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  • Christine Camozzi

Female Athlete Triad and relative Energy Deficiency in Sport

Supporting Healthy Adolescent Females Athletes


A healthy female athlete enters grade twelve after years of active involvement in the school community. They’re looking forward to another year of participation in sports. This year ends up being different than past years and the pressure to be better is high. They register for every Phys.Ed class offered. They are spotted training alone during after school hours. They are eating salads for lunch and stop bringing post training snacks. They are looking skinnier each week. They’ve been massaging their calves after races and wincing while they jog. They continually ask for more training. They are losing confidence. They’re graduating next year and once they get to University, they’ll grow out of this...right?


Were any parts of this story familiar to you? This story addresses what I wish to speak to you about today and that is the clinically relevant consequences of adolescent female athletes feeling pressured to train harder, eat less and reach an unattainable level of perfection. These consequences are known as The Female Athlete Triad (Triad) and Relative Energy Deficiency in Sport (RED-S). If you haven’t heard of The Triad or RED-S, please allow me to fill you in before I show you how you can become the next best coach in the field.


Female Athlete Triad


The Female Athlete Triad focuses on the outcomes of low energy availability such as impaired bone health, menstrual dysfunction and disordered eating. It is estimated to affect 20-60% of Female Athletes (Canadian Academy of Sports Nutrition, 2019).


Relative Energy Deficiency in Sport (RED-S)

More recently, the Female Athlete Triad has been expanded as new research is arising suggesting that there are more health disparities due to energy deficiency than just the Triad.


Due to this, a new term called Relative Energy Deficiency in Sport (RED-S) focuses on the health disparities I listed earlier AND the performance disparities as a result of low energy availability. Some of these performance detriments include decreased muscle strength, endurance, concentration, coordination and glycogen stores. It is ironic that female athletes are pressured to lose weight to become faster when the components of becoming faster are actually reduced with low energy availability.

Individuals do not grow out of the Triad or RED-S and the immediate and long-term effects may creep into the individual's life, creating many health disparities including:

  • Infertility

  • Increased stress fractures

  • Suppressed immune system

  • Premature osteoporosis

  • Mood Changes

  • Depression and Anxiety

  • Burnout


Risk Factors


Adolescent female athletes become at risk for the Triad and RED-S when there is:

  • Emphasis and reward for leanness in sports with endurance, aesthetic or weight-class components such as track and field, cross country running, triathlon, gymnastics, wrestling, figure skating, diving, rowing, cross country skiing and volleyball (DynaMed, 2020).

  • History of critical comments from coaches, parents and teammates about eating or weight (De Souza, 2014)

  • Early start of sport specific training (De Souza, 2014)

  • Overtraining (De Souza, 2014)

  • Inappropriate coaching behavior (De Souza, 2014)

  • Pressure to loose weight (De Souza, 2014)

  • History of stress fracture, injury and menstrual irregularities (De Souza, 2014)

  • Psychological factors, such as low self-esteem and perfectionism (Canadian Academy of Sports Nutrition, 2019).

  • Teams that have a culture to win at all costs

I’m going to let you think about these risk factors. How many of these do we have the power to eliminate or reduce...


My hope isn’t to make you feel guilty but rather to remind you and empower you of how vital of a person you are to a multitude of young people. Coaches underestimate the power they have to influence their athlete’s behaviors. Athletes may not be able to go home and talk to their families, but they may feel comfortable talking to you. You have the potential to be their confidant, mentor, hero. As coaches, we have a duty to our athletes. We need to keep them safe, heathy, happy. The Triad and RED-S can be prevented, and we have the power to diminish or eliminate the risk factors. Awareness and education are the first steps in changing behaviors so let's begin to learn how you can further support the overall well-being of adolescent female athletes for life.


Strategies


1. Communication Strategies

  • Avoid verbally comparing athletes to each other.

  • Banish comments involving weight or physique and be a role model for positive body image.

  • Be vigilant of the athlete who is always doing extra. This is not always healthy behavior and shouldn’t always be praised.

  • After posing a piece of information to athletes, ask them how they interpreted it. E.g. When saying “increasing your stride length is going to decrease your 400m time” follow up by asking “what does this mean to you?” This comment may sound to the athlete that they need to lose weight, to create skinner, faster legs when this is not at all what you meant.

  • Athletes may not feel hunger signs even though their body needs fuel. Remind athletes to have a minimum of three full meals and three snacks throughout the day.

2. Training Strategies

  • Focus on performance goals (endurance, strength, power, mental rehearsal) rather than physical goals (weight, leanness).

  • Train smarter not harder. Training for long hours isn’t necessarily as beneficial as a well-planned hour practice.

  • Increasing training volume isn’t always bad, just make it clear to athletes that they MUST fuel more. It’s like burning a fire. To keep it going you must keep adding more wood.

  • Be specific of your training expectations when you aren’t seeing them and emphasize the importance of recovery/rest days for performance.

  • Steer clear of training sessions that are Boot Camp style as they simply tire athletes out and expend calories without providing any performance gain.

3. Leadership and Education Strategies

  • Teach and model positive coping skills. This will be particularly important if your athletes are transitioning to University/Collegiate Sport.

  • Teach females about the importance of tracking their periods. If you aren’t comfortable, find someone who is.

  • As humans, we all struggle with this one but remember that your individual opinions and experiences aren’t always the scientific facts. Supply factual, referenced information to your athletes.

  • Seek information from exercise professionals such as Kinesiologists, Sports Dietitians and Strength and Conditioning coaches to provide you with current information on training and nutrition.

  • Be aware of how a uniform may make athletes uncomfortable and be open to ideas to change the uniform.

  • Be a role model for proper nutrition. For example, pull out a sports bar after practice to eat and encourage your athletes to do the same. I remember one of my coaches bringing boxes of granola bars to practice and physically handing out the bars to us during long practices while allowing us to finish before moving on. That stuck with me.

  • Make sure your leaders on your team display healthy athletic behaviors so younger athletes can look up to them.

  • Oral contraception (often known as birth control) is not a proper means of treating the athlete’s menstrual dysfunction. It will mask the underlying cause of menstrual loss and not protect against bone loss.

As a coach myself, I understand that we are only one person, so I encourage you to speak up, share this video and blog article with your colleagues, parents and older athletes to help you in creating a healthy sports community.


Early Intervention


While we want to prevent the Triad and RED-S from happening in the first place, the best way to prevent the negative health outcomes are through recognition of the warning signs and early intervention.


The most common warning signs include:

  • Irregular or absent periods for 3+ months

  • Stress “reactions” or fractures

  • A preoccupation with weight, body size or shape

  • Noticeable weight loss

  • Excessive or compulsive exercise habits

  • Signs of fatigue

  • Decrease in performance

  • Complaining of always being cold


Here are some steps to help you approach the situation:

  • Speak to parents/guardians about your concerns immediately.

  • Direct parents and guardians to seek proper medical resources (Family Physician, Dietitian, Mental Health Practitioner) and follow up with them.

When approaching the athlete:

  • Communicate with a criticize free attitude

  • Be prepared for denial but don’t stop fighting for this athlete. It is better for them to have a medical consultation and be fine than to let them continue and risk them suffering in the long term.

  • If the athlete is very dedicated to the sport, don’t be afraid to suspend their participation until they seek consultation. Although you may initially have an upset athlete, it will show them that you care more about them than just their performance.

  • Be sensitive and stay positive

The great news is that athletes can recover from the consequences of low energy availability. Treatment will differ depending on the athletes’ symptoms so it’s important to regularly communicate with parents/guardians to understand their recovery. As many of you may know from being a former athlete or current athlete, having your athletic identity tampered can lead to a serious grieving process. Keeping this in mind I believe it is fundamental to be empathetic with athletes and reassure them that they will get back on track.


Circling Back


Now that you are experts on the Triad and RED-S, let’s circle back to the story I left you with at the beginning of this blog article where you probably figured out that the athlete was struggling with symptoms of energy deficiency. This athlete did indeed go to University next year. They didn’t however make the rowing team they tried out for because they were severely underweight, and the coaches were worried this individual would not produce enough power to keep the boat moving. This crushed the athlete. Thankfully, an assistant rowing coach ran out after them and directed them to the right people for support. After getting the professional help the athlete needed and joining a team that fostered overall wellbeing, they eventually went on to become a successful and healthy University athlete and future coach.


I will always be incredibly grateful for that one assistant rowing coach who noticed the warning signs and steered me in the right direction. I have heard several stories of female athletes who have struggled similarly for years and have never been able to get the support they need from coaches to get back on track. Their stories have empowered me to empower you. I ask you now, do you want to be that coach whom the athlete will forever love, trust and appreciate for helping them in becoming a lifelong successful, healthy and confident individual? A coach who will often come to the athlete’s mind at whatever level they reach in their sport? And a coach whom the athlete will always think of as the most important person in getting them to where they are? Considering that you read this post and watched the video; I know that you’ll choose to be this coach. I believe that you can be the person who helps athletes have the longest and happiest career. Create and model a healthy sports training environment, be vigilant of the warning signs of the Triad and RED-S and show that you care.


If you would like to learn more about Female Athlete Triad and Relative Energy Deficiency in Sport and how you can support a healthy training environment for your athletes, please contact me or see the resources attached to this article below.





References

Canadian Academy of Sports Nutrition. (2014-2019). Female Athlete Triad. Retrieved from: https://www.caasn.com/female-athlete-triad.html


De Souza, M., Nattiv, A., Joy, E., Misra, M.,Williams, N., Mallinson, R., Gibbs, J., Olmsted, M., Goolsby, M., Matheson, G. (2014). 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad. Br J Sports Med, 48, 289. doi:10.1136/bjsports-2013-093218


Drinkwater, B. (2002). Summary Statement, The Female Athlete Triad

Retrieved from https://womensportinternational.org/index.php/female-athlete-triad/


DynaMed: EBSCO Information Services. (1995-2018). Record No. T922488, Female Athlete Triad; [updated 2018 Nov 30, cited Aug 11th,2020]. Retrieved from https://www-dynamed-com.myaccess.library.utoronto.ca/condition/female-athlete-triad#LOW_ENERGY_AVAILABILITY


Mountjoy, M., Ackerman, K., Lebrun, C., Meyer, N., Torstveit, M., Sundgot-Borgen, M., Blauwet, C., Lundy, B., Sherman, R., Budgett, R., Burke, L., Constantini, N., Melin, A., Tenforde, A. (2018). International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update. International Journal of Sport Nutrition and Exercise Metabolism, 28, 316-331. https://doi.org/10.1123/ijsnem.2018-0136

Williams, N., Koltun, K., Strock N., De Souza, M. (2019). Female Athlete Triad and Relative Energy Deficiency in Sport: A Focus on Scientific Rigor. Exerc. Sport Sci. Rev, 47 (4), pp. 197–205. DOI: 10.1249/JES.0000000000000200

Female and Male Athlete Triad Coalition. (2020). What is the Female Athlete Triad? The Female and Male Triad Coalition. An International Consortium. https://www.femaleandmaleathletetriad.org/athletes/female-athlete-triad/


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