(This article has been reprinted from the USTA High Performance Coaching Newsletter, Vol. 4, No. 1/2002)
By Carol L. Otis M.D. FACSM
Member, USTA Sports Science Committee
What is the Female Athlete Triad?
The Female Athlete Triad is a set of related medical problems found in physically active women: disordered eating, amenorrhea and osteoporosis. It was first described in 1992. Hopefully, after reading this article you will recognize symptoms of the Triad in tennis players you coach and can help recognize and prevent it.
How does it start?
Exercise and sport do not cause the Triad. Instead, pressures placed on women to diet and be unrealistically thin cause it. Faced with pressures to lose weight, women turn to dieting and disordered eating practices, the first part of the Triad. Most women in Western culture are highly “weight sensitized.” Between 60 and 80% are dieting to look like the “ideal” woman portrayed in the media.
Most athletic women have a muscular (mesomorphic) body type, whereas the “ideal” woman is a tall, thin (ectomorphic) body. This is a rare body type, but one idealized.
Most people do not realize that body type, like height, is genetic and dieting will not change the inherited body type. Although there is not scientific evidence to support it, many athletic women are told to lose weight to get faster on the court. They may also diet to fit into revealing tennis clothing or to avoid weight gain when injured.
Excessive dieting is clearly linked to the development of disordered eating practices. These range from fasting and restrictive fat-free diets to using diuretics, laxatives, appetite suppressants and self-induced vomiting. These practices do not result in real weight loss, but rather cause dehydration, low blood sugar and loss of lean muscle mass. These practices will impair athletic performance.
What does it mean when a woman stops having her menstrual period?
Contrary to popular belief, it is not normal for a physically-active woman to stop having her period. Any change in the menstrual cycle is a symptom of something wrong. A woman who does not start her period by age 16 or whose period stops for 3 months or who has less than 6 periods a year should see her physician for complete evaluation. In the case of the Triad, the “energy drain” from disordered eating and poor nutrition causes the menstrual cycle to stop (amenorrhea).
When menstrual cycles stop, the result is low hormone levels (estrogen in particular). Low hormone levels cause the third part of the Triad, the loss of bone mass, called osteoporosis. Young women who stop menstruating can lose as much as 5% bone mass a year. When combined with inadequate intake of calcium, young women can have the bone mineral density of a seventy-year-old woman.
The Female Athlete Triad has been called old bones in young women. Low bone mass can be an underlying cause of stress fractures, and complete fractures. This loss of bone mass is only detected by a specialized x-ray called a DEXA bone densitometry. All women should get at least 1000 mg./ day of calcium, and women with irregular menses need up to 1500 mg/ day.
Who is at risk?
Many factors put tennis players at risk. These include pressures to lose weight, stress, weight-gain during puberty plus underlying personality factors. Individuals who are perfectionist, obsessive compulsive, have low self esteem, poor body image or a history of depression and abuse may turn to disordered eating to try to lose weight in a mistaken effort to appear more “perfect” or to feel “in control”.
In 1999, an NCAA study reported that 8% of collegiate women tennis players have disordered eating and 50-60 % are at risk due to poor body image, a “drive for thinness” and experimentation with disordered eating practices.
These athletes are largely uneducated about the ineffectiveness and risks of these practices which include dehydration, low blood sugar, mood swings, loss of muscle mass, and decreased athletic performance. They also may hide these practices and deny that they are struggling with body image and weight issues.
What Can You Do?
De-emphasize weight. Many women already are very sensitive to their weight and may even take off-hand comments the wrong way. Advocate the importance of health and well being; promote normal and realistic healthy body images.
As a coach you are in the front line to demonstrate good eating habits and proper nutrition for your athletes and also to recognize the dangers of the Triad. Help women appreciate their own unique body type and reinforce that healthy bodies come in many different sizes and shapes. If you recognize the signs or symptoms of the Triad, help them get to a professional. Have a support team for referrals that includes nutritionists, physicians, and mental health providers.
Warning Signs of the Female Athlete Triad
1. Weight shifts of /-2 lbs. in a few days (dehydration weight loss practices).
2. Weight loss 10% or more below ideal body weight.
3. Frequent comments about poor body image and/or efforts to lose weight.
4. Using extreme diets, compulsive exercise, laxatives, or diuretics to control weight.
5. Physical Signs: swollen parotid (cheek) glands due to vomiting, yellow color on palms, very slow pulse, dry skin, and hair loss.
6. Age of first menstruation later than age 16.
7. Irregular menstrual cycles: fewer than 6 per year or absence of menstrual cycles for 3 months.
8. Stress fractures.
What can Coaches do?
1. Learn about the Female Athlete Triad and signs of disordered eating.
2. De-emphasize weight as a performance issue. Concentrate on speed, strength, recovery, and technique.
3. Refer nutrition, weight and medical issues to nutritionists, medical professionals.
4. Model healthy eating behavior. Assure your athletes eat and know it is OK to eat.
5. Help women build a healthy self-image with positive feedback about their strengths and abilities no matter their body type.
6. Emphasize the diversity in body types. Many different body types, sizes, and shapes are successful in tennis.
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Otis, CL, and Roger Goldingay. The Athletic Woman’s Survival Guide Human Kinetics, 2000.
Brownell, KD. Et. Al. Eating, body weight and performance in athletes. Lea and Febiger, 1992
Johnson, C et. Al. Athletes and eating disorders: the NCAA study. Int. J Eating Disorders, 1999Sept. 26 (2) p 179-88
www.sportsdoctor.com Dr. Carol Otis’s web site. Information about sports and health
www.edap.org (Eating Disorders Awareness and Prevention)
www.gurze.com Gurze publishes books on eating disorders