders can be very serious, early detection is important. If you have concerns about an athlete, Loughborough University Centre for Research into Eating Disorders can provide you with advice, assessment and support where required.
6. Prevention of bone loss is crucial - peak bone mass may not be achieved if bone remodelling processes are interrupted.
7. Amenorrhea should always be investigated for other possible causes.
Role of the Coach: Managing the training environment
1. Nutrition education and input – Healthy eating (junior and beginner athletes) – Sports nutrition, pre and post training fuel.
2. Motivation, self esteem and support – Well-being – Psychological support
3. Weight for performance – Factors to consider
Nutrition education and input
• Recovery strategies – encourage athletes to bring food with them – ‘tuck shop’ of food for after training
• Nutrition talks or advice for parents at your club – Pre and post exercise nutrition
• UCoach – nutrition booklets and materials that can be distributed
NB: If you are concerned about an athlete’s eating behaviour, always investigate it further - early detection is crucial
Weight for performance Is weight loss or modification appropriate? Factors to take into account:
• Age • Training history • Level of competition • Performance vs. body dissatisfaction?
– Guided nutritional input – Appropriate targets that are monitored – Appropriate time frame
Any Questions?
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