The Female Athlete Triad.docx
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The Female Athlete Triad.docx
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TheFemaleAthleteTriad
TheFemaleAthleteTriad
AureliaNattiv,M.D.,FACSM,AnneB.Loucks,Ph.D.,FACSM,MelindaM.Manore,Ph.D.,R.D.,FACSM,CharlotteF.Sanborn,Ph.D.,FACSM,JorunnSundgot-Borgen,Ph.D.,MichelleP.Warren,M.D.
Mar 01, 2010
AbstractandIntroduction
Abstract
Thefemaleathletetriad(Triad)referstotheinterrelationshipsamongenergyavailability,menstrualfunction,andbonemineraldensity,whichmayhaveclinicalmanifestationsincludingeatingdisorders,functionalhypothalamicamenorrhea,andosteoporosis.Withpropernutrition,thesesamerelationshipspromoterobusthealth.Athletesaredistributedalongaspectrumbetweenhealthanddisease,andthoseatthepathologicalendmaynotexhibitalltheseclinicalconditionssimultaneously.Energyavailabilityisdefinedasdietaryenergyintakeminusexerciseenergyexpenditure.LowenergyavailabilityappearstobethefactorthatimpairsreproductiveandskeletalhealthintheTriad,anditmaybeinadvertent,intentional,orpsychopathological.Mosteffectsappeartooccurbelowanenergyavailabilityof30kcal·kg −1 offat-freemassperday.Restrictiveeatingbehaviorspracticedbygirlsandwomeninsportsorphysicalactivitiesthatemphasizeleannessareofspecialconcern.Forpreventionandearlyintervention,educationofathletes,parents,coaches,trainers,judges,andadministratorsisapriority.AthletesshouldbeassessedfortheTriadatthepreparticipationphysicaland/orannualhealthscreeningexam,andwheneveranathletepresentswithanyoftheTriad'sclinicalconditions.Sportadministratorsshouldalsoconsiderrulechangestodiscourageunhealthyweightlosspractices.Amultidisciplinarytreatmentteamshouldincludeaphysicianorotherhealth-careprofessional,aregistereddietitian,and,forathleteswitheatingdisorders,amentalhealthpractitioner.Additionalvaluableteammembersmayincludeacertifiedathletictrainer,anexercisephysiologist,andtheathlete'scoach,parentsandotherfamilymembers.ThefirstaimoftreatmentforanyTriadcomponentistoincreaseenergyavailabilitybyincreasingenergyintakeand/orreducingexerciseenergyexpenditure.Nutritioncounselingandmonitoringaresufficientinterventionsformanyathletes,buteatingdisorderswarrantpsychotherapy.Athleteswitheatingdisordersshouldberequiredtomeetestablishedcriteriatocontinueexercising,andtheirtrainingandcompetitionmayneedtobemodified.Nopharmacologicalagentadequatelyrestoresbonelossorcorrectsmetabolicabnormalitiesthatimpairhealthandperformanceinathleteswithfunctionalhypothalamicamenorrhea.
Introduction
Becausethebenefitsofexercisefaroutweightherisks,theAmericanCollegeofSportsMedicine(ACSM)encouragesallgirlsandwomentoparticipateinphysicalactivitiesandsports.In1992,however,anassociationofdisorderedeating,amenorrhea,andosteoporosisseeninactivitiesthatemphasizealeanphysiquewasrecognizedasthefemaleathletetriad(Triad). [148,215] ThisPositionStandreplacesthe1997ACSMPositionStand, [155]updatesourunderstanding,andmakesnewrecommendationsforscreening,diagnosis,prevention,andtreatmentoftheTriad.
EvidenceClassification
ThisPositionStandpresentsclinicalrecommendationsforguidingprimarycare().WeusedcriteriaproposedbytheAmericanAcademyofFamilyPhysicians [52] forevaluatingthestrengthofscientificevidencesupportingtheseclinicalrecommendations.Thesecriteriacategorizethestrengthofscientificevidenceasfollows:
A,consistentandgood-qualityevidenceforclinicaloutcomesonmortality,morbidity,symptoms,cost,andqualityoflife;B,inconsistentorlimitedqualityevidenceforthesesameclinicaloutcomes;andC,evidenceonbiochemical,histological,physiologicalandpathophysiologicaloutcomes,whichincludehormoneconcentrations,bonemineraldensity(BMD),andasymptomaticmenstrualdisorderssuchasshortlutealphaseandanovulation;andevidencebasedoncasestudies,consensus,usualpractice,andopinion.Toavoidmisunderstanding,thisPositionStanddifferentiatesbetweentwosubcategoriesofevidence:
C-1,evidencebasedonbiochemical,histological,physiological,andpathophysiologicaloutcomes;andC-2,evidencebasedoncasestudies,consensus,usualpractice,andopinion.ThisPositionStandalsopresentsevidencestatementsaboutthecurrentstateofknowledge().Althoughtheclinicalrecommendationcriteriawerenotdevelopedforevaluatingevidencesupportingstatementsaboutthecurrentstateofknowledge, [52] weusedthesesamecriteriatoevaluatethisevidence,aswell.
Table1. Strengthofevidencetaxonomy.
Grade
ReasonforC
EvidenceStatements
Severeundernutritionimpairsreproductiveandskeletalhealth.
A
DE/EDandamenorrheaoccurmorefrequentlyinsportsthatemphasizeleanness.
A
Onaverage,BMDislowerinamenorrheicthanineumenorrheicathletes.
C
1
MenstrualirregularitiesandlowBMDincreasestressfracturerisk.
A
InFHA,increasesinBMDaremorecloselyassociatedwithincreasesinweightthanwithOCP/HRTadministration.
C
1
ClinicalRecommendationsforScreeningandDiagnosis
ScreeningfortheTriadshouldoccuratthepreparticipationexamorannualhealthscreeningexam.
C
2
AthleteswithonecomponentoftheTriadshouldbeassessedfortheothers.
C
2
Athleteswithdisorderedeatingshouldbereferredtoamentalhealthpractitionerforevaluation,diagnosisandtreatment.
C
2
TodiagnoseFHA,othercausesofamenorrheamustbeexcluded.
B
BMDshouldbeassessedafterastressorlowimpactfractureandafteratotalof6monthsofamenorrhea,oligomenorrhea,orDE/ED.
C
2
ClinicalRecommendationsforTreatment
MultidisciplinarytreatmentfortheTriaddisordersshouldincludeaphysician(orotherhealth-careprofessional),aregistereddietitian,and,forathleteswithDE/ED,amentalhealthpractitioner.
C
2
Thefirstaimoftreatmentistoincreaseenergyavailabilitybyincreasingenergyintakeand/orreducingenergyexpenditure.
C
1
AthleteswithoutDE/EDshouldbereferredfornutritionalcounseling.
AthletespracticingrestrictiveeatingbehaviorsshouldbecounseledthatincreasesinbodyweightmaybenecessarytoincreaseBMD.
C
1
TreatmentforDE/EDincludesnutritionalcounselingandindividualpsychotherapy.Cognitivebehavioral,grouptherapyand/orfamilytherapymayalsobeused.
B
AthleteswithDE/EDwhodonotcomplywithtreatmentmayneedtoberestrictedfromtrainingandcompetition.
C
2
OCPshouldbeconsideredinanathletewithFHAoverage16ifBMDisdecreasingwithnonpharmacologicalmanagement,despiteadequatenutritionandbodyweight.
C
2
EvidenceCategories:
A—Consistent,good-qualityevidenceonmorbidity,mortality,symptomimprovement,costreduction,andqualityoflife.B—Inconsistentorlimitedqualityevidenceonthesameoutcomes.C—Otherevidence:
1—Evidenceonbiochemical,histological,physiologicalandpathophysiologicaloutcomes,whichincludehormoneconcentrations,bonemineraldensity,andasymptomaticmenstrualdisorderssuchasshortlutealphaseandanovulation;2—casestudies,consensus,usualpractice,opinion.
Definitions:
DE/ED—disorderedeatingoreatingdisorders;BMD—bonemineraldensity;FHA—functionalhypothalamicamenorrhea;OCP—oralcontraceptivepills;HRT—hormonereplacementtherapy.
Table1. Strengthofevidencetaxonomy.
Grade
ReasonforC
EvidenceStatements
Severeundernutritionimpairsreproductiveandskeletalhealth.
A
DE/EDandamenorrheaoccurmorefrequentlyinsportsthatemphasizeleanness.
A
Onaverage,BMDislowerinamenorrheicthanineumenorrheicathletes.
C
1
MenstrualirregularitiesandlowBMDincreasestressfracturerisk.
A
InFHA,increasesinBMDaremorecloselyassociatedwithincreasesinweightthanwithOCP/HRTadministration.
C
1
ClinicalRecommendationsforScreeningandDiagnosis
ScreeningfortheTriadshouldoccuratthepreparticipationexamorannualhealthscreeningexam.
C
2
AthleteswithonecomponentoftheTriadshouldbeassessedfortheothers.
C
2
Athleteswithdisorderedeatingshouldbereferredtoamentalhealthpractitionerforevaluation,diagnosisandtreatment.
C
2
TodiagnoseFHA,othercausesofamenorrheamustbeexcluded.
B
BMDshouldbeassessedafterastressorlowimpactfractureandafteratotalof6monthsofamenorrhea,oligomenorrhea,orDE/ED.
C
2
ClinicalRecommendationsforTreatment
MultidisciplinarytreatmentfortheTriaddisordersshouldincludeaphysician(orotherhealth-careprofessional),aregistereddietitian,and,forathleteswithDE/ED,amentalhealthpractitioner.
C
2
Thefirstaimoftreatmentistoincreaseenergyavailabilitybyincreasingenergyintakeand/orreducingenergyexpenditure.
C
1
AthleteswithoutDE/EDshouldbereferredfornutritionalcounseling.
AthletespracticingrestrictiveeatingbehaviorsshouldbecounseledthatincreasesinbodyweightmaybenecessarytoincreaseBMD.
C
1
TreatmentforDE/EDincludesnutritionalcounselingandindividualpsychotherapy.Cognitivebehavioral,grouptherapyand/orfamilytherapymayalsobeused.
B
AthleteswithDE/EDwhodonotcomplywithtreatmentmayneedtoberestrictedfromtrainingandcompetition.
C
2
OCPshouldbeconsideredinanathletewithFHAoverage16ifBMDisdecreasingwithnonpharmacologicalmanagement,despiteadequatenutritionandbodyweight.
C
2
EvidenceCategories:
A—Consistent,good-qualityevidenceonmorbidity,mortality,symptomimprovement,costreduction,andqualityoflife.B—Inconsistentorlimitedquali
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