You train at the gym consistently, try to eat clean, monitor your weight and body composition, and think you look pretty good. Then you open up a magazine, see the gorgeous bodies modeling clothes that you know you’ll never fit into, get depressed, and think that you have a lot more work to do. Or you’re competing hard in your sport, but you want to get that extra edge. Maybe if you lost a little weight you could run faster or jump higher. Oh, what a tangled web we women weave. These thoughts run through athletic women’s heads on a daily basis. Unfortunately, these self-destructive introspections can lead to a serious syndrome called The Female Athlete Triad. The Female Athlete Triad, a syndrome described by the American College of Sports Medicine (ACSM) in 1992, is the combination of three disorders that can all decrease women’s physical performance and cause morbidity and mortality [1]. The three components are disordered eating, amenorrhea, and osteoporosis, and they are interrelated to each other in their origins, development, and ultimate consequences. The disordered eating usually occurs first, which leads to the menstrual dysfunction, and osteoporosis [2]. This four-part series will enlighten you on how and why The Female Athlete Triad developed, and then describe each component in a separate article.

Is It Healthy To Be Fit?
Voluptuous and lean bodies in skimpy bra tops and Daisy Duke shorts are all the rage. Open up a fitness or bodybuilding magazine and you’ll see more skin than in an “R” rated movie. The fashion industry pays homage to skinny models who wear clothes like a hanger, with the appropriate bones sticking out for hanging purposes. The U.S. women’s soccer team wins the World Cup and instead of their athletic prowess being touted, we see their victory dance of shirtless, sport’s bra images all over the popular media. No wonder that women are so confused when it comes to physical fitness, health, and beauty. On one hand, we have growing evidence that physical fitness increases the quality of life and may prolong it, and on the other hand we have the stereotype that women must be fat-free and have large breasts. What’s a woman to do? A recent survey of 101 exercising women revealed that their primary reason for exercise was not to be physically fit or healthy, but for weight management and to improve their appearance [3]. This finding was independent of actual body mass measurements. The supplement industry also emphasizes looking good at any cost. With the public wanting a quick fix to weight problems, the number of weight loss products and lose weight quick schemes has skyrocketed. But, being thin or lean or muscular doesn’t necessarily mean being healthy. Athletes involved in competitive sports many times use unhealthy methods to achieve goals. For example, take the wrestler who dehydrates before a match to make weight, or any athlete that uses drugs to gain a competitive edge.

Unrealistic Expectations
So women are inundated with mixed messages. Look thin, have muscles, win at any cost, but be healthy and live a long life. Certainly because of these mixed messages, unrealistic expectations can develop. This is the groundwork for the development of The Female Athlete Triad. Although the ACSM suggests that women who participate in sports based upon appearance and requiring low body weight like dance, gymnastics, and distance running are more susceptible to developing The Female Athlete Triad, women who participate in a “wide range of physical activities” are potentially at risk [1]. Factors that can predispose an athlete to this syndrome include focusing on an ideal weight, pressure from coaches, family members, and from the athlete themselves to achieve, social isolation that comes from exclusive involvement in a sport, family history of disordered eating, and society expectations [4]. Traits like perfectionism and compulsiveness that are common to “type-A” personalities and high level athletes are also associated with the triad [2]. In addition, athletes are more prone to body image concerns because they have a heightened body awareness [2].

Body Composition Controversies
Another circumstance to consider when discussing The Female Athlete Triad is the controversy surrounding body fat percentages and the methods that are used to obtain these measurements. Some common methods are skin-fold measurements; bioelectrical impedance, underwater weighing, and near infrared reactance. All of these methods have some inherent error because they are indirect measurements. The only way to directly measure body composition is to grind the entire body up and perform a chemical analysis. This, of course, is too extreme, and then the athlete would not be able to participate! Despite the inaccuracies and inconsistencies of methods, sports can sometimes dictate a certain ideal body fat percentage to obtain the best performance [5]. Unfortunately, this implies that there is a definite known number and that every person is the same. Recommendations are usually based on averages, but rarely are elite athletes average. In addition, there are so many variables to consider, like coordination and balance, training history, and body structure, basing performance on a body composition number seems ridiculous. Body fat percentage is also commonly used to determine weight loss. However, there seems to be an association of body composition assessment with unhealthy weight management [6].

What Can Be Done
Because women deny or underreport symptoms, the true prevalence of this triad cannot be determined [7]. Signs and symptoms of The Female Athlete Triad are weight loss, suspicious eating behaviors, excessive exercise, frequent stress fractures, and menstrual dysfunction [4]. It is important for anyone involved with a female athlete, including physicians, trainers, coaches, friends, and family members, to know the warning signs of this triad and intervene. Prevention is always the best treatment. Early recognition and therapy require a multidisciplinary approach that can prevent serious complications, and perhaps, even death. Overall, a majority of women receive significant health benefits from regular exercise and should be encouraged to adopt regular physical activity in their lives [1]. This series of articles is not meant to discourage athletic participation, rather it is to educate and inform about a growing trend, and hopefully, prevent or stop the trend from becoming an athletic woman’s epidemic.

References
1. Otis, C.L., et al., American College of Sports Medicine position stand. The Female Athlete Triad [see comments]. Med Sci Sports Exerc, 1997. 29(5): p. i-ix.
2. West, R.V., The female athlete. The triad of disordered eating, amenorrhoea and osteoporosis. Sports Med, 1998. 26(2): p. 63-71.
3. Cash, T.F., P.L. Novy, and J.R. Grant, Why do women exercise? Factor analysis and further validation of the Reasons for Exercise Inventory. Percept Mot Skills, 1994. 78(2): p. 539-544.
4. Grooms, A.M., The female athlete triad. J Fla Med Assoc, 1996. 83(7): p. 479-481.
5. Houtkooper, L.B., Body composition assessment and relationship to athletic performance, in Nutrition for sport & exercise, J.R. Berning and S.N. Steen, Editors. 1998, Aspen Publishers: Gaithersburg. p. 155-166.
6. Oppliger, R.A. and S.L. Cassady, Body composition assessment in women: special considerations for athletes. Sports Med, 1994. 17(6): p. 353-357.
7. Thein, L.A. and J.M. Thein, The female athlete. Journal of Orthopedic and Sports Physical Therapy, 1996. 23(2): p. 134-148.