18 minute read
Jessica Quilter-Jones (Year 12
Have awareness levels of the Female Athlete Triad (FAT) increased in Australia in the last decade?
Jessica Quilter-Jones (Year 12) The Illawarra Grammar School, 10/12 Western Avenue, Wollongong, NSW, Australia, 2500
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Abstract: This study explored FAT awareness levels among female athletes, coaches/trainers and health professionals in Australia. The catalyst for this scientific investigation was the finding by Miller et al (2012) that only 10% of exercising Australian women participants could identify all three components of the FAT, and other studies that showed low awareness levels among coaches and doctors (Troy 2006;
Mukherjee 2016). Limited awareness of the
FAT means that female athletes are not being treated correctly or issues can go undiagnosed and turn into larger health problems.
Participants completed a 12-question survey using online survey platform, Qualtrics, to measure current FAT awareness levels among female athletes, coaches/trainers, and health professionals. Survey responses were analysed using a chi square independents test with an alpha value of 0.05. 50.7% of participants reported that they were aware of the FAT.
Only 25% of participants correctly identified all three FAT components. Physiotherapists displayed higher levels of awareness than athletes, doctors, and coaches. The study’s results suggest that awareness has increased, but that awareness falls short of optimal levels required for FAT prevention, detection, and treatment.
Introduction
The FAT is a medical condition with serious long-term health implications but diagnosis rates are low, which results in inadequate or delayed treatment. The FAT was first defined in 1992 by the American College of Sports Medicine (ACSM) as ‘three separate but interrelated entities; eating/low energy availability, menstrual disturbance/amenorrhea, and bone loss/osteoporosis’ (Laframboise et al, 2013). However, since 2007 the ACSM ‘recognises that the [FAT] is a spectrum of symptoms and conditions ranging between health and disease’ (Laframboise et al, 2013). ‘It includes three components: low energy availability, menstrual dysfunction, and low bone-mineral density’ (Nattiv et al. 2007). Energy Availability (EA): is ‘the amount of energy that remains in the body to be used for training and sport performance. Female athletes experience energy deficient states with high-energy expenditure due to training without adequate compensation in energy intake’ (Laframboise et al, 2013). When EA ‘is reduced below 30kcal per kg, the body suppress reproductive function and bone formation’ (Laframboise et al, 2013). In this way, inadequate EA is the trigger for the other two aspects of the FAT. Menstrual function: insufficient EA can contribute to menstrual dysfunction or ‘amenorrhea’ (defined as the absence of a period for > 3months), which can cause infertility (Hoch et al, 2007). Bone Density: is a medical measure of the amount of minerals per square centimetre of bone and determines the strength or weakness of a bone. Poor bone density can result in osteoporosis, which causes the bones to become weak, brittle, and fragile (Bone Density, 2021). Female athletes whose EA is inadequate may become more susceptible to broken bones or fractures (Australian Institute of Health and Welfare, 2020). This risk is linked to amenorrhea because reduced oestrogen production impacts adversely on bone density. Miller et al (2012) investigated the knowledge, attitudes, and behaviours of 180 Australian women who exercised at Melbourne sporting clubs and fitness centres. Participants were aged between 18-40 and undertook at least two hours of exercise a week. ‘Half the respondents reported never having experienced any component of the female athlete triad, with 39%, 11%, and 0.6% reporting that they had experienced one, two, and three components, respectively. When asked, “Have you ever heard about the ‘female athlete triad’? If yes, could you describe it?” 10% of the sample could name all three components of the triad (energy deficiency, menstrual dysfunction, and poor bone health)’ (Miller et al, 2012).
Folscher et al (2015) investigated FAT knowledge, occurrence of disordered eating and FAT risk amongst participants in the 2014 89 km Comrades Marathon event. The authors used the Low Energy Availability in Females questionnaire (LEAF-Q) and Female Athletes Screening Tool (FAST). Seven questions concerning the elements of the FAT were asked to determine the knowledge and understanding of the female athletes. 92.5% of the 306 female athlete study participants had never heard of the FAT, and only 7.5% were able to identify all elements of the FAT (Folscher et al, 2015). Mukherjee et al (2016) investigated awareness and knowledge of the FAT among 240 female high school athletes from western USA, and 13 coaches, via a 34 question cross-sectional survey. ‘Only 9 athletes had heard of the Triad, and none could correctly list the Triad components. Three coaches had heard of the Triad, but only 1 could correctly identify all 3 components. Few coaches knew of the relationships between Triad components’ (Mukherjee et al, 2016). Troy et al al (2006) surveyed 240 American health care professionals and coaches and found that only 48% of physicians and 8% of coaches were ‘able to identify all 3 components of the Female Athlete Triad.’ Among physicians there were notable differences between specialties, ranging from 69% for physical medicine and rehabilitation specialists to 17% for gynaecologists (Troy et al, 2006). A study by Tenforde et al (2020) found similar results to Troy et al (2006). Participants were physicians and allied health professionals who attended the 2018 Harvard Sports Medicine meeting. 163 of the 386 physicians at the conference responded to the survey. ‘Fellowship trained physicians in sports medicine were significantly more likely to be aware of Triad (91%)…compared to those without fellowship training (63% and 23%). Physicians with fellowship training in sports medicine were more likely to express comfort treating athletes with Triad (57%) compared to those without fellowship training (26%)’ (Tenforde et al, 2020).
An important philosophical argument that underpins the research discussed here is whether inadequate understanding of women’s health contributes to inadequate education and resourcing. This is an important ethical consideration, as illustrated by the recent comments by elite British sprinter Dina AsherSmith who called for ‘more research into menstruation after cramping during 100m championship final’ (ABC, 2022). Innovations have been made in this area, such as the AIS ‘Female Performance & Health Initiative’ (Australian Institute of Sport, 2019), the ‘Female Athlete Triad a clinical guide’ a book published in 2014 (Gordon et al, 2014), and the American organisation the ‘Female and Male Athlete Triad Coalition’.
In light of these studies and developments it is important to understand the current levels of awareness of FAT amongst Australian athletes, coaches/trainers and health professionals so that gaps in awareness can be addressed.
Scientific Research Question
To what extent has awareness of the FAT increased among the sporting and medical communities in Australia in the last 10 years?
Methodology
Subjects A questionnaire was administered to 132 participants. Participants were drawn from five categories: female athletes (42); coaches (11); personal trainers (7); physiotherapists (18); and doctors (54). Not all respondents answered each survey question. The eligibility criterion for female athletes was adapted from Miller et al (2012): engagement in at least 2 hours of exercise each week. Female athletes and coaches came from a variety of sports including soccer, tennis, and athletics.
Instruments A questionnaire consisting of 12 questions was administered via the online survey platform, Qualtrics. It included three demographic questions, eight questions adapted from Mukherjee’s 2016 study (Appendix C), and an additional question was added to the survey for doctors and physiotherapists (‘Do you screen female athletes for the triad?’). Demographic information collected was on age, gender and whether the participants was a: female athlete; coach; personal trainer; physiotherapist; or
doctor. Qualtrics was used instead of Survey Monkey because it is free and tabulates the data within the program.
Procedures A recruitment email (Appendix E) was sent to potential participants which explained the aims of the study, the anonymous nature of the survey, and the fact that the questionnaire was adapted from Mukherjee (2016) (Appendix C). This email was disseminated across different social media sites and group chats such as ‘doctor running mums’, ‘Athletics Wollongong’, ‘Tennis Nareena Hills’, ‘UOW Soccer’, ‘Uphysio’ and ‘Personal trainers Wollongong’. In addition, the email was sent across different year groups and faculties at TIGS, and via word of mouth to different health professionals. The survey was left open for 10 weeks. This ensured that the data obtained and the sample size would be large enough for validity. Data were analysed using a Chi Square Independence test (Appendix C – Table 1 & 2). This was considered more appropriate than a Ttest, because a T-test is for when the study has a ‘dependent quantitative variable and an independent categorical variable’ (What is the difference between a chi-square test and a t test?, n.d). In the present study, both variables were categorical, and therefore a chi square test was deemed to be most appropriate.
Results
On the first of the study’s two primary survey questions, 49.2% of respondents (n = 126) reported that they had heard of the ‘FAT’ (Figure 1 and table 1 - Appendix A). Awareness levels were the highest amongst physiotherapists (94.44%) and lowest for doctors (37.73%). For the other categories awareness levels were: personal trainers (75%), female athletes (40.54%) and coaches (40%). The chi square test for this first question (‘Have you heard of the triad?’) revealed a chi square of 0.031746032, a p-value of 0.8585862 and an alpha value of 0.5 (p-value > 0.5 therefore null hypothesis cannot be rejected) (Table 1 - Appendix B). Moreover, the ‘expected numbers’ indicate that there is an ‘even’ chance that respondents had or haven’t heard of the FAT illustrating a lack of awareness for respondents who were supposed to be ‘experts’ in this field.
The second of the primary survey questions asked whether the participants could identify all three components of the FAT. 22 of the 88 respondents (25%) who attempted this question answered it correctly (Figure 2 and table 3 Appendix A). Of the respondents who, on the previous question, had reported having heard of the FAT (n=61) 29.5% of respondents could correctly identify the 3 components (Figure 2). All three (100%) of the coaches who had heard of the ‘FAT’ could identify the 3 components. The rates for the other categories were: physiotherapists (35.29%), doctors (25%), female athletes (23.53%) and personal trainers (0%). The second chi square test for the second question (ie could the respondents who had ‘heard’ of the FAT correctly identify the three components of the FAT?) revealed a chi square value of 10.24590164, p-value of 0.00136989 and an alpha value of 0.5 (Table 2 - Appendix B). These results would indicate that the null hypothesis is rejected because the p-value is < than the alpha value (0.5), however, it included the respondents who were aware of the FAT.
The study’s five secondary questions asked participants to respond to a number of propositions that expressed attitudes and knowledge about female athlete’s bodies and performance (Appendix A).
72% of respondents (n = 129) ‘strongly disagreed’ or ‘disagreed’ that “Low body fat is extremely important for sports performance”. 21 female athletes (51.21%) and 8 doctors (15.38%) ‘agreed’ with this statement.
86.8% of respondents (n = 130) ‘strongly disagreed’ and ‘disagreed’ (43.0% ‘strongly disagreed’ and 43.8% ‘disagreed’) that “Ideal body weight and leanness should be constantly emphasised to the athlete?”. Only 2 respondents (both female athletes) ‘strongly agreed’ with this statement.
74.60% of respondents (n = 130) disagreed that “Low body fat also makes the athlete lighter in body weight and thus improves performance?” (24.6% ‘strongly disagreed’ and 50% ‘disagreed’). 41.46% of female athletes agreed with this statement, as did 18.87% of doctors.
89% of respondents (n = 119) agreed that “Low body fat does not mean high muscle mass (lean mass)” (36.9% ‘strongly agreed’ and 52.1% ‘agreed’).
80.3% of respondents (n = 132) disagreed (30.3% ‘strongly disagreed’ and 50% ‘disagreed’) that “Female Athletes work harder than non-active female athletes. So, it is normal for them to miss their menstrual cycle on a regular basis?” 6.98% of female athletes strongly agreed, and 18.87% of doctors agreed with this statement. 99.22% of respondents (n = 130) disagreed (75.38% ‘strongly disagree’ and 23.84% ‘disagree’) that “Female Athletes should eat less to achieve/maintain a lighter body weight”.
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No. of respondents
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50
40
30
20
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6264
22 15 33
17 20
4 6 6 2 1
Type of respondent
Yes No
The final question was directed at health professionals: ‘Do you screen female athletes for the Triad?’. 13 of 18 physiotherapists (72.22%) answered yes. Only 10 of 40 doctors (25%) reported that they screen female athletes for the FAT.
Figure 2: Number of Participants Who Had Heard of the ‘FAT’ and Could Identify the Three Components
No. of respondents
50 45 40 35 30 25 20 15 10 5 0 13
4 3 43
4 11
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6 5 18
Type of respondent
yes No
Discussion
The results indicated that general awareness of the FAT has significantly improved in 10 years, though there are large variations between the different categories of respondents. However, accurate knowledge about the FAT (i.e. knowing all 3 components) is still very low. The results from the independents chi square test support these findings, that there is no statistically significant difference in awareness (p-value >0.5) (ie the null hypothesis is supported). Results can be compared with baselines drawn from the Miller et al (2012) study for female athletes, the Mukherjee et al (2016) study for female athletes and coaches, and the Troy (2006) study for coaches and health professionals. In the Miller study only 10% of female athletes could identify all three components (Miller et al, 2012). In the present study, 40.54% of female athletes answered ‘yes’ to the question, ‘have you heard of the Triad?’ (Table 1 - Appendix A) and 23.53% reported that they had heard of the FAT and correctly identified all three components (Table 3 - Appendix A). This suggests that awareness has increased in the last decade, but remains low.
For coaches, Mukherjee et al (2016) found that only 15.2% had heard of the FAT, and Troy et al (2006) found that only 8% were able to identify all 3 FAT components. By comparison, in the present study, 27.27% of coaches correctly identified the 3 components (Table 2 - Appendix A). Troy et al found that 48% of physicians were able to identify all 3 components of the FAT (Troy et al, 2006). In the present study, only 37.73% of doctors had heard of the FAT, and only 25% of doctors who had heard of the ‘FAT’ could correctly identify the 3 components. Awareness was higher amounts physiotherapists: 94.44% reported awareness of the FAT (Table 1 – Appendix A), and 35.29% correctly identified the 3 components (Table 3 - Appendix A). These comparisons with previous studies suggest that there has been an improvement in awareness of the FAT for most categories of participants. The exception, surprisingly, was doctors – the only category where awareness levels were lower than the baseline drawn from previous studies. Another noteworthy result is that 3 female athletes ‘strongly agreed’ that it is normal for an athlete to miss their ‘menstrual cycle on a regular basis because they work harder than “non-active females”’. Further to this, 10 doctors, 2 coaches and 1 physiotherapist also ‘agreed’ that this is ‘normal’ (Table 8 – Appendix A). This suggests there is still a lack of awareness of the dangers that menstrual dysfunction can pose to a female athlete’s health, including amenorrhea – which can significantly impact an athlete’s health, because oestrogen levels regulate bone density. More positively, only 1 female athlete agreed with the statement ‘female athletes should eat less to achieve/maintain a lighter body weight’. The large majority of participants, including 35 doctors, 17 physiotherapists, 7 personal trainers and 10 coaches ‘strongly disagreed’ with the statement (Table 9 - Appendix A). This is significant because ‘energy availability’ is important in determining menstrual function and bone density. Identifying the signs and symptoms of the FAT is pivotal to prevention. This means the role of the coach is fundamental as they are in a position that regularly interacts with the athlete. However, only 40% of coaches had heard of the FAT (Table 1 – Appendix A) and only 27.27% could correctly identify all components (Table 2 - Appendix A). These low levels are a cause for concern because a lack of awareness limits the ability of coaches to identify the signs and symptoms early. Validity The validity of this study was influenced by the difficulty of controlling how respondents engaged with the survey, noting that it was based solely on self-reporting. Respondents may have overreported or underreported their opinion on a question. Some respondents may have chosen the answer that the researcher ‘expected’ of them or neglected to answer a question because they did not know the answer. However, the process of ‘data cleaning’ was employed to help improve the validity of the study. For ethical reasons participants were told in advance what the survey was about, and some may have researched what the FAT was before beginning the survey. Also, participants were not randomly selected across different sporting and medical disciplines and may have had a particular interest in the topic. Therefore, the findings of this study may overstate awareness levels in Australia. The small sample size for coaches (11) and personal trainers (7) might also have skewed the results. Lastly, the definition of the FAT was changed in 2007, when amenorrhea was removed as one of the elements of the FAT. This may have influenced the results on correctly identifying the three components of the FAT, if participants had acquired their knowledge before 2007 – it is noted that 17 doctors incorrectly identified ‘amenorrhea’ as the third element (Table 11 Appendix A).
Reliability Reliability was high in this study because most questions were drawn from the earlier Mukherjee study (2016) and were disseminated in the same format via an online survey. However, the Mukherjee study only measured coach and female athlete awareness, and so the survey was modified to include physiotherapists and doctors – because the awareness of health
professionals is important for FAT prevention, diagnosis and treatment. Reliability was impacted by the fact that some respondents did not answer all questions, which resulted in sample size variations across different survey questions.
Implications and future directions The findings of this study suggest that the education and training about FAT that is available to athletes, coaches and health professionals in Australia may be inadequate. Prioritising awareness of the FAT is important because ‘one in four to one in five female athletes present with at least one component of the female athlete triad, which places them at greater risk for developing the complete condition’ (Miller et al, 2012). Increased awareness by coaches and health professionals can play a pivotal role in primary prevention, early detection, and management of the FAT across different sports. There is also a need for stronger education and advocacy amongst athletes. Consideration should be given to establishing an Australian organisation modelled on the USA’s Female and Male Athlete Triad Coalition, to educate individuals and sporting organisations about the components of the FAT, and prevention and intervention best practice (Female and Male Athlete Triad Coalition, 2002).
Conclusion
This study was designed to assess whether awareness of the FAT among female athletes, coaches/trainers and health professionals had improved over the last decade in Australia. The results indicate that general awareness of the FAT has increased, but familiarity with the specific components of the FAT – bone density, menstrual function and energy availability –remains low. This study’s findings support the deployment of additional resources to better educate female athletes, coaches, personal trainers, physiotherapists and doctors, in order to improve prevention, diagnosis and treatment of the FAT. Further research is required into the use and effectiveness of screening and preventative interventions.
References
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