Nutritional Considerations for Female Athletes

Guillermo Escalante, DSc, MBA, ATC, CSCS Department of Kinesiology, California State University, San Bernardino, San Bernardino, California

ABSTRACT with a range of indicators of physiolog- a wealth of erroneous information ical and psychological well-being such available on the Internet and hundreds THIS ARTICLE PROVIDES AN as cardiovascular fitness, mood, and of unqualified/improperly credentialed OVERVIEW OF CURRENT LITERA- self-esteem (7), most of the literature “experts” providing nutritional advice TURE RELATED TO NUTRITIONAL shows that the prevalence of eating to the public. Female athletes seeking CONSIDERATIONS FOR THE disorders and disordered eating (DE) to lose body fat, gain muscle mass, or FEMALE ATHLETE. THE PREVA- is higher in athletes compared to that improve performance may seek guid- LENCE OF THE FEMALE ATHLETE of nonathletes (30,51). ance from unreliable sources and hence TRIAD, EATING DISORDERS, AND may put their bodies, and/or perfor- Research also indicates that women, BODY IMAGE ISSUES AMONG mance, at risk. Research indicates that regardless of whether they participate FEMALE ATHLETES WILL BE RE- athletes who are encouraged to diet by in sports or not, are at greater risk for VIEWED. FURTHERMORE, DETRI- their coaches may resort to faster more body dissatisfaction (14,15) and DE MENTS IN HEALTH AND/OR dangerous methods of weight control (17,19) than men. Compared to male SPORTS PERFORMANCE FROM (e.g., self-induced vomiting or fasting) athletes, female athletes are more likely LACK OF PROPER NUTRITION WILL to shed pounds quickly (46). The to engage in compulsive exercising and strength and conditioning professional BE DISCUSSED. RECOMMENDA- pathological weight-loss methods such can help to guide female athletes in the TIONS FOR APPROPRIATE NUTRI- as abuse of laxatives or diets pills, self- right direction and steer them to seek TIONAL GUIDELINES TO SAFELY induced vomiting, and fasting with the advice from reliable/qualified sources DECREASE BODY FAT, INCREASE goal to achieving top sporting perfor- and provide them with appropriate MUSCLE MASS, AND IMPROVE mance and superior physical condition support. Recognition of DE behaviors OVERALL SPORTS PERFORMANCE (12). Data indicate that although the or body image issues among athletes WILL BE ADDRESSED. CONSIDER- prevalence of clinical eating disorders ATIONS WHEN PROVIDING BODY should be identified as quickly as pos- ranges from 0 to 8% among profes- sible by strength and conditioning COMPOSITION ADVICE FOR THE sional and college female athletes coaches so that they may be properly FEMALE ATHLETE ARE REVIEWED. (49), many of them are “at risk” for referred to a mental health professional eating disorders which places them at for further intervention because these risk for menstrual irregularity, bone in- INTRODUCTION issues could create major health and juries, cardiovascular problems, depres- he participation of females in psychological problems. sion, lower athletic performance, social sports has greatly increased over isolation, and poorer quality of life (32). In an effort to prevent athletes from Tthe last several decades. Accord- following nutritional recommendations ing to the National Federation of State The purpose of this article is to from unreliable sources, it is recom- High School Associations, of the 7.5 provide practical nutrition-related mended that strength and conditioning million athletes who participated in information to the strength and condi- professionals work in conjunction with a school-sponsored activity in 2008– tioning professional when working team coaches, athletic trainers, physi- 2009, 41% were females (4). In 1972, with female athletes. Research has cians, psychologists, and sports trained females comprised only 7% of the total indicated that although risk factors dieticians to readily provide reliable re- number of athletes (4). Naturally, as the such as menstrual disorders, DE, low sources for their athletes. Instead of trend of increased participation in high bone mineral density (BMD), and school athletics has risen, so has the body image issues are prevalent among KEY WORDS: female athletes, knowledge and recog- number of women participating in col- body image; eating disorders; female nition of these risk factors among lege, professional, and recreational athlete; weight loss; body fat; muscle coaches and athletes was low (13). sports increased. Although participa- mass; sports performance tion in sports and exercise is associated When it comes to nutrition, there is

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allowing athletes to seek information translate to metabolic and reproductive and dietary restraint were related on their own, bringing a qualified pro- suppression (52) that potentially results directly to bulimic symptoms (1). Fur- fessional on board to provide some in a multitude of health concerns. thermore, the researchers suggest that basic nutrition education to the team Research has reported that the preva- general sociocultural pressures are influ- could prove to be beneficial. Further- lence of clinical menstrual disorders ential but weight and appearance pres- more, the professional who comes to (FHA and oligomenorrhea) in female sures in the sport environment may be give the nutrition lesson(s) can poten- athletes include both high school (6) even more pervasive and negative for tially make himself available for one- and premenopausal women (8). Clinical female athletes (1). on-one consultation to help improve signs of menstrual disorders have been Low BMD in female athletes has been the intervention. If budgeting prevents shown to range from 1 to 61% in exer- investigated with the diagnostic crite- these types of services, then it is recom- cising women and are documented at ria set forth by the World Health mended that strength and conditioning significantly higher rates than in Organization for postmenopausal coaches compile a list of reliable resour- nonathletic premenopausal women women, which are based on T scores ces (i.e., books, approved websites, etc.) (5). Lean build athletes and aesthetic instead of Z scores. A T score is that athletes can reference as informa- athletes (cheerleading, dance, and defined as the number of SD above tion on where reliable information can gymnastics) have a significantly higher or below the mean peak BMD of be found. Educating athletes on the prevalence of menstrual disorders—26.7 young adults of the same age and eth- types of credentials that their source and 28.2%, respectively—when com- nicity. Research for female athletes shouldhavecouldalsoprovetobean pared to that of general high school that used the World Health Organiza- effective intervention so that they are not athletes (43). The prevalence of second- tion criteria found the prevalence of T loosely following anybody’s information. ary amenorrhea has been reported to be scores between 21.0 and 22.5, which as high as 65% in elite long distance is classified as osteopenia, to range PREVALENCE OF THE FEMALE runners compared to 2–5% in the gen- from 22 to 50% (42). Furthermore, ATHLETE TRIAD AND EATING eral population (22). Although primary the prevalence of T scores less than DISORDERS amenorrhea prevalence is less than 1% 22.5, which is classified as osteoporo- The female athlete triad was first rec- in the general population, the preva- sis, ranged from 0 to 13% (42). These ognized more than 20 years ago based lence in collegiate cheerleading, diving, prevalence rates are significantly high- on the association of DE, functional and gymnastics athletes has been er than those reported in the normal hypothalamic amenorrhea (FHA), reported to be as high as 22% (9). population. and osteoporosis observed in recreational and elite-level exercising women DE and eating disorders among female (42). After several years of progress in athletes often go unnoticed and it is FEMALE ATHLETES AND BODY IMAGE ISSUES the scientific understanding of the therefore difficult to estimate their real female athlete triad, the American Col- prevalence. Research has indicated Body dissatisfaction is another area of lege of Sports Medicine redefined the that the reported lifetime prevalence concern among female athletes. This triad in 2007. The most recent model of of anorexia nervosa and bulimia nerv- characteristic becomes apparent when the triad is a syndrome linking low osa in female athletes ranges from 0.5 there is discrepancy between an indi- energy availability (EA) with or with- to 3.7% and from 1.1 to 4.2%, respec- vidual’s image of their body, which is out disordered eating (DE), menstrual tively (49). Furthermore, disordered usually in terms of body weight and disturbances, and low BMD across eating, which is characterized by shape, and the body they perceive as a continuum of healthy (optimal EA, abnormal eating behaviors but does being ideal. Research has demon- normal and regular menstrual cycles, include all the diagnostic criteria for strated that body dissatisfaction is asso- and optimal BMD) to unhealthy and eating disorders, has a lifetime preva- ciated with a drive for thinness (28), increasingly severe clinical presenta- lence rate ranging from 0 to 27% (18). dieting (48), disordered eating patterns tions of each component (42). The Due to the lack of standardized assess- (47) and the development of clinical triad comes as a result of failure to ment tools and consistent criteria for eating disorders (25). intake adequate energy to compensate defining disordered eating, the preva- The literature suggests that body for energy used during exercise; this lence estimates can even range as high image issues may come about as condition is commonly called low as 62% among female athletes (11). a result of several factors. One factor EA. Low EA has been commonly Research investigating the psychosocial that affects athletes and nonathletes observed in exercising women (42) correlates of bulimic symptoms among alike is the typical sociocultural pres- and is particularly found in women National Collegiate Athletic Associa- sure to be thin (48); the media is an involved in leanness, aesthetic, and/or tion Division I female collegiate gym- example of a means that this ideal is endurance sports and activity (50). If nasts and swimmers/divers found that communicated to the public. Athletes, a state of energy deficiency remains negative affect (negative emotions and however, are often faced with a second- for a prolonged period of time it may poor self-concept), body dissatisfaction, ary pressure known as sports pressure

58 VOLUME 38 | NUMBER 2 | APRIL 2016 Copyright © National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited. (21). The sports pressure regarding an optimal health and performance (39). indicated that athletes with stress frac- athlete’s physique may come from In addition to a lack of nutrient intake, tures are more likely to have lower their teammates or coaches as a body female athletes could be at risk for vita- BMD, lower dietary calcium intake, cur- ideal for optimal sports performance. min and mineral insufficiency as a result rent menstrual irregularity, and lower or- Further complicating this matter is of the lack of nutrient intake itself, al contraceptive use (41). Although the fact that some women’s sports such menstruation, and inflammatory re- attaining a bone scan to determine the as gymnastics and figure skating judge sponses to heavy physical activity BMD for every female athlete is highly an athlete based on aesthetics of their (39). An energy deficit sustained over impractical and costly, researchers have body in addition to their performance. a period of several weeks to several evaluated several risk factors that signif- Another factor that may create body months can lower leptin, estradiol, icantly predict low BMD. These risk fac- image issues among female athletes is and insulin-like growth factor-1, and tors include late age at menarche, low the constraints and paradoxes placed can increase cortisol (31,36). These body weight (,90% ideal body weight), on them where the socially acceptable hormone alterations can decrease oste- low body mass index (,18.5 kg/m2), message is that female athletes may par- oblast activity and increase bone oligomenorrhea/amenorrhea, and cur- ticipate in sports as long as it does not resorption which can in turn create rent participation in a leanness sport or weaken their heterosexual attractive- an imbalance in bone turnover that activity (24). ness (33). A final factor that may influ- may lead to a decrease in BMD (31). Sports performance is clearly affected ence body image issues is known as the Furthermore, higher cortisol levels by lack of proper macronutrient and objectification theory (23). This theory have been associated not only with micronutrient intake. Optimal energy suggests that in the Western society, lower BMD but also with increased intake and nutrition can improve exer- women’s bodies are sexually objectified scores of anxiety and depressive symp- cise performance and maintain overall for the use and pleasure of others and toms (36) that may lead to social iso- health in physically active individuals women are socialized to view their bod- lation and a lower quality of life. (45). However, to maintain low body ies as objects and internalize an observ- Menstrual dysfunction, sometimes fat or body weight, female athletes er’s perspective of their own bodies; called menstrual irregularity, includes often restrict energy intake to make internalization of this standard may lead primary amenorrhea, secondary amen- weight goals (45). Due to the lack of women to feel shame about their bodies orrhea, and oligomenorrhea (42). Pri- proper energy intake and/or diversity (32). This body shame has been linked mary amenorrhea is a delay in in the diet and/or declines in nutri- to higher body surveillance, body dis- menarche; the defining age for primary tional status due to heavy physical satisfaction, a lower psychological well- amenorrhea is 15 years (42). Secondary activity, female athletes may also expe- being, and more eating problems in amenorrhea is a cessation of menstrua- rience problems in maintaining an ade- young women (26). tion for 3 consecutive months in a post- quate micronutrient status (37,39). More common micronutrients lacking HEALTH CONCERNS AND menarche woman. Oligomenorrhea is DETRIMENTAL PERFORMANCE menstrual cycles occurring greater than among female athletes include iron, DUE TO POOR NUTRITION 35 days apart (42). Long-term men- calcium, and vitamin D. Table 1 out- Some of the major concerns with lack strual dysfunction has been linked with lines some important functions of of proper nutrition for female athletes low BMD. More importantly, however, is selected macro and micro nutrients. include a multitude of health issues that the amount of skeletal mass acquired and detrimental sports performance. during adolescence is one of the most SAFE AND EFFECTIVE important factors in determining osteo- NUTRITIONAL Some of the health concerns that RECOMMENDATIONS FOR THE may arise include menstrual disorders, porosis and fracture risk later in life FEMALE ATHLETE (27). Hence, having menstrual dysfunc- low BMD, cardiovascular dysfunction, It is important for the strength and musculoskeletal injuries, depression, tion at an early age can severely impact conditioning professional to provide social isolation, and a poorer quality a woman’s bone health later in life. Men- proper referrals and support for female of life. These health concerns are not strual dysfunction has also been linked to athletes requiring nutritional guidance independent of each other; instead, other health consequences such as car- to improve their body composition or problems with one typically lead to diovascular dysfunction, endothelial dys- with a need to lose weight. Because it problems in other areas. function, abnormal metabolic hormonal has been documented that more than Inadequate nutrition can be defined as profile (usually due to inadequate energy 60% of elite athletes from leanness and a long-term exposure to a negative intake), and muscle injuries (29,40). nonleanness focused sports reported energy balance where energy con- Low BMD among female athletes, in pressure from their coaches concern- sumed is significantly less than energy addition to potentially predisposing ing body shape (34), the method in expended. However, adequate vitamin adolescent girls to osteoporosis and which the information is communi- and mineral intake is also an important an increased fracture risk later in life, cated to the athlete is critical. It is component for any athlete to sustain can lead to injuries. Research has important to realize that body

Table 1 Avoiding any punitive action as Functions of selected macronutrients and micronutrients a result of the assessed values. It is also important that the entire sup- Nutrient Function port/education team, which should Carbohydrates Provide energy for working muscles and the central nervous consist of some (and in some occasions system, support fat metabolism, and prevent protein from all) of the following professionals—the being used as energy. Carbohydrates are the preferred source coach, strength coach, dietician, athletic of energy for muscle contraction and biologic work trainer, physician, and psychologist—all share the same approach in terms of Proteins Responsible for most of the work in the cells and are required for the structure, function, and regulation of the body’s tissues providing accurate and consistent infor- and organs. They are made up long chains of amino acids mation to the athlete. The credibility of the support/education system can eas- Fats Used to build new cells and is important for normal brain ily be questioned and doubted by the development and nerve function. Fat is needed to carry and athlete if there is evidence of inconsis- help absorb fat-soluble vitamins such as vitamins A, D, E, and tent information provided to them by K. Fat can be converted into energy when there is a lack of energy available various professional sources. Evidence has shown that the risk of eating disor- Water Used in the cells, organs, and tissues to help regulate ders in young athletes may be reduced temperature and maintain bodily functions. It distributes in supportive sporting and coaching en- nutrients such as minerals, vitamins, and glucose to the cells vironments (20), which is one of the first as well as removes toxins that the organs reject through the steps in providing safe and effective urine and feces. Water is easily lost through breathing, sweating, and digestion nutritional recommendations for female athletes. Iron Supports the function of proteins and enzymes essential for maintaining physical and cognitive performance. Another step in providing safe and Predominantly, iron is incorporated in the proteins effective nutrition recommendations hemoglobin and myoglobin which are responsible for the for the female athlete is in the timing transport and storage of oxygen. When hemoglobin levels of when the information is given. Tell- decline, maximal oxygen consumption declines as well ing an athlete that they need to lose weight or body fat at the beginning Calcium and These micronutrients are critical for bone health. Deficiency in vitamin D either micronutrient results in impaired bone mineralization. of their competitive season is counter- Calcium must be consumed from food or supplements but productive because they should be vitamin D can come from dietary sources or from cutaneous focusing on sport-specific activities synthesis in response to UVB radiation from the sun and fueling their bodies to maximize performance. Placing athletes on a caloric deficit at the beginning of weight/body fat topics communicated “within the desirable range” rather their competitive season could poten- to the athlete could be a sensitive sub- than a raw value, such as “your body tially hamper their performance. ject for them and must be discussed fat level is 18%.” Hence, the time to address body with compassion, education, and sup- Providing athletes with information weight/body composition issues is at port. Robertson et al. (44) recommend on how they have changed between the start of their off-season program that athletes should be informed that the assessments, rather than offering the immediately after the competitive sea- purpose of doing body composition as- current value (e.g., “your muscle son. During this time period, the ath- sessments is to monitor any unhealthy mass has increased since the last lete will not only have more time to changes that may occur and to deter- measurement”). seek the help of the appropriate sup- mine whether exercise and eating strat- Increasing the focus on muscle mass port team personnel but they will also egies are having the desired impact. and decreasing the focus on body fat. be in a position where a caloric deficit Robertson et al. (44) suggest the follow- Using body composition values as will not impede their sports perfor- ing strategies recommended in the 2013– a means of helping to explain mance. Furthermore, it will give ath- 14 NCAA Sports Medicine Handbook changes in objectively measured per- letes more time to achieve realistic (10) to be included when measuring formance outcomes. weight-loss/body fat loss goals instead body composition to achieve this goal: Focusing on the changes in body of feeling the need to quickly reduce Obtaining body composition values composition as the basis of recom- their weight/body fat when the season with 1 athlete at a time. mending dietary changes to either is in place. It is important to note, Giving athletes information on body sustain positive changes or reverse however, that in cases where female composition using phrases such as negative changes. athletes are suffering from menstrual

60 VOLUME 38 | NUMBER 2 | APRIL 2016 Copyright © National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited. dysfunction (or other components of improve performance. If these are their pre- and postexercise is a relatively fail- the female athlete triad) during the goals, caloric restriction should be safe general guideline that reflects the season, the nutritional interventions eliminated. Table 2 can be modified as current evidence showing a maximal (and sometimes psychological inter- athletes will need to be slightly hyper- acute anabolic effect of 20–40 g. They ventions) are appropriate. Research caloric to increase muscle mass and also stated that carbohydrate dosage recently demonstrated that a 6-month isocaloric (at minimum) to improve and timing relative to resistance training carbohydrate-protein (CHO-PRO) sports performance. To increase muscle is a gray area lacking enough evidence supplement (360 kcal/d, 54 g mass, an intake of an extra 300–500 to form specific recommendations. CHO/d, and 20 g PRO/d) interven- kcal/d is recommended (2). However, they did discuss that carbo- tion improved energy status enough hydrate availability during and after A final recommendation for athletes to reverse exercise-related menstrual exercise is of greater importance to trying to lose body fat, gain muscle dysfunction (16). endurance as opposed to hypertrophy mass, or maintain their weight is nutri- goals. Their recommendation on carbo- Table 2 outlines some basic nutritional ent timing. Aragon and Schoenfeld (3) hydrate intake to maximize muscle gain recommendations for the female ath- recently published a literature review is to ensure that athletes meet their total lete looking to lose body fat. on nutrient timing and recommended daily carbohydrate intake throughout Sometimes, female athletes will have that a high-quality protein dosed at the day as opposed to focusing on spe- goals to build more muscle mass and 0.4–0.5 g/kg of lean body mass at both cifically timing carbohydrate dosages.

Table 2 Nutritional recommendations to lose body fat

Category Recommendation Goal setting Make the goal realistic. Although it is possible to lose weight quickly, setting high weight-loss goals may lead to failure. Drastic weight loss is often the result of not only body fat loss, but also loss of water and a loss of muscle mass. The more muscle mass that is lost, the slower the metabolism becomes. Losing 1– 2 pounds of body fat per week is recommended (2) Caloric restriction Caloric restriction is necessary to lose body fat, but an excessive caloric restriction can lead to major health issues. A modest caloric deficit of 500 cal/d from what the body burns in a day is enough to lose a pound of body fat per week (46). A metabolic cart can be used to more accurately measure an athlete’s basal metabolic rate (BMR), or the Harris–Benedict equation for women can be used. That equation is as follows: BMR (cal/d) 5 655.1 + (9.5663 3 weight in kg) + (1.85 3 height in cm) 2 (4.676 3 age in years). Once the BMR is calculated, a physical activity level factor is used to estimate total daily energy requirement. The BMR value is multiplied by 1.53 (sedentary/light activity), 1.76 (active or moderately active), or 2.25 (vigorous active). For weight loss, 500 cal is subtracted from the total daily energy requirement (2) Caloric expenditure Burning extra calories is another good method to lose body fat, but excessive caloric expenditure can also lead to health problems. A modest increase in caloric expenditure of 250–500 cal/d is enough to create a caloric deficit that is not detrimental to health and can still induce weight loss Macronutrient A registered dietician specializing in sports nutrition is the best person to determine an athlete’s intake macronutrient intake. Avoiding specific foods all together (i.e. carbohydrates) is usually not recommended and may lead to failure in adhering to a successful weight-loss plan. Macronutrient intake will vary based on the athlete’s sport, position, needs, age, sex, weight, lean body mass, and several other factors. Generally, protein intake should be 1.5–1.7 g/kg of body weight (45), carbohydrate intake should be 55% of total calories (2), and the remaining calories should come from fat Iron intake Female athletes not experiencing an iron deficiency should incorporate foods rich in iron in their diet, such as meat, seafood, and legumes coupled with foods rich in ascorbic acid (to help absorb the iron), such as dark green leafy veggies, peppers, guavas, broccoli, and berries. Female athletes identified with an iron deficiency should eat these foods and take iron-fortified foods or an iron supplement (38) Calcium/vitamin D Supplemental levels of 2,000 mg of calcium and 800 mg of vitamin D per day have been shown to reduce the intake incidence of stress fractures by 20% among female navy recruits undergoing 9 wk of initial military training (35) Water Maintenance of hydration during exercise is strongly related to a high level of athletic performance. The hydration beverage should contain approximately 100 mg sodium per 240 mL water and approximately 6–8% carbohydrate for exercise events lasting longer than 1 hour (45). Women should also consume at least 88 oz of water (2)

CONCLUSION an appropriate strength and condition- depressive disorder. Med Sci Sports Exerc The evidence presented thus far indi- ing program for athletes, using the strat- 37: 2032–2037, 2005. cates that female athletes are at risk for egies and approaches presented in this 8. Beals KA and Hill AK. The prevalence of disordered eating, body image issues, article can be useful in working with disordered eating, menstrual dysfunction, menstrual dysfunction, low BMD, female athletes. Finally, the basic nutri- and low BMD among US collegiate a negative energy balance, and a myr- tional guidelines presented in this arti- athletes. Int J Sport Nutr Exerc Metab 16: 1–23, 2006. iad of other health concerns that relate cle can act as a guideline when working to one another. Some of these health with other professionals involved with 9. Beals KA and Manore MM. Disorders of the female athlete triad among collegiate concerns can lead to an increase in the nutrition of female athletes, such as athletes. Int J Sport Nutr Exerc Metab 12: cardiovascular risk factors, hormonal the physician, dietician, athletic trainer, 281–293, 2003. imbalances, musculoskeletal injuries, and psychologist. 10. Benardot D. Guideline 2e: Assessment of and poor sports performance. Female Conflicts of Interest and Source of Funding: body composition. In Editor A and Editor B, athletes, more so than male athletes, The author reports no conflicts of interest eds. In: NCAA Sports Medicine are at a higher risk of developing eat- and no source of funding. Handbook. Indianapolis, IN: National ing disorders or disordered eating pat- Collegiate Athletic Association, 2002. terns. Female athletes participating in p. 45–47. 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