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DiPietro, Loretta; Stachenfeld, Nina S.

Medicine & Science in Sports & Exercise: December 1997 - Volume 29 - Issue 12 - p 1669-1671
Letters to the Editor-in-Chief

The John B. Pierce Laboratory and the Department of Epidemiology & Public Health, Yale University, New Haven, CT

Dear Editor-in-Chief:

The American College of Sports Medicine's position stand concerning disordered eating, amenorrhea, and osteoporosis as it relates to participation in sport and other physical activity (1) brings attention to several very important issues. This current position stand describes the components of the recently-defined Female Athlete Triad(11) and charges scientists, educators, and clinicians with the tasks of surveillance and treatment of this syndrome. Although we believe that knowledge of this topic is valuable to the welfare of young athletes, we are also concerned about how this information will be interpreted and used among the general public.

The position stand arrives at a time when the reported prevalence of regular, vigorous activity in adolescent girls (2) and the prevalence of overweight in the population (5) are steadily moving away from the Year 2000 Objectives. Certainly, as a population we need to increase our efforts in promoting the benefits of an active lifestyle among children and adolescents. Further, as girls and young women are beginning to attain the level of accessibility and achievement in organized sport as their male counterparts, we have a responsibility to keep them healthy and safe; yet the creation of a new form of pathology for women undermines this hard-earned success and has other serious implications for their health and well-being. Our goal in responding to the position stand is to offer another (more public health-oriented) view of the Triad and to extend the recommendations of the College with regard to preventive strategies.

There is little doubt that the occurrence of any single component(disordered eating, amenorrhea, or osteoporosis) of the Female Athlete Triad is quite serious; indeed, each one of these potentially has important consequences for growth, development, and function over the life-span. The occurrence of all three components simultaneously over many years in a young women would probably increase the risk of health and functional problems exponentially. But there are no prevalence data on the Triad; moreover, cross-sectional prevalence estimates for any single component vary substantially (see 3) and longitudinal data on any one component do not exist. Therefore, although serious in any one individual, the true magnitude of this syndrome has not been determined at the population level. The question is whether the actual magnitude of the Triad is significant enough to warrant the policing of young girls because they areactive, or active and lean. Asked another way, does the population attributable risk [PAR = prevalence (%)·relative risk (RR)] of the Triad and related long-term complications due to sport and physical activity even begin to approach the PAR of obesity and associated metabolic disorders due to sedentary behavior?

The etiology of the Female Athlete Triad is complex, and the interrelations of the components are not completely understood. In essence, the latter two components (amenorrhea and osteoporosis) are preceded by distorted body image, disordered (i.e., restrictive) eating, and underweight. A chronic negative energy balance and underweight, combined with exercise stress, are important elements in the pathway to amenorrhea, but underweight is neither a necessary nor a sufficient condition for lapses in the menstrual cycle. Amenorrhea occurs frequently in the adolescent female population, even in the absence of marked undernutrition and underweight (9), and there are many underweight athletes who menstruate regularly (6). To rely on body weight and/or reported caloric intake as a primary screening criterion may result in substantial misclassification of adolescent and young women as “disordered.” If hypoestrogenemia were the primary biological culprit in chronic amenorrhea and associated bone loss, then routine blood screening, as part of the prerequisite yearly physical, should appropriately identify (i.e., minimize the false positives) young girls at serious health risk. However, there is a substantial amount of variability in estrogen concentrations both within and among younger women, and the level of hypoestrogenemia associated with an increased risk to function seems difficult to determine as heredity plays such an influential role in athleticism, estrogen/androgen status, body composition, and bone density(6). Risk is even more difficult to determine in light of the fact that there are no prospective epidemiologic data linking amenorrhea (or its reversal) to infertility and osteoporosis in later years.

Because we challenge the implied causal role of sport and physical activity in the pathway to the Triad, we borrow from the health education literature a framework that recognizes the contributions of a constellation of factors toward a given behavior. These can be classified according to their function into predisposing, enabling, and reinforcing factors(4). We propose that there is a cluster of psychopathological factors which may predispose a young girl to disordered eating in our presently “weight-obsessed” society; such predisposing factors (or traits) may include low self-esteem, neuroticism, narcissism, obsessive/compulsive behavior, depression, and a predominately external locus of control (7). Certain activities and sports that involve perfectionism or judgement against an external standard provide an attractive and acceptable arena in which to express these traits. In addition, increased exercise will maximize energy expenditure and, hence, exercise also becomes a useful tool for controlling weight in those already preoccupied with self-perfection. But physical activity and sport may not be the underlying causal factors of the Triad-especially in older adolescent(i.e., 15-18 yr) and young adult women. Perhaps there are a small number of girls who begin elite competition at a very young age (say, 9- to 11-yr-old gymnasts, dancers, or figure skaters) who subsequently develop restrictive eating patterns that contribute to a later puberty and, consequently, delayed fat gain; however, for most, excessive exercise and athletic participation may simply be enabling factors for the expression of these negative personality traits and no more a cause of distorted body image and restrictive eating than a buffet table at a restaurant is the cause of binge eating. Daily exposure to the general milieu of the athletic community, and to coaches, officials, and parents who are also obsessed with perfectionism, provides constantly the reinforcing factors necessary to sustain these traits. Together, our premises suggest that the basis of distorted body image and disordered eating as they relate to the Triad is psychopathological and not athletic. Accordingly, the issues of identification, treatment, and clearance are best addressed by qualified pediatric and psychiatric health care providers.

It is quite probable that the vast majority of lean, competitive women have no underlying psychiatric morbidity. In fact, the literature suggests that physically active people have better mental health than their sedentary peers. Thus, to suggest that “potentially all physically active girls and women could be at risk” for the Triad (1) based on limited data could distract from the recent national efforts to promote physical activity in young girls and women (8). Further, do we really want to restrict the many physical and psychosocial benefits derived from participation in sport and other physical activity, which for most women may ultimately translate into a life-time of being physically active? Clearly, if participation is to be considered dangerous, the cost to both sport and society will be high (10).

So, rather than “targeting” active young women “at risk” for the Triad, perhaps we as a College and a society could focus our efforts on the risk conditions or those reinforcing factors that may make participation in exercise and sports unsafe for young people. As stated in the position stand, educating all athletes, coaches, and parents about the components of the Female Athlete Triad is a necessary component of any preventive strategy. Examples of additional public policy efforts might include: 1) raising the age criterion for elite competition; 2) raising minimal thresholds for weight classifications or competition and basing these on body mass index, rather than on simple body weight; 3) changing form-fitting athletic clothing styles to something that is both functional and flattering to the adolescent female body; 4) monitoring the coaching environment, not athletes, and those adults exhibiting “win at any cost” attitudes and behaviors discouraged from working with young people; and, above anything else, 5) supporting the value of young women regardless of their size, speed, strength, or athletic prowess.

Loretta DiPietro

Nina S. Stachenfeld

The John B. Pierce Laboratory and the Department of Epidemiology & Public Health, Yale University, New Haven, CT

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©1997The American College of Sports Medicine