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The Female Athlete Triad: Putting Adolescent Girls at Risk

June 10, 2008 - 7:30am
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The Female Athlete Triad: Putting Adolescent Girls at Risk

Kathy (not her real name), a star performer on her high school soccer team, was concerned. The slender 15-year-old had missed her last couple of menstrual periods and was experiencing fatigue and general malaise. Pregnancy was not the cause…athletics and poor nutrition were.

Kathy is one of more than 2.9 million teenage girls participating in high school sports across the United States. While sports can provide numerous health benefits, women on the playing fields can incur some health risks.

Components of the Triad

According to Bonnie Nye, MD, Kathy's doctor and medical director of the Sports Medicine Clinic at The Children's Hospital of Philadelphia, the teenager's physical condition is not uncommon. Dr. Nye, as well as the American Academy of Pediatrics (AAP), believes that young women in sports face a trio of possible health complications. Called the "female athlete triad," these risks are disordered eating, ]]>amenorrhea]]> (absence of menstruation), and decreased bone mineral density.

Too Few Nutrients and Fluids

According to Dr. Nye, Kathy's lifestyle is similar to that of many young girls. The high school sophomore would often dash to school in the morning, leaving home without eating breakfast or drinking any fluids. If she had anything to drink, it would be a cup of coffee, the caffeine in which would act as a diuretic, causing Kathy to lose rather than retain vital fluids.

At school, Kathy would have nothing to eat or drink until lunch. Kathy's lunch was a hurried 20-minute affair, washed down by ice tea purchased from a cafeteria vending machine. Ice tea, and most sodas, also contain caffeine and have a diuretic effect. So, by the time Kathy reached soccer practice, she was already ]]>dehydrated]]>, before even engaging in vigorous athletic activity.

Disordered Eating, Menstrual Problems, Osteoporosis

Dr. Nye refers to Kathy's eating patterns as "disordered eating." This is different than an eating disorder, which Dr. Nye says is the intentional manipulation of a diet for unhealthy reasons. In Kathy's case, her lifestyle and lack of proper nutritional guidance were keeping her from eating properly.

The AAP says that disordered eating can cause amenorrhea, another component of the female athlete triad. The abnormal absence of menstrual periods puts young women at risk for ]]>osteoporosis]]>, a disease that leads to fragile bones and an increased risk of fractures to the hip, spine, and wrist.

Athletes Shouldn't Diet

It is because athletic teenagers need plenty of calories that physicians at The Nemours Foundation, a nonprofit children's health organization, state that, absent a doctor's specific instructions, "Dieting is not a part of being an athlete."

Girls More at Risk

Sue Sanders, RD, a former college athlete and professor of Food Science and Technology at New York University, says that young girls are more likely than boys to engage in disordered eating. This is because they tend to take part in sports in which weight and appearance are concerns, such as gymnastics, dancing, diving, skating, swimming, and running. This can lead to poor nutritional habits or worse, ]]>anorexia]]> and ]]>bulimia]]>.

In addition, a young girl's perception of her body is susceptible to outside influences. A peer-reviewed study of 550 girls in grades 5-12 published in Pediatrics, the journal of the AAP, found that 69% of the girls said pictures in magazines influenced their ideas of the perfect body shape. Nearly half of the girls surveyed said they wanted to lose weight because of the magazine pictures; however, only 29% of them were actually overweight.

Ways to Prevent Poor Body Image

The experts offer the following tips to parents to help prevent poor body image in their children:

  • Choose your words carefully. Sanders says parents need to talk to their daughters about what is an appropriate female body shape. This means not only monitoring what their daughters are reading in magazines and watching on television, but also discussing the unhealthiness and unattractiveness of being overly thin. Inadvertent remarks made by adults also affect how teenage girls see themselves, Sanders says. Her advice: Parents and coaches should foster a positive sense of self-esteem in young girls and stay away from using such loaded words as "chubby" and "baby fat."
  • Set a good example. Dr. Nye says that adults, particularly parents, have a role to play in setting good examples for their daughters. Mothers should not obsess about their own weight or diet. "Girls get feelings about their bodies from their mothers," she says. So it's up to parents to provide a good nutritional role model. Healthful foods should be served and eaten at home, and at appropriate times of the day.
  • Encourage drinking plenty of water. Dr. Nye stresses that drinking water before, during, and after exercise is just as important as having the right equipment. Parents and coaches should teach young athletes to drink water regardless of whether they feel thirsty or not. (In fact, feeling thirsty is a sign of dehydration.)
  • Look and listen. Parents need to know the signs and symptoms that their daughters' health may be at risk. Pay close attention to girls who voice concerns about weight and body fat. Other warning signs include abnormal weight loss, overemphasis on fat-free foods, changes in eating patterns, and over-exercising.


American Academy of Pediatrics

Osteoporosis and Related Bone Diseases National Resource Center


Canadian Association for the Advancement of Women and Sport and Physical Activity

The Female Athlete Triad


2007 statistics—gender equity in high school and college athletics: most recent participation and budget statistics. Women's Sports Foundation website. Available at:http://www.womenssportsfoundation.org/cgi-bin/iowa/issues/article.html?record=1017. Accessed April 1, 2008.

Benjamin HJ. The female adolescent athlete: specific concerns. Pediatric Annals. 2007; 36:719-726.

Last reviewed February 2008 by ]]> Kari Kassir, MD]]>

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.


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