Course:KIN366/ConceptLibrary/Female Athlete Triad

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KIN 366
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Instructor: Dr. Shannon S.D. Bredin
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According to the American College of Sports Medicine the female athlete triad (Triad) is the name given to the “interrelationships among energy availability, menstrual function, and bone mineral density, which may have clinical manifestations including eating disorders, hypothalamic amenorrhea and osteoporosis” (Nattiv, A., Loucks, A., Manore, M., Sanborn, C., Sundgot-Borgen, J., & Warren, M., 2007). The Triad is documented as affecting adolescent and developed female athletes in sports that stress a specific body image, weight class restriction, and/or endurance (De Souza & Williams, 2004; Nazem & Ackerman, 2012). The three components of the Triad do not need to occur simultaneously for an athlete to face negative health effects (Nazem & Ackerman, 2012). As the three aspects may present at different time periods, it is important to maintain vigilance with athletes health (Nazem & Ackerman, 2012). The Triad is commonly found in elite athletics that emphasize leanness (Sundgot-Borgen & Torstveit). Some outcomes of the Triad include musculoskeletal injuries, stress fractures, hypothalamic amenorrhea, adverse cardiovascular effects (Rauh, M. J., Barrack, M., & Nichols, J. F.,2014; Nazem & Ackerman, 2012; Barrack M.T. et al., 2013).

Contemporary Relevance

Humans are not immune to scrutiny and pressures to fulfill a societal demand (Laframboise, M. A., Borody, C., & Stern, P., 2013). With the pressure to succeed coming at athletes from all angles eating disorders prove to be an important trigger for the female athlete triad. Despite the ability of athletics to “increase self-esteem and self-confidence”, females still face extreme psychological pressures in sport (LaFramboise et al., 2013). Researchers agree that eating disorders are not caused by coaches but may be a result of negative coaching methods (Sundgot-Borgen, 1994). Media opinions coupled with input from parents, coaches, and the opposition all allow for body image issues to advance among developing girls. These issues have the ability to increase disordered eating patterns, essentially opening the door for the Triad to invade the lives of impressionable youth.

Although young children are at a lowered risk of the Triad due to lack of menarche onset, it is still crucial to encourage varied physical activity in developing children to increase bone strength at an early age (Caine et al., 2006). This varied physical activity, specifically in ball-based sports has shown reduced stress fractures and improve bone health in youth (Tenforde, A. S., Sainani, K. L., Sayres, L. C., Milgrom, C., & Fredericson, M., 2014).

Epidemiology

Low Energy Availability

The low energy availability aspect of the female athlete triad refers to the result of decreased energy following disordered eating. Low energy availability causes the body’s physiological mechanisms to reduce the “amount of energy used for cellular maintenance, thermoregulation, growth, and reproduction” (Nattiv et al.,, 2007). Biologically this is designed to restore energy balances in the body and promote survival following the physiological compensation (Nattiv et al.,, 2007). However, this restoration of balance causes impaired health (Nattiv et al.,, 2007).

Disordered eating is defined by “a disturbance of weight control behaviour or eating habit with resultant “clinically significant impairment of physical health or psychosocial functioning” (Fairburn & Harrison, 2003). There are three classifications of eating disorders: Anorexia nervosa, bulimia nervosa, and atypical eating disorders (Fairburn & Harrison, 2003). Anorexia nervosa (AN) is outlined by a body weight of less than 85% of the expected value (American Psychiatric Association, 2000). AN is specifically categorized by “persistent and irrational fear of gaining weight or becoming at; disrupted body image; and amenorrhea” (American Psychiatric Association, 2000). Bulimia nervosa (BN), is classified by repeated binge eating followed by preventative weight gain methods such as purging. The combination of binging and purging two or more times a week for a period of 3 or more months is categorized as bulimia nervosa. Atypical eating disorders refers to all other clinically severe forms of disordered eating that do not coincide with the “diagnostic criteria for AN or BN” (Fairburn, 2003).

Eating disorders are a relevant problem among adolescent and young women (Lewinsohn, P. M., Striegel-Moore, R. H., & Seeley, J. R. (2000). Anorexia Nervosa has a lower relative onset age that Bulimia Nervosa (Lewinsohn et al., 2000). AN’s onset ranging from 10 to 19 years of age, while the highest incidence of BN is found among females “aged 20 through 39” (Lewinsohn et al., 2000). The occurrence of eating disorders is higher in female athletes than non-athletes (Sundgot-Borgen, 1994). Disordered eating is also more commonly found in sports that stress low body weight or leanness. Anorexia Athletica is the name given to a form of disordered eating found in athletes who do not meet specific diagnostic requirements for AN or BN (Sundgot-Borgen & Torstveit, 2004). Anorexia Athletica is categorized by “an intense fear of gaining weight or becoming fat…[despite already being] underweight” (Sundgot-Borgen, 2004). The underweight classification is gained through: reduction of energy intake, excessive exercising, bingeing, self-induced vomiting (purging), and the use of laxatives or diuretics (Sundgot-Borgen & Torstveit, 2004). Following disordered eating, women develop menstrual irregularities, specifically, amenorrhea (Yeager, K. K., Agostini, R., Nattiv, A., & Drinkwater, B., 1993).

Menstrual Irregularities

The average onset age of menarche in 90% of healthy females is 13.75 years (Chumlea, W. C., Schubert, C. M., Roche, A. F., Kulin, H. E., Lee, P. A., Himes, J. H., & Sun, S. S. 2003). In elite athletes the age of menarche can be varied based on their “reduced food intake and vigorous activity resulting in reduced fat/lean ratio… associated with lack of menstrual cycles (Frisch, R. E., Wyshak, G., & Vincent, L.1980). Long-term perspective studies have showed an increase in luteal deficiency and anovulation with only exercise expenditure (Nattiv et al.,, 2007).

In a 2002 study, researchers found that the females tested had varied menarche ages (Beals & Manore, 2002). In aesthetic sports, the age of menarche was much older than those in endurance/team sports (Beals & Manore, 2002). This delay in age of the onset of menarche is known as Primary amenorrhea (Nattiv et al., 2007). Amenorrhea is defined as “the absence of menstrual cycles for more than 90 days” (Nattiv et al., 2007). There are 2 forms of amenorrhea, Primary amenorrhea and Secondary amenorrhea (Nattiv et al., 2007). Secondary amenorrhea is defined as “amenorrhea beginning after the beginning of menarche” (Nattiv et al., 2007). Amenorrhea indicates a decreased estrogen production; the drop in estrogen levels can drop to postmenopausal rates (Yeager et al, 1993). These decreased estrogen levels can lead to the onset of reduced bone mineral densities (Riggs, B. L., Khosla, S., & Melton, L. J. 1998). Functional hypothalamic amenorrhea is also a consideration within the Triad as it common stems from exercise and stress and can a result of changes in energy availability (Nazem & Ackerman, 2012).

Low Bone Mineral Density (BMD)

With menstrual irregularities come health detriments in regards to bone mineral densities. (BMD). Postmenopausal women face estrogen deficiency, which leads to an increase in bone reabsorption and leads to osteoporosis (Riggs et al., 1998). The NIH Consensus Development Panel defines Osteoporosis as ‘‘a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture’’(Nattiv et al., 2007; Riggs et al, 1998). Shockingly this disease is also present in young female athletes following the onset on amenorrhea (Yeager et al., 1993). In fact, Osteoporosis is found in up to 13% of female athletes and osteopenia is found in 22-25%. Though the effects of amenorrhea do not immediately cause osteoporosis they do speed the process of skeletal demineralization (Nattiv et al., 2007). Likewise, the revival of menses does not immediately improve BMD.

Bone mineral density is a measure of the amount of the mineral matter per square centimeter of bone. Measuring BMD gives an accurate prediction of fracture risks (Marshall et al., 1996). One’s internal bone structure, bone density, and quality of bone protein dictate their bone strength and fracture risk (Nattiv et al.,, 2007). Thus, an athlete’s BMD is a look into their history with energy availability and menstrual status coupled with her “genetic endowment and exposure to other nutritional, behavioural and environmental factors” (Nattiv et al., 2007). Athletes in weight bearing sports tend to have 5-15% higher BMD than non-athletes due to repeated strain on one’s bones when load bearings (Nattiv et al., 2007).

Health Consequences

General Consequences

The three components of the female athlete triad lead to broad health effects. The interplay of low energy availability, effects of amenorrhea, and low BMD have reflected evidence of suppressing an individual’s immune system (Montero et al., 2002). Effects of the Triad also negatively effect skeletal muscle oxidative metabolism (Harber, Petersen, & Chilibeck, 1998).

Specific Consequences

Decreased Energy Availability

Disordered eating results in lack of fulfillment of nutritional demands. Deficiency of nutrients impairs one’s ability to maintain muscle mass, build bone, and repair damage tissue. The decreased energy availability also initiates that Triad as the body’s responds via physiological mechanisms to suppress the amount of energy used for: cellular maintenance, thermoregulation, growth, and reproduction” (Nattiv et al., 2007).

Menstrual Dysfunction

Menstrual dysfunction over a long period of time can lead to infertility (Nattiv, et al., 2007). While regular menses is being restored in recovering athletes, unexpected pregnancies are possible occurrences as a consequence of premature ovulation (Nattiv, et al., 2007). Unfortunately, the restoration of menses does not compensate for the losses of BMD that occurred earlier, but it does help to rebuild bone and alleviate the future risk of osteoporosis and fractures (Nattiv, et al., 2007).

Menstrual irregularities coupled with a decreased caloric intake and high exercise levels have been associated with several clinical manifestations (De Souza & Williams, 2004). These manifestations include: disordered eating, stress fractures, osteoporosis and serve to increase one’s risk for premature cardiovascular disease (De Souza & Williams, 2004). Athletes with luteal deficiency can also be at risk for “infertility due to poor follicular hypoestrogenism or failure of implantation (Nattiv et al., 2007)

Amenorrhea is reflective of a hypoestrogenic state, and it is known that a lack of estrogen inhibits osteoclast activity, and therefore bone continually breaks down (Meczekalski, Podfigurna-Stopa, & Genazzani, 2010; Nattiv, et al., 2007; Nazem & Ackerman, 2012). Osteoclasts are specialized bone cells that aid in the resorption of bone during bone remodeling (Nazem & Ackerman, 2012). Consequently, for athletes who have the triad, the reality is that the harmful effects of amenorrhea dominate over the beneficial effects of physical activity engagement (Nazem & Ackerman, 2012). Hypoestrongenism has also been shown to cause endothelial dysfunction which has been linked to the presence of cardiovascular disease later in life (Lieberman, et al., 1994).

Bone Mineral Density

Low Bone Mineral Density in young women and adolescents has been proven to have long term affects. Osteoporosis is a prime example of this. As “Osteoporosis is not always caused by accelerated bone mineral loss in adulthood”, it is suggested that it can occur due to failure to accumulate proper BMD in childhood (Nattiv et al.. 2007). BMD levels increase in compared to the decreasing menstrual cycles an athlete experiences with amenorrhea, as this progresses the likelihood of restoring full bone health also decreases (Nattiv et al., 2007). All of these factors put female athletes at an increased risk of stress fractures, specifically in the: pelvis, hip, and spine (Nattiv et al., 2007; Yeager et al, 1993).

Psychological Effects

Athletics revolve around competition. Thus, women who choose to pursue a sport where body image is a constant factor in their successes and failures are challenged by the views of others and ultimately, their view of themselves. The psychological pressures placed on female athletes to be extremely thin and fit the mould created for them by western society plays a large role in the development of eating disorders (LaFramboise et al., 2013). Athletes who are faced with the Triad often also experience: low self-esteem, depression, and anxiety disorders (Lilenfeld, L. R., Kaye, W. H., Greeno, C. G., Merikangas, K. R., Plotnicov, K., Pollice, C.,...Nagy, L., 1998).

Practical Applications and Recommendations

Coaches and Staff

Coaches and Staff of sport with high prevalence of the female athlete triad need to be aware of the risk factors athletes bring with them to the sport. Athletes who have a restricted dietary intake, exercise for prolonged periods of time, and are vegetarian fall into the category of high risk (Nazem & Ackerman, 2012; Rauh, M. J., Barrack, M., & Nichols, J. F., 2014). Coaches can utilize their relationships with their athletes to foster positive body image ideals. Coaches can introduce this by leading education programs, which convey resources and information to students on disorders associated with athleticism. Ideally, the programs should also include a section on healthy weight loss, thereby allowing the coaches and team staff to provide the athletes with instructions for safe weight loss, which would be beneficial to athletic performance. Placing emphasis on the skills and passion for the sport they can remove the negative body image opinions athletes may have. By building confidence in young and impressionable athletes one allows their athletes to develop far-reaching skills.

Pre-participation screenings to identify if an athlete is high risk and/or have pre-existing symptoms of the Triad are recommended for the athlete’s health and safety (Nichols, J. F., Rauh, M. J., Lawson, M. J., Ji, M., & Barkai, H. S., 2006).

Healthcare Professionals

Despite the recognition of the female athlete triad in 1992 medical personal still lack the knowledge to accurately treat the illness. In a 2006 study, researchers surveyed various medical personal that were likely to encounter the triad (Troy et al., 2006). This included, “physicians, physical trainers, athletic trainers and coaches”(Troy, K., Hoch, A. Z., & Stavrakos, J. E., 2006). Of the physicians, “only 9% … felt comfortable treating the female athlete triad” ”(Troy et al., 2006). Furthermore, only 4% of pediatricians felt comfortable with the treatment.

This evidence makes it obvious that more education needs to be put in place for medical personal to gain the knowledge and skills to properly recognize and treat the Triad. Athletes who are at high levels of competition in sports with an emphasis on body size need to have regular check-ups to maintain their health. It is suggested that screening for symptoms of the female athlete triad be a part of all check ups with young girls and women (Yeager et al, 1993). If an athlete is diagnosed with the Triad it will take a multidisciplinary approach to rehabilitate her (Sabatini, 2001).

Supporters

An athlete’s support system is their protection from the female athlete triad. Following this it is important to recognize an athletes limits within their sport. With pressure from all aspects of their sport it is important the athlete feels supported from family, friends, teachers, and anyone else they may look to for guidance. Preventative measures exist surrounding psychological help as well as physiological methods. Studies have shown a decrease in stress fractures in young athletes as it promotes bone health (Tenforde, A. S., Sainani, K. L., Sayres, L. C., Milgrom, C., & Fredericson, M., 2014). If your young child begins their sporting career with a varied set of athletics they are likely to develop strong bones due to the alternating skills set needed (Tenforde et al., 2014)

As one cannot directly observe their child’s bone mineral density of a day-to-day basis it is important to keep a look out for other common symptoms. These symptoms include: fasting, skipping meals, binging/purging, and the use of diet pills or laxatives (Barrack, M., Rauh, M., Barkai, H., & Nichols, J., 2008; Sanborn, C., Horea, M., Siemers, B., & Dieringer, K., 2000). Supporters should also look for Russell’s sign (Daluiski, Rahbar, & Meals, 1997). Russell’s sign refers to the damage caused by repetitive contact of the incisors with the skin on the back of the hand that occurs during self-induced vomiting, such as in bulimia nervosa (Daluiski et al., 1997).

Other Terms Defined

Anovulation: The absence of ovulation (Nattiv et al., 2007)

Menarche: The first appearance of menstruation (Nattiv et al., 2007)

Osteopenia: low bone mineral density, occur prior to osteoporosis (Nattiv et al., 2007)

Functional Hypothalamic Amenorrhea: Amenorrhea occurring due to increased exercise expenditure without reducing dietary intake (Nattiv et al, 2007)

References

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Barrack, M. T., Ackerman, K. E., & Gibbs, J. C. (2013). Update on the female athlete triad. Current reviews in musculoskeletal medicine, 6(2), 195-204.

Barrack, M., Rauh, M., Barkai, H., & Nichols, J. (2008). Dietary restraint and low bone mass in female adolescent endurance :runners. American Journal of Clinical Nutrition, 87(1), 36-43.

Beals, K. A., & Manore, M. M. (2002). Disorders of the female athlete triad among collegiate athletes. International journal of sport nutrition and exercise metabolism, 12, 281-293.

Caine, Dennis, John DiFiori, and Nicola Maffulli. "Physeal injuries in children’s and youth sports: reasons for concern?." British journal of sports medicine 40.9 (2006): 749-760.

Chumlea, W. C., Schubert, C. M., Roche, A. F., Kulin, H. E., Lee, P. A., Himes, J. H., & Sun, S. S. (2003). Age at menarche and racial comparisons in US girls. Pediatrics, 111(1), 110-113.

Daluiski, A., Rahbar, B., & Meals, R. (1997). Russell's sign: Subtle hand changes in patients with bulimia nervosa. Clinical :orthopaedics and related research, 343, 107-109.

De Souza, M., & Williams, N. (2004). Physiological aspects and clinical sequelae of energy deficiency and hypoestrogenism in :exercising women. Human Reproduction Update, 10(5), 433-448

Fairburn, C. G., & Harrison, P. J. (2003). Eating disorders. The Lancet, 361(9355), 407-416.

Frisch, R. E., Wyshak, G., & Vincent, L. (1980). Delayed menarche and amenorrhea in ballet dancers. New England Journal of Medicine.

Harber, V., Petersen, S., & Chilibeck, P. (1998). Thyroid hormone concentrations and muscle metabolism in amenorrheic and :eumenorrheic athletes. Canadian Journal of Physiology and Pharmacology, 23(3), 293-306.

Laframboise, M. A., Borody, C., & Stern, P. (2013). The female athlete triad: a case series and narrative overview. The Journal of the Canadian Chiropractic Association, 57(4), 316–326.

Lewinsohn, P. M., Striegel-Moore, R. H., & Seeley, J. R. (2000). Epidemiology and natural course of eating disorders in young women from adolescence to young adulthood. Journal of the American Academy of Child & Adolescent Psychiatry, 39(10), 1284-1292.

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Lilenfeld, L. R., Kaye, W. H., Greeno, C. G., Merikangas, K. R., Plotnicov, K., Pollice, C., . . . Nagy, L. (1998). A :controlled family study of anorexia nervosa and bulimia nervosa: psychiatric disorders in first-degree relatives and effects :of proband comorbidity. Archives of General Psychiatry, 55(7), 603-610.

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Rauh, M. J., Barrack, M., & Nichols, J. F. (2014). ASSOCIATIONS BETWEEN THE FEMALE ATHLETE TRIAD AND INJURY AMONG HIGH SCHOOL RUNNERS. International Journal of Sports Physical Therapy, 9(7), 948–958.

Riggs, B. L., Khosla, S., & Melton, L. J. (1998). A unitary model for involutional osteoporosis: estrogen deficiency causes both type I and type II osteoporosis in postmenopausal women and contributes to bone loss in aging men. Journal of bone and mineral research, 13(5), 763-773.

Sabatini, S. (2001). The female athlete triad. The American journal of the medical sciences, 322(4), 193-195

Sanborn, C., Horea, M., Siemers, B., & Dieringer, K. (2000). Disordered eating and the female athlete triad. Clinics in :Sports Medicine, 19(2), 199-213.

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