Kayla is a 16-year-old competitive soccer player. Like many of her teammates, she has irregular periods—generally only a few times per year. Her coach told her that it is normal to have irregular periods, so she doesn’t think too much of it. Last season, she sustained a stress fracture and had to sit out the championship game. She describes herself as a healthy eater, focusing on fresh produce and lean meats, as she is trying to be “fit” to optimize her performance. She claims she eats “a lot” more than her non-athlete friends. She guesses that she eats about 2,000 calories a day because a fitness magazine told her this is a good number of calories for an active female. She denies any disordered eating and was told by her pediatrician that she is in the normal weight range. Kayla is just a healthy, athletic teen, right?
As a pediatrician specializing in adolescent medicine, I frequently see patients just like Kayla. Unfortunately, many teen athletes are getting inaccurate or just plain wrong information about their health. Despite her good intentions, Kayla is suffering from something called the Female Athlete Triad, which is a syndrome of three interrelated components: 1) decreased energy availability (eating too few calories to support calories burned), 2) irregular periods and 3) decreased bone density. This condition can negatively impact sports performance. In more severe cases, the Female Athlete Triad may place athletes at risk for dangerous medical conditions like cardiac arrhythmias, electrolyte abnormalities and poor mental health.
When athletes fail to meet their caloric demands, nearly all systems in the body can be affected. Below are some signs or symptoms that suggest inadequate caloric intake:
Fatigue
Low blood pressure and fainting or near-fainting episodes or dizziness (also a sign of dehydration)
Cold hands and feet
Weight loss (*normal or even overweight individuals can still be malnourished if weight loss occurs too quickly)
Hair loss
Dry skin
Constipation
Low resting heart rate (*normal resting heart rate is around 60-80 beats per minute. Heart rate may be slightly less than 60 in athletes, but is almost never normally less than 45-50)
In girls, irregular or absent periods
Frequent injuries or stress fractures
Depression or anxiety
Common Myths
The Female Athlete Triad is a condition that only affects females Yes and no. Males obviously cannot “qualify” for the irregular period component of the Triad. However, males who do not meet their nutritional needs experience the same physiological response, including the negative impact on bone health. Young male athletes have remarkably high caloric demands, which can make it difficult to meet their nutritional needs. Despite popular misconceptions, eating disorders are very common among young men, and boys often go many years before receiving a proper diagnosis.
2,000 calories per day is an appropriate caloric intake for a teen athlete
Caloric needs vary drastically between individuals depending on multiple factors, such as gender, body size, muscle mass, genetics and energy expenditure. We frequently see teen athletes in our clinic, particularly in endurance sports, with caloric needs of 4,000 calories per day, or more. It is common for teens to be inadvertently under-fueling their bodies. On the other hand, eating disorders, with intentional caloric restriction and an extreme desire for thinness, are also very common in athletes of all sports. If you have questions about your teen’s caloric needs, please seek the advice of a registered dietitian for an individualized assessment.
Athletes should only eat “healthy” foods
It is true that everybody should prioritize more healthful foods like fresh produce and lean meats and fish. However, these foods tend to be less calorically dense, so it can be challenging to meet a growing, active teen’s nutritional needs eating the most healthful foods alone. Healthy and calorically dense foods, such as avocados, nuts, oils, and whole milk yogurt are a great addition to the active teen’s diet. In addition, all teens should learn how to include treats in their diet in moderation. It will help set them up for a healthy relationship with food for a lifetime.
It is normal for female athletes to have irregular periods
In females, irregular periods may be normal in the first one to two years after having a first period. But after the first two years, irregular periods are never normal. While conditions like polycystic ovarian syndrome may be to blame, in female athletes, inadequate caloric intake is very often the culprit. When a female athlete does not meet her caloric needs, her body fails to produce the necessary hormones required to have menstrual cycles. These hormones are also necessary to help build peak bone mass. Without them, the risk of fractures and osteoporosis increases. The teen years are a critical period to increase bone mass. Bone mass is only accrued into the 20s, after which it must last a lifetime. If your teen daughter has not had her first period by age 15, or if she is having irregular cycles a couple of years after her first period, please seek a medical evaluation.
If your teen is experiencing any of the above signs or symptoms, please seek care with a physician. Our Center for Adolescent Health is well equipped to evaluate and treat teens and young adults, ages 12-21, with concerns about their nutrition, as well as to provide comprehensive primary care to this population.
Resources
De Souza MJ, Nattiv A, Joy E, Misra M, Williams NI, Mallinson RJ, Gibbs JC, Olmsted M, Goolsby M, Matheson G; Expert Panel. "2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013." British Journal of Sports Medicine. 2014 Feb;48(4):289.
Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, Warren MP, & American College of Sports Medicine. "American College of Sports Medicine position stand. The female athlete triad." Medicine & Science in Sports & Exercise. 2007 Oct;39(10):1867-82.
Yu, Christine. "The Condition That's Quietly Sidelining Female Athletes." Outside Magazine. 15 Sep. 2017.
The Female Athlete Coalition: www.femaleathletetriad.org/
Katherine Hill, MD
Katherine Hill, MD, is a board-certified Stanford pediatrician with special interests in Adolescent Medicine and care of the teen athlete. She completed her undergraduate training at Stanford University, where she was a member of the Stanford women's varsity swim team. She then received her MD from the Stanford School of Medicine, and completed her residency training in Pediatrics at Stanford. Her research has focused on the Female Athlete Triad in collegiate athletes. She lives with her husband and young son in Belmont, California. She is currently accepting new patients at the Stanford Teen and Young Adult Clinic in Sunnyvale, CA.
Stanford Center for Adolescent Health 1195 West Fremont Avenue Sunnyvale, CA 94087 Clinic phone: 408-637-5959
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