IOC Consensus Statement on the Female Athlete Triad

Protecting the health of the athlete is the primary goal of the International Olympic Committee’s Medical Commission (IOC MC). While athletes should be encouraged to strive for excellence, there is an obligation on the part of coaches, team physicians, other health care providers, International Federations, and sport governing bodies to recognise pressures, actions, and situations that may be detrimental to the athlete’s health. One area of concern for many female athletes is the pressure to meet unrealistic weight or body fat levels. Some may respond to this pressure with excessive dieting and slip into disordered eating, which in turn can lead to a serious eating disorder such as anorexia nervosa or bulimia nervosa. Disordered eating can lead to low energy availability (an energy intake inadequate to meet energy expenditure), which can disrupt the reproductive cycle and result in amenorrhea. The combination of disordered eating and irregular menstrual cycles eventually lead to a decrease in endogenous oestrogen and other hormones, resulting in low bone mineral density hence the term Female Athlete Triad”.

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Effect of the Female Athlete Triad on the health and performance of the athlete

Child and Adolescent Athletes

Pubertal growth is a critical component of the growth process; the increase in oestrogen is related to clinically important increases in bone length and bone mineral content, and fusion of the epiphysis. Participation in regular exercise is important to optimise physical and psychological development. However inadequate nutrition (particularly low energy intake) creates a scenario where athletes may be at increased risk of reduced growth, delayed maturation and primary amenorrhea, as well as impaired performance. This may expose these athletes to increased risk of future short stature, low bone mineral density and secondary amenorrhea. Catch-up growth of bone length and mass, and pubertal progression have been reported with dietary intervention and/or reduced training schedules, and may reduce deficits in skeletal growth; however, final stature may be compromised when maturation is severely delayed or when the epiphysis is nearing fusion. It is recommended that the nutrition and growth and development of all young athletes are monitored, particularly in sports where body image or leanness is a performance advantage.

Adult Athletes

Low energy availability and pathogenic weight control behaviours predispose the female athlete to menstrual dysfunction, subsequent decreased bone mineral density, increased risk of stress fractures, and a potential increase in the risk of premature osteoporosis and cardiovascular disease. Disordered eating is often accompanied by psychological problems, including decreased self-esteem, anxiety, and depression. These problems affect performance significantly. When the three disorders of the Female Athlete Triad occur together, the potential health consequences become more serious, and often life-threatening.

Identifying the Female Athlete Triad

Early identification of athletes at risk of developing the Female Athlete Triad is important for preventing its progression and improving prognosis. Therefore, athletes who display symptoms of disordered eating and/or menstrual irregularity should be referred for further evaluation by a health care provider. Disordered eating may include behaviours such as using extreme weight control methods and restricted and/or binge eating. The Female Athlete Triad does not necessarily manifest itself in athletes who are thin; the Female Athlete Triad can occur in athletes of any size.

Physicians, health care providers and coaches should be aware of risk factors such as cultures that equate thinness with popularity and success, previous history of disordered eating and sports in which leanness or specific weight is important. The coach can also play an important role in identifying “at risk” or symptomatic athletes.

Treating the Female Athlete Triad

Effective treatment of the Female Athlete Triad athlete involves a multidisciplinary team including a nutritionist, psychologist, and/or psychiatrist, headed by a physician experienced in sports medicine. The goal of treatment is to restore energy balance, healthy eating habits, mental health and normal menstrual cycles, and to improve bone health. Nutritional counselling is an essential component of the treatment plan. If the athlete is unable to respond to the recommendations of the physician and nutritionist, then a referral to a psychologist or psychiatrist specialised in eating disorders is necessary. Increased nutritional intake with a subsequent weight gain will result in the resumption of menses and an increase in bone mineral density. A decrease in training may be necessary. Hormone therapy is often prescribed for amenorrheic athletes, however scientific evidence supporting its use is inconclusive. Education of the athlete, coach and the athlete’s entourage is an important component of the treatment plan. Athletes with anorexia nervosa or bulimia nervosa should be excluded from competition. It is important that coaches emphasise that good health rather than weight ensures optimal performance. The coaches’ support of treatment will encourage an athlete’s compliance with the treatment plan.

Preventing the Female Athlete Triad

Preventing disordered eating is the key to Female Athlete Triad prevention. It is essential for coaches to increase awareness of the Female Athlete Triad and increase understanding of nutritional principles and how they impact health and performance. Athletes, health care professionals and their entourage should have the opportunity to undertake educational programmes to support the female athlete. Annual pre-participation screening should include questionnaires and physical examinations to identify early signs of the Female Athlete Triad. Other medical encounters can also be used for this purpose. International and National Federations and National Olympic Committees are encouraged to develop coach and team physician Female Athlete Triad education programmes, and where possible modify rules to reduce the incidence of the drive for thinness and subsequent unhealthy eating behaviours.

Position Stand on the Female Athlete Triad

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