The Female Athlete Triad, Part 2

Anorexia is characterized by extreme weight loss due to a desire to be thin. The hallmark of anorexia is a distorted body image, whereby an individual feels fat despite being underweight.

Bulimia is characterized by severe guilt surrounding eating, with episodes of binge eating followed by some sort of purging behavior. Purging behaviors include fasting, diuretics, self-induced vomiting, laxatives and excessive exercise.
Females account for 90 percent of reported eating disorders. The occurrence of eating disorders peaks in adolescence. Though they occur in all sports, eating disorders tend to occur more commonly in sports which emphasize leanness, such as cross country running, swimming, rowing and wrestling, or sports in which scoring is subjective, such as skating, gymnastics and diving.

Pathogenic Behavior or Eating Disorder?
It is important to differentiate the use of pathogenic behaviors (for example, a wrestler that practices behaviors to make a weight class) from true eating disorders, which are distortions of body image. Eating disorders occur more common in athletes, though the reasons for this are less clear.

Eating disorders are not about food. The qualities that put an athlete at risk for eating disorders are the same qualities that often make them succeed as an athlete: They are determined, perfectionists, high-achievers and goal-setters. They tend to excel in school and are very critical of themselves.

Eating disorders often begin innocently, as experimentation with ways to decrease weight or percentage of body fat. Some athletes spiral into a true psychological disorder whereby body image is distorted. Many times, self-esteem issues are central to athletes who feel extremely guilty about eating. They see themselves as weak because they cannot withstand hunger pangs. Often they develop an eating disorder as a means to gain control over some aspect of their life. They may not feel in control of their schoolwork, their personal life or whether they “start” on the team, but they can control what they put in their mouth.

Being able to tell if an athlete has an eating disorder is often a difficult task, given that there are many shared characteristics. Though an individual with anorexia may be easier to spot due to their extreme thinness, individuals with bulimia nervosa are often at or above their ideal weight and may be more difficult to recognize. Fortunately, bulimic individuals often seek help because they feel their eating patterns are out of control.

Medical Consequences of Eating Disorders
Eating disorders can be life threatening, with a mortality rate reported as high as 18 percent. Anorexia has as part of its definition amenorrhea. Other eating disorders are also associated with menstrual dysfunction. Therefore, the risk for decreased bone mineral density with resulting stress fractures and premature osteoporosis exists.

Starvation can cause multi-organ dysfunction, difficulties fighting infection and injuries, and depression. In addition, if an athlete employs diuretics, laxatives or self-induced vomiting, the resulting electrolyte disturbances can cause abnormal heart rhythms and gastrointestinal disease. The most common cause of eating disorder mortality is suicide.

Psychological counseling is the cornerstone of treatment for eating disorders. Eating disorder treatment begins with recognition. Once an eating disorder is recognized in an athlete, the treatment is multidisciplinary. Psychological counseling is essential for successful treatment. Evaluation of medical problems, with lab tests or an EKG, for example, and medical monitoring is also important.

The female triad’s effect on bone health is separate from the effects of menstrual dysfunction. Treatment of coexistent menstrual dysfunction is essential, and often a baseline measurement of BMD. A dual energy X-ray absorptiometry scan is useful in determining treatment. The athlete’s activity level should be assessed, if and when he or she requires hospitalization. Appropriate weight and percentage of body fat levels are decisions that must be individualized. There is no simple algorithm to use for these decisions.

Communication with the athlete, parents, coaches and administration, yet maintaining respect for confidentiality issues, make the female athlete triad a complex medical problem to treat.

Prevention?
Triad-related questions should be implemented as part of the pre-participation physical examination of young athletes. The female athlete triad is a concern for all female athletes, and methods to increase awareness of both menstrual dysfunction and disordered eating are of critical importance. Providing adequate information about proper nutritional practices and optimizing body composition without negatively effecting health are areas in which future work is necessary. Early recognition, treatment and prevention through education are the essential tools for combating the female athlete triad.