Column: Sports Health, by Brian Pickering

A clinical report released by the American Academy of Pediatrics is encouraging physicians to be aware of the female athlete triad.

Those from the medical field that work with athletes were originally taught that the triad was in interrelationship of disordered eating, amenorrhea, and osteoporosis.  New understanding has evolved this thinking to be energy availability, menstrual function, and bone health. What was once thought to be a single problem is now viewed as three separate issues ranging on a spectrum from optimal to disease state.  Athletes may have one of these issues or any combination of the three.  Females affected by the triad can have risk factors of cardiovascular disease and long-term health issues.

We know that the female athlete triad can be triggered by strenuous sports training and not consuming enough calories to meet the body’s demands.  This state of energy availability is defined as the daily energy intake minus daily energy expenditure.  For adult females, this intake should be 45kcal/kg of fat-free mass per day in order for well-maintained reproductive, bone, and cardiovascular health.  In adolescents that are growing, this number may be higher.  Teenagers, boys and girls, need between 1800 and 2500 calories a day just to be teens.  Adding in a sport will increase the needed caloric intake.  For example, the average teenager burns 100 calories running one mile.  For a soccer player that may run four to six miles in a practice, this increases the necessary calories by about 500.

Most athletes are not intentionally failing to consume the calories needed to maintain appropriate energy availability.  Parents should understand that kids don’t need to have an eating disorder to be affected by the triad.

A deficit of caloric intake with intense training for athletics, dance, or other physical activity, can impact bone health and lead to stress fractures.  If parents are having difficulties figuring out their child’s dietary needs, a registered dietitian can help create a good eating plan for the athlete and discuss optimal caloric intake on a daily basis with the athlete.  Males are not immune to the issues of bone health from negative energy availability, either.

It is important that adolescents are building bone density and strength during their teenage years.  Bone mass gains during this time are important for maintaining bone mass and preventing osteoporosis as they go through their adult years.  It has been found that about 90 percent of all adult bone mass has been gained by the end of adolescence.  Participating in weight bearing activities during teenage years and a proper diet can improve gains in bone mass.

Female athletes should be screened for the female athlete triad during their preparticipation exams (sports physicals).  Physicians should assess nutrition, menstrual, fracture, and exercise history.  Should there be a concern it is best to involve an interdisciplinary team in the treatment and education of the athlete.  The physician can work with a dietitian, the certified athletic trainer, behavioral health specialist, and an exercise physiologist in developing a plan.

How prevalent is the issue of the female athlete triad?  First, the issue is not one that only affects adolescents.  Professional athletes into middle age can be affected by any of these areas.  Most studies and review of records indicate only about 1 percent of high school female athletes, and up to 16 percent of all female athletes, have problems with all three areas simultaneously.

In high school athletes, 4-18 percent of girls are affected by two of the areas at the same time, and 16-54 percent may be dealing with one of the issues.  Athletes competing in endurance, aesthetic (gymnastics, diving), or weight-based sports (wrestling, judo, boxing) are at the highest risk of involvement.  Other factors may include dieting, early sport specialization, or abuse among others.

Brian Pickering is the specialty care clinic coordinator for Lake Region Healthcare.

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