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Special Populations

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Knowledge and atttitudes of university female athletes about the female athlete traid

WILLIAM F. SIMPSON, HEATHER L. HALL, REBECCA C. COADY, MICHELLE DRESEN, JAMES D. RAMSAY, and MONICA HUBERTY

The College of St. Scholastica, Duluth, MN; Elmhurst College, Elmhurst, IL; Carroll College, 
Waukasha, WI; and University of Wisconsin-Stevens Point, Stevens Point, WI

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SIMPSON, W.F., H. L. HALL, R. C. COADY, M. DRESEN, J. D. RAMSAY, and M. HUBERTY. Knowledge and attitudes of university female athletes about the female athlete triad. JEPonline Vol 1, No 1, 1998. Since the Female Athlete Triad was published in 1992, many efforts have been made to alert the athletic community about the relationship which is shared by disordered eating, amenorrhea and osteoporosis. The knowledge of athletes was investigasted at three midwestern universities regarding the female athlete triad. A total of 189 athletes from two Division III institutions and one Division I institution participated. Overall the subjects had normal height, weight, and body mass index. Most athletes knew they were at risk for osteoporosis at their age, however they did not understand the association it had with amenorrhea. At the Division I school, subjects (a) reported more stress fractures, (b) was the only school to report no history of eating disorders and (c) was the school with the highest percentage of athletes that had been told losing weight will increase performance. Getting the message out about the triad is imperative especially to the athletes so they will be in a better position not to become complacent and begin poor health practices.

Key Words: FEMALE ATHLETES, FEMALE TRIAD, EATING DISORDERS, AMENORRHEA, OSTEOPOROSIS

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Introduction
It has been well established that the female athlete triad [defined as the relationship of disordered eating, amenorrhea, and osteoporosis] is a serious health risk for athletic girls and women (1,2). Since the American College of Sports Medicine's Women's Task Force identified these three health concerns in 1992, the medical and scientific communities have attempted to alert those individuals who have contact with female athletes to be more sensitive about the signs of disordered eating, amenorrhea and the risk for young women in developing early osteoporosis (3-5).

Aside from the athlete herself, many individuals including coaches, parents, athletic trainers, athletic administrators, university team physician, or the family physician play an influential role in the life of athletes. Although these individuals are typically very helpful in many matters related to coaching, they also inadvertently contribute to the genesis of an eating disorder. For example, a coach who makes a seemingly innocent comment regarding a young girl's recent, yet normal increase in body weight during adolescence or a suggestion that decreasing her weight will increase athletic performance may influence her in thinking that she is "fat" and needs to lose weight (6). Hence, getting the information about the dangers of poor eating practices to adults in various authoritative positions is certainly important and feasible.

The knowledge that each individual athlete has concerning the dangers of poor nutrition, lack of menses and the effect upon performance and overall health is an issue that must be addressed at all levels of athletics. This includes elementary school through college. A young girl will be in a better position to resist peer pressure or pressure from an uninformed coach if she is taught at an early age about the dangers of low body weight and/or fat and decreased performance.

The purpose of this study was to survey intercollegiate varsity athletes at three midwestern universities regarding their menstrual function, knowledge about the female athlete triad, comprehension of unhealthy behaviors and the connection to future health problems such as osteoporosis. Two schools were Division III non- scholarship programs and one school was a Division I program that grants full athletic scholarships.

Materials and Methods
Participating Institutions
Three Midwestern institutions participated in this investigation. Institution "A" is a medium sized Division III school located in a small city that has a reputation for successful athletic programs with many of its teams regionally and nationally ranked. Institution "B" is also a Division III school. However, it is a small private college located in a large urban location with little emphasis placed on athletic performance. Institution "C" is a Division I school located in an urban area. About 85% of the athletes at this institution receive athletic scholarships.

Subjects
Each head coach was contacted regarding the desire to administer the Female Athlete Triad survey to each varsity team. The following sports were represented from each institution. School "A", soccer [soc], softball [sft]. tennis [ten], cross country [xcon], and volleyball [vball]. Institution "B" included soc, sft, vball, and basketball [bball] and from "C", sft, ten, xcon, bball, vball, and gymnastics [gym]. All participants were full members of their respective squad at the time the data collection took place. Athletes that were "red-shirting" were not included in this analysis. Approval of this investigation was granted from the Institutional Review Board for the Protection of Human Subjects.

Instrument
The data collection instrument was a 24 question survey constructed by the investigators. It was designed to address questions about menstrual history, attitudes about missing a period, disordered eating practices, and the athletes' risk for developing osteoporosis. Demographic information included number of years competing, height, weight, menarche age, use of oral contraceptives, and history of seeking help from a medical professional for menstrual and/or eating disorders or treatment for stress fractures.

Procedures
All three institutions followed the same procedures for administration of the survey instrument. Investigators met with the entire team and coaches prior to a scheduled practice for teams that were in season. For those sports that were not in season, investigators met with the team during an off season training period or formal team meeting. Athletes were informed that participation in this investigation was voluntary, and that all information would be confidential. An informed consent was distributed to all participants to review prior to completion of the survey instrument. Once the athletes were identified, a blank business sized envelope was distributed along with the survey. Athletes were instructed to complete the survey, place it in the envelope and seal it. Lastly, they were requested to place their sealed envelope into a large office sized envelope which was collected by the investigators. Athletes were asked to complete the survey to the best of their ability. Data collection took place during the month of October at institutions "A" and "B" and during December at institution "C".

Data Analysis
Statistical analysis including means, ranges, and standard deviations were completed for all questions. Self-reported height and weight were used to calculate Body Mass Index [BMI]. The Statview statistical package for Macintosh, version 4.0 was used on a Macintosh Quadra 660 . Prevalence rates are reported for each school. Individual sports are not reported due to extremely small sample sizes in some sports at all three schools.

Results
A total of 189 athletes participated in this investigation, with 73 from "A" [20 xcon, 17 soc, 14 sft, 13 vball, and 9 ten], 50 from "B" [15 soc, 14 vball, 11 sft and 10 bball] and 66 from "C" [ 21 xcon, 15 sft, 13 gym, 6 bball, 6 vball and 5 ten]. Overall height, weight, BMI estimates and menarche age for subjects from all three schools were within normal limits and may be found in Table 1. There were individual exceptions at all three institutions which included BMIs as low as 16 [xcon] and as high as 34 [soc and sft].

Responses to questions #1 [For the past 12 months, have you menstruated on a regular basis [i.e., did you cycle every 21-35 days?], #4 [Have you ever not had a period for more than 3 months?], #6 [Do you feel that it is healthy and OK to miss periods over a long duration?], #7 [Are women of your age at risk for developing osteoporosis [brittle bones]?] and #8 [Are you aware of any risks associated with being amenorrheic [not having regular periods] and the development of early osteoporosis?] were consistent among the three institutions as illustrated in Table 2.

Question # 5 [Do you feel that it is healthy and OK to miss a period?] was answered by institutions "A" and "C" consistently [50% and 59% respectively]. However, only 34% of the athletes at institution "B" felt that it was healthy to miss a period. Additionally, in response to question # 12 [Are you aware that participating in disordered eating practices can lead to amenorrhea [lack of periods?], institution "B" reported that 48% understood this fact while at institutions "A" and "C", 74% and 78%, respectively, indicated that they understood disordered eating may lead to osteoporosis.

Question # 11 [Have you ever been told that if you were to decrease weight, your athletic performance would improve], both Division III institutions similarly responded [26% "A" and 34% "B"]. However, 52% at the Division 1 institution ["C"] indicated that they had been told decreasing weight would help their performance.

Current and past disorder eating behaviors were addressed by question #9 [Have you ever participated in the following eating patterns? (a) anorexia nervosa [starving yourself] (b) bulimia nervosa [binge eating and vomiting] and #10 [Are currently participating in these behaviors?]. Athletes at institutions "A" and "B" indicated a history of these behaviors [19 % and 16 % for #9A and 12 % and 10 % for #9B, respectively]. However, no athletes reported any history of these practices at institution "C". Further, 5 % at institution "A" responded "yes" to question #10; 6 % at "B" and 2 % from institution "C". These data can be found in Table 3.

Subjects were also asked if they had ever seen a physician/healthcare professional for the following: (a) menstrual disorders, (b) eating disorders, and (c) stress fractures (questions #21A, #21B, and #21C). Athletes at all three institutions reported seeking medical help for menstrual disorders [11%, 16%, and 18%] institutions "A," "B", and "C" respectively (refer to Table 4). There were no athletes from institutions "A" and "C" who reported they had sought help with eating disorders. Only 4% reported "yes" from institution "B" in regards to seeking help from a health professional. Twenty-three percent of the athletes at Institution "C" reported seeking medical attention for stress fractures, while 11% and 18% sought help from institutions "A" and "B" respectively. Fifty-five percent of all athletes at all institutions reported having a yearly gynecological examination including a pap smear (question #22).

Discussion
The athletes included in this survey were all average healthy height and weight which one would expect for college aged athletes. Body mass index was also within normal ranges for athletes as was menarche age. This cohort is consistent with non-athletes at institution "A" (7). These data differ somewhat from those previously reported by Sundgot-Borgen and Larsen (8) who found athlete's mean BMI 20.8 and menarche age at 14.0 years. However, their data were drawn from a larger cohort of athletes who were considered their country's elite female athletes.

Seventy-six percent of the athletes in this cohort menstruated on a regular basis with 14% indicating a history of amenorrhea. Half of the athletes [49%] felt it was "OK" to occasionally miss a period, and 97% felt that missing periods for a long period was unhealthy. These findings were considered positive in light of the fact the majority of the athletes knew that it was unhealthy to stop cycling. It is interesting that only 35% report knowing that amenorrhea may be a risk factor for early osteoporosis. This finding suggests that the athletes knew that menstrual dysfunction is potentially dangerous, but did not understand what the long term effects might be. The fact that 78% responded "yes" when asked if they [college aged women] were at risk for developing osteoporosis suggests they knew that amenorrhea can be hazard for good health, but have yet to be educated to the relationship of amenorrhea and early osteoporosis. Amenorrhea is an important marker for athletes that may be in trouble since it is the best indicator that an athlete may be suffering from the female athlete triad (9).

Patukian (3) reported that women comprise 90% of all eating disorders. Previous investigations have indicated that prevalence of eating disorders in athletic women may range from 3% to 62% (2,4,10). Sundgot-Borgen (6) suggests much of the variation is attributed to whether or not the data are collected by self-report or clinical interview. In that this investigation used a self-report survey, the potential for inaccurate reporting should be considered in light of the findings.

The current investigation found that the two Division III programs [institutions "A" and "B"] had athletes report anorexic and bulimic practices. However, the Division I program [institution "C"] athletes reported no cases for either clinical eating disorder. This finding was surprising since Petrie (11) reported 60% of 215 Division I college gymnasts met criteria for sub-clinical eating disorders and 22% reported participating in disordered eating. One of the major differences between a Division I and Division III program is athletic scholarships. Division I athletes often receive full or partial athletic scholarships to attend school and participate in their sport during the normal competitive season and mandatory off season training programs. The Division III athlete receives no compensation or scholarships for athletic participation, and is expected to place academics first with athletics second throughout the academic year. Division III programs have off season training programs, but coaches are not allowed to place the practices as mandatory.

Due to the stresses that a Division I program can impose on an athlete, it is highly doubtful that none of the 66 athletes in the survey had participated in either clinical eating disorder. One of the major sports at this institution is gymnastics, which is known to have a high prevalence of eating disorders as do other sports that emphasize leanness (3,8,12). The stressors are very evident since institution "C" had the highest percentage of athletes who indicated that they had been told that if they were to lose weight their performances would increase.

The distinct relationship of eating disorders, amenorrhea and early osteoporosis is illustrated in the responses regarding physician visits. When asked if any visits to a physician were due to eating disorders, only 4% reported "yes" from institution "A" while the other two school's respondents indicated zero. However, 23% of the athletes at institution "C" indicated that they had been treated by a health care professional or physician for stress fractures, while 18% reported problems with stress fractures at "B" and only 11% at "A". Stress fractures may be a sign of early osteoporosis in athletes. Karpakka et al (13) reported a case study of a 26 year old athlete who had a history of bulimia over nine years in concert with secondary amenorrhea for 8 years. At the time the study was published, she was being treated for recurrent stress fractures at the left hip.

Fifteen percent of all the athletes in this cohort reported seeing a physician for menstrual disorders, and overall 14% had indicated secondary amenorrhea. However, only 11% at "C" reported seeing a physician or have secondary amenorrhea. This again may be under-reporting of the truth. Over half [57%] reported that they regularly see a gynecologist every year and receive a pap smear.

Summary
The results of this survey suggest to that female athletes at these three institutions do not totally understand the health consequences of simply missing numerous menses or participating in disordered eating. They appear to acknowledge that they are at risk for osteoporosis at their age. However, they do not understand the reason why there is a risk. Educational programs for coaches and medical staff [re: physicians and athletic trainers], parents, athletic administrators, and especially the female athlete are essential if the athletes are to become educated against poor advice and/or peer pressure to participate in disordered eating practices. Further, they need to understand that should they cease to menstruate, they should take action early in order to prevent the likelihood of other serious medical complications [such as reproductive cancer] besides osteoporosis. 

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References
1. Yeager, K. K., Agostini, R., Nattiv, A., and Drinkwater, B. The female athlete triad: disordered eating, amenorrhea, Osteoporosis. Medicine and Science in Sports and Exercise, 1993;25: 775-777.
2. Nattiv, A. and Lynch, L. The female athlete triad-managing an acute risk to long-term health. The Physician and Sports Medicine, 1994B;22:60-68.
3. Putukian, M. The female triad: eating disorders, amenorrhea, and osteoporosis. Clinics in Sports Medicine, 1994;78:345-354.
4. Nattiv, A., Agostine, R., Drinkwater, B., and Yeager, K., K. The female athlete triad-the inter-relatedness of disordered eating, amenorrhea, and osteoporosis.Clinics in Sports Medicine, 1994A;13: 405-418.
5. Kirkendall, D., T. Issues in training the female athlete. Soccer Journal, 1993;38:31-34.
6. Sundgot-Borgen, J. and Larsen, S. Preoccupation with weight and menstrual function in female elite athletes. Scandinavian Journal of Medicine and Science in Sports, 1993B;3:156-163.
7. Simpson W. F., Ramsay, J.D., and J. C. Probst. Prevalence of cigarette smoking, alcohol, drug use and exercise patterns in 18 and 19 year old undergraduate students. 1997; In review.
8. Sundgot-Borgen, J. and Larsen, S. Pathogenic weight-control methods and self-reported eating disorders in female elite athletes and controls. Scandinavian Journal of Medicine and Science in Sports, 1993A;3:150-155.
9. Skolnick, A. A. Female athlete triad' risk for women. Journal of American Medical Association, 1993;270:921-923.
10. Beals, K. A. and Manore, M. M. The Prevalence and consequences of subclinical eating disorders in female athletes. International Journal of Sports Nutrition, 1994;4:175-195.
11. Petrie, T. A. Disordered eating in female collegiate gynmasta: prevalence and personality/attitudinal correlates. Journal of Sport and Exercise Psychology, 1993;15:424-436.
12. Bale, P. Body Composition and menstrual irregularities of female athletes. Sports Medicine, 1994;17:347-352.
13. Karpakka, J. Leppavuori, J., Orava, S., and Heikkinen, J. Recurrent stress fractures in a female athlete with primary amenorrhea: A Case Study. Clinical Journal of Sports Medicine, 1994;14:136-138.

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Appendix A Survey Instrument

FEMALE ATHLETE TRIAD SURVEY

INSTRUCTIONS: Please answer the following questions as best as you can. Circle or fill in your response in the space provided. PLEASE DO NOT PLACE YOUR NAME ON THE SURVEY FORM OR PLACE ANY OTHER IDENTIFYING MARKS. If you have any questions, please do not hesitate to ask.

1. For the past 12 months, have you menstruated on a regular basis [i.e., did you cycle every 21-35 days?] Y N

2. If you answered "no" to #1, which of the following best describes your past years menstrual history?

a. had 6-10 periods, but irregular

b. had 6-10 periods, regularly but missed a few months in a row

c. had 3-6 periods

d. had 3 periods

e. did not menstruate

3. Have you ever missed periods:
a. during the competitive season

b. during the off season

c. both

d. have not missed a period

4. Have you ever not had a period for more than 3 months? Y N

5. Do you feel that it is healthy and OK to miss a period? Y N

6. Do you feel that it is healthy and OK to miss periods over a long duration? Y N

7. Are women of your age at risk for developing osteoporosis [brittle bones]? Y N

8. Are you aware of any risks associated with being amenorrheic [not having regular periods] and the development of early osteoporosis? Y N

9. Have you ever participated in the following disordered eating patterns?

a. anorexia nervosa [starving yourself] Y N

b. bulimia nervosa [binge eating and vomiting] Y N

10. Are you currently participating in these behaviors? Y N

11. Have you ever been told that if you were to decrease weight, your athletic performance would improve? Y N

12. Are you aware that participating in disordered eating practices can lead to lack of periods ? Y N

Demographic Information

13. Sport ___________________

14. Years competing in this sport ___________________

15. Years competing in competitive sports ___________________

16. Do you compete in other varsity sports? ___________________

17. Height __________ Weight __________

18. If known, current percent body fat ?________% When done [year]______

19. Age of menarche [when you started menstruating] ________

20. Do you use oral contraceptives? Y N

21. Have you ever seen a physician or health care professional for:

a. menstrual disorders Y N

b. eating disorders Y N

c. stress fractures Y N

22. Do you have regular yearly gynecological exams [including a pap smear]? Y N

23. What class [size] high school did you graduate from ? A B C

24. Did you attend a public or private high school? __________

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American Society of Exercise Physiologists
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