Introduction
Women had to strive to participate at the Olympic Games. The Modern Olympic Games started in 1896, but it took thirty-two years and that is until 1928 before female athletes were allowed to compete in Gymnastics and sixty-four years later in 1960 in Track and Field. The reason for such a disparity and delay in the onset of allowing women to compete in Track and Field at the Olympics was because many women used to pass out after the 800 meters run. Competitive female athletes strived to be the world’s best however due to the high demands to be the best, many young athletes were driven to extreme behaviors such as limiting food intake or excessive training. When female athletes eat inadequately and over train, their bodies start going into what we call the ‘Triad’ which cause amenorrhea (loss of menstruation) and results in low bone mineral density which leads to stress fracture. This condition is characterized or simply called the Female Athletes Triad.
What Is The Triad ?
Female Athlete Triad is defined by the American College of Sports Medicine (ACSM) as “a spectrum of abnormalities in energy availability, menstrual function and bone mineral density.” There are several facets of the Triad which can affect an athlete’s career. Women that participate in sports that focus on lean body mass such as Gymnastics, Ballet or Track and Field are more likely to be afflicted by the Triad. Nazem et al estimates that 4.3% of elite athletes have all three components of the Triad. The Triad starts due to a lack of nutrients the body needs to replenish itself.
Low Energy intake
Due to the high stress levels of exercise that a female athlete goes through with her body, it is essential she replenishes her body with adequate nutrition. According to the American Academy of Orthopedic Surgeons, low energy is defined as “inadequate caloric intake caused by pathologic caloric restriction [such as Anorexia or Bulimia] or by expending more energy than the body is design for at a given time.” Some athletes may experience low appetite due to excessive training. According to some research, “athletes often lack the appetite necessary to promote food compensation for energy expenditure from an intense exercise regimen.” Female athletes may be under high pressure to have a certain body type which may lead to eating disorders. Athletes do not have to have an eating disorder to be diagnosed as having Triad. Athletes with food insecurity may also fall under the category of low energy intake which may lead to amenorrhea. Having a body mass index (BMI) of < 17.5kg/m^2 is categorized as underweight which can cause low energy availability. Athletes eating < 45 kcal/kg of muscle mass is considered low energy while < 30 kcal/kg can cause extensive negative effects such as amenorrhea.
Menstruation Abnormality
Amenorrhea is the absence of menstruation for a long duration. Generally, a regular menstrual cycle occurs every 28 days. According to Matzkin et al, “amenorrhea is the absence of menarche after age 15 and the cessation of menses for consecutive cycles after menarche”. There are several hormones, such as the gonadotropin-releasing hormone (GnRH), that affect the release of estrogen which inhibits menstruation. Estrogen is very important hormone in the body. It reduces bone broken down which increases bone growth. Having less estrogen causes bones to become fragile thereby increasing the risk for stress fractures. Female athletes that have amenorrhea are more likely to have stress fractures due to a significant correlation between low estrogen and reduced bone mineral density.
Bone Mineral Density (BMD)
Most females reach their peak bone by the age of 26 and their greatest growth between the age of 11 and 14. There are several components to bone development which includes the intake of protein, calcium and vitamin D as well as weight-bearing exercise. Bone density can be measured using dual energy x-ray absorptiometry (DXA), quantitative computed tomography (QCT) or peripheral QCT (pQCT). These devices help to distinguish between the bones volume, density, thickness and separation. According to the American College of Sports Medicine, DXA uses a z-score which “defines low BMD in athlete as a z-score between -1 and -2 along with clinical risk factors for fracture”. Since estrogen is normally found lowered in females with the Triad it may also lead to osteoporosis. Though amenorrhea may lead to estrogen deficiency which may cause low bone density, it may be reversed.
Recovery from Triad
There are several factors that may help reverse low bone mineral density. The most important factor is to educate athletes about optimal nutrition. According to recent research, nutrition and exercise are the most important factor in treating and preventing female athlete Triad. Increasing energy intake has been shown to reverse amenorrhea. Over the counter contraceptives have also been shown to help regulate menstruation though it should not be taken for more than two years. Also, eating well balanced meals that contain foods high in vitamin D, calcium and protein may help bone development. If an athlete is unable to consume these nutrients, supplementation may be required. Vitamin D is a fat-soluble vitamin and has an upper limit intake of 600 to 800 IU, while calcium’s intake limit is 1,000 mg. Consuming more than the recommended maximum amount will cause adverse effect. Weight-bearing exercises have been shown to have a positive correlation with increasing bone density. Prevention of Female Athlete Triad is possible by providing proper education to athletes, coaches, trainers and healthcare providers.
Huliamatu Bah, MA, RD/LD
owner of BioBah Nutrition
based in Oklahoma City, OK
hulia@biobahnutrition.com