Combatting FAT in athletics:

Evaluation and Treatment of

the Female Athlete Triad

MAGGIE KEMP

SPORTS NUTRITION: SP17.NUTR663 SEC. 1

PROFESSOR OSCAR COETZEE

What is the Female Athlete Triad (FAT)?

3 criteria:

Low energy availability (negative energy balance)

Amenorrhea (1◦ = absence/delay of menses and female characteristics in

adolescent girls, 2◦ = absence of menstruation for > 3 months in adult female

athletes)

Decreased bone mass density

*Some definitions suggest a fourth criteria of endothelial dysfunction

Who is most at risk?

Those who participate in sports with:

Subjective scoring of female performance (ballet, gymnastics, ice skating)

Endurance sports (running, cycling, rowing)

Sports with weight categories

Sports that require tight or revealing clothing

Other contributing factors:

Frequent weigh-ins

Consequences suffered due to weight gain

Pressure to win from coaches/parents

Societal pressure to look thin

Athletes psychological factors such as having a “Type A” personality with a high

desire to win/compete

Controlling behavior from coaches and parents

Disordered Eating: Where the triad begins

Prevalence for disordered eating is estimated to range between 16-72% in female athletes vs 5-10% in non-athletes

Signs of disordered eating:

Negative calorie balance

Purposefully restricting food intake

Use of laxatives, enemas, or diuretics

Purging after meals

Engaging in additional exercise specifically to “off-set” eating meals higher in calories

Erratic eating, missing meals or avoidance of specific foods

Use of diet pills or appetite suppressants

Physical Symptoms of Disordered Eating

Hypothermia (low body temperature)

Bradycardia

Orthostatic hypotension

Low Body Fat

Disordered Eating

Consequences include:

Nutritional deficiencies (particularly Ca and Fe)

Decline in performance

Low levels of estrogen, causing less frequent periods or amenorrhea (lack of menstruation >3 months)

Osteopenia or osteoporosis (compounded by low estrogen levels, estrogen is needed for optimal calcium absorption

Bloodwork to evaluate:

CBC

Electrolytes

BUN

Creatinine

Glucose

Phosphorous

Mg

Albumin

Two potential causes of negative calorie

balance

Intentional restriction of calories Disordered Eating: 28-62% of female

athletes suffered from disordered eating compared to 5-10% of non-athletes

Athlete displays intense fear of gaining weight

Reduces/restricts calories and/or

Exercises excessively to “make up” for extra calories ingested

May display binging/purging behaviors

Unintentional restriction of

calories

Inability to keep up with caloric intake

required by the high energy demand of

their sport

Lack of time to fuel adequately

Lack of knowledge as to fuel and nutrition

requirements

Consequences of Low Energy Availability

PART 2 OF THE TRIAD:

FUNCTIONAL HYPOTHALAMIC AMENORRHEA OR MENSTRUAL IRREGULARITIES

Function

Results from suppression of hypothalamic-pituitary-ovarian axis

Cause: alteration in gonadotropin-releasing hormone, leads to disruption of LH pulses and gonadal steroid release from ovaries

Resultant deficiency in estrogen causes decreased Bone Mineral Density (part 3 of triad)

PART 3 OF THE TRIAD:

LOW BONE MINERAL DENSITY (Osteopenia, Osteoporosis)

Results from low estrogen levels as well as insufficient calcium intake

Body leaches calcium from the bones to keep blood levels stable for necessary functions leading to decreased bone density

♀

Disordered Eating

Amenorrhea Osteoporosis

Subtypes of Disordered Eating

Anorexia Athletica

Anorexia nervosa: Refusal to maintain body weight, fear of gaining weight, body

image disturbance, amenorrhea

Bulimia: Binge eating plus compensatory mechanisms (vomiting, caloric

restriction, excess exercise, averaging 2 x/week for >3 months)

Eating disorder not otherwise specified (may fit criteria for some eating disorders

but not all of the criteria for a single eating disorder)

Other consequences of Disordered Eating

Decreased estrogen levels leading to:

Hormonal imbalance, which can cause anxiety and depression, leading to further

exasperation of psychological symptoms

Increased LDL cholesterol

Endothelial dysfunction (increases risk of CVD)

Decreased immune function

Decreased absorption of calcium

Hormonal consequences of Low Energy

Availability

Decrease of:

Leptin

T3

Insulin

IGF-1

Glucose

Increase in:

Ghrelin

Cortisol

Growth hormone

The consequences: Part 2 of FAT

Menstrual dysfunction

Low Energy Availability Results in:

Decreased GnRH production from hypothalamus

Decreased stimulation of pituitary glad to produce LH and FSH

Decreased stimulation of ovaries to produce estrogen and progesterone

Resulting in abnormal menses and

Failure to reach peak bone mass (if occurs prior to age 25-30)

Types of Menstrual Dysfunction

Amenorrhea (absence of menses for > 3 months

Anovulation

Luteal phase defect

Oligomenorrhea (long menstrual cycles)

All of the above contribute to infertility

Bloodwork to evaluate amenorrhea

CBC

Chemistry profile

ß-HCG

TSH

Free thyroxine

Prolactin

FSH (to r/o ovarian insufficiency)

The consequences: Part 3 of FAT,

decreased bone mineral density

Perhaps the most severe consequence of FAT as it can cause irreversible bone loss

and stress fractures

Osteopenia:

Prevalence is 22-50% in female athletes vs 12% in general population

Osteoporosis:

0-13% vs. 2.3% in general population)

Table 1: Bone mineral density (BMD) definitions

American College of Sports

Medicine

Population

Terminology

Premenopausal female athletes

Low BMD

Osteoporosis

Criteria Z-Score: −1 to −2 with secondary

clinical risk factors for fracture

(eg, chronic malnutrition, eating

disorders, hypogonadism,

glucocorticoid exposure,

previous fractures)

Z-Score: ≤ −2 with secondary

clinical risk factors for fracture

Bone Health

Greatest accretion of bone mass occurs during puberty (around 11-14 yo)

Depending on age of onset, duration of FAT and time to recover, bone mass

density may improve, but never “catch-up” to normal

92 % of total body bone mineral content occurs by age 18

99% occurs by the age of 26

FAT in adolescents carries the most severe disruption to bone health as peak

bone mass may never be attained

Adults with only a 10% loss in bone mass density are at 2-3 x increased risk of

fracture

Screening for FAT:

FAT can be hard to detect because the athletes may look to be of optimum health based on body appearance

Requires detailed screening questions including:

Number of menstrual periods in the previous 12 months as well as inquiry as to ANY disruptions in cycle historically as well

NOTE: ANY disruption in cycle in an athlete warrants further investigation by a nutritionist and referral to a reproductive endocrinologist or OBGYN to rule out hormonal issues. This often is the first overt sign of FAT.

Sample questionnaire for athletes: http://www.femaleathletetriad.org/~triad/wp-content/uploads/2008/11/ppe_for_website.pdf

http://www.femaleathletetriad.org/~triad/wp-content/uploads/2008/11/ppe_for_website.pdf

http://www.femaleathletetriad.org/~triad/wp-content/uploads/2008/11/ppe_for_website.pdf

http://www.femaleathletetriad.org/~triad/wp-content/uploads/2008/11/ppe_for_website.pdf

Screening for FAT

High school and college athletes bring recognition and often funds to the facilities

that they play for. There are laws which prohibit them from being paid for their

contributions through funds (outside of scholarships); however, these

organizations have a responsibility to not only keep them from being harmed due

to their performance, but to help them should they suffer physical effects from the

sport. Benefits which should be required of all athletic departments, particularly

those of college-level athletes include:

Recommended benefits for athletes

Pre-participatory screening for symptoms/signs of FAT by a physician with NO financial interest in their passing the exam

Annual health exams and/or full health evaluations if amenorrhea, recurrent injury, or stress fractures occur (Note: if even 1 out of the 3 parts of the triad is present, the other 2 should be further investigated. A diagnosis of FAT can be made based on only 1 of the 3 criteria being present)

Outlined protocol for evaluation for any athlete failing screening for this condition including required visits with:

Sports psychologist to evaluate for disordered eating

Sports nutritionist to evaluate:

body fat analysis (bod pod, skin-fold, bioelectrical impedance)

Signs of disordered eating based on eating habits

Request 7-day food log and evaluate for deficiencies in calorie intake, calcium, magnesium, and vitamin D

Optimum recommended menu for athlete based on their requirements and nutrient deficiencies (the typical athlete personality type responds well to regimen and removes the guess work

Recommendation for high quality supplements based on need (calcium, multivitamin/mineral supplement, iron)

Recommended benefits for athletes

If either of those evaluations dictate further treatment, the athlete should be required to see:

Orthopedist to screen for osteopenia/osteoporosis

Reproductive endocrinologist or OBGYN to evaluate any noted menstrual irregularities

Recommendations for nutritional deficiencies include the following:

Vitamin D, Calcium and/or iron supplementation (if warranted) based on bone scan and bloodwork results

Hormone therapy (if unable to return to a normal menstrual status after a period of 2-3 months) as well as recommendation to investigate oocyte preservation to preserve future fertility

The above screening and evaluations should be benefits offered at no cost to the athlete and be a requirement for athletic participation

Treatment of FAT

Many athletes could be resistant to changing habits and in particular gaining

weight due to fears regarding their appearance as well as the effect it could have

on performance. One good strategy to deal with this would be to set-up a

contract between the athlete and the healthcare provider/coach which spells out

requirements that the athlete needs to meet in order to continue or resume

athletic competition. This approach can work well with the regimented personality

type that is generally seen in athletes and can be very motivational if such

contract is enforced.

Treatment of FAT

Many athletes are taking birth-control pills which can mask the symptoms of the

FAT, this can be good in that they have supplemental estrogen, but it is better to

address the root cause and fix the calorie insufficiency rather than use BCP’s as a

crutch which can cover-up the issue

Treatment of FAT

If an athlete is diagnosed with FAT or a stress fracture:

Order bone scan

Recommend high quality calcium supplement, investigate other potential nutrient deficiencies

Calcium should be supplemented at 1500 mg/day and consist of calcium carbonate and/or citrate in elemental form

Calcium supplements should be taken in a ratio of 2mg of calcium to 1 mg of magnesium and 1 IU of Vitamin D3 (cholecalciferol)

Calcium should be taken with food and dosage spread throughout the day

In addition to calcium, take magnesium to increase synthesis of osteocalcin and strengthen connective tissue matrix, and Boron, silicon, and Vitamin K to decrease calcium loss through the urine

Refer to sports nutritionist to R/O eating disorder, evaluate body fat, negative calorie balance, and nutrient deficiencies (calcium, magnesium, vitamin D, iron)

Treatment of Fat

Iron Deficiency:

1/3 to ½ of female athletes suffer low iron stores which leads to a decreased oxygen carrying ability and affects sports performance

If diagnosed with iron deficiency based on lab work (do NOT suggest supplemental iron unless they are deficient due to toxicity of excess iron):

Recommend increasing iron intake

Heme iron is the most absorbable form

Non-heme is less absorbable due to fiber content

Absorbability of non-heme iron is increased if eaten alongside meat

Absorbability of iron is increased when eaten or supplemented alongside foods high in vitamin C

Supplemental form of choice is ferrous sulfate, 1-3 x/day with food if tolerated

If experiencing nausea, can try ferrous gluconate

DO NOT take supplemental iron at the same time as calcium or fiber supplementation

Treatment of FAT

The primary goal is increased calorie intake allowing for restoration of menstrual cycles

LH is disrupted by a diet consisting of <30 kcal/kg of fat-free mass

Restoration of cycles generally requires caloric intake of 45 kcal/kg of fat-free mass

Can use birth-control pills or transdermal estrogen (if unable to resume cycle naturally)

Leptin injections (increases appetite)

Bisphosphonates are anti-resorptive bone medications, good for post-menopausal women, but remain in the bones for years and can be teratogenic and therefore should NOT be used in premenopausal women

Mechanical stimulation to treat bone loss (mimics physical activity for those whose treatment includes restriction of physical activity)

Education to prevent FAT

Best strategy is prevention of the disorder through education of athletes and the

coaches that work with them

Discuss what behaviors lead to the disorder

Discuss long-term consequences of the disorder (emphasize irreversible

decreased bone density leading to osteoporosis, fractures, etc.) Amenorrhea

leading to further bone loss and potential loss of fertility, increased risk of CVD

due to endothelial dysfunction, accidental pregnancy due to irregular

menstruation, decreased performance due to low energy availability

References:

1. Brunet, M. (2010). Unique considerations of the female athlete. Canada: Delmar.

2. 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.

3. Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., . . . Ljunggvist, A. (2014, February 3). The IOC consensus statement: Beyond the female athlete triad-Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine, 48, 491-497. doi:10.1136/bjsports-2014-093502

4. Nazem, T.G., & Ackerman, K.E. (2012, July). The female athlete triad. Sports Health, 4(4), 302-309. doi:10.1177/1941738112439685

5. Mountjoy, M., Hutchinson, M., Cruz, L., Lebrun, C. (n.d.). Introduction: Female Athlete Triad Pre Participation Evaluation. Retrieved fromhttp://www.femaleathletetriad.org/~triad/wp-content/uploads/2008/11/ppe_for_website.pdf