The Female Athlete Triad

Female athlete Triad and eating disorders

- athletes with eating disorders should be required to meet established criteria to continue exercising to continue exercising, and their training and competition may need to be modified -minimum body weight- body weight for participation - evidence of adequate hormonal status or menstrual history -bone mineral density scores -cannot guarantee the safety but you can enhance it by making sure the athlete is fit to participate

Osteoporosis

- chronic condition characterized by low bone mass and micro architectural deterioration of bone tissue leading to enhanced skeletal fragility and increased risk of fracture - principal cause of premenopausal osteoporosis in active woman is decreased ovarian hormone production and hypostrogenmia -athletes may be at risk for fractures during their competitive years and premature osteoporotic fractures in the futures - osteoporosis causes weak bones - in this common disease, bones lose minerals (calcium) - they become fragile and break easily

Spectrum of energy availability

- clinical eating disorders -subclinical eating disorders -low energy availability -energy expenditure is high -adequate energy availability -excessive energy availability -currently there are not large scale studies that have examined the prevalence of low energy availability among diverse groups of female athletes -effects of low energy availability on health and athletic performance depends on the severity and chronicity of the behaviours - diagnosis- meet all the criteria -sub clinical - meet some of the criteria

Female bone health

- female athletes have higher BMD than non athletic counter parts UNLESS they have menstrual dysfunction -risk of stress fractures is two to four higher in amennorrheic athletes -direct correlation between stress factors and ammennorhea -bone density declines in proportion to the number of menstrual cycles missed -myburgh and colleagues showed a direct correlation between time spent ammenrrheic and number of stress fractures in 1990 - low bone mineral density may be irreversible resulting in lifetime lower bone density

Energy availability

- female athletes need to take special care to avoid low energy availability -food deprivation increases hunger however the same deficit produced by exercise energy expenditure (over exercising) does not -hunger appears to be mediated by oral and GI rather than metabolic mechanisms -hunger is not a reliable indicator of energy requirements -athletes must learn to eat by discipline not by hunger

Hypothalamic dysfunction

- low energy availability disrupts the hypothalamic pituitary ovarian axis -decreasing gonadotropin releasing hormone (GnRH) disrupts pituitary secretion of Lutenizing hormone (LH) and Follicle stimulating hormone (FSH) -disruption of LH and FSH shuts down stimulation to the ovary, ceasing production of estradiol -menstruated is inhibited -low estradiol level create a hormonal environment that mimics that seen in menopause -amenorrhea -loss of bone mass - osteoporosis -restricting energy intentionally -low energy availability plays havoc with hormones

Female athlete triad -bone loss

- no pharmacological agent adequately restores bone loss or corrects metabolic abnormalities that impair health and performance in athletes with functional hypothalamic amenorrhea

Treatment Goal

- restore reproductive and metabolic hormones by increasing energy availability -increase energy intake -reduce energy expenditure -weight gain of 1-2 kg or 10% decrease in exercise load in either duration or intensity is often sufficient to reverse reproductive dysfunction -take in more calories than they are expending -this is difficult for the athlete as they are intentionally restricting calories

Female Athlete Triad

- the female athlete triad refers to the interrelationships among energy availability, menstrual function and bone mineral density, which may have clinical manifestations including -eating disorders -functional hypothalamic amenorrhea (not menstruating) -and osteoporosis (weak brittle bones)

Low bone mass and osteoporosis

-although imperfect DEXA is currently the most accepted diagnostic tool - international society for clinical densitometry recommends using Z scores in young patients - Young woman with a low T or Z score is no longer considered to be osteopenia or osteoporotic but is said to have BMD low for chronologic age or below expected range for age

Female Athlete Triad assessment

-athletes should be assessed for the Triad at the pre participation physical and or annual health screening exam, and whenever an athlete presents with any of the Triads clinical conditions -weight -weight changes -menstrual history -BMD fractures -diet history - signs of low energy types and volumes of food -physical signs of malnutrition or disordered eating -weight relative to height and age

Female Athlete Triad

-energy availability is defined as dietary energy intake minus exercise energy expenditure -dietary intake- exercise expenditure -low energy availability appears to be the factor that impairs reproductive and skeletal health in the triad, and it causes may be inadvertent or psychopathological -part of a mental condition -at first it was intentional to lose weight or slim down and then it went beyond that -most effects appear to occur below an energy availability of 30 kcal/kg /day of FFM -body composition rather than body weight is an important determinant of thresholds for adequate energy availability

Prevention of Female Athlete Triad

-goal is prevention rather than treatment -educational programs targeting coaches, athletes, parents, athletic trainers,school administrators - currently there is a lack of such programs -nutrition education -emphasis should be placed on concept of food as energy for training and recovery rather than on body weight -less emphasis on body weight and more about getting the energy your body needs -sport administrator should be also consider rule changes to discourage unhealthy

Hormone Therapy

-in women who have not responded to non pharmacological treatment, initiate therapy with low does oral contraceptive to raise estrogen concentrations and prevent further bone loss -minimal bone increases have been noted in women with hypothalamic amenorrhea on oral contraceptives but increases in BMD of 6-17% have been seen with spontaneous reversal of amenorrhea -only if needed

Disordered eating

-includes a wide spectrum of unhealthy eating behaviours -skipping meals or limiting calories -restricting certain foods such as those high in protein or fat -binging or purging -diet pills, laxatives, diuretics - anorexia nervosa, bulimia nervosa -cheat meal models binging -may be intentional or unintentional -overt dieting and restricting of foods -desire to lose a few pounds before an event -inadvertently failing to balance energy expenditures with adequate energy intake

Functional Hypothalamic amenorrhea

-it has generally been assumed that low body fat levels and exercise related chemicals (such as beta endorphins and catecholamines) disrupt the interplay of the sex hormones estrogen and progesterone -recent studies have shown that there are no differences in the body composition, or hormone levels in amenorrhoeic athletes as compared to regularly cycling athletes -functional hypothalamic amenorrhoea has been shown to be directly attributable to a low energy availability - many women who diet or who exercise at a high level do not take in enough calories to expend on their exercise as well as to maintain their normal menstrual cycles

Treatment is multidisciplinary

-nutritional interventions - development of personalized nutrition plan with the aim of normalizing eating and ensuring adequate energy availability -exercise interventions - tailored exercise prescription or recommendations that limits over training and promotes adequate rest - psychological- awareness of behaviour. Cognitive behavioural therapy has been shown to be most efficacious therapy for eating disorders. Treatment for depression if present -might need to treat for depression and anxiety - food is the symptom of the eating disorder not the case- need to deal with psychological aspect

Bone Health

-spectrum of bone health -low bone mass -osteopenia - stress fractures -osteoperosis- worst- weak, brittle, break very easily -bone strength is characterized by bone mineral content and density as well as quality of bone - bone quality refers to the process of bone turnover -most of the bone you are going to make is done in adolescents and early adult hood if lost it can't be fixed easily -females gain more than 50% of skeletal mass during adolescence and reach peak bone mass between 18-25 years -young women menstrual dysfunction during these years are at risk for losing 2% of bone mass annually instead of 2-4%

Who is at risk?

-sports that emphasize low body weight have been associated with development of Female athlete triad -subjective scoring of performance (skating and dancing) -endurance sports (distance running) -body contour revealing clothing (diving, swimming, body building, track,cheerleading) -weight categories (wrestling, horse racing) there is a weight class - emphasis on prepubertal body shape (gymnastics) -some sports now have weight standards where you have to be a certain weight to compete -have put age restrictions- so less teens are put at risk -there are eating disorders in males

Menstrual Dysfunction

Prevalence studies -wide range of prevalence estimates cab be explained by methodological differences among studies including differences among studies in athletic populations studied, failure to control for OCP use, assessment and definition of menstrual dysfunction. -Despite differences, menstrual dysfunction is more prevalent in sports that emphasize leanness -menstrual dysfunction is NOT a normal part of training

Amenorrhea

Primary amenorhea -16 or older that have never menstruated - have secondary sex characteristics Secondary sex characteristics -absence of 3 or more consecutive menstrual cycles in a girl who has begun menstruating -amenorrhea associated with exercise is hypothalamic in origin