Female Athlete or Active Protocols

Week 38: Female Athletes

Topic 02: The Female Athlete Triad

What is the female athlete triad?

The female athlete triad is a combination of three conditions or situations that often occur together in female athletes. These are:

1.    Low energy availability

2.    Menstrual dysfunction– often amenorrhoea (lack of periods)

3.    Low bone mineral density.

Let’s have a look at each of these in more detail. 

1. Low energy availability

This basically means that the woman is not eating enough to meet her daily requirements and to match the level of exercise she is doing. It may be related to an eating disorder or ‘disordered eating’ of some kind, especially for sports in which leanness and low body weight is encouraged, such as running, dancing, gymnastics or skating. This can then result in low body weight and a very low body fat percentage. 

We’ll have a closer look at the ‘disordered eating’ and psychological factors below in the ‘Factors to consider’ section. 

2. Menstrual dysfunction

This often means amenorrhoea, which is defined as cessation of the menstrual cycle for three months or more – more specifically, hypothalamic amenorrhoea. So why and how does this happen?

In a normal menstrual cycle, the hypothalamus in the brain releases gonadotropin releasing hormone (GRH). This stimulates the pituitary gland to release follicle stimulating hormone (FSH) and luteinising hormone (LH), which in turn stimulate the ovaries to release oestrogen and progesterone respectively. These hormones together allow ovulation to occur and orchestrate the menstrual cycle, with the ultimate goal of reproduction. But when there is lack of energy availability, or a low body weight/body fat percentage, the hypothalamus does not release enough GRH to stimulate the rest of the cycle. This means that levels of the other hormones drop, ovulation may not occur, and periods stop. This is essentially a survival mechanism – the body is trying to conserve its resources and prioritise survival – reproduction is not necessary at this time. In fact, the last thing the body needs is to spend energy and nutrients on building a baby! 

3. Low bone mineral density

The final condition in the triad is lowered bone mineral density, which can lead to fractures and potentially osteoporosis. The key factor here is lack of oestrogen (due to the altered cycle of hormone production, as above), as oestrogen stimulates normal bone mineralisation in women. Other factors causing lowered bone mineral density can include lack of the necessary bone-supporting nutrients such as calcium, magnesium and fat-soluble vitamins A, D and K in the diet, and lowered adrenal function (as the adrenals should also secrete oestrogen). 

*Note that you may have a client who has just has low energy/low body weight and amenorrhoea, without yet having low bone mineral density – but the approach we outline below would be the same. 

Implications and consequences

The implications and negative outcomes of the female athlete triad can be far-reaching, impacting not only day-to-day performance and wellbeing, but also long-term health. 

They can include:

·      Low energy and general weakness.

·      Poor recovery and repair from training.

·      Increased muscle breakdown for energy.

·      Adrenal fatigue. As we’ve seen previously in the course, when glucose availability is low, the adrenals produce cortisol, which stimulates glycogen release and gluconeogenesis to increase blood glucose levels. So if glucose is constantly low, the adrenals are constantly stimulated and have to work harder. Other factors here are the likelihood of overtraining and potentially a lack of adequate sleep, both of which can contribute to adrenal fatigue.

·      Low thyroid function, which then further impacts energy levels and further disrupts sex hormone production and the menstrual cycle.

·      Lack of sex drive, primarily due to reduced sex hormone production.

·      Infertility. This can be a primary motivation to change, when a woman realises that her situation may impact her chances of having a baby. 

·      Depression. This can be related to low thyroid function / low adrenal function, but also because oestrogen increases the sensitivity of serotonin receptors – so lack of oestrogen can cause symptoms of serotonin deficiency.

·      Compromised heart health. Oestrogen has a protective effect against cardiovascular disease, which is why women have a lower risk of heart disease than men until menopause.

·      Long-term osteoporosis. Low bone mineral density may not be completely reversible, impacting the woman’s health into old age.

·      Premature ageing, due to low oestrogen levels.

Causes: eating disorders / ‘disordered eating’ versus other causes

As we mentioned above, a common factor in the female athlete triad is eating disorders or disordered eating. The term ‘eating disorder’ tends to refer to diagnosed conditions such as anorexia nervosa or bulimia nervosa. ‘Disordered eating’ is a wider term referring to any abnormal relationship with food or eating behaviour. In this context, it means a behaviour carried out to lower body weight or control body shape beyond what is ‘normal’ or healthy. It can include skipping meals, deliberately eating a very low-calorie diet, obsessive calorie counting, or fasting (intermittent or otherwise) to control weight. This may be relatively common in female athletes who participate in a sport or activity that requires or celebrates lean definition and low body weight, as mentioned above. However, it can also be seen in women who work out in order to achieve a specific body shape or who gain satisfaction from losing fat weight, gaining muscle and being ‘ripped’.

Another cause can simply be that the woman is undereating for her needs, without deliberately doing so. She may have not realised that she needs to eat more, or may not be eating enough of a specific food group – especially carbohydrates, or is training so hard that her current diet is not providing her with adequate nourishment and calories. This can be easier to work with, as it’s primarily a case of altering the diet (and training regime, if this comes within your remit) as you would with any other client who is underweight or over-training.

One of the first steps you will take, then, is to determine whether your client has a pattern of disordered eating, as this will be a primary factor in how you work with that person. 

Factors to consider when working with a client – especially if disordered eating is a cause

The next variable that will determine your approach with a client is whether she recognises she has a problem and is prepared to change (or to what extent she is prepared to change). This is the most important step towards recovery, and if this is not the case, the client may need extra psychological support and/or more time before you start making big dietary changes.

Complicating factors in moving forward can include:

·      Fear of gaining weight. Eating more can be a huge psychological hurdle.

·      Women can feel that they are defined by their lean or toned body shape or athletic performance, especially if they have been that way for a long time. Letting go of that ‘identity’ can be extremely difficult. 

·      Having a lean, toned, strong body is praised and encouraged in our society. This is ‘normal’ for men, but a healthy woman shouldnaturally have a higher body fat percentage and a more curvy body shape, and so achieving that ‘ripped’ look takes a much greater toll on their health. 

·      Self-esteem. Women in particular are prone to negative self-talk. They may also be particularly vulnerable to or worried about what other people may think of them or say to them if they miss training sessions or start to gain some weight. 

·      Intensive exercise can be addictive for anyone, especially if their self-worth is defined by their achievements or their resulting body shape. Gradual adjustments in the training schedule may be needed.

Approach to working with a client

1. Referral to a doctor

If you suspect that your client may have an eating disorder but she hasn’t already had a diagnosis, it is important to first of all refer her back to her GP. You can continue to work with her, but the GP should be notified. ‘Disordered eating’ that isn’t at the level of an eating disorder is a bit more of a ‘grey area’.

2. External support

Secondly, a client who comes to you with any of the symptoms of female athlete triad and has disordered eating of any kind is probably going to need more support than a nutritionist can give her. She is likely to need external psychological support, from a counsellor or cognitive behavioural therapist for example, and she may need to find this support before you start working together. She also needs to have the support of family and friends, partly to avoid any potential for misplaced criticism or comments when she starts to gain weight or change her exercise pattern. Some people find that the more people they tell about what they are going through, the easier it is to make progress and stay on track. 

3. Nutritional support

The following are priorities when it comes to giving nutritional support. 

Note that it is important to work gradually and make small changes for someone with disordered eating of any kind. Making big changes is likely to make her run a mile!

·      Eating more.Simply start by getting the person to eat more, often more carbs in particular. For someone with disordered eating, you may start by just getting her to add a potato or two or half a cup of rice to her current meal, and gradually increase.

·      Gradually increase carbohydrate intake. A woman may need to consume about 30 to 40 per cent of calories as carbohydrates to make progress in restoring her menstrual cycle. This can be a big increase for some people!

·      Introduce snacks or more frequent meals.Although eating three meals a day can be a more sensible strategy for the average person, eating snacks or more frequent meals can be necessary for an athlete to consume enough calories and nutrients for their needs. Get your client to introduce snacks if she isn’t already doing this, again starting small for someone with disordered eating.

·      Does your client need to eat less fat?Although it may seem unlikely, for some women – especially those who follow a paleo-inspired diet or other low-carb diet – eating too much fat may be a problem. Fat actually suppresses appetite, can allow carbohydrate intake to drop very low and can even reduce overall calorie intake, leading to weight and fat loss.

·      Discuss appetite/hunger and food intake with the client.Your client may say that she doesn’t eat because she doesn’t feel hungry. But hunger doesn’t necessarily indicate what the body needs, especially when training intensively. This may link in with reducing fat intake and potentially even protein intake, which make us feel fuller, in favour of more carbohydrates.

·      Cut out stimulants.Caffeine can suppress appetite and stimulates the adrenal glands. As for any client, cutting down gradually is often best. 

Cautions – what notto do:

·      In general, don’t restrict her diet further.Apart from altering macronutrient ratios, or potentially replacing poor quality foods with healthier alternatives, it can be best not to cut any foods out of your client’s diet, such as gluten or dairy (unless there’s a true allergy or severe intolerance). Disordered eating is about control and restriction, and the focus needs to be on getting away from that, as a priority.

·      Counting calories is often a no-no.Although you want your client to increase her calorie intake, counting calories is likely to be counter-productive. Firstly, because seeing her calorie intake increase can be scary for the client; and secondly, because you want to get her away from that element of control that counting calories brings. However, it may be helpful initially to show your client how many calories she shouldbe eating for the exercise she is doing (which may be more than double what she is currently consuming!) as it can help encourage her to eat more. 

·      Intermittent fasting (or any other type) is not usually recommended. Don’t restrict food intake to a certain period of the day at this point. 

Also consider the following:

·      Like for anyone else who is overtraining or experiencing adrenal fatigue, the client needs to prioritize adequate sleep, rest days,relaxationand recreation. 

·      Adrenal support. You may need to consider adrenal support for the client. Review the lesson on Cortisol and Thyroid Support and overtraining and the supplements sections. In particular, you may want to consider magnesium, vitamin C, B vitamins (or a multi), and adaptogens. 

·      Support for digestion.When starting to eat more, the client may benefit from digestive support supplements, for example a digestive enzyme. 

Topic 03: Low Iron

Another common situation you will come across in female athletes is low iron levels.

Iron is of course a critical nutrient for exercise performance, due to its role in transporting oxygen around the body. The prevalence of iron deficiency is higher in athletes than non-athletes (in fact, iron deficiency anaemia is sometimes known as ‘sports anaemia’), and is an especially common problem in women due to menstruation. [1]  

Contributing factors to iron deficiency

As well as prolonged exercise and training, contributing factors to iron deficiency can include the following. 

·      Heavy periods (although less likely in athletes)

·      Poor iron intake – especially with vegetarian or vegan diets, or other restricted diets – e.g. for weight loss.

·      Low stomach acid

·      Gut disorders – in particular coeliac disease or Crohn’s disease, especially if recently diagnosed or untreated

·      Bleeding or internal bleeding of any kind (red flag – refer to a doctor if suspected)

·      Recent childbirth or breastfeeding

·      Long-term use of aspirin or other anti-inflammatory medications (can cause ulceration and bleeding in the gut)

·      Medications that reduce stomach acid, such as proton-pump inhibitors (e.g. omeprazole).

As discussed in previous modules, it is vital to investigate potential underlying causes for each client rather than just jump into iron supplementation.

Deficiency signs and symptoms

·      Fatigue, listlessness, weakness

·      Pale skin

·      Restless leg syndrome

·      Sore tongue or angular stomatitis (cracking and infection at the corners of the mouth)

·      Brittle nails, or spoon-shaped nails that curve outwards

·      Poor focus and concentration

·      Poor immunity.

Remember that these can also be signs of other conditions too, so it’s important to get the client tested (see below) if you suspect iron deficiency.

Iron testing: haemoglobin versus serum ferritin

If you suspect iron deficiency in a client, it’s vital to have this confirmed with a blood test, particularly before giving supplements. Testing can easily be done through the client’s GP. 

Haemoglobinis tested as part of a standard full blood count and is an indicator of iron levels in the body. However, haemoglobin will only start to decline when iron deficiency is quite severe. 

Ferritinis a protein that complexes with iron; around 25 per cent of the body’s iron is stored in ferritin. Levels of ferritin start to decline before haemoglobin declines, and therefore a serum ferritin test can be a better indicator of the primary stages of iron deficiency. 

For this reason, the client should request to have both haemoglobin and ferritin levels tested, both initially and on re-tests.

Food sources of iron

There are two primary types of iron in foods.

Heme ironis only found in animal foods. It is better absorbed than non-heme iron (see below) – up to 30 per cent is absorbed [2]. Good sources of heme iron include red meat, organ meats, poultry and fish, with small amounts found in eggs. These foods should be increased in the person’s diet if possible. 

Non-heme ironis found in both animal foods and plants, but plants onlycontain this form. It is more poorly absorbed – some sources say around 8–10 per cent is absorbed [2], others give a wider range. The best sources of non-heme iron include green leafy vegetables (especially spinach and chard); beans, lentils and chickpeas; sesame seeds and blackstrap molasses. Absorption of non-heme iron can be increased when eaten with heme iron from animal foods. In vegetarians or vegans, regular intake of these plant sources of iron in conjunction with an iron supplement (and considering the ‘Other factors’ in the section below) can be supportive.

Iron supplements

If the woman is iron-deficient and is nottaking a prescription iron from her doctor, then an iron supplement is generally advised. 

Good, well-absorbed forms of iron supplementation can include the following:

·      Iron bisglycinate.This is now one of the most popular forms in supplementation, as it is much less likely to cause digestive problems (e.g. constipation) than the commonly prescribed ferrous sulphate.

·      Ferrous gluconate

·      Ferrous fumarate

·      Iron citrate

Iron supplements can be best taken on an empty stomach, if the person tolerates this. This generally means at least half to one hour before a meal. If they feel nauseous or experience other digestive problems when doing this, then they may need to take the supplement with a meal. 

Note that some supplements only provide about 15 or 20mg of iron per capsule or dose. For someone who currently iron-deficient – particularly if she has anaemia – increasing the dose to three or four times this amount for a period of time may be needed. It is advisable to get serum ferritin and haemoglobin retested at regular intervals if doing this – more on this below.

Other factors to consider

·      Sources of vitamin C– generally fruit or a vitamin C supplement – can assist the absorption of iron and can be helpful if consumed with iron supplements or iron-rich foods.

·      Iron supplements should NOT be taken at the same time as other supplements containing minerals, particularly calcium or zinc, as they will compete for absorption. 

·      Tea andcoffee, and dairyfoods can also interfere with absorption of iron. When taking iron supplements or eating iron-rich foods, it’s best to avoid tea and coffee for up to 2 hours afterwards. 

·      Soyamay interfere with iron absorption – this can be a problem for vegetarians or vegans who rely on soya for their protein intake. It’s advised not to take iron supplements at the same time as eating soya – and another reason to get away from using soya as a primary source of protein.

·      Vitamin Adeficiency can have a negative effect on iron absorption and metabolism in the body. Vitamin A is thought to help with non-heme iron absorption in the gut; and it is also thought to be needed by the body to mobilise iron from storage so it can be used. Therefore, if your client is deficient in vitamin A, they may not be able to absorb or utilise iron in the body as well as they should – this can result in anaemia even when the person is consuming adequate levels of iron. 

Re-tests / toxicity

Iron can build up in the body and have negative effects in excess. Notably, it is a pro-oxidant, meaning it increases oxidative damage in the body. For this reason, those who are taking iron supplements should be re-tested at least every two to three months (more often if on a very high dose) to check their iron status and adjust the dose of supplementation. 

References:

1.     Sacirovi? S et al. Monitoring and prevention of anemia relying on nutrition and environmental conditions in sports.Mater Sociomed. 2013;25(2):136-9.

2.    Haas, E. and Levin, B. (2006). Staying healthy with nutrition.Berkeley: Celestial Arts. Page 188