More girls and women participate in sport than ever before. The opportunities created by Title IX have increased female participation at the scholastic and collegiate level. The successes of American women at the 1996 Atlanta Olympic Games and the 1999 Women's World Cup of Soccer were covered more extensively by major media outlets than any other women's sporting events in history. Women's professional leagues now operate successfully in the sports marketplace and draw significant numbers of fans and network television coverage.

The majority of women in sport certainly derive significant health and social benefits from running, jumping, throwing, and swimming -being on the team. Yet everyday, thousands of women may be at risk of significant harm from their participation in sport. Girls and women who may consider themselves at the peak of health may, in fact, be in danger of severe injury, illness, or even death. The cause of this risk: the Female Athlete Triad.

Any of the components of the Triad is harmful by itself; together they can cause a decrease in performance, medical and psychological harm, and in severe cases death. It is the responsibility of every female athlete, coach, parent, sport administrator, trainer, and team physician working with female athletes to know about the Triad, its causes, how to recognize it, how to prevent it from occurring, and what to do if it occurs.

The causes of disordered eating are complex. External and internal pressures to be thin may cause the Triad to develop in an athlete. Coaches, fellow athletes, parents, judges, officials, the media, or others may encourage athletes to be thin because they believe this will enhance performance or appearance. Nothing could be worse for an athlete who is susceptible to disordered eating.

External and internal pressures to win also may be a cause of the Triad. Overly controlling and zealous coaches and parents may cause athletes to feel they lack control over their lives and sports; to gain perceived control over some aspect of their lives, athletes may turn to excessive exercise and controlling their food intake.

The chief cause of the amenorrhea component of the Triad is an energy imbalance brought on when athletes do not eat enough to balance the energy they expend in training. This energy imbalance -the net result of under eating and hard workouts -negatively affects the body's regulatory systems, which leads to amenorrhea and osteoporosis.

Although any athlete may suffer from the Triad, girls and women who participate in sports that place a premium on appearance or thinness are especially susceptible, including the following²:

• Sports where performance is subjectively judged (i.e., dance, figure skating, diving, gymnastics, aerobics)
• Endurance sports (i.e., distance running, cycling, cross-country skiing)
• Sports where athletes wear revealing clothing (i.e., volleyball, swimming, diving, cross-country skiing, track and field, cheerleading)
• Sports with weight categories (i.e., wrestling, weightlifting, rowing, some martial arts)
• Sports where a pre-pubescent body is emphasized (i.e., figure skating, gymnastics, diving)

Teen-age athletes in these sports, who also must cope with biological changes, peer pressure, society's glorification of thinness and the focus on body image that occur during puberty, are particularly at risk of suffering from the Triad.

Paradoxically, the most likely candidates for the Triad may have the same characteristics most prized by coaches³: extreme dedication to sport; prompt and attentive; always fit; perfectionistic about technique and training; self-critical and seemingly self-reliant, and; trains longer and harder than expected. These characteristics, however, can also be the early warning signs of the Triad. Coaches must trust their instincts and as soon as they "feel" something is not normal, pay close attention for other warning signs.

Unusual food behaviors may be a sign of disordered eating. Road trips are an especially good time to observe eating habits. Potentially dangerous behaviors include:

• .Frequent bathroom visits, especially after meals (which may indicate self-induced vomiting or laxative use )

• Frequent comments about weight, appearance, and food
• Hoarding or hiding food
• Bingeing and/or purging
• Dieting or restricting food intake, especially during hard training
• Not being honest about food
• Feeling fat when normal or thin
• Using diet pills, diuretics, or laxatives
• Excessive efforts to please the coach or parents
• Unexplained weight loss or fluctuations
• Moving food around the plate without eating
• Commenting about teammates eating patterns
• Eating alone
• Public eating patterns not consistent with body weight (e.g., eats a lot, but is too thin)

Coaches should also be aware of unusual mood patterns, sleep disturbances, and impaired concentration. Physical manifestations of disordered eating include dry hair and skin, cold hands and feet, fine hair on the face or body (looking "furry"), puffy cheeks, bloodshot eyes, and eroded tooth enamel.

There are no obvious physical signs to the outside observer that a female is not menstruating, therefore, amenorrhea is difficult to recognize. Beyond amenorrhea, coaches must know that having irregular periods is unhealthy and is a warning sign.

Osteoporosis may manifest itself in the form of stress fractures. Although not all stress fractures are the result of the Female Athlete Triad, one should certainly take a close look at the nutritional and training habits, and menstrual history of any female athlete with a stress fracture.

To recognize the Triad, coaches must also honestly evaluate their own beliefs, behavior and other external factors affecting their athletes. Excessive pressure to win can hurt a coach's self- awareness, making it difficult to recognize signs of the Triad. As the people who may be in the best position to recognize the Triad in its early stages -- when interventions have a better chance of being effective--coaches must make a commitment to knowing and consciously attempting to be aware of the signs of the Triad.

Communicating with and educating athletes, coaches, parents, medical staff, judges and officials, and adli1inistrators about the Triad are the most important aspects of prevention. Coaches must take the lead in ensuring that everyone involved in a sports program is aware of the risks and signs associated with the Triad; educational programs, team meetings, and informational materials ought to be built into every seasonal plan. Educational programs should include⁴:

• Giving athletes the message that sports participation is about having fun and being physically and mentally healthy
• The message that "winning at all costs" is not a program philosophy
• Nutrition education
• Emphasizing strength and fitness over thinness and body weight
• Information about normal maturation and development processes
• Encouraging athletes to discuss eating, maturation and menstruation, and personal issues with a confidential contact person

It is never too soon to start educating athletes and parents about the Triad.

Because disordered eating is a disease related to issues surrounding control and body image, coaches should foster independence in athletes from an early age. Teaching young athletes to assume responsibility for their training, nutrition, performance, and other issues helps them develop a sense of intrinsic control over various aspects of their sport and lives. This sense of control can make sport more fun because independent athletes must examine their reasons for participating; athletes who participate because "I want to" are at less risk than athletes who do so because "coach or mom/dad says so".

Coaches must examine their won beliefs regarding weight and body size, and how these characteristics affect performance. Weight gain and body changes are a normal process in growing children and adolescents. Coaches should never conduct public or team wiegh0ins or single out athletes for weigh-ins. There is a lack of research to support a relationship between being thin and improved performance. In fact, weight loss can lead to dehydration, fatigue, poor concentration, and injury.

Evaluating skills and fitness is far superior to weight and body fat measurements in determining performance outcomes.

Weight management issue should be discussed with a health care professional.

Every athlete should have a pre-participation medical screening and be encouraged to develop an on-going relationship with a health care provider they trust.

Coaches must have an increased awareness of the Female Athlete Triad and act if they suspect an athlete is suffering from any aspect of the Triad. To ignore this obligation is irresponsible coaching. Every coach must take seriously this duty to prevent further problems related to the Triad because not doing so can lead to serious health complications or death.

Treatment of the Triad is beyond the scope of training of most coaches. A coach's commitment to action includes consulting with a health care professional to develop a plan if an athlete exhibits any of the signs of the Triad. In fact, developing a referral network of medical, counseling, and nutrition experts is part of having a sound team health management plan. Because each athlete must be treated as an individual, the health management plan may vary from athlete to athlete.

A coach should never accuse an athlete of disordered eating; accusations can drive an athlete to hide behaviors. Approaching an athlete about such a sensitive issue must be done with utmost care and only after consultation with a health care professional.

The best treatment of the Triad, however, is prevention. Communication, trust, and education are the best prevention tools in a coach's arsenal. Creating a team environment of openness and caring for one another may be the best source of early information about a potential problem. Learning about and making efforts to prevent the Triad must be a primary obligation of any coach working with athletes who may be at risk--no victory or athletic achievement is more important than the health, dignity, and worth of the human beings who entrust their lives to coaches.

1 Yeager, K.K., R. Agostini, A. Nattiv, and B. Drinkwater. The female athlete triad. Medicine and Science in Sports and Exercise 25:775-777, 1993.

2 American College of Sports Medicine position stand: the female athlete triad. Medicine and Science in Sports and Exercise, 29:i-ix, 1997.

3. Otis, C.L. Too slim, amenorrheic, fracture-prone: the femle athlete triad. ACSM's Health and Fitness Journal, Vol 2, 1:20-25, 1998.