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DISORDERED EATING AND THE FEMALE ATHLETE TRIAD
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DISORDERED EATING AND THE FEMALE ATHLETE TRIAD Charlotte F. Sanborn, PhD, Marianna Horea, MBS, Beverly J. Siemers, PhD, and Kathy I. Dieringer, ATC, LAT, OPA-C
Female athletes are under intense pressure to have a low percentage of body fat, not only to enhance performance but also for the sake of appearance. This pressure is compounded by society’s emphasis on a svelte look and the psychologic makeup of an elite athlete who is goal oriented and a perfectionist. A vulnerable athlete trying to maintain a low body weight may succumb to disordered eating, which may lead to amenorrhea and subsequent bone loss or osteoporosis. These interrelated, cascading events have been termed the female athlete triad.30,43 The components of the female athlete triad, including definitions, clinical criteria for diagnosis, and a discussion of prevalence in athletes versus nonathletes, are presented in this article. A discussion follows of prevention strategies and programs for female athletes. Finally, the article concludes with screening and therapeutic intervention for the female athlete triad. COMPONENTS OF THE FEMALE ATHLETE TRIAD Disordered Eating At the time that the female athlete triad was first introduced as a serious syndromerBthe term eating disorder was reserved for the clinical
From the Center for Research on Women’s Health (CFS), Department of Kinesiology (MH), Texas Woman’s University, Denton; Private practice in Exercise Physiology and Nutrition, Dallas (BJS); and the Matrix Rehabilitation Clinic (KID), Denton, Texas
CLINICS IN SPORTS MEDICINE
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diagnosis of anorexia nervosa or bulimia nervosa, based on the Diagnostic and Statistical Manual, third edition (DSM 111) of the American Psychiatric Association, rite ria.^ Since the criteria for these two conditions were established for nonathletes, it was observed that an athlete may not meet the classic definitions but may have a pathogenic weight control pr0b1em.l~The term disordered eating, which referred to a wide spectrum of abnormal patterns of eating, was adopted for the female athlete triadj3 The harmful behaviors listed range in severity from restricting food intake; using diet pills, diuretics, or laxatives; having periods of binge eating and purging; to having anorexia nervosa and bulimia nervosa at the extreme end of the spectrurn?O,43 The concern for the athlete is that the pathway to a frank eating disorder often begins with simply monitoring food intake, progresses to restricting foods, such as fats or red meats, then evolves into limiting acceptable foods, and finally becomes voluntary ~tarvation.~ The standard clinical diagnosis of anorexia nervosa or bulimia nervosa is based on the criteria from the Diagnostic and Statistical Manual, fourth edition (DSM IV), of the American Psychiatric AssociationP A person is vulnerable for developing anorexia nervosa and bulimia nervosa during late adolescence or early adulthood? The prevalence of eating disorders seems to have increased in recent decades among the general population. Between 0.5% and 1.0% meet the full criteria for anorexia nervosa with a slightly higher rate of 1%to 3% for bulimia n e r ~ o s a The . ~ essential characteristics of anorexia nervosa include the following: severe self-imposed weight loss, altered body image, an intense fear of becoming fat, and amenorrhea (Table 1). The essential features of bulimia nervosa are as follows: binge eating; inappropriate compensatory behaviors to prevent weight gain such as self-induced vomiting, using laxatives or diuretics, fasting, or exercising vigorously; and great concern about body shape and weight (Table 2). The latest edition of the DSM4 has included another category for eating disorders that do not fully meet the criteria of anorexia nervosa or bulimia nervosa, eating disorder not otherwise specified (NOS). As with the term disordered eating, this eating disorder classification helps
Table 1. DIAGNOSTIC CRITERIA FOR ANOREXIA NERVOSA
A. Refusal to maintain body weight at or above 85% of normal weight for age and height B. Intense fear of gaining weight or becoming fat, although underweight C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight D. In postmenarchal females, amenorrhea From American Psychiatric Association: Diagnostic Criteria from DSM IV.Washington, DC, American Psychiatric Association, 1994, pp 544-545; with permission.
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Table 2. DIAGNOSTIC CRITERIA FOR BULIMIA NERVOSA
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by the following: 1. Eating, in a discrete period (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time under similar circumstances 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) B. Recurrent inappropriate compensatory behavior to prevent weight gain, such as selfinduced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. C . The binge eating and inappropriate compensatory behaviors occur, on average, at least twice a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. From American Psychiatric Association: Diagnostic Criteria from DSM IV. Washington, DC, American Psychiatric Association, 1994, pp 549-550; with permission.
to diagnose athletes who have a problem but fail to meet all the criteria for anorexia nervosa or bulimia nervosa (Table 3). For example, there can be many similarities between amenorrheic athletes and patients with anorexia nervosa, such as ritualized dietary habits, compulsive behavior, low intake of food, heightened energy expenditure, and, of course, absence of menses or amenorrhea. The body weight of the amenorrheic athlete, however, may be higher than that of the DSM IV criteria of 15% below normal weight for age and height. The athlete’s weight may seem adequate because of the increased weight of lean tissue mass. The amenorrheic athlete would have weighed substantially less without the increased musculature developed by training and thus would have displayed the emaciated appearance associated with anorexia nervosa. The classification of disordered eating or nonspecified eating disorder helps to identify athletes who might otherwise Table 3. CRITERIA FOR EATING DISORDER NOT OTHERWISE SPECIFIED
A. For females, all of the criteria for anorexia nervosa are met except that the individual has regular menses. B. All the criteria for anorexia nervosa are met except that, despite significant weight loss, the person’s current weight is in the normal range. C. All the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week for a duration of less than 3 months. D. The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies). E. Repeatedly chewing and spitting out, but not swallowing, large amounts of food. F. Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of bulimia nervosa. From American Psychiatric Association: Diagnostic Criteria from DSM IV. Washington, DC, American Psychiatric Association, 1994, p 550; with permission.
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be missed. Because eating disorder NOS is a new classification, prevalence data are not available for this category. Amenorrhea
Athletes have a higher prevalence of delayed menarche (older than 16 years) and primary13 and secondary amenorrhea12 than nonathletes. A prevalence of 2% to 5% is reported for the general population, with a higher percentage in athletes ranging from 3.4% to 66%. The highest frequency of amenorrhea has been found to be among ballet dancer^'^ and runne~s.3~ Currently, the caloric deficit or energy drain theory is being actively investigated as a factor possibly responsible for the reproductive disorder.24A surprising finding has been how low the total caloric intakes are as reported by female athletes, regardless of their menstrual status. The average recommended energy allowance for light to moderately active women aged 15 to 24 years is 2200 kcal per In fact, the mean total consumption for female athletes has been reported from as low as 1272 kcal per dayz5to as high as 2400 kcal per day.gThese athletes seem to be in a caloric deficit. The question arises whether a negative caloric balance or caloric energy drain might be the explanation of athletic amenorrhea. The hypothesis is that the athlete is expending more calories than she is consuming, resulting in too few calories or too little energy to maintain the endocrine reproductive system. Overall, the amenorrheic athlete tends to consume fewer calories per day than the regularly menstruating athlete does; however, the differences have not always been significant because of the variations reported. A theme that continues to surface is the finding of eating disorders among the amenorrheic, not the regularly menstruating, athletes. The question remains: Is amenorrhea related to exercise or is amenorrhea a symptom of eating disorder? Osteoporosis
For the female athlete triad the term osteoporosis refers to premature bone loss or inadequate bone formation or both, resulting in low bone mass, microarchitectural deterioration, increased skeletal fragility, and an increased risk of fracture.43Medical concerns of the hypogonadal state are that the amenorrheic athlete is at a greater risk of low bone mass (premature osteoporosis)and stress fractures. Amenorrheic athletes have been shown to have low bone mass*O,25, 36; however, the prevalence of osteoporosis among female athletes is unknown. The hypogonadal state offsets the potentially beneficial effect of exercise on bone mass in the amenorrheic athlete. The finding of reduced bone mass is alarming because these women are losing bone mass at a time when bone should be forming. Optimal levels of peak bone may not be reached, predispos-
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ing the amenorrheic athlete to premature osteoporosis. The concern is whether the decrease in bone mineral density seen in the amenorrheic athlete is a premature, irreversible loss. Resumption of ovarian function has been shown to result in a significant increase in vertebral bone mineral density." Although increases in bone mineral density can occur during the first 2 years after resumption of menses, the values may remain below age-normative den~ities.'~, 23 PREVALENCE OF THE FEMALE ATHLETE TRIAD
Although all female athletes are potentially at risk for the development of the female athlete triad, the magnitude is not known.43Obtaining true prevalence data is difficult to virtually impossible because of the secretive nature of eating disorders and underreporting by female athletes.38 Underreporting eating disorders among female athletes always will be a problem because of the fear of being discovered and the potential consequences to their athletic careers. Risk factors for the development of the female athlete triad have centered around common underlying psychopathologic features of eating disorders: overconcern with body size, fear of being fat, and body image disturbance^.^^ The emphasis on obtaining an optimal weight for athletic performance may amplify societal pressures to be thin and thus increase the female athlete's risk of developing eating disorder^.^^ The prevalence of disordered eating among female collegiate athletes has been reported to be between 4% and 39% for meeting the medical criteria for anorexia nervosa and bulimia nervosaI6and has been documented to be as high as 62% for pathogenic weight control behavior.33The concern regarding these studies is that surveys were used to estimate the prevalence of eating disorders. For populations of female athletes, the use of questionnaires, inventories, surveys, or self-reports may not be valid14,39 and may underestimate the actual ~ r e v a l e n c eBecause .~~ of these problems, instruments should be used cautiously for screening and should be followed by personal interviews and clinical examinations when warranted.38 Preoccupations with weight and dieting have become so pervasive among young women, including female athletes, that it has become the normative behavior3I,41; however, not all female athletes develop diagnosable eating A number of additive risk factors have been proposed for the development of eating disorders.37,41 General and sports-related risk factors', 4, 15, 20, 30, 31, 37, 38 for the development of eating disorders are as follows: General Predisposing Risk Factors Chronic dieting Low self-esteem Family dysfunction Physical or sexual abuse
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Biologic factors Perfectionism Lack of nutrition knowledge Sport-specific Trigger Factors Emphasis on body weight for performance or appearance Pressure to lose weight from parents, coaches, judges, and peers Drive to win at any cost Self-identity as an athlete only (no identity outside sports) Early intervention of training or sudden increase in training Exercises through injury Overtrained and undernourished Traumatic event (e.g., injury or loss of coach) Vulnerable times (e.g., adolescent growth spurt, entering college, retiring from athletics, postpartum depression) PREVENTION STRATEGIES
The keys to prevention of the female athlete triad are twofold and include educational programming and the establishment of the athlete’s health care team. First, an effective prevention strategy must include educational programming directed not only to the athletes but also to their coaches and, in the case of younger athletes, to their parents. Topics that should be addressed include dispelling myths regarding body weight and body fat and their relationship to performance, providing nutritional education, and dealing with other issues of personal wellness. Dispelling Body Fat Myths Two myths that are pervasive among coaches and athletes are: ”thinner is better” and “every sport has an ideal body weight.” There is a common misconception that there is a highly negative correlation between performance and body fat or body weight (Fig. 1A). The coach and athlete translate this supposed relationship to mean that the lowest percentage of body fat or lowest weight will contribute to the highest possible performance. The reality is that no optimal values for body composition have been established for any sport. The association between body composition and performance must be individualized for each athlete (Fig. 1B). There may be a point at which an athlete weighs too much, negatively affecting performance and increasing her risk of musculoskeletal injury; however, there is also a point at which an athlete’s percentage of body fat or body weight becomes too low. She is unable to provide sufficient strength, power, or energy for optimal training and performance and is at risk for injury, illness, overtraining, or the development of more serious medical conditions such as those of the female athlete triad. A specific percentage of fat (body weight)
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Figure 1. The relationship between body fat and performance. A, The misconception is that a highly negative correlation exists with any body fat as excess. 6,Optimal body fat is a range based on individualized performance and nutrition needs.
should not be recommended but rather a range that is realistic and appropriate for the athlete. If weight loss is recommended, nutrition education is necessary to ensure proper dieting. The athlete’s performance during practice and competition should be monitored continually to help evaluate and establish an optimal range of weight. Sometimes a minimal weight must be established for some athletes, below which she is not allowed to train or compete. A weight loss or gain recommendation should be established that does not exceed 5% of total body weight at 1- to 2-lb increments per week. Once this weight is achieved and stabilized, subsequent recommendations are based on thorough reevaluation of body composition, performance, and nutrition a s s e ~ s m e n t . ~ ~
Nutrition Education Nutrition education, directed by a sports dietitian, is also a necessary part of preventing the female athlete triad. The coaches must be involved in this educational programming because it is often they who make decisions about what and where their athletes eat while training and competing on the road. The goals of the nutrition program should include the following: Replace nutrition myths with facts Educate athletes about nutrient-dense food choices in the context of training, competing, and retiring from competitive athletics Provide hands-on practice in food selection, shopping, and preparation Promote dietary habits that are consistent with long-term health
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and prevention of disease, such as cardiovascular disease and osteoporosis Some basic ideas that should be emphasized are that the diet should provide adequate calories to meet the athlete’s energy needs. The diet should be balanced, providing all macronutrients and micronutrients from a wide variety of foods. In addition, athletes should be encouraged to maintain nutritional consistency during the competitive and off-seasons to avoid frequent and drastic changes in body composition. Nutrition education programs for collegiate athletes need to be varied to accommodate freshmen who may know little about nutrition, sophomores and juniors who may have had some prior counseling, and graduating seniors who are approaching retirement. Regardless of age or experience level; however, athletes need programmatic intervention through which the health risks of disordered eating and amenorrhea must be addressed, reviewed, and reemphasized. Issues of Personal Wellness
Athletes are not only vulnerable to the specific stresses related to sports participation but may have difficulty handling multiple life challenges, sometimes unrelated to their sport, that often predispose them to an eating disorder. Additional health-related issues that can affect female athletes, such as time management, stress management, drug or alcohol use, spirituality, and issues related to sexuality, may be incorporated into an educational program aimed at preventing the female athlete triad. By providing the athlete with information and strategies for preventing or handling these additional pressures, educational programs may prevent athletes from falling prey to negative coping mechanisms such as restricting eating or purging. The Athlete’s Health Care Team
For years, professionals associated with athletics have recognized that a team approach is most effective in the prevention of and intervention in eating disorders or amenorrhea among athletes. It is recommended that the athlete’s health care team include the coach, athletic trainer, physician, exercise physiologist, counselor or psychiatrist, and nutritionist. The role of the coach on this team is controversial because a coach‘s involvement may be perceived as a threat to the athlete. The coach‘s role should be minimal and used mainly for information purposes. For the athlete who is a minor, the parents must be involved, especially after the intervention has occurred. The objectives of a preventive and intervention team program should include the following: Creating and delivering preventive educational programming for athletes
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Establishing a central, nonthreatening location to which an athlete can turn to receive assistance in weight-related and other healthrelated issues Providing guidelines for the coaching staff on proper communication with athletes regarding weight control and eating disorders Creating a code of ethics regarding communication among members of the athlete’s health care team to maintain confidentiality Establishing a single, consistent intervention for each athlete with any health-related problem. Education is paramount to the success of this program. The athlete must have a resource to turn to for nutrition and weight control, and such information should be presented in a nonthreatening environment. The topic of disordered eating need not be addressed directly, as long as nutritional issues and healthy eating options are empha~ized.’~ It is important, however, that the athletes understand the purpose and objectives of the intervention and performance team so that they are aware of this vital resource. In addition to athlete education, separate education for coaches is imperative. Coaches must understand the need to dispel myths regarding the relationship among body composition, performance, and n ~ t r i t i o n .Most ~ important, coaches must recognize the power and influence that their comments about body appearance and weight control have on athletes who already tend to be dissatisfied with their bodies. Because most coaches typically do not possess adequate knowledge of these issues, the best approach is to refer athletes to other members of the athlete’s health care team for assistance when weight control becomes an issue. Once referred, the athlete’s body composition, nutritional habits, and performance history are evaluated by various members of the team, and a plan of action is developed. This type of proactive approach to weight control issues provides the athlete with proper information to prevent pathologic weight control behaviors. If an athlete is identified as engaging in disordered eating patterns, she should be referred immediately to a team member, usually the athletic trainer, for intervention. At that point, the athlete is confronted and referred to the team physician, psychologist, and nutritionist for evaluation. These referrals are mandatory, and attendance must be verified by the athletic trainer. From this point, the team physician coordinates all communication and care of the athlete. Following the referral, the athlete’s progress is monitored by the team, with confidentiality carefully ensured. Return to engaging in sports is based on a multidisciplinary evaluation and the athlete’s health status. PHYSICAL AND PSYCHOLOGIC SCREENING FOR THE FEMALE ATHLETE TRIAD
Female athletes suspected of having an eating disorder should be evaluated by a multidisciplinary team of health care professionals trained
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in eating disorder intervention. The purpose of the screening process is to gather information on medical history and dietary and exercise behaviors and to evaluate the athlete for existing psychopathology and medical complications. Screening also provides each specialist the opportunity to establish rapport with the athlete for future contact whether it be for preventative education, routine medical care, or eating disorder intervention. The basic screening components involve psychosocial history, medical education, nutrition assessment, and physical activity assessment. Medical Examination The medical examination should include a detailed medical history, physical examination, and basic laboratory tests.', 20, u, 26 In the medical history, information about age of menarche, frequency and length of menstrual periods, date of last period, and use of hormones should be documented. Any family history of reproductive problems should be noted. An attempt must be made to rule out causes of amenorrhea other than hypothalamic insufficiency, such as thyroid, pituitary, or autoimmune disorders; androgen excess; or anabolic steroid use. A progestin challenge may be administered after pregnancy has been ruled out. A hormone profile should include luteinizing hormone (LH), follicle-stimulating hormone (FSH), LH to FSH ratio, thyroid-stimulating hormone, and prolactin. The physical examination should include anthropometrics, such as height, weight, and if appropriate, some measure of body composition. It is helpful to obtain pediatric growth charts and plot current height and weight. Often patients are able to recall previous weight fluctuations, which also may be plotted. The use of skinfold calipers to estimate percentage of fat should be avoided or used with extreme caution. The reporting of body composition should be in relative changes and not in absolute percentage of fat. In addition, body mass index (BMI) may not be reliable for athletes because of the increase in lean tissue. Vital signs should include pulse rate, body temperature, and blood pressure (supine and on standing to evaluate potential orthostatic problems). For the older athlete, a pelvic examination should be performed and a Papanicolaou's stain should be taken. In the younger adolescent, a pelvic and breast examination may be inappropriate, especially for the athlete with an eating disorder. The parotid glands and thyroid gland should be palpated and the throat and mouth inspected. A dermatologic examination should evaluate for lanugo or dry skin. A cardiac evaluation must include a resting EKG especially if the pulse is less than 50 beats per minute, electrolyte abnormality is present, or frequent purging is reported.20 Laboratory tests that are recommended as part of the medical evaluation of athletes suspected of having an eating disorder or the female athlete triad include urinalysis and blood chemistry. Urine should be analyzed for pH. A complete blood count and sedimentation rate should
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be used to check for anemia, inflammation, or infection. A blood chemistry profile for electrolytes and thyroid, liver, and kidney function is recommended. Psychosocial History
A routine psychologic evaluation and social history should be completed once an athlete has been identified as at risk. Areas of concern include relationship and maturational issues, history of drug or alcohol abuse, physical or sexual abuse, self-mutilation, depression, and suicidal ideations or attempts. Other issues to be addressed focus on stressful family and relationship events, such as deaths, illnesses, divorce, and finances. Changes in academic performance, training environment, or performance are also important considerations in evaluating the athlete. Nutrition Assessment
A thorough dietary analysis is necessary to evaluate caloric intake and eating behaviors. Macronutrient and micronutrient composition, fluid intake, use of any type of supplements (e.g., shakes, bars, vitamins, herbs, and pills) should be examined. Eating patterns should be elucidated: food choices, ritualistic behaviors, timing of meals, caffeine, binge eating or purging, chewing or spitting, hoarding, and so forth. Physical Activity Assessment
A physical activity inventory should be obtained to assess past and current exercise and activity patterns. Type of activity, frequency, duration, and intensity should be traced along with tracking the athlete's performance record over time. Particular attention should be paid to changes in physical activity in relation to changes in weight and any alteration of menstrual function. In athletes, understanding changes in training volume or intensity over the competitive season can be useful. An attempt also should be made to separate activity that is part of the athlete's organized training schedule for her sport from activity done outside of training. THERAPEUTIC INTERVENTION FOR THE FEMALE ATHLETE TRIAD
Therapeutic intervention must include medical management and nutrition and exercise counseling in addition to psychotherapy.', 7, 15, 42 The time course for treatment of a frank eating disorder is highly variable, but the norm for extended care is 4 years or longer. How and
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where to begin treatment depends on the condition of the athlete. The levels of care progress from prevention, to outpatient, to day hospital, to inpatient or residential care. The components of care are the same regardless of the level, with the only difference being the amount of structured support provided. Referrals for medical specialists are based on the outcomes of the initial screening. For example, a cardiologist may need to provide a medical release for the resumption of physical activity for any athlete with cardiovascular abnormality or an orthopedic surgeon or a primary care sports medicine physician may need to evaluate stress fractures or overuse injuries. A special medical concern for the athlete with amenorrhea is osteoporosis. Menstrual function and bone health are related intimately. Hypoestrogenism is the primary cause of loss of bone mass leading to osteoporosis in postmenopausal women. Of primary concern in the premenopausal amenorrheic athlete is the prevention or cessation of bone loss caused by hypoestrogenemia. Sex steroids commonly are prescribed to treat athletes with amenorrhea.16, Although limited data are available, it does seem that hormone therapy increases bone density in athletes with amen~rrhea.~,In the only randomized, controlled clinical trial to date, Hergenroeder et all8 found that oral contraceptives (0.035 mg of ethinyl estradiol) increased bone mineral density in young women with hypothalamic amenorrhea. The increased bone mineral density was observed in the lumbar spine and total body density but not in the femoral neck region. Contrary to the findings of Prior et al,32 no increases in bone mineral density were found in the medroxyprogesterone treatment group. Restoration of bone mineral density, however, seems to be slow and may compromise acquisition of peak bone mass.18,27 Other antiresorptive therapy such as alendronate sodium is approved for only postmenopausal women, and no long-term safety data are available at this time. Many athletes resist hormonal therapy. They may believe that exogenous hormones and menstruation adversely affect their performance. In addition, many athletes are similarly reluctant to alter training regimens. Another concern is that the prescription of oral contraceptives and the resumption of menses may mask the underlying eating disorder pathology. Increasing caloric intake and decreasing training volume may be the most appropriate approach. Educating the athlete about nutrition and exercise is a vital step in her treatment program. Although she may know the caloric and fat content of many foods, she also may believe many of the myths associated with nutrition and performance. It is important to communicate to the athlete the difference between feeling fat and being fat. Discuss with her that fat is not a feeling, it is a fuel.2I It may be helpful to create a timeline (for example, the pediatric growth charts) on which are displayed as much of the information gathered in the first interview as possible. This method provides the athlete with a visual account of her experiences paralleled with her health history. Once the athlete sees how her weight and health status fluctuate with emotional stressors, the athlete will begin to understand that her eating disorder is related to the
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way in which she ineffectively copes with challenges in her life. Calculate, with the athlete, her caloric needs for activities in her life. Emphasis should be placed on energy requirements for optimal athletic performance and on a healthy balance in all areas of life. At this stage the athlete’s health care team should develop and revise the athlete’s refeeding and weight gain and exercise plan according to the needs set forth in the medical examination. The athlete should make small but cumulative changes in her eating behavior, perhaps beginning with an increase of 100 kcal per week for the athlete who is in energy deficit. Sharing meals with friends or teammates can be a useful strategy for an athlete to encourage social eatingz1Finally, a plan for relapse must be created. The athlete must be taught how to anticipate and identify situations that may increase her risk of relapsing. She must be provided with and learn to use more positive coping mechanisms for dealing with stressful situations. The therapist should determine modalities for psychotherapy. Over the course of treatment, the combination of intervention techniques (individual, family, group, and support group) may change as the athlete’s needs change. The decision to allow an athlete to continue training and competition during treatment depends on the initial health status of the athlete, compliance with treatment, and improvement in her condition. Compliance and improvement may be measured in several ways, including weight gain, resumption of menses, and consistent attendance at counseling sessions. The athlete’s health care team may choose to draw up a written contract with the athlete that details the conditions under which the athlete may be allowed to train or compete. A contract places the decision to return to her sport into the hands of the athlete and can be a motivating tactic.
SUMMARY
Female athletes are under intense pressure to have a low percentage of body fat for performance, which may result in a vulnerable athlete resorting to disordered eating, developing amenorrhea, and suffering the consequences of osteoporosis. Prevention of disordered eating practices among female athletes requires a de-emphasis of a low percentage of body fat and a good nutrition education program. The female athlete triad is a serious syndrome that requires a multidisciplinary approach to diagnosis and treatment. ACKNOWLEDGMENT The authors wish to thank Nancy Candelaria, Jan Jones, David Nichols, and Jake McBee for assistance in preparation of this article.
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25. Marcus R, Cann C, Madvig P, et al: Menstrual function and bone mass in elite women distance runners. Ann Intern Med 102158, 1985 26. Marshall LA: Clinical evaluation of amenorrhea. In Agostini R (ed): Medical and Orthopedic Issues of Active and Athletic Women. Philadelphia, Hanley & Belfus, 1994, p 530 27. Micklesfield LK, Reyneke L, Fataar A, et al: Long-term restoration of deficits in bone mineral density is inadequate in premenopausal women with prior menstrual irregularity. Clin J Sport Med 8:155, 1998 28. Miller KK, Klibanski A: Amenorrheic bone loss. J Clin Endocrinol Metab 84:1775, 1999 29. National Research Council: Recommended Dietary Allowances, ed 10. Washington, DC, National Academy Press, 1989, p 284 30. Otis CL, Drinkwater €3, Johnson M, et al: ACSM Position Stand: The Female Athlete Triad. Med Sci Sports Exerc 29:i-ix, 1997 31. Petrie TM: Disordered eating in female collegiate gymnasts: Prevalence and personality/ attitudinal correlates. Journal of Sport and Exercise Psychology 15:424, 1993 32. Prior JC, Vigna YM, Barr SI, et al: Cyclic medroxyprogesterone treatment increases bone density: A controlled trial in active women with menstrual cycle disturbances. American Journal of Medicine 96521, 1994 33. Rosen LW, Hough DO: Pathogenic weight-control behaviors of female college gymnasts. The Physician and Sports Medicine 16:141, 1988 34. Sanbom CF: Fact and fat of body composition. In Berning JR, Steen SN (eds): Sports Nutrition for the 90s: The Health Professional's Handbook. Gaithersburg, Aspen Publications, 1991, p 299 35. Sanbom CF, Martin BJ, Wagner WW: Is athletic amenorrhea specific to runners? Am J Ob Gyn 143:859, 1982 36. Snead DB, Stubbs CC, Weltman J, et al: Dietary patterns, eating behaviors, and bone mineral density in women runners. Am J Clin Nutr 56:705, 1992 37. Stiegel-Moore RH, Silberstein LR, Rodin J: Toward an understanding of risk factors for bulimia. Am Psych 41:246, 1986 38. Sundgot-Borgen J: Eating disorders in female athletes. Sports Med 17:188, 1994 39. Sundgot-Borgen J: Prevalence of eating disorders in elite female athletes. Int J Sport Nutrition 3:2940, 1993 40. Sundgot-Borgen J: Risk of trigger factors for the development of eating disorders in female elite athletes. Med Sci Sports Exerc 26:41&419, 1994 41. Williamson DA, Netemeyer RG, Jackman LP, et al: Structural equation modeling of risk factors for the development of eating disorder symptoms in female athletes. Int J Eating Disorders 17387, 1995 42. Yates A: Compulsive Exercise and the Eating Disorders: Toward an Integrated Theory of Activity. New York, Brunner/Mazel, 1991, p 259 43. Yeager K, Agostini R, Nattive A, et al: The female athlete triad: Disordered eating, amenorrhea, osteoporosis. Med Sci Sports Exerc 2577.5, 1993
Address reprint requests to Charlotte F. Sanborn, PhD Texas Woman's University 304 Administration Drive Denton, TX 76201
THE ATHLETIC WOMAN
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DISORDERED EATING AND THE FEMALE ATHLETE TRIAD Charlotte F. Sanborn, PhD, Marianna Horea, MBS, Beverly J. Siemers, PhD, and Kathy I. Dieringer, ATC, LAT, OPA-C
Female athletes are under intense pressure to have a low percentage of body fat, not only to enhance performance but also for the sake of appearance. This pressure is compounded by society’s emphasis on a svelte look and the psychologic makeup of an elite athlete who is goal oriented and a perfectionist. A vulnerable athlete trying to maintain a low body weight may succumb to disordered eating, which may lead to amenorrhea and subsequent bone loss or osteoporosis. These interrelated, cascading events have been termed the female athlete triad.30,43 The components of the female athlete triad, including definitions, clinical criteria for diagnosis, and a discussion of prevalence in athletes versus nonathletes, are presented in this article. A discussion follows of prevention strategies and programs for female athletes. Finally, the article concludes with screening and therapeutic intervention for the female athlete triad. COMPONENTS OF THE FEMALE ATHLETE TRIAD Disordered Eating At the time that the female athlete triad was first introduced as a serious syndromerBthe term eating disorder was reserved for the clinical
From the Center for Research on Women’s Health (CFS), Department of Kinesiology (MH), Texas Woman’s University, Denton; Private practice in Exercise Physiology and Nutrition, Dallas (BJS); and the Matrix Rehabilitation Clinic (KID), Denton, Texas
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diagnosis of anorexia nervosa or bulimia nervosa, based on the Diagnostic and Statistical Manual, third edition (DSM 111) of the American Psychiatric Association, rite ria.^ Since the criteria for these two conditions were established for nonathletes, it was observed that an athlete may not meet the classic definitions but may have a pathogenic weight control pr0b1em.l~The term disordered eating, which referred to a wide spectrum of abnormal patterns of eating, was adopted for the female athlete triadj3 The harmful behaviors listed range in severity from restricting food intake; using diet pills, diuretics, or laxatives; having periods of binge eating and purging; to having anorexia nervosa and bulimia nervosa at the extreme end of the spectrurn?O,43 The concern for the athlete is that the pathway to a frank eating disorder often begins with simply monitoring food intake, progresses to restricting foods, such as fats or red meats, then evolves into limiting acceptable foods, and finally becomes voluntary ~tarvation.~ The standard clinical diagnosis of anorexia nervosa or bulimia nervosa is based on the criteria from the Diagnostic and Statistical Manual, fourth edition (DSM IV), of the American Psychiatric AssociationP A person is vulnerable for developing anorexia nervosa and bulimia nervosa during late adolescence or early adulthood? The prevalence of eating disorders seems to have increased in recent decades among the general population. Between 0.5% and 1.0% meet the full criteria for anorexia nervosa with a slightly higher rate of 1%to 3% for bulimia n e r ~ o s a The . ~ essential characteristics of anorexia nervosa include the following: severe self-imposed weight loss, altered body image, an intense fear of becoming fat, and amenorrhea (Table 1). The essential features of bulimia nervosa are as follows: binge eating; inappropriate compensatory behaviors to prevent weight gain such as self-induced vomiting, using laxatives or diuretics, fasting, or exercising vigorously; and great concern about body shape and weight (Table 2). The latest edition of the DSM4 has included another category for eating disorders that do not fully meet the criteria of anorexia nervosa or bulimia nervosa, eating disorder not otherwise specified (NOS). As with the term disordered eating, this eating disorder classification helps
Table 1. DIAGNOSTIC CRITERIA FOR ANOREXIA NERVOSA
A. Refusal to maintain body weight at or above 85% of normal weight for age and height B. Intense fear of gaining weight or becoming fat, although underweight C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight D. In postmenarchal females, amenorrhea From American Psychiatric Association: Diagnostic Criteria from DSM IV.Washington, DC, American Psychiatric Association, 1994, pp 544-545; with permission.
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Table 2. DIAGNOSTIC CRITERIA FOR BULIMIA NERVOSA
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by the following: 1. Eating, in a discrete period (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time under similar circumstances 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) B. Recurrent inappropriate compensatory behavior to prevent weight gain, such as selfinduced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. C . The binge eating and inappropriate compensatory behaviors occur, on average, at least twice a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. From American Psychiatric Association: Diagnostic Criteria from DSM IV. Washington, DC, American Psychiatric Association, 1994, pp 549-550; with permission.
to diagnose athletes who have a problem but fail to meet all the criteria for anorexia nervosa or bulimia nervosa (Table 3). For example, there can be many similarities between amenorrheic athletes and patients with anorexia nervosa, such as ritualized dietary habits, compulsive behavior, low intake of food, heightened energy expenditure, and, of course, absence of menses or amenorrhea. The body weight of the amenorrheic athlete, however, may be higher than that of the DSM IV criteria of 15% below normal weight for age and height. The athlete’s weight may seem adequate because of the increased weight of lean tissue mass. The amenorrheic athlete would have weighed substantially less without the increased musculature developed by training and thus would have displayed the emaciated appearance associated with anorexia nervosa. The classification of disordered eating or nonspecified eating disorder helps to identify athletes who might otherwise Table 3. CRITERIA FOR EATING DISORDER NOT OTHERWISE SPECIFIED
A. For females, all of the criteria for anorexia nervosa are met except that the individual has regular menses. B. All the criteria for anorexia nervosa are met except that, despite significant weight loss, the person’s current weight is in the normal range. C. All the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week for a duration of less than 3 months. D. The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies). E. Repeatedly chewing and spitting out, but not swallowing, large amounts of food. F. Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of bulimia nervosa. From American Psychiatric Association: Diagnostic Criteria from DSM IV. Washington, DC, American Psychiatric Association, 1994, p 550; with permission.
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be missed. Because eating disorder NOS is a new classification, prevalence data are not available for this category. Amenorrhea
Athletes have a higher prevalence of delayed menarche (older than 16 years) and primary13 and secondary amenorrhea12 than nonathletes. A prevalence of 2% to 5% is reported for the general population, with a higher percentage in athletes ranging from 3.4% to 66%. The highest frequency of amenorrhea has been found to be among ballet dancer^'^ and runne~s.3~ Currently, the caloric deficit or energy drain theory is being actively investigated as a factor possibly responsible for the reproductive disorder.24A surprising finding has been how low the total caloric intakes are as reported by female athletes, regardless of their menstrual status. The average recommended energy allowance for light to moderately active women aged 15 to 24 years is 2200 kcal per In fact, the mean total consumption for female athletes has been reported from as low as 1272 kcal per dayz5to as high as 2400 kcal per day.gThese athletes seem to be in a caloric deficit. The question arises whether a negative caloric balance or caloric energy drain might be the explanation of athletic amenorrhea. The hypothesis is that the athlete is expending more calories than she is consuming, resulting in too few calories or too little energy to maintain the endocrine reproductive system. Overall, the amenorrheic athlete tends to consume fewer calories per day than the regularly menstruating athlete does; however, the differences have not always been significant because of the variations reported. A theme that continues to surface is the finding of eating disorders among the amenorrheic, not the regularly menstruating, athletes. The question remains: Is amenorrhea related to exercise or is amenorrhea a symptom of eating disorder? Osteoporosis
For the female athlete triad the term osteoporosis refers to premature bone loss or inadequate bone formation or both, resulting in low bone mass, microarchitectural deterioration, increased skeletal fragility, and an increased risk of fracture.43Medical concerns of the hypogonadal state are that the amenorrheic athlete is at a greater risk of low bone mass (premature osteoporosis)and stress fractures. Amenorrheic athletes have been shown to have low bone mass*O,25, 36; however, the prevalence of osteoporosis among female athletes is unknown. The hypogonadal state offsets the potentially beneficial effect of exercise on bone mass in the amenorrheic athlete. The finding of reduced bone mass is alarming because these women are losing bone mass at a time when bone should be forming. Optimal levels of peak bone may not be reached, predispos-
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ing the amenorrheic athlete to premature osteoporosis. The concern is whether the decrease in bone mineral density seen in the amenorrheic athlete is a premature, irreversible loss. Resumption of ovarian function has been shown to result in a significant increase in vertebral bone mineral density." Although increases in bone mineral density can occur during the first 2 years after resumption of menses, the values may remain below age-normative den~ities.'~, 23 PREVALENCE OF THE FEMALE ATHLETE TRIAD
Although all female athletes are potentially at risk for the development of the female athlete triad, the magnitude is not known.43Obtaining true prevalence data is difficult to virtually impossible because of the secretive nature of eating disorders and underreporting by female athletes.38 Underreporting eating disorders among female athletes always will be a problem because of the fear of being discovered and the potential consequences to their athletic careers. Risk factors for the development of the female athlete triad have centered around common underlying psychopathologic features of eating disorders: overconcern with body size, fear of being fat, and body image disturbance^.^^ The emphasis on obtaining an optimal weight for athletic performance may amplify societal pressures to be thin and thus increase the female athlete's risk of developing eating disorder^.^^ The prevalence of disordered eating among female collegiate athletes has been reported to be between 4% and 39% for meeting the medical criteria for anorexia nervosa and bulimia nervosaI6and has been documented to be as high as 62% for pathogenic weight control behavior.33The concern regarding these studies is that surveys were used to estimate the prevalence of eating disorders. For populations of female athletes, the use of questionnaires, inventories, surveys, or self-reports may not be valid14,39 and may underestimate the actual ~ r e v a l e n c eBecause .~~ of these problems, instruments should be used cautiously for screening and should be followed by personal interviews and clinical examinations when warranted.38 Preoccupations with weight and dieting have become so pervasive among young women, including female athletes, that it has become the normative behavior3I,41; however, not all female athletes develop diagnosable eating A number of additive risk factors have been proposed for the development of eating disorders.37,41 General and sports-related risk factors', 4, 15, 20, 30, 31, 37, 38 for the development of eating disorders are as follows: General Predisposing Risk Factors Chronic dieting Low self-esteem Family dysfunction Physical or sexual abuse
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Biologic factors Perfectionism Lack of nutrition knowledge Sport-specific Trigger Factors Emphasis on body weight for performance or appearance Pressure to lose weight from parents, coaches, judges, and peers Drive to win at any cost Self-identity as an athlete only (no identity outside sports) Early intervention of training or sudden increase in training Exercises through injury Overtrained and undernourished Traumatic event (e.g., injury or loss of coach) Vulnerable times (e.g., adolescent growth spurt, entering college, retiring from athletics, postpartum depression) PREVENTION STRATEGIES
The keys to prevention of the female athlete triad are twofold and include educational programming and the establishment of the athlete’s health care team. First, an effective prevention strategy must include educational programming directed not only to the athletes but also to their coaches and, in the case of younger athletes, to their parents. Topics that should be addressed include dispelling myths regarding body weight and body fat and their relationship to performance, providing nutritional education, and dealing with other issues of personal wellness. Dispelling Body Fat Myths Two myths that are pervasive among coaches and athletes are: ”thinner is better” and “every sport has an ideal body weight.” There is a common misconception that there is a highly negative correlation between performance and body fat or body weight (Fig. 1A). The coach and athlete translate this supposed relationship to mean that the lowest percentage of body fat or lowest weight will contribute to the highest possible performance. The reality is that no optimal values for body composition have been established for any sport. The association between body composition and performance must be individualized for each athlete (Fig. 1B). There may be a point at which an athlete weighs too much, negatively affecting performance and increasing her risk of musculoskeletal injury; however, there is also a point at which an athlete’s percentage of body fat or body weight becomes too low. She is unable to provide sufficient strength, power, or energy for optimal training and performance and is at risk for injury, illness, overtraining, or the development of more serious medical conditions such as those of the female athlete triad. A specific percentage of fat (body weight)
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should not be recommended but rather a range that is realistic and appropriate for the athlete. If weight loss is recommended, nutrition education is necessary to ensure proper dieting. The athlete’s performance during practice and competition should be monitored continually to help evaluate and establish an optimal range of weight. Sometimes a minimal weight must be established for some athletes, below which she is not allowed to train or compete. A weight loss or gain recommendation should be established that does not exceed 5% of total body weight at 1- to 2-lb increments per week. Once this weight is achieved and stabilized, subsequent recommendations are based on thorough reevaluation of body composition, performance, and nutrition a s s e ~ s m e n t . ~ ~
Nutrition Education Nutrition education, directed by a sports dietitian, is also a necessary part of preventing the female athlete triad. The coaches must be involved in this educational programming because it is often they who make decisions about what and where their athletes eat while training and competing on the road. The goals of the nutrition program should include the following: Replace nutrition myths with facts Educate athletes about nutrient-dense food choices in the context of training, competing, and retiring from competitive athletics Provide hands-on practice in food selection, shopping, and preparation Promote dietary habits that are consistent with long-term health
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and prevention of disease, such as cardiovascular disease and osteoporosis Some basic ideas that should be emphasized are that the diet should provide adequate calories to meet the athlete’s energy needs. The diet should be balanced, providing all macronutrients and micronutrients from a wide variety of foods. In addition, athletes should be encouraged to maintain nutritional consistency during the competitive and off-seasons to avoid frequent and drastic changes in body composition. Nutrition education programs for collegiate athletes need to be varied to accommodate freshmen who may know little about nutrition, sophomores and juniors who may have had some prior counseling, and graduating seniors who are approaching retirement. Regardless of age or experience level; however, athletes need programmatic intervention through which the health risks of disordered eating and amenorrhea must be addressed, reviewed, and reemphasized. Issues of Personal Wellness
Athletes are not only vulnerable to the specific stresses related to sports participation but may have difficulty handling multiple life challenges, sometimes unrelated to their sport, that often predispose them to an eating disorder. Additional health-related issues that can affect female athletes, such as time management, stress management, drug or alcohol use, spirituality, and issues related to sexuality, may be incorporated into an educational program aimed at preventing the female athlete triad. By providing the athlete with information and strategies for preventing or handling these additional pressures, educational programs may prevent athletes from falling prey to negative coping mechanisms such as restricting eating or purging. The Athlete’s Health Care Team
For years, professionals associated with athletics have recognized that a team approach is most effective in the prevention of and intervention in eating disorders or amenorrhea among athletes. It is recommended that the athlete’s health care team include the coach, athletic trainer, physician, exercise physiologist, counselor or psychiatrist, and nutritionist. The role of the coach on this team is controversial because a coach‘s involvement may be perceived as a threat to the athlete. The coach‘s role should be minimal and used mainly for information purposes. For the athlete who is a minor, the parents must be involved, especially after the intervention has occurred. The objectives of a preventive and intervention team program should include the following: Creating and delivering preventive educational programming for athletes
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Establishing a central, nonthreatening location to which an athlete can turn to receive assistance in weight-related and other healthrelated issues Providing guidelines for the coaching staff on proper communication with athletes regarding weight control and eating disorders Creating a code of ethics regarding communication among members of the athlete’s health care team to maintain confidentiality Establishing a single, consistent intervention for each athlete with any health-related problem. Education is paramount to the success of this program. The athlete must have a resource to turn to for nutrition and weight control, and such information should be presented in a nonthreatening environment. The topic of disordered eating need not be addressed directly, as long as nutritional issues and healthy eating options are empha~ized.’~ It is important, however, that the athletes understand the purpose and objectives of the intervention and performance team so that they are aware of this vital resource. In addition to athlete education, separate education for coaches is imperative. Coaches must understand the need to dispel myths regarding the relationship among body composition, performance, and n ~ t r i t i o n .Most ~ important, coaches must recognize the power and influence that their comments about body appearance and weight control have on athletes who already tend to be dissatisfied with their bodies. Because most coaches typically do not possess adequate knowledge of these issues, the best approach is to refer athletes to other members of the athlete’s health care team for assistance when weight control becomes an issue. Once referred, the athlete’s body composition, nutritional habits, and performance history are evaluated by various members of the team, and a plan of action is developed. This type of proactive approach to weight control issues provides the athlete with proper information to prevent pathologic weight control behaviors. If an athlete is identified as engaging in disordered eating patterns, she should be referred immediately to a team member, usually the athletic trainer, for intervention. At that point, the athlete is confronted and referred to the team physician, psychologist, and nutritionist for evaluation. These referrals are mandatory, and attendance must be verified by the athletic trainer. From this point, the team physician coordinates all communication and care of the athlete. Following the referral, the athlete’s progress is monitored by the team, with confidentiality carefully ensured. Return to engaging in sports is based on a multidisciplinary evaluation and the athlete’s health status. PHYSICAL AND PSYCHOLOGIC SCREENING FOR THE FEMALE ATHLETE TRIAD
Female athletes suspected of having an eating disorder should be evaluated by a multidisciplinary team of health care professionals trained
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in eating disorder intervention. The purpose of the screening process is to gather information on medical history and dietary and exercise behaviors and to evaluate the athlete for existing psychopathology and medical complications. Screening also provides each specialist the opportunity to establish rapport with the athlete for future contact whether it be for preventative education, routine medical care, or eating disorder intervention. The basic screening components involve psychosocial history, medical education, nutrition assessment, and physical activity assessment. Medical Examination The medical examination should include a detailed medical history, physical examination, and basic laboratory tests.', 20, u, 26 In the medical history, information about age of menarche, frequency and length of menstrual periods, date of last period, and use of hormones should be documented. Any family history of reproductive problems should be noted. An attempt must be made to rule out causes of amenorrhea other than hypothalamic insufficiency, such as thyroid, pituitary, or autoimmune disorders; androgen excess; or anabolic steroid use. A progestin challenge may be administered after pregnancy has been ruled out. A hormone profile should include luteinizing hormone (LH), follicle-stimulating hormone (FSH), LH to FSH ratio, thyroid-stimulating hormone, and prolactin. The physical examination should include anthropometrics, such as height, weight, and if appropriate, some measure of body composition. It is helpful to obtain pediatric growth charts and plot current height and weight. Often patients are able to recall previous weight fluctuations, which also may be plotted. The use of skinfold calipers to estimate percentage of fat should be avoided or used with extreme caution. The reporting of body composition should be in relative changes and not in absolute percentage of fat. In addition, body mass index (BMI) may not be reliable for athletes because of the increase in lean tissue. Vital signs should include pulse rate, body temperature, and blood pressure (supine and on standing to evaluate potential orthostatic problems). For the older athlete, a pelvic examination should be performed and a Papanicolaou's stain should be taken. In the younger adolescent, a pelvic and breast examination may be inappropriate, especially for the athlete with an eating disorder. The parotid glands and thyroid gland should be palpated and the throat and mouth inspected. A dermatologic examination should evaluate for lanugo or dry skin. A cardiac evaluation must include a resting EKG especially if the pulse is less than 50 beats per minute, electrolyte abnormality is present, or frequent purging is reported.20 Laboratory tests that are recommended as part of the medical evaluation of athletes suspected of having an eating disorder or the female athlete triad include urinalysis and blood chemistry. Urine should be analyzed for pH. A complete blood count and sedimentation rate should
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be used to check for anemia, inflammation, or infection. A blood chemistry profile for electrolytes and thyroid, liver, and kidney function is recommended. Psychosocial History
A routine psychologic evaluation and social history should be completed once an athlete has been identified as at risk. Areas of concern include relationship and maturational issues, history of drug or alcohol abuse, physical or sexual abuse, self-mutilation, depression, and suicidal ideations or attempts. Other issues to be addressed focus on stressful family and relationship events, such as deaths, illnesses, divorce, and finances. Changes in academic performance, training environment, or performance are also important considerations in evaluating the athlete. Nutrition Assessment
A thorough dietary analysis is necessary to evaluate caloric intake and eating behaviors. Macronutrient and micronutrient composition, fluid intake, use of any type of supplements (e.g., shakes, bars, vitamins, herbs, and pills) should be examined. Eating patterns should be elucidated: food choices, ritualistic behaviors, timing of meals, caffeine, binge eating or purging, chewing or spitting, hoarding, and so forth. Physical Activity Assessment
A physical activity inventory should be obtained to assess past and current exercise and activity patterns. Type of activity, frequency, duration, and intensity should be traced along with tracking the athlete's performance record over time. Particular attention should be paid to changes in physical activity in relation to changes in weight and any alteration of menstrual function. In athletes, understanding changes in training volume or intensity over the competitive season can be useful. An attempt also should be made to separate activity that is part of the athlete's organized training schedule for her sport from activity done outside of training. THERAPEUTIC INTERVENTION FOR THE FEMALE ATHLETE TRIAD
Therapeutic intervention must include medical management and nutrition and exercise counseling in addition to psychotherapy.', 7, 15, 42 The time course for treatment of a frank eating disorder is highly variable, but the norm for extended care is 4 years or longer. How and
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where to begin treatment depends on the condition of the athlete. The levels of care progress from prevention, to outpatient, to day hospital, to inpatient or residential care. The components of care are the same regardless of the level, with the only difference being the amount of structured support provided. Referrals for medical specialists are based on the outcomes of the initial screening. For example, a cardiologist may need to provide a medical release for the resumption of physical activity for any athlete with cardiovascular abnormality or an orthopedic surgeon or a primary care sports medicine physician may need to evaluate stress fractures or overuse injuries. A special medical concern for the athlete with amenorrhea is osteoporosis. Menstrual function and bone health are related intimately. Hypoestrogenism is the primary cause of loss of bone mass leading to osteoporosis in postmenopausal women. Of primary concern in the premenopausal amenorrheic athlete is the prevention or cessation of bone loss caused by hypoestrogenemia. Sex steroids commonly are prescribed to treat athletes with amenorrhea.16, Although limited data are available, it does seem that hormone therapy increases bone density in athletes with amen~rrhea.~,In the only randomized, controlled clinical trial to date, Hergenroeder et all8 found that oral contraceptives (0.035 mg of ethinyl estradiol) increased bone mineral density in young women with hypothalamic amenorrhea. The increased bone mineral density was observed in the lumbar spine and total body density but not in the femoral neck region. Contrary to the findings of Prior et al,32 no increases in bone mineral density were found in the medroxyprogesterone treatment group. Restoration of bone mineral density, however, seems to be slow and may compromise acquisition of peak bone mass.18,27 Other antiresorptive therapy such as alendronate sodium is approved for only postmenopausal women, and no long-term safety data are available at this time. Many athletes resist hormonal therapy. They may believe that exogenous hormones and menstruation adversely affect their performance. In addition, many athletes are similarly reluctant to alter training regimens. Another concern is that the prescription of oral contraceptives and the resumption of menses may mask the underlying eating disorder pathology. Increasing caloric intake and decreasing training volume may be the most appropriate approach. Educating the athlete about nutrition and exercise is a vital step in her treatment program. Although she may know the caloric and fat content of many foods, she also may believe many of the myths associated with nutrition and performance. It is important to communicate to the athlete the difference between feeling fat and being fat. Discuss with her that fat is not a feeling, it is a fuel.2I It may be helpful to create a timeline (for example, the pediatric growth charts) on which are displayed as much of the information gathered in the first interview as possible. This method provides the athlete with a visual account of her experiences paralleled with her health history. Once the athlete sees how her weight and health status fluctuate with emotional stressors, the athlete will begin to understand that her eating disorder is related to the
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way in which she ineffectively copes with challenges in her life. Calculate, with the athlete, her caloric needs for activities in her life. Emphasis should be placed on energy requirements for optimal athletic performance and on a healthy balance in all areas of life. At this stage the athlete’s health care team should develop and revise the athlete’s refeeding and weight gain and exercise plan according to the needs set forth in the medical examination. The athlete should make small but cumulative changes in her eating behavior, perhaps beginning with an increase of 100 kcal per week for the athlete who is in energy deficit. Sharing meals with friends or teammates can be a useful strategy for an athlete to encourage social eatingz1Finally, a plan for relapse must be created. The athlete must be taught how to anticipate and identify situations that may increase her risk of relapsing. She must be provided with and learn to use more positive coping mechanisms for dealing with stressful situations. The therapist should determine modalities for psychotherapy. Over the course of treatment, the combination of intervention techniques (individual, family, group, and support group) may change as the athlete’s needs change. The decision to allow an athlete to continue training and competition during treatment depends on the initial health status of the athlete, compliance with treatment, and improvement in her condition. Compliance and improvement may be measured in several ways, including weight gain, resumption of menses, and consistent attendance at counseling sessions. The athlete’s health care team may choose to draw up a written contract with the athlete that details the conditions under which the athlete may be allowed to train or compete. A contract places the decision to return to her sport into the hands of the athlete and can be a motivating tactic.
SUMMARY
Female athletes are under intense pressure to have a low percentage of body fat for performance, which may result in a vulnerable athlete resorting to disordered eating, developing amenorrhea, and suffering the consequences of osteoporosis. Prevention of disordered eating practices among female athletes requires a de-emphasis of a low percentage of body fat and a good nutrition education program. The female athlete triad is a serious syndrome that requires a multidisciplinary approach to diagnosis and treatment. ACKNOWLEDGMENT The authors wish to thank Nancy Candelaria, Jan Jones, David Nichols, and Jake McBee for assistance in preparation of this article.
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