The Female Athlete Triad
Bulimia Nervosa: Purging type
regularly engages in self inducing vomiting
Risk Factors
Athletes at risk for low energy availability: restrict dietary intake, exercise for prolonged periods, limit the types of food they eat
Risk Factors Specific to Sports for Developing Eating disorders
Characteristics of sport, emphasis on leanness or individual competition Sudden increase of training volume Injury or illness results in fear or weight gain
Anorexia Nervosa
Characterized by restrictive eating Refusal to maintian body weight at or above a minimally normal weirght for age and heigh
Outflow Tract Abnormalities
Consider when primary amenorrhoea and normal sexual development Endometrial lining Obstructed outflow tract
Amenorrhea
Continually to be the problem that first brings a female athlete to medical attention 2-5% in general female population 8.5% in unselected adolescent population 19% in Olympic marathon athletes 3.4-66^ of certain groups of athletes
Weight Loss Performance
Could reducing body fat improve sports performance? No evidence will enhance in already lean athletes Further loss of lean mass- adverse effects
Body Composition and Amenorrhoea
Critical fat content for normal menstrual function? Possible, but vary widely among individuals Regional adiposity? Fat threshold in femoral region?
Menstrual Disorders
Delayed menarche- onset of menses after age of 15 years, retrospective definition Review- establishment of ovarian cycle
Disordered Eating
Eating disordesr: anorexia nervoa, bulimia nervosa Binge eating Other disordered eating behaviors
Pituitary Reason
Energy availability: LH pulsatility is disrupted within 5 days when energy availability is reduced by >33% High prolactic levels (secreted by pituitary gland)- suppressed GnRH secretion
Prevalence
High in female athletes than the general female population Higher in aesthetic, weight dependent sports, and leanness sports
Health consequences of Amenorrhea: Hypoestrogenism
Impaired endothlium dependent arterial vasodilation reduces perfusion of working muscle, impaired skeletal muscle oxidative metabolism Unfavorable lipid profile
Low Energy Availability
Inadequate energy intake compared to energy expenditure Insufficient stored energy to maintain physiological processes
Low Energy Availability Energy Balance
Increase energy expenditure, sports participation
Health Consequences of Amenorrhea
Infertility While recover, may ovulate before menses are restored, unexpected pregnany Musculoskeletal injuries higher
Anorexia Nervosa
Intense fear of gianing weight or becoming fat, enough though underweight Rapid weight loss
Other symptoms
Irregular periods Chronic sore throat Worn tooth enamel Swollen salivary glands Heartburn Constipation Dehydration Electrolyte imbalance
Lowe Energy Availability
Is source of the other two components (amenorrhea and osteoporosis) Physiological adaptations, energy conservation- menstrual cycle disturbances and affected bone metabolism
Eating Disorders on Sports Performance
Loss of endurance due to dehydration: reduced plasma volume, impaired thermoregulation and nutrient exchange, decreased glycogen availability
Other symptoms
Loss of menstrual periods Brittle hair and nails Yellowing skin Cold sensitivity Slow reaction or lethargy Depression Long term- anemia, thinning bones, damage to heart, organ failure, and death
Body Composition and Osteoporosis
Low body weight is a risk factor for osteoporosis In general, large muscle mass also large bone mass; muscle strength is a determinant of bone muscle density in the skeletal regions on which the muscles act
Mechanism for Menstrual Disorders in the Triad
Low energy availability alters levels of metabolic hormones and substrates: insulin, cortisol, growth hormone, glucose, fatty acids Metabolic signals to GnRH secreting neurons
Menstrual Disorders
Luteal phase deficiency- a lag of more than 2 days in histological development of endometrium Endometrium biopsies, progesterone measurements
Menstrual Disorders: Oligomenorrhea
Menstrual cycles occur at intervals longer than 35 days, with only 4-9 periods a year Usually associated with anovulation
Bulimia Nervosa: Non purging type
Other inappropriate compensatory behaviors, such as self induced vomiting, misuse of laxatives, diuretics, fasting or excessive exercise
Ovarian Reason
Ovarian failure- few or no functional oocytes remaining When estrogen is present but not progesterone, the endometrium develops but bleed erratically and infrequent
Ovarian Reason
Polycysitc ovarian disease- chronic anovulation with excessive androgen Administration of androgens
Triad
Potentially irreversible health consequences Tend to occur in female athletes participating in sports where successful performance is dependent on, physiologically and/or aesthetically, a low body fat content
Cause of Amenorrhea and Menstrual Dysfunctions
Pregnancy
Body Composition and Sports Performance
Principle driving force behind the development of female athlete triad Body fat tend to be lower: sports that require moving/lifting the body mass Elite sports women < non elite < non athletes
Health Consequences of Disordered Eating
Psychological problems: low self esteem, depression, anxiety disorders Medical complications involve many systems Mortality rates higher: fluid and electrolyte abnormalities, suicide
Bulimia Nervosa
Recurrent episodes of binge eating and then purging or other compensatory behaviors in order to prevent weight gain Eating an amount of food larger than most people would eat A sense of lack of control over eating during the episode
Low Energy availability Energy Balance
Reduce energy intake: disordered eating behaviors - fasting, binge eating and purging, use diet pills, laxatives Eating disorders
Treatment Considerations
Reduce exercise volume, intensity? Estrogen or progesterone treatment Assessment of eating disorders GnRH, LH, FSH treatment
Low Energy Availability
Reproductive dysfunction - low estrogen concentrations - impairs bone health Low energy availability also causes endocrine changes- further impairs
Risk Factors Specific to Sports for Developing Eating Disorders
Sport attracts individuals who are anorectic Pressure to reduce weight, and rapid periods of restrictive dieting or weight cycling Characteristics of sport, emphasis on leanness or individual competition
Hypothalamic Reason
Stressful life events: physical and emotional stress GnRH producing cells in hypothalamus
Triad
The three interrelated spectrum: low energy availability (with or without eating disorders), amenorrhea, and osteoporosis
Hypothalamic Reason
When the GnRH pulses that reach the pituitary gland decrease below a critical frequency or concentration, or are disorders Low energy availability alters metabolic hormone levels and substrates - metabolic signal to GnRH secreting neurons to disrupt GnRH pulsatility
Eating disorder not otherwise specific
Who do not meet all criteria for anorexia nervosa or bulimia nervos. Ex an individual who: Meet all anorexia nervosa criteria but has regular menses Meet all bulimia nervosa criteria but binges and purges less than twice per week
Menstrual Disorders: Amenorrhea
Absence of menstrual bleeding for 3 months Primary amenorrhoea- have not had menstrual bleeding by 15 years. A daly in age of menarche Secondary amenorrhoea
Bulimia Nervosa
Affected individuals usually in normal weight range or just slightly overweight Deep fear or gaiing weight
Treatment
Aim-increase energy availability Trusting relationship between the athlete and care providers Training and competition during treatment Type of treatment: individual, group, family / inpatient vs out patient / nutrition counseling/ medication for mood problems
Menstrual Cycle and Bone
Amenorrheic atheletes have lower lumbar spine bone mineral density than eumenorrheic matched for body composition Hormonal status: estrogen
Eating Disorders on Sports Performance
Anaerobic performance and muscle strength typically decrease after rapid weight reduction, resumed after rehydration Possible mood alterations
Mechanism for Menstrual Disorders in the Triad
Animal studies- reducing dietary intake by >30% causes infertility Human - LH pulsatility is disrupted within 5 days when energy avaialbility reduced by 33% to <30 kcal/kg/FFM/day Menses can restore when energy availability increases