Female athlete triad:
IMPORTANCE OF FUELING FOR PEAK
PERFORMANCE & LONG TERM HEALTH
IN HIGH SCHOOL WOMEN
Megan Fuetterer
Dietetic Intern, OHSU
CPT, NASM
GOALS
•OVERVIEW OF FEMALE ATHLETE TRIAD
•HOW TO IDENTIFY
•FUELING STRATEGIES
•DEVELOP ACTION STEPS
WHAT IS THE TRIAD?
Originally defined in 1992
Initially recognized as three separate
but interrelated entities:
1. Disordered Eating
2. Amenorrhea
3. Osteoporosis
Most Commonly seen in young female athletes in sports
emphasizing a lean physique.
2007 acsm position stand
Now recognizes a spectrum of symptoms and conditions
between health and disease.
The 3 spectrums include:
1. Energy Availability
2. Menstrual Function
3. Bone Mineral Density
Also identifies that low energy availability may occur
unintentionally, with or without disordered eating.
May occur alone or in combination.
Importance
Although energy availability may change daily, the
effects on menstrual cycle may not be seen for months,
and an effect on bone mineral density may not be seen
for years.
Poses significant health risks with potentially irreversible
consequences, including disorders of the skeletal,
endocrine, cardiovascular, reproductive, and central
nervous systems.
There is a great need for prevention, early diagnosis and
Total Energy Expenditure
TEE = Amount of energy required for metabolic function
RMR (Resting Metabolic Rate) = Basal + thermic effect
of food
EEE (Exercise Energy Expenditure) = Daily living +
exercise
RMR + EEE = TEE
Energy balance & Body
Weight
When TEE = Calorie Intake it is described as “energy
balance”
It’s not that simple...
When there is a calorie deficit, the body responds by
decreasing RMR to conserve energy.
Body weight may be stable BUT at a cost!
Decreased calories available for important metabolic
functions.
Energy availability
Amount of energy available for body functions after
accounting for energy expended from exercise and
physical activity.
EI (Energy Intake)
- EEE (Exercise Energy Expenditure)
Energy Availability
KEY CONCEPT: Energy availability must meet energy
needs for basic physiological processes (RMR).
Behaviors leading to low
energy availability
Abnormal eating behaviors:
- Dietary restraint
- Binge eating
- Eating in secret
Inadvertently failing to meet increased training needs
Clinical eating disorders:
- Anorexia
- Bulimia
- Orthorexia
- Anorexia athletica
Outcomes
Regardless of cause, a cascade of physiological and
neuroendocrine adaptations occur. Altered levels of
metabolic, growth, and reproductive hormones.
Functional Hypothalmic Amenorrhea
Menstrual irregularity
Eumenorrhea: Menstrual cycles that occur at a median
interval
of 28 days (plus or minus 7 days).
Primary Amenorrhea: Onset of menses >/= 15 yrs of
age.
Secondary Amenorrhea: Absence of menstrual cycles for
3 or
more consecutive months or < 3 cycles per
year.
Bone mineral density
Spectrum ranging from optimal bone health to
osteoporosis.
Physical activity should positively impact bone mineral
density.
Bone mineral density declines as the number of missed
menstrual cycles accumulates.
This can be attributed to lower estrogen levels, similar
to
those experienced by post-menopausal women with
increased risk for osteoporosis and fractures.
prevalence
Disordered Eating:
•In one study, eating disorders were present in 31% of
female athletes compared with only 5.5% in the general
population.
•Another study revealed clinical eating disorders in 25%
of female athletes competing in endurance sports,
aesthetic sports, and weight-class sports compared with
9% of the general population.
•A study in female elite swimmers found that 44.9% of
the participating athletes had disordered eating patterns.
Mendelsohn FA, Warren MP. Anorexia, bulimia, and the female athlete triad. Endocrinol Metab Clin North Am 2010;39:155-67.
prevalence
Amenorrhea:
•Primary amenorrhea is found in less than 1% of the
general population but is present in 22% of college
women competing in cheerleading, diving, and
gymnastics.
•Secondary amenorrhea is found in 2 to 5% of the
general population compared to up to 69% of ballet
dancers and 65% of distance runners.
Mendelsohn FA, Warren MP. Anorexia, bulimia, and the female athlete triad. Endocrinol Metab Clin North Am 2010;39:155-67.
Prevalence
Bone Mineral Density:
•It is shown that athletes with amenorrhea have 10-25%
lower bone mineral density at their lumbar spine than
the general population.
•Female athletes with amenorrhea are 2 to 4 times more
likely to suffer from a stress fracture.
London S. Education key to preventing female athlete triad. Clinical Psychiatry News 2008;36(8):43.
Health Consequences
•Possible cardiovascular effects (lack of estrogen)
•Negative current and future bone health
•Increased fracture risk
•Reproductive dysfunction
•Metabolic consequences
•Impaired vascular endothelial function
•Psychological effects (low self-esteem, depression,
anxiety)
•Gastrointestinal disorders
•Nutrient deficiencies
performance consequences
•Excessive fatigue
•Increased recovery time
•Decreased training adaptations
•Impaired performance
Change the mindset
Nutrition Basics
ure. Ideas for a healthy, fitness, and performance plate. Figure courtesy of Nanna Meyer, Ph.D., R.D. CSSD and Katie Frushour, R
Nutrition basics
ure. Ideas for a healthy, fitness, and performance plate. Figure courtesy of Nanna Meyer, Ph.D., R.D. CSSD and Katie Frushour, R
nutrition basics
ure. Ideas for a healthy, fitness, and performance plate. Figure courtesy of Nanna Meyer, Ph.D., R.D. CSSD and Katie Frushour, R
Rules to live by
daily calorie needs
Estimating Resting Energy Expenditure (REE):
Females REE =10 x body weight in pounds
Determining Activity Factor (AF):
Activity Level
Activity Factor
Moderate (walking, dancing, tennis, gardening, cycling,
etc.)
1.6
Very Active (full-time athletes, team sports, climbing, etc.)
1.9
Extremely Active (full-time athletes w/ daily strenuous
training)
2.2
Calculating Total Daily Calorie Needs (TEE):
REE x AF = TEE
Formulas complements of the University of Arizona Cooperative Extension works. http://cals.arizona.edu/pubs/health/az1390.pdf
Macronutrients
Carbohydrate: major fuel source for working muscles
1 gram of carb = 4 calories
50-60% of total caloric intake
Protein: important for muscle growth & tissue repair
1 gram of protein = 4 calories
10-15% of total caloric intake
About 0.7-1 grams/lb body weight
Fat: secondary fuel source to carbohydrate
1 gram of fat = 9 calories
30-35% of total caloric intake
Grandjean, AC. Macronutrient intake of US ahtletes compared with the general population and recommendations made for
athletes. Am J Clin Nutr 1989:49;1070-6.
Nutrition before exercise
•Consume a carbohydrate-rich snack or meal before
exercise to top off muscle stores. With pre-competition
jitters, liquid meal replacements may be a better choice
than whole foods.
•Include small amounts of protein in your pre-exercise
meal. Protein helps build and repair muscle tissue.
Adequate protein before exercise may help reduce postexercise muscle soreness.
•Aim for carbohydrate:protein in a 2-4:1 ratio.
•Choose pre-exercise meals that are low in fat and fiber
SCAN Nutrition Fact Sheet: Eating Before Exercise. Issue 3, April 2009.
Campbell B. Kreider RB. ISSN position stand: protein and exercise. Journal of ISSN. 2007;4:8.
•Peanut
& honey
on toast +Exercise
instant breakfast
3-4 butter
Hours
Before
drink
•Fruit and yogurt smoothie + low-fat granola
•Oatmeal with honey and almonds + skim milk +
banana
•Low-fat cottage cheese + apple butter, crackers &
grapes
•Lean hamburger on bun w/ salad & yogurt-fruit
parfait
•Turkey and swiss sandwich + fruit + sports drink
•
Low-fat
tuna
melt
sandwich
+
fruit
cup
+
fat-free
SCAN Nutrition Fact Sheet: Eating Before Exercise. Issue 3, April 2009.
yogurt
30-60 Min before exercise
•Sports drink
•Sports gel, sports beans or gummies
•Piece of fruit or jam sandwich
SCAN Nutrition Fact Sheet: Eating Before Exercise. Issue 3, April 2009.
eating during exercise
•Nutrition is necessary if exercise lasts longer than 90
minutes.
•Aim for 30-60 g/hr of carbohydrate.
•Some studies have shown the inclusion of protein
during a workout can decrease muscle damage and
increase endurance in subsequent workouts
•Nutrition during prolonged exercise requires the proper
mix & timing of fluids, carbohydrate, electrolytes, and
potentially protein. Too little fluid or too much carb can
result in cramping and other GI problems.
•Experiment & record tolerance to figure out what works
best
Wallis G. Oxidation of Combined Ingestion of Maltodextrins and
2005;37(3):426-32.
SCAN
Nutrition Fact Sheet: Eating During Exercise. Issue 4, April 2009.
Fructose During Exercise. Med Sci Sports Exerc.
options during exercise
•Sports drinks that contain carbohydrate and
electrolytes, while avoiding ingredients that may slow
digestion.
•Easily digested carbohydrate-rich foods during
endurance events, for example, banana, bread or roll
with jam or honey, sports foods (gels, gummy chews), or
bite-sized pieces of low-fat granola or sports bars.
SCAN Nutrition Fact Sheet: Eating During Exercise. Issue 4, April 2009.
Post-exercise Nutrition
•Restore fluid and electrolytes (sodium and potassium)
lost in sweat; weigh before and after exercise and
hydrate to replenish what was lost
• Replace muscle fuel (carbohydrate) utilized during
practice
• Provide protein to aid in repair of damaged muscle
tissue and to stimulate development of new tissue
• Begin nutrition recovery with a snack or meal within 1560 minutes following practice or competition
SCAN Nutrition Fact Sheet: Eating For Recovery. Issue 1, April 2009.
Ways to refuel
•Mini bagel + 1 Tbsp peanut butter + 1 cup chocolate
milk
•1/2 of a turkey sandwich + 1 medium banana
•1 cup of oatmeal + 1 cup skim milk + 10 amonds
•1 low fat string cheese + 1 oz turkey jerky +1 medium
apple
•Wheat tortilla with 1/3 cup beans & 1/4 cup low fat
cheese
•1 cup skim milk + 2 graham crackers w/ 1 Tbsp almond
butter
•Smoothie made with yogurt and frozen berries
•Stir
fryFactwith
leanForsteak,
broccoli,
SCAN
Nutrition
Sheet: Eating
Recovery. Issue
1, April 2009. bell peppers, & brown
rice
Hydrating
•Drink 8-20 ounces of fluid (water or sports drink) an
hour before exercise.
•Continue drinking during exercise, up to 16-24 ounces
of fluid per hour (4 to 6 ounces every 15 minutes).
•Track your sweat loss by weighing yourself before and
after exercise. Drink 16-24 ounces for every pound of
weight lost.
•Use water to hydrate if exercising for under an hour.
Consider a sports drink to replace fluid and electrolytes
lost in sweat if exercising over an hour or if you are a
SCAN Nutrition Fact Sheet: Hydration for the Teen Athlete. Issue 17, February
salty sweater. 2012.
Change the Mindset
Do not take the health approach
- This is the quickest way to turn a young athlete off
- Not applicable to the young athlete
Instead take the Fuel & Recovery approach
- Always relate education back to their sport
- Use analogies and stories that are real to them
- Get to the root of what is important to the athlete
Change the mindset
What does proper fueling
mean for you and your
athletes?
Thank You