combatting fat in athletics (2)
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Combatting FAT in athletics:
Evaluation and Treatment of
the Female Athlete Triad
MAGGIE KEMP
SPORTS NUTRITION: SP17.NUTR663 SEC. 1
PROFESSOR OSCAR COETZEE
What is the Female Athlete Triad (FAT)?
3 criteria:
Low energy availability (negative energy balance)
Amenorrhea (1◦ = absence/delay of menses and female characteristics in
adolescent girls, 2◦ = absence of menstruation for > 3 months in adult female
athletes)
Decreased bone mass density
*Some definitions suggest a fourth criteria of endothelial dysfunction
Who is most at risk?
Those who participate in sports with:
Subjective scoring of female performance (ballet, gymnastics, ice skating)
Endurance sports (running, cycling, rowing)
Sports with weight categories
Sports that require tight or revealing clothing
Other contributing factors:
Frequent weigh-ins
Consequences suffered due to weight gain
Pressure to win from coaches/parents
Societal pressure to look thin
Athletes psychological factors such as having a “Type A” personality with a high
desire to win/compete
Controlling behavior from coaches and parents
Disordered Eating: Where the triad begins
Prevalence for disordered eating is estimated to range between 16-72% in female athletes vs 5-10% in non-athletes
Signs of disordered eating:
Negative calorie balance
Purposefully restricting food intake
Use of laxatives, enemas, or diuretics
Purging after meals
Engaging in additional exercise specifically to “off-set” eating meals higher in calories
Erratic eating, missing meals or avoidance of specific foods
Use of diet pills or appetite suppressants
Physical Symptoms of Disordered Eating
Hypothermia (low body temperature)
Bradycardia
Orthostatic hypotension
Low Body Fat
Disordered Eating
Consequences include:
Nutritional deficiencies (particularly Ca and Fe)
Decline in performance
Low levels of estrogen, causing less frequent periods or amenorrhea (lack of menstruation >3 months)
Osteopenia or osteoporosis (compounded by low estrogen levels, estrogen is needed for optimal calcium absorption
Bloodwork to evaluate:
CBC
Electrolytes
BUN
Creatinine
Glucose
Phosphorous
Mg
Albumin
Two potential causes of negative calorie
balance
Intentional restriction of calories Disordered Eating: 28-62% of female
athletes suffered from disordered eating compared to 5-10% of non-athletes
Athlete displays intense fear of gaining weight
Reduces/restricts calories and/or
Exercises excessively to “make up” for extra calories ingested
May display binging/purging behaviors
Unintentional restriction of
calories
Inability to keep up with caloric intake
required by the high energy demand of
their sport
Lack of time to fuel adequately
Lack of knowledge as to fuel and nutrition
requirements
Consequences of Low Energy Availability
PART 2 OF THE TRIAD:
FUNCTIONAL HYPOTHALAMIC AMENORRHEA OR MENSTRUAL IRREGULARITIES
Function
Results from suppression of hypothalamic-pituitary-ovarian axis
Cause: alteration in gonadotropin-releasing hormone, leads to disruption of LH pulses and gonadal steroid release from ovaries
Resultant deficiency in estrogen causes decreased Bone Mineral Density (part 3 of triad)
PART 3 OF THE TRIAD:
LOW BONE MINERAL DENSITY (Osteopenia, Osteoporosis)
Results from low estrogen levels as well as insufficient calcium intake
Body leaches calcium from the bones to keep blood levels stable for necessary functions leading to decreased bone density
♀
Disordered Eating
Amenorrhea Osteoporosis
Subtypes of Disordered Eating
Anorexia Athletica
Anorexia nervosa: Refusal to maintain body weight, fear of gaining weight, body
image disturbance, amenorrhea
Bulimia: Binge eating plus compensatory mechanisms (vomiting, caloric
restriction, excess exercise, averaging 2 x/week for >3 months)
Eating disorder not otherwise specified (may fit criteria for some eating disorders
but not all of the criteria for a single eating disorder)
Other consequences of Disordered Eating
Decreased estrogen levels leading to:
Hormonal imbalance, which can cause anxiety and depression, leading to further
exasperation of psychological symptoms
Increased LDL cholesterol
Endothelial dysfunction (increases risk of CVD)
Decreased immune function
Decreased absorption of calcium
Hormonal consequences of Low Energy
Availability
Decrease of:
Leptin
T3
Insulin
IGF-1
Glucose
Increase in:
Ghrelin
Cortisol
Growth hormone
The consequences: Part 2 of FAT
Menstrual dysfunction
Low Energy Availability Results in:
Decreased GnRH production from hypothalamus
Decreased stimulation of pituitary glad to produce LH and FSH
Decreased stimulation of ovaries to produce estrogen and progesterone
Resulting in abnormal menses and
Failure to reach peak bone mass (if occurs prior to age 25-30)
Types of Menstrual Dysfunction
Amenorrhea (absence of menses for > 3 months
Anovulation
Luteal phase defect
Oligomenorrhea (long menstrual cycles)
All of the above contribute to infertility
Bloodwork to evaluate amenorrhea
CBC
Chemistry profile
ß-HCG
TSH
Free thyroxine
Prolactin
FSH (to r/o ovarian insufficiency)
The consequences: Part 3 of FAT,
decreased bone mineral density
Perhaps the most severe consequence of FAT as it can cause irreversible bone loss
and stress fractures
Osteopenia:
Prevalence is 22-50% in female athletes vs 12% in general population
Osteoporosis:
0-13% vs. 2.3% in general population)
Table 1: Bone mineral density (BMD) definitions
American College of Sports
Medicine
Population
Terminology
Premenopausal female athletes
Low BMD
Osteoporosis
Criteria Z-Score: −1 to −2 with secondary
clinical risk factors for fracture
(eg, chronic malnutrition, eating
disorders, hypogonadism,
glucocorticoid exposure,
previous fractures)
Z-Score: ≤ −2 with secondary
clinical risk factors for fracture
Bone Health
Greatest accretion of bone mass occurs during puberty (around 11-14 yo)
Depending on age of onset, duration of FAT and time to recover, bone mass
density may improve, but never “catch-up” to normal
92 % of total body bone mineral content occurs by age 18
99% occurs by the age of 26
FAT in adolescents carries the most severe disruption to bone health as peak
bone mass may never be attained
Adults with only a 10% loss in bone mass density are at 2-3 x increased risk of
fracture
Screening for FAT:
FAT can be hard to detect because the athletes may look to be of optimum health based on body appearance
Requires detailed screening questions including:
Number of menstrual periods in the previous 12 months as well as inquiry as to ANY disruptions in cycle historically as well
NOTE: ANY disruption in cycle in an athlete warrants further investigation by a nutritionist and referral to a reproductive endocrinologist or OBGYN to rule out hormonal issues. This often is the first overt sign of FAT.
Sample questionnaire for athletes: http://www.femaleathletetriad.org/~triad/wp-content/uploads/2008/11/ppe_for_website.pdf
http://www.femaleathletetriad.org/~triad/wp-content/uploads/2008/11/ppe_for_website.pdf
http://www.femaleathletetriad.org/~triad/wp-content/uploads/2008/11/ppe_for_website.pdf
http://www.femaleathletetriad.org/~triad/wp-content/uploads/2008/11/ppe_for_website.pdf
Screening for FAT
High school and college athletes bring recognition and often funds to the facilities
that they play for. There are laws which prohibit them from being paid for their
contributions through funds (outside of scholarships); however, these
organizations have a responsibility to not only keep them from being harmed due
to their performance, but to help them should they suffer physical effects from the
sport. Benefits which should be required of all athletic departments, particularly
those of college-level athletes include:
Recommended benefits for athletes
Pre-participatory screening for symptoms/signs of FAT by a physician with NO financial interest in their passing the exam
Annual health exams and/or full health evaluations if amenorrhea, recurrent injury, or stress fractures occur (Note: if even 1 out of the 3 parts of the triad is present, the other 2 should be further investigated. A diagnosis of FAT can be made based on only 1 of the 3 criteria being present)
Outlined protocol for evaluation for any athlete failing screening for this condition including required visits with:
Sports psychologist to evaluate for disordered eating
Sports nutritionist to evaluate:
body fat analysis (bod pod, skin-fold, bioelectrical impedance)
Signs of disordered eating based on eating habits
Request 7-day food log and evaluate for deficiencies in calorie intake, calcium, magnesium, and vitamin D
Optimum recommended menu for athlete based on their requirements and nutrient deficiencies (the typical athlete personality type responds well to regimen and removes the guess work
Recommendation for high quality supplements based on need (calcium, multivitamin/mineral supplement, iron)
Recommended benefits for athletes
If either of those evaluations dictate further treatment, the athlete should be required to see:
Orthopedist to screen for osteopenia/osteoporosis
Reproductive endocrinologist or OBGYN to evaluate any noted menstrual irregularities
Recommendations for nutritional deficiencies include the following:
Vitamin D, Calcium and/or iron supplementation (if warranted) based on bone scan and bloodwork results
Hormone therapy (if unable to return to a normal menstrual status after a period of 2-3 months) as well as recommendation to investigate oocyte preservation to preserve future fertility
The above screening and evaluations should be benefits offered at no cost to the athlete and be a requirement for athletic participation
Treatment of FAT
Many athletes could be resistant to changing habits and in particular gaining
weight due to fears regarding their appearance as well as the effect it could have
on performance. One good strategy to deal with this would be to set-up a
contract between the athlete and the healthcare provider/coach which spells out
requirements that the athlete needs to meet in order to continue or resume
athletic competition. This approach can work well with the regimented personality
type that is generally seen in athletes and can be very motivational if such
contract is enforced.
Treatment of FAT
Many athletes are taking birth-control pills which can mask the symptoms of the
FAT, this can be good in that they have supplemental estrogen, but it is better to
address the root cause and fix the calorie insufficiency rather than use BCP’s as a
crutch which can cover-up the issue
Treatment of FAT
If an athlete is diagnosed with FAT or a stress fracture:
Order bone scan
Recommend high quality calcium supplement, investigate other potential nutrient deficiencies
Calcium should be supplemented at 1500 mg/day and consist of calcium carbonate and/or citrate in elemental form
Calcium supplements should be taken in a ratio of 2mg of calcium to 1 mg of magnesium and 1 IU of Vitamin D3 (cholecalciferol)
Calcium should be taken with food and dosage spread throughout the day
In addition to calcium, take magnesium to increase synthesis of osteocalcin and strengthen connective tissue matrix, and Boron, silicon, and Vitamin K to decrease calcium loss through the urine
Refer to sports nutritionist to R/O eating disorder, evaluate body fat, negative calorie balance, and nutrient deficiencies (calcium, magnesium, vitamin D, iron)
Treatment of Fat
Iron Deficiency:
1/3 to ½ of female athletes suffer low iron stores which leads to a decreased oxygen carrying ability and affects sports performance
If diagnosed with iron deficiency based on lab work (do NOT suggest supplemental iron unless they are deficient due to toxicity of excess iron):
Recommend increasing iron intake
Heme iron is the most absorbable form
Non-heme is less absorbable due to fiber content
Absorbability of non-heme iron is increased if eaten alongside meat
Absorbability of iron is increased when eaten or supplemented alongside foods high in vitamin C
Supplemental form of choice is ferrous sulfate, 1-3 x/day with food if tolerated
If experiencing nausea, can try ferrous gluconate
DO NOT take supplemental iron at the same time as calcium or fiber supplementation
Treatment of FAT
The primary goal is increased calorie intake allowing for restoration of menstrual cycles
LH is disrupted by a diet consisting of <30 kcal/kg of fat-free mass
Restoration of cycles generally requires caloric intake of 45 kcal/kg of fat-free mass
Can use birth-control pills or transdermal estrogen (if unable to resume cycle naturally)
Leptin injections (increases appetite)
Bisphosphonates are anti-resorptive bone medications, good for post-menopausal women, but remain in the bones for years and can be teratogenic and therefore should NOT be used in premenopausal women
Mechanical stimulation to treat bone loss (mimics physical activity for those whose treatment includes restriction of physical activity)
Education to prevent FAT
Best strategy is prevention of the disorder through education of athletes and the
coaches that work with them
Discuss what behaviors lead to the disorder
Discuss long-term consequences of the disorder (emphasize irreversible
decreased bone density leading to osteoporosis, fractures, etc.) Amenorrhea
leading to further bone loss and potential loss of fertility, increased risk of CVD
due to endothelial dysfunction, accidental pregnancy due to irregular
menstruation, decreased performance due to low energy availability
References:
1. Brunet, M. (2010). Unique considerations of the female athlete. Canada: Delmar.
2. Laframboise, M.A., Borody, C., & Stern, P. (2013). The female athlete triad: a case series and narrative overview. The Journal of the Canadian Chiropractic Association, 57(4), 316-326.
3. Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., . . . Ljunggvist, A. (2014, February 3). The IOC consensus statement: Beyond the female athlete triad-Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine, 48, 491-497. doi:10.1136/bjsports-2014-093502
4. Nazem, T.G., & Ackerman, K.E. (2012, July). The female athlete triad. Sports Health, 4(4), 302-309. doi:10.1177/1941738112439685
5. Mountjoy, M., Hutchinson, M., Cruz, L., Lebrun, C. (n.d.). Introduction: Female Athlete Triad Pre Participation Evaluation. Retrieved fromhttp://www.femaleathletetriad.org/~triad/wp-content/uploads/2008/11/ppe_for_website.pdf
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