Female Triad
By Dr. Russ Ebbets
Off The Road Column
Children Running Can v. Should
Initially this was seen as a paradoxical finding. It was believed that weight-bearing exercises, of which running was one, would actually strengthen the bony skeleton by making it more dense due to the increased stress of exercise. The adage – the body adapts to the stresses placed upon it – for some reason was not holding true.
Further investigation revealed that these females had a very low body fat levels, below 12%, and that they had temporarily lost their monthly period, a condition called amenorrhea.
Putting one and one together it was suspected that the athlete’s diet had somehow played a role in the development of the stress fractures. Upon examination, it was revealed that many of the runners existed on what was termed a "narrow food selection" of things like yogurt and bagels with no red meat and plenty of water, purposely avoiding foods that would put on "unnecessary weight." This incidental finding was one of the classic signs of the eating disorder anorexia nervosa.
Now the athlete’s clinical picture included three things: an eating disorder, anorexia; a physiologic disorder, amenorrhea; and a radiographic finding, osteopenia, signaling osteoporosis. Together anorexia, amenorrhea and osteoporosis came to be called the Female Triad. While the short-term effects have been troubling, the long-term implications are frightening.
Initially one might counter these finding with the benefits of an active fitness program – a strengthened heart, weight reduction, a social outlet, personal empowerment and personal satisfaction. Few would argue these points but when training is taken to excess, running and compulsive exercise patterns can have negative effects. The Russians taught that training and competing are not natural or healthy things to do for your body. Another way of putting it is that maximal use is always abuse.
The first step in the development of this unholy trio is probably the development of the eating disorder anorexia. Eating disorders, as I see them, are about self esteem and control issues. While authorities may champion their pet theories that include viruses, food allergies or some genetic predisposition the question I always raise that remains awkwardly unanswered is why is the prevalence of anorexia almost exclusively a white, middle to upper middle class female problem? The answer as I see it, is that this is the same population that Hollywood, Madison Avenue and the fashion industry dictate body image to.
Anorexia develops in female distance runners for a slightly different reason than just fashion. Being an athletic female in the United States is difficult. Female athletic role models are slowly surfacing but even as they do their athletic accomplishments are championed more as "celebrity" with sexy photos, posed pictures and athletic fashion statements than strictly for their athletic accomplishments.
Because of this social situation female athletes must concern themselves not only
being judged for their performance marks but also how they "looked" while performing. It makes it easy for a runner to develop a warped sense of self-reliance (a control issue) and to develop a compulsive drive to achieve one’s goals. This focus and drive extends into all aspects of the athlete’s life, especially their dietary habits.
Further compounding this situation is that there is a common running belief (probably accurate) that for every ten pounds you lose you can drop your 10k time about a minute. Ten pounds for 10,000 steps is an extra 100,000 pounds, over a 10k, which your muscular system must propel forward. Also consider the drain this extra weight puts on the body’s energy stores (water, blood, electrolytes) needed to service the larger body volume. This becomes a real problem for those whose core training philosophy dictates that "more is better," the more weight lost, the better.
As the body weight drops and drops the fat stores are depleted. Once a woman’s fat content drops below 12% they become amenorrheic, there is the loss of the monthly period. Biologically there is good reason for this. If a woman’s body fat stores drop below 12% there are not enough energy stores for her to support the life of a fetus, her body is in more of a survival mode, not conducive to pregnancy. No period, no ovulation, no pregnancy.
To a compulsive personality this is a plus. It is another area that can be controlled. The nuisance of the monthly cycle need not be dealt with and training and racing schedules can be more consistent. And with the weight loss, performance will probably be enhanced. How could all this be bad?
In the short term, over the course of a season this might not be bad. The problem develops when the pattern is extended for a year or years or career. That can lead to early osteoporosis, bony deformation and degenerative arthritis in the weight bearing joints.
How the early osteoporosis develops can be explained by simple chemistry. Normally the acid-base balance in the body is slightly basic. A normal blood pH is 7.4. Anorexia creates an acidic state in the body. One of the ways to balance the body’s pH level is through diet, a "balanced diet." The anorexic does not have a balanced diet. There is a "narrow food selection" and by design there is not much food.
Further upsetting the acid-base balance of the body is that heavy training makes the body more acidic. That is one reason why one gets sick training too hard too soon. Lactic acid in a trained athlete is one of the limiting factors in performance. In the case of the anorexic, without proper foods to rebalance one’s body chemistry, the body looks to the bones.
Our bones have calcium in them. Calcium acts as a buffer in our bodies, neutralizing the acidic state and normalizing the blood pH to the 7.4. If the diet does not include enough natural buffering foods, fruits and vegetables, then the body in its intuitive wisdom attempts to achieve and acid-base balance by leaching calcium, the buffering agent, from the bones.
In spite of the weight-bearing activity, once the bones lose calcium, they lose density and become softer and more brittle leading to stress fractures in the short run or if the pattern is repeated long enough, the development of bony deformities and degenerative joint disease, particularly at the hips. While foot stress fractures are a common running injury, anorexics suffer stress fractures of the shin, thigh and pelvis. Interestingly, the body’s breakdown may be a veiled attempt to protect itself. Can’t run, can’t expend energy, leading to a weight gain (to a more "normal" weight) and the body heals up.
There is no easy solution to the problem. An athlete with the triad has probably already tossed this article, dismissing it with the attitude, "Nobody is going to tell me how to do my sport." Or there may be the denial that somehow, in spite of all the signs and symptoms, they will be the one to dodge the bullet. "Anyway," the rationalization goes, "I’m running well (maybe the best ever), so how could anything be wrong?"
This is an equally difficult problem for the coach. This condition is not exhibited by a slacker but rather the more motivated, goal-oriented individuals on the team. You wind up sanctioning those more disciplined and dedicated who are probably the best athletes on the team.
While logical discussion might not be possible, one must at least make an effort. Professional diet counseling may be necessary and a revisiting of one’s athletic goals and long-term aspirations may be in order. Ignoring the problem won’t make it go away.
The long-term tragedy of the Female Triad is that the amount of calcium bone deposition maxes out while a female is in her 30’s. Those that are osteoporotic in their 30’s, with natural progression, are destined for greater osteoporotic problems later in life than the "average" women, and all the TUMS in the world are not going to help.
At what cost comes glory? The mindset of irrational control must be confronted. One’s greatest strength is one’s greatest weakness. The Female Triad, in reality, represents a loss of control. Training with intention remains the ultimate control.