1996 Atlanta Forum

WSI Convenes International Forum on the Female Athlete Triad – Atlanta, USA

WomenSport International convened an international forum on the Female Athlete Triad: Eating Disorders, Amenorrhea, and Osteoporosis in Atlanta this past September just prior to the 4th Olympic Scientific Congress. The Forum was designed to bring world-wide attention to the Triad and resulted in the appointment of a joint task force of the IOC Medical Commission and WSI to address this issue.

Attendees at the Forum included representatives of the International Amateur Athletic Federation, International Skating Union, International Gymnastics Federation, International Tennis Association, USA Gymnastics, USA Track and Field, USA Figure Skating Association, USA Swimming Association, the NCAA, NFSHSAand WSI. Experts in the areas of eating disorders, sports medicine, and body composition and nutrition were present to provide expertise in those areas.

The group was unanimous in agreeing on the need for mandatory education for coaches so they can identify the early precursors of eating disorders and learn how to avoid actions which encourage undue concern about body weight and/or fat. Similar educational programs would be planned for parents, athletes, health professionals, and others who have a responsibility for athletes. WSI will prepare a core curriculum which each sport body can adapt to its own needs. All materials will be translated into other languages so they can used in a number of other countries.

USA Gymnastics volunteered to use their Task Force Committees to write a Bill of Rights for athletes, coaches, and parents and to prepare a series of Red Flag lists to aid parents and coaches in detecting athletes at risk for an eating disorder and to assist parents in evaluating the suitability of a coach or sports program for their child. The new age eligibility criteria adopted by the International Tennis Federation (ITF) and the Women’s Tennis Council (WTC) for their young players formed the basis for a discussion on increasing the age for participation at various levels of competition, setting a minimal level of percent body fat, requiring a mandatory yearly medical examination, evaluating the role that ‘scanty’ sports uniforms play in an athlete’s concern about her weight, encouraging judges to de-emphasize appearance and place more emphasis on mastery of the sport and artistry, and organizing a media summit to educate members of the media and encourage change in the way they cover women’s sports.

Enlisting the cooperation and expertise of the IOC Medical Commission in working with the WSI Task Force will be helpful in encouraging the international sports federation to take the recommendations of the IOC-WSI Joint Task Force (JTF) into serious consideration. IOC representatives to the JTF are: Prof. Arne Ljungqvist, M.D., Sweden; Prof. Ken Fitch, M.D., Australia; and Dr. W.D. Montag, Germany. WSI members are Naama Constantini, M.D., Israel; Ruth Highet, M.D., New Zealand; Jorunn Sundgot-Borgen, Ph.D., Norway; Jane Wilson, M.D., UK; and Barbara L. Drinkwater, Ph.D., USA (Chair).

What is the Female Athlete Triad?

When girls and women are pressured to meet unrealistic weight goals as a means of improving performance and/or visual appeal, many of them slip into a pattern of disordered eating which in turn often leads to a serious eating disorder such as anorexia or bulimia, amenorrhea (absence of menses), and bone loss (osteoporosis). Although any of these can occur in isolation, the emphasis on weight loss often begins a cycle in which all three occur in sequence–hence the term “Female Athlete Triad.”

What is disordered eating?
Disordered eating can range from a poor nutrition and/or inadequate caloric intake to meet the energy demands of the sport, to a serious eating disorder such as anorexia or bulimia. All forms of disordered eating are likely to diminish athletic performance and increase the athlete’s risk of developing serious medical problems.

Everyone personally involved with the athlete–the parents, coach, trainers, and team physicians should be alert to the following signs of an eating disorder:

Anorexia nervosa:

  • Weight at or below 15% of normal weight for age and height
  • Intense preoccupation with weight and fear of becoming fat
  • Feeling “fat” even when they are thin
  • Amenorrhea


  • Episodes of binge eating accompanied by a feeling of lack of control over what and how much is eaten
  • Purging behavior (self-induced vomiting, laxatives, excessive exercise, diuretics, etc.)
  • Overconcern with body shape or weight.

What is amenorrhea?

  • Primary Amenorrhea is defined as having had no menstrual periods by 16 years of age.
  • Secondary Amenorrhea is defined by the absence of menstrual bleeding for 3 consecutive months or fewer then three periods in a year.
  • Oligomenorrhea is defined as irregular periods with 35-90 days between periods.

Not all athletes with these menstrual irregularities have disordered eating, but the above conditions are common among those athletes who participate in sports where a low body weight is presumed to improve performance or the body shape may influence judges’ scoring. The incidence is high in gymnastics, distance running, ballet, and figure skating, but can occur in any sport where the athlete is pressured to lose weight.

What is osteoporosis?

Osteoporosis is a disease characterized by low bone mass and microarchitectural deterioration of the bone tissue leading to increased bone fragility and an increased risk of fractures. In the female athlete this can result from inadequate bone formation during the critical growth years and/or a premature loss of bone mass in the young adult years.

Who is at risk?
All athletes are at risk if they are pressured to lose weight to meet an unrealistic standard of body fat or body weight. This pressure may come from the coach, the parents, teammates, or the athlete herself. While the incidence may be higher in elite athletes, the Female Athlete Triad can occur at any age or level of skill if the pressure or desire to excel leads an athlete to attempt to lose weight through severe dietary restriction or other inappropriate methods. The prevalence of disordered eating among female athletes has been reported to range from 15% to 62% depending on the activity.

What are the consequences of the Triad?
Sports performance: Muscle mass as well as fat is lost during extreme dieting and performance may deteriorate. Other side-effects of poor nutrition can result in fatigue, electrolyte imbalance, anemia, and depression–all of which contribute to a poor performance.

Health problems: There are a number of serious medical complications arising from the Female Athlete Triad. Some of these are reversible, but others permanently impair the major organ systems, including the kidneys, heart, gastrointestinal tract, and skeleton. In addition, there are problems with fluid and electrolyte balance, the central nervous system, and endocrine function. The final outcome for some young athletes is death.

What can be done to prevent the Female Athlete Triad?
WSI and the Medical Commission of the International Olympic Committee have recently established a joint working committee to examine ways in which the Triad can be prevented and to further examine the range of health related issues facing girls and women in sport. This working committee will be looking at ways in which to develop materials and programs to:

  1. Educate the athletes, parents, coaches, health professionals, and athletic administrators about the seriousness of the problem and how to recognize the warning signs.
  2. Establish standards of conduct for coaches which prohibit the type of behavior, such as daily weigh-ins, which encourage disordered eating.
  3. Examine the rules governing each sport to see if changes in the rules might discourage the type of behavior that leads to the Female Athlete Triad.
  4. Promote the positive aspects of sport, the enjoyment of the athlete and the physical, social, and psychological benefits.

In addition, WSI is developing an educational campaign which will not only stress the health related risks of the Triad but also emphasize the benefits for girls and women
of regular participation in sport and physical activity.