Eating less to lose weight or play better can lead to big problems for girls who play sports. If young female athletes don’t get enough calories to make up for what they burn during practices and games, they might miss their periods and have weak bones. The combination of a poor diet, periods that aren’t regular and weak bones is called the female athlete triad.
In this segment, Terra Blatnik, MD discusses the symptoms of the female athlete triad, how it can cause health issues later in life, and when a patient should be referred to a specialist.
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The Female Athlete Triad
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Learn more about Terra Blatnik, MD
Terra Blatnik, MD
Terra Blatnik, MD is a Washington University pediatric sports medicine physician at St. Louis Children’s Hospital.Learn more about Terra Blatnik, MD
Transcription:
The Female Athlete Triad
Melanie Cole (Host): Eating less to lose weight or play better can lead to big problems for girls who play sports. In young female athletes, if they don't get enough calories to make up for what they burn during practice and games they might miss their periods or have weak bones. This combination of poor diet and periods that aren't regular and weak bones is called the “female athlete triad”. My guest today is Dr. Terra Blatnick. She's a Washington University Pediatric Sports Medicine Physician at St. Louis Children's Hospital. Welcome to the show, Dr. Blatnick. Tell us what is the female athlete triad. How does it come about and how long does it take to come about?
Dr. Terra Blatnick (Guest): The female athlete triad, the definition of it has definitely changed, especially over the last ten years. Initially the definition of it was amenorrhea osteoporosis and disordered eating. They found that they really needed a wider, broader definition to really encompass everyone that has elements of the triad. So, now we look at it as menstrual function, bone mineral density and, energy availability to more accurately represent the spectrum that we are looking at. An athletes can have any one of these things. They could have one part of it, they may have just the menstrual dysfunction, and they may have just issues of energy availability. So, there really is a wide spectrum of things that we look for. It can happen over a short or long period of time. So as soon as the athletes start restricting eating, they can get the tumbledown effect and have effect on these other things that we talked about including the bone mineral density and then their menstrual function will be affected as well.
Melanie: Who's the first person that would notice some of these things? Would it be a parent or coach or would it be the pediatrician at a well visit?
Dr. Blatnick: I think a well-tuned in parent will be the first person probably to recognize it. They may notice changes in eating habits of their young athlete and that may trigger to them that something has changed although the pediatrician may notice it more when they're looking at ways and things, a sort of more objective measures at least at well visits and things like that.
Melanie: What are some of the warning signs, the epidemiology of this particular situation? What should pediatricians and parents be on the lookout for?
Dr. Blatnick: I think certain sports definitely put athletes at risk. Sports that emphasize leanness, things like ice skating, gymnastics, dance, those really are the high risk group, although we also see it significantly in cross country runners or distance runners as well. So, if you have an athlete in those sort of groups you need to really keep a closer watch on them. I think the other thing to look for is if you're noticing changes in their eating habits, if they're seem to be not eating as much, if they seem a bit concerned about what they are eating or the things that they're having at home, then, that may be something that you need to look for and keep an eye on that weight and keep a closer watch on those girls.
Melanie: Do we know what causes the triad energy deficiency with or without the disorder eating? Do we know where this is really coming from?
Dr. Blatnick: A lot of it just comes down to pressure in sports, I think, in general. So, a lot of these girls are girls that strive to be perfect in the sport that they're in and being perfect they often think includes having a low weight. They think that that low weight is going to help them perform better in their sport. So, they start restricting their eating because they think it's going to make them better at what they do.
Melanie: Are there some long term effects if a young girl does come up with this?
Dr. Blatnick: The biggest effect really is on bone health. Kids accrue, or actually everyone accrues, most of their bone mineral density in their adolescent and early 20's. So, if they have issues with energy availability their bone mineral density starts to go down. This can have significant long term effects like osteoporosis as they get older. There are also cardiovascular effects as well too. There are effects within the vascular system of the triad and so they may have higher risk of heart disease and things as they get older as well, too.
Melanie: Dr. Blatnick, speak about the main goal of treatment in young female athletes with the triad.
Dr. Blatnick: I think the main goal of treatment is really changing their mindset about how they view their bodies and how they look at participation and performance in sports. They need to understand that thinner is not necessarily always better and that they will have things like fatigue and you really need to look at the immediate period. Kids don't tend to look forward. If you say, “You're going to get osteoporosis when you get older” they don't necessarily know what that means for them but if you talk to them about their performance and how it's affecting their life currently, then that seems to have a bit more bearing on them.
Melanie: Speak about the multi-disciplinary approach to treatment. Who might be involved if a pediatrician recognizes these symptoms and sends a female athlete to a specialist for treatment? Who might be involved in this type of treatment?
Dr. Blatnick: The main players in this are psychology as well as nutrition. Meeting with a nutritionist is often helpful for these girls. They can find out what is a healthy way to eat but also a way to get in the calories that they need to get the energy output that they're using for all of their sports. Sometimes some of them don't even know that they're not taking enough calories. They may not be aware that there are spending so much and just not taking enough, so meeting with a nutritionist can be helpful. Then, I think a psychologist is really the main person that's involved. So, they really need to work on changing the mindset of the athlete and teaching them to love and accept their body and accept the fact that they can perform well even if they aren't necessarily five to ten pounds lighter than what they want to be.
Melanie: Do you spot challenges in treating the young female athlete because making the initial diagnosis of the condition might be difficult as the athlete might not want to admit some of these things?
Dr. Blatnick: Yes. I do often find that there is a certain element of deception sometimes in these things. They don't want to admit that they are restricting calories or that they do have issues with body image. It takes a skillful either family member or a pediatrician to pick up on something that's changing. So, looking at weights over time, looking at performance and looking at sleep patterns and things like that. They need to look for little tiny clues that might say that something is going on. And also taking a good menstrual history, too, finding out if they're missing their periods or aren't having as many periods as they should have in a year, maybe clue in enough that something's going on.
Melanie: In summary, Dr. Blatnick, tell us what you'd like other pediatricians to know about recognizing issues with their female athletes or the female athlete triad?
Dr. Blatnick: I think just having it in mind is important. So, if you don't think about it, if it's not on your radar, then you're not going to recognize it. If you're seeing adolescent girl athletes, particularly those in sports that emphasize leanness like gymnastics, ice skating, cross-country running, each year when you see them for their well visit, you need to really look out and see how is their weight doing? Are they having regular periods? See if you can see something small because even if you see something small, say you send them to the dietician, that may help, just something small. They may want help. They may not recognize that they need it but they actually want it.
Melanie: What can a pediatrician expect from your team at St. Louis Children's Hospital when referring a patient to you?
Dr. Blatnick: We really try to provide comprehensive care for all pediatric and adolescent athletes. We try to provide them with not only services as far as injuries go but also we're developing dietetic services, cardio services, all sort of aspects that go into a young athlete's life. And so, we're trying to provide comprehensive care for them.
Melanie: Thank you so much for being with us today. A physician can refer a patient by calling children's direct physician access line at 1-800-678-HELP. That's 1-800-678-4357. You're listening to radio rounds with St. Louis Children's Hospital. For more information on resources available at St. Louis Children's Hospital you can go to www.stlouischildrens.org. That's www.stlouischildrens.org. This is Melanie Cole. Thanks for listening.
The Female Athlete Triad
Melanie Cole (Host): Eating less to lose weight or play better can lead to big problems for girls who play sports. In young female athletes, if they don't get enough calories to make up for what they burn during practice and games they might miss their periods or have weak bones. This combination of poor diet and periods that aren't regular and weak bones is called the “female athlete triad”. My guest today is Dr. Terra Blatnick. She's a Washington University Pediatric Sports Medicine Physician at St. Louis Children's Hospital. Welcome to the show, Dr. Blatnick. Tell us what is the female athlete triad. How does it come about and how long does it take to come about?
Dr. Terra Blatnick (Guest): The female athlete triad, the definition of it has definitely changed, especially over the last ten years. Initially the definition of it was amenorrhea osteoporosis and disordered eating. They found that they really needed a wider, broader definition to really encompass everyone that has elements of the triad. So, now we look at it as menstrual function, bone mineral density and, energy availability to more accurately represent the spectrum that we are looking at. An athletes can have any one of these things. They could have one part of it, they may have just the menstrual dysfunction, and they may have just issues of energy availability. So, there really is a wide spectrum of things that we look for. It can happen over a short or long period of time. So as soon as the athletes start restricting eating, they can get the tumbledown effect and have effect on these other things that we talked about including the bone mineral density and then their menstrual function will be affected as well.
Melanie: Who's the first person that would notice some of these things? Would it be a parent or coach or would it be the pediatrician at a well visit?
Dr. Blatnick: I think a well-tuned in parent will be the first person probably to recognize it. They may notice changes in eating habits of their young athlete and that may trigger to them that something has changed although the pediatrician may notice it more when they're looking at ways and things, a sort of more objective measures at least at well visits and things like that.
Melanie: What are some of the warning signs, the epidemiology of this particular situation? What should pediatricians and parents be on the lookout for?
Dr. Blatnick: I think certain sports definitely put athletes at risk. Sports that emphasize leanness, things like ice skating, gymnastics, dance, those really are the high risk group, although we also see it significantly in cross country runners or distance runners as well. So, if you have an athlete in those sort of groups you need to really keep a closer watch on them. I think the other thing to look for is if you're noticing changes in their eating habits, if they're seem to be not eating as much, if they seem a bit concerned about what they are eating or the things that they're having at home, then, that may be something that you need to look for and keep an eye on that weight and keep a closer watch on those girls.
Melanie: Do we know what causes the triad energy deficiency with or without the disorder eating? Do we know where this is really coming from?
Dr. Blatnick: A lot of it just comes down to pressure in sports, I think, in general. So, a lot of these girls are girls that strive to be perfect in the sport that they're in and being perfect they often think includes having a low weight. They think that that low weight is going to help them perform better in their sport. So, they start restricting their eating because they think it's going to make them better at what they do.
Melanie: Are there some long term effects if a young girl does come up with this?
Dr. Blatnick: The biggest effect really is on bone health. Kids accrue, or actually everyone accrues, most of their bone mineral density in their adolescent and early 20's. So, if they have issues with energy availability their bone mineral density starts to go down. This can have significant long term effects like osteoporosis as they get older. There are also cardiovascular effects as well too. There are effects within the vascular system of the triad and so they may have higher risk of heart disease and things as they get older as well, too.
Melanie: Dr. Blatnick, speak about the main goal of treatment in young female athletes with the triad.
Dr. Blatnick: I think the main goal of treatment is really changing their mindset about how they view their bodies and how they look at participation and performance in sports. They need to understand that thinner is not necessarily always better and that they will have things like fatigue and you really need to look at the immediate period. Kids don't tend to look forward. If you say, “You're going to get osteoporosis when you get older” they don't necessarily know what that means for them but if you talk to them about their performance and how it's affecting their life currently, then that seems to have a bit more bearing on them.
Melanie: Speak about the multi-disciplinary approach to treatment. Who might be involved if a pediatrician recognizes these symptoms and sends a female athlete to a specialist for treatment? Who might be involved in this type of treatment?
Dr. Blatnick: The main players in this are psychology as well as nutrition. Meeting with a nutritionist is often helpful for these girls. They can find out what is a healthy way to eat but also a way to get in the calories that they need to get the energy output that they're using for all of their sports. Sometimes some of them don't even know that they're not taking enough calories. They may not be aware that there are spending so much and just not taking enough, so meeting with a nutritionist can be helpful. Then, I think a psychologist is really the main person that's involved. So, they really need to work on changing the mindset of the athlete and teaching them to love and accept their body and accept the fact that they can perform well even if they aren't necessarily five to ten pounds lighter than what they want to be.
Melanie: Do you spot challenges in treating the young female athlete because making the initial diagnosis of the condition might be difficult as the athlete might not want to admit some of these things?
Dr. Blatnick: Yes. I do often find that there is a certain element of deception sometimes in these things. They don't want to admit that they are restricting calories or that they do have issues with body image. It takes a skillful either family member or a pediatrician to pick up on something that's changing. So, looking at weights over time, looking at performance and looking at sleep patterns and things like that. They need to look for little tiny clues that might say that something is going on. And also taking a good menstrual history, too, finding out if they're missing their periods or aren't having as many periods as they should have in a year, maybe clue in enough that something's going on.
Melanie: In summary, Dr. Blatnick, tell us what you'd like other pediatricians to know about recognizing issues with their female athletes or the female athlete triad?
Dr. Blatnick: I think just having it in mind is important. So, if you don't think about it, if it's not on your radar, then you're not going to recognize it. If you're seeing adolescent girl athletes, particularly those in sports that emphasize leanness like gymnastics, ice skating, cross-country running, each year when you see them for their well visit, you need to really look out and see how is their weight doing? Are they having regular periods? See if you can see something small because even if you see something small, say you send them to the dietician, that may help, just something small. They may want help. They may not recognize that they need it but they actually want it.
Melanie: What can a pediatrician expect from your team at St. Louis Children's Hospital when referring a patient to you?
Dr. Blatnick: We really try to provide comprehensive care for all pediatric and adolescent athletes. We try to provide them with not only services as far as injuries go but also we're developing dietetic services, cardio services, all sort of aspects that go into a young athlete's life. And so, we're trying to provide comprehensive care for them.
Melanie: Thank you so much for being with us today. A physician can refer a patient by calling children's direct physician access line at 1-800-678-HELP. That's 1-800-678-4357. You're listening to radio rounds with St. Louis Children's Hospital. For more information on resources available at St. Louis Children's Hospital you can go to www.stlouischildrens.org. That's www.stlouischildrens.org. This is Melanie Cole. Thanks for listening.