Prevalence and Risk Factors of the Female Athlete Triad among Young Athletes

Abstract

The purpose of this literature review is to examine research conducted between 2007-2017 in which authors investigated (a) how the female athlete triad affects young female athletes and (b) how to develop successful risk factor screening for the triad. The female athlete triad is a condition characterized by low energy availability, low bone density, and menstrual dysfunction. The prevalence of this condition has increased as the number of female athletes in high school sports has risen. Some of the researchers’ studies reviewed in this paper examined the prevalence of the female athlete triad in athletes compared to non-athletes, reporting that athletes and non-athletes are just as likely to have risk factors for developing the triad.Other authorsinvestigated the correlation between risk factors for the female athlete triad and musculoskeletal injuries, finding that as the number of risk factors increased, so did the number of injuries.Others examined the relationship between nutritional knowledge and disordered eating, discovering that participants with disordered eating had a high level of nutritional knowledge. The authors of the studies reviewed here all agreed that future researchersshould focus on developing an effective screening toolto discover early onset of risk factors for eating disorders to address those factors before the condition has progressed. In addition, the authors agreed that future researchersshould investigate effective strategies for decreasing the prevalence of the risk factors for the components of the female athlete triad.

Prevalence and Risk Factors of the Female Athlete Triad among Young Athletes

Introduction

The purpose of this literature review is to examine research conducted between 2007-2017 in which authors investigated (a) how the female athlete triad affects young female athletes and (b) how to develop successful risk factor screening for the triad. The number of young female participation in scholastic sports has increased dramatically in the past decade.Specifically, in the United States, participation by girls in interscholastic sports increased from 1.84 million between 1988 and 1989 to 3 million from 2007 to 2008 (Rauh, Nichols, &Barrack2010). In addition to the increase in sports participation by young girls, there has been a corresponding increase in injuries among female athletes. For instance, in two of the studies reviewed in this paper, the authors found a relationship between participation in sports and musculoskeletal injuries(Barrack et al.; Rauh et al, 2010).Torstveit,Rosenvinge, and Sundgot-Borgen (2007) also found that there is a relationship between increased participation by girls in sports and the increase in the occurrence of the female athlete triad.The female athlete triad consists of low energy availability (with or without disordered eating), menstrual dysfunction, and low bone mineral density (Torstveit et al., 2007). Torstveit and colleaguesemphasized that the combined effect of the triad components increased the likelihood of musculoskeletal injury.

Currently, there is no widely accepted method for accurately screening for the triadcomponentsor their risk factors.The development of an effective, evidence-based screening tool would thus improve the likelihood of early treatment and of decreased injury rates among female athletes. Some authors have conducted research regarding the female athlete triad among collegiate and elite female athletes; however, few authors have conducted research regarding the female athlete triad among high school athletes. Consequently, there is a gap in the scholarly literature about young female athletes and the female athlete triad. Moreover, although there has been a call for an effective screening tool for the risk factors of the female athlete triad, a challenge for developing such a tool is that some sports, such as gymnastics and diving, demand athletes to be leaner for successfully competing, compared to other sports. Thus, leanness sport athletes might match the criteria for disordered eating, but they might not have an eating disorder.

Review of the Literature

Torstveit, et al. (2007) studied three aspects of eating disorders among female athletes. First, they comparedthe prevalence of disordered eating behavior in elite female athletes with controls from the general population. Second, they investigated common characteristics of elite female athletes with clinical eating disorders. Three, they evaluated the predictive validity of the components of the female athlete triad relative to eating disorders among female elite athletes and controls. Torstveit and his cohortsfound no difference between athletes and controls in the prevalence of disordered eating and clinical eating disorders, after adjusting for age. Nonetheless, they also reported a higher percentage of leanness sport athletes with eating disorders, compared to athletes in non-leanness sports and to controls.

A later study done by Hoch et al (2010) found results similar to Torstveit et al. (2007) when comparing the number of athletes with female athlete triad risk factors and controls. Hoch et al. purposed to determine the prevalence of the female athlete triad in high school varsity athletes in different sports compared to controls. The investigators found that 78% of high school athletes and 65% of sedentary students had one or more components of the triad. The authorsemphasized that this finding was significant because even girls who do not play sports may develop one or more of the components of the female athlete triad. Both Torstveit et al. and the Hoch et al. studies used questionnaires to asses eating behavior, menstrual status, and physical activity. They both also measured their participants’ bone mineral density and body composition by dual energy x-ray absorptiometry.

Authors of two later studies added a new dimension to the scholarly knowledge base, exploring the association between musculoskeletal injuries and the female athlete triad. First, Rauh et al. (2010) aimed to address why authors of recent prospective studies of high school populations had reported higher musculoskeletal injury rates among female athletes than male athletes competing in similar sports. The investigators were particularly interested in the association between all three components of the female athlete triad and musculoskeletal injuries. Rauh and his colleagues found a clear association between musculoskeletal injuriesand disordered eating, menstrual dysfunction, and low bone mineral density; the most prominent risk factor was menstrual dysfunction. The authors noted that each one of the factors was a separate risk factor for injury but that the risk for injury increased when all three factors were combined. Likewise, Barrack et al. (2014) found that the risk for developing female athlete triad syndrome was higher when the risk factors were combined. Their study evaluated the effect of the components of the female athlete triad separately and when combined. In particular, they wished to determine whether the incidence of bone-stress injuries in physically active girls and women increased when the components of the triad were combined. The researchers found that the risk of bone-stress injuries increased from 15% to 20% for single risk factors, to 30% to 50% for combined risk factors of the female athlete triad. The authors thus emphasized that as the number of triad risk factors accumulate, the risk for bone-stress injury increases. Both the Rauh et al. (2010) and the Barrack et al. (2014) studies were cohort studies; that is, they were observational studies that followed participants forward in time to be able to accurately measure the incidence rate of injuries.

Finally, Raymond-Barker, Pertoczi, and Quested(2007) assessed the nutritional knowledge of female athletes who were at risk fordeveloping the female athlete triad syndrome, comparing them to controls.Raymond-Barker et al. discovered that the lack of difference in nutritional knowledge between those who were at risk and those that were not suggested that lack of knowledgedid not explain the restricted eating associated with the female athlete triad. They also found that athletes have more knowledge of nutrition compared to the non-athletic population. The authors therefore suggested that underlying reasons for disordered eating could be cognitive and motivational.

Recommendations and Conclusions

While every author agreed that the female athlete triad posed a threat to the health and safety of girls in sports, each one had a different topic of inquiry, thus allowing for a more in-depth understanding of the risks. After reviewing these five recent studies, I conclude that when components of the female athlete triad are combined, the risk of musculoskeletal injury is higher than when only one component is evident. Athletes and non-athletes may both develop the components of the female athlete triad, but athletes in leanness sports are more likely to have disordered eating. Moreover, lack of nutritional knowledge did not cause disordered eating. All of the authors highlighted the need for ongoing research to create an effective, evidence-based screening tool for the risk factors of the female athlete triad. Appropriate screening could then lead to early detection and treatment of the triad, ultimately decreasing the rate of injury among female athletes.

Raymond-Barker et al. (2007) further stressed that lack of nutritional knowledge is not to blame for disordered eating among athletes or among non-athletes. They observed that although girls may know what constitutes healthy nutritional intake and can pass a nutritional knowledge test,theyare not applying that knowledge to their own lives. The Raymond-Barker et al. study in particular increased my awareness of the need for schools to consider taking a more active role in teaching the importance of nutrition. Further, it increased my awareness of the need for students to apply that knowledge and therefore become more proactive in healthy eating and exercise habits. Coaches, athletic trainers, parents, or girls who focus on the attainment of a particular body type—for a sport or not—may each play a role in the development of the female athlete triad or even one or two of the components. This leads me to believe that even though girls may have knowledge regarding safe and effective national and exercise habits, the pressure to look a certain way or to succeed in a sport might be the determining factor in motivating athletes and non-athletes to engage in disordered eating and excessive exercise.

This increased awareness of the incidence of and risk factors for female athlete triad will be especially important in my future career as a physical therapist (PT). Physical therapists who have knowledge of the signs and symptoms of the triad are more likely to offer multidisciplinary care for their patients (e.g., referring them to mental health counselors and nutritionists). The PT can thus be a part of that multidisciplinary team, assisting with promoting healthy eating and exercise behaviors, in addition to their major role of treating and preventing physical injuries. Moreover, PTs often have prolonged interactions with athletes based on the length of the rehabilitation program. The PT can add unique expertise to a multidisciplinary team; this is especially important because the triad is a complex disorder requiring comprehensive intervention.