Reprinted from Eating Disorders Review
July/August 2006 Volume 17, Number 4
©2006 Gürze Books
The female athlete triad includes the interrelated problems of disordered eating, amenorrhea, and osteoporosis. The International Olympic Committee’s Medical Commission (IOMC) recently posted a position stand on the female athlete triad on the Olympic Committee’s web site (http://multimedia.olympic.org/pdf/en_report_917.pdf).
Drs. Roberta Trattner Sherman and Ron A. Thompson offered a case study to demonstrate the special issues that arise when treating an athlete with disordered eating and how the recommendations in the IOMC Position Stand on the Female Athlete Triad can be used to effectively manage such issues (Int J Eat Disord 2006; 39:192).
According to the authors, disordered eating by athletes typically involves a willful attempt to create a negative energy balance. Part of this is based on the premise that a thinner or leaner body can lead to enhanced performance, such as in distance running or lightweight rowing. Athletes may also believe that being thinner may help them get a better score in sports where they are heavily judged by body size and appearance, such as diving, figure skating, or gymnastics.
Tirade over the Triad: A Case Study
A 19-year-old female collegiate long-distance runner visited the athletic department physician just before a conference meet because her training was not going well. After he had examined her, the physician referred her for an evaluation for a possible eating disorder. The athlete had been amenorrheic for more than 8 months and weighed 102 lb at 5 ft, 5 in (body mass index:17.0 kg/m2). Dual-energy x-ray absorptiometry scanning (DEXA) yielded a score in the normal range. The athlete was told that until she was further evaluated and medically cleared, she would be considered injured and would not be allowed to train or to compete. She reluctantly agreed to be evaluated for an eating disorder.
The authors point out that the term “triad” should not be interpreted to mean that all three components of the female athlete triad must be present to warrant intervention or assessment. The IOMC position statement also emphasizes that the presence of any one of the components indicates the need to assess the athlete for the presence of the other two.
The athlete was furious that she was being “forced” to submit to treatment. Her feelings were acknowledged and she was informed that the rules about competing and participating in her sport were in place to protect her. However, she denied that she had an eating problem and reported that her daily caloric intake was from 2000 to 2500 kcal. A weekly food log she was forced to keep indicated a daily intake closer to half that amount, even while she was typically running 50 to 60 miles a week in addition to participating in weight training. Further investigation revealed that she did other running and calisthenics, and had been treated for an eating disorder three years earlier in high school, when her weight fell to 99 lb (BMI: 16.5).
Based on restrictive eating, amenorrhea, body image disturbance and weight at the time of her evaluation, she was diagnosed with anorexia nervosa. However, she was told that she could begin training and competing when she was able to increase her caloric intake and restore her weight. She still angrily stated that she did not need treatment and could increase her caloric intake and gain weight without treatment.
It appeared to be a standoff until the psychologist told her that she could see a dietitian, but had to follow the dietitian’s plan. The athlete returned to the psychologist and angrily said she would not work with the dietitian.
The psychologist arranged a meeting with the athlete, psychologist, coach, physician, dietitian, and athletic trainer. After all parties expressed their opinions and concerns, the coach held firm and agreed that the athlete needed to enter treatment and could not train or compete until her treatment providers agreed that it was appropriate.
This case illustrated the IOMC position, which recommends referral to a dietitian for any symptomatic or at-risk athlete, particularly one who resists treatment. As the authors note, the referral to a dietitian is meant to be diagnostic. That is, the athlete is presented with a meal plan designed by the dietitian to meet the athlete’s nutritional needs for health and performance. If, as in this case, the athlete is unwilling or unable to follow the plan, she is referred back for treatment. The case also showed how healthcare professionals worked with the athlete and the coach in a “sports family” session. The coach was not involved in any decisions about the athlete’s weight, just as is suggested by the IOC.
After 4 months of treatment, the athlete’s menstrual cycle returned but was light and short. The athlete was adamant about returning to training; however, she was informed that she needed to increase her intake by an additional 200 to 300 kcal/day to regain normal menstruation. She was allowed to begin slowly with short, moderate runs, and daily caloric intake was slowly increased. As she gradually gained weight, she was able to return to training.
The new position of the IMOC places the emphasis on the athlete’s health rather than on weight or body composition. In addition, it recommends a process for managing an athlete who refuses a referral for evaluation or treatment or refuses to comply with treatment recommendations.
This process can be helpful to the athlete in several ways, according to Drs. Sherman and Thompson. It relies on the belief that participating in sports is so important to an athlete that he or she can be motivated to seek treatment by withholding or reinstating sport participation. When athletes are told they cannot compete or train given their health status, some view it as punishment. To counteract this, according to the authors, athletes should be told that they are regarded as injured, and injured athletes must be evaluated to determine the extent of injury as well as the potential risk if they train or compete while injured.