Mick: Dr. Cobb, We have heard more and more reports recently about the importance of female runners keeping a healthy lifestyle.

Dr. Cobb: Running can be the cornerstone of a healthy lifestyle for your child, as it prevents depression, promotes confidence and self-esteem, and wards off many chronic diseases. However, girls who run are at risk for a serious disorder known as the "female athlete triad", which is a combination of disordered eating, lack of menstrual periods, and fragile bones. This syndrome may lead to early osteoporosis and spontaneous fractures, prolonged psychological difficulties with weight and food, and anorexia nervosa and bulimia nervosa. The good news is that eating disorders and associated problems can be prevented, if young girls are educated about proper nutrition and encouraged to run in moderation.

Mick: What is osteoporosis and what causes it?

Dr. Cobb: Though we think of osteoporosis as an old person's disease, it is a disease that takes root in the young. Estrogen and nutrition are critical factors in a girl's bone development, and if they are not sufficient when a child is young, her bones will suffer in later life. The critical time for building the skeleton is in the early teenage years, just before and after puberty. Peak bone mass is achieved by a woman's late twenties. After this, she loses a little bone each year. Therefore, if a young girl fails to build sufficient bone in youth, she will develop thin bones (osteoporosis) much earlier in life than a woman with a healthy bone reserve.

Young women runners, who want to be lean for their sport, often restrict the amount or types of food that they eat. Meanwhile, they are burning hundreds of calories through exercise. The resulting energy drain may lead to menstrual disturbances - in trying to conserve energy, the body decreases its production of estrogen and prevents menstruation. Without sufficient estrogen and nutrition, bone development slows and bone loss may even occur.

If a girl is undernourished during the critical time when she's supposed to be building bone, these years of deprivation will be written into her skeleton, much like narrow tree rings reveal a history of drought. Though some recovery is possible, the damage can never be completely erased.

The longer disordered eating behaviors and menstrual irregularities persist, the greater the detriment to the skeleton. Some women runners in their twenties and thirties have bone strengths that would be normal for a 70-or 80-year old women. They may spontaneously break an arm, rib, leg, hip, or vertebra. Additionally, their chance for developing a stress fracture is high.

Mick: What are the most important components of a high performance diet? What MUST a female athlete be sure to eat and drink every day?

Dr. Cobb: There is no one "magic" food that will guarantee high performance. Most importantly, young female athletes should be discouraged from restricting their diets or becoming too rigid in their food choices. Female athletes must eat enough calories every day to sustain their energy output; the calories should come from a well-balanced, varied diet that includes not only fruits and vegetables (the foods we typically think of as "healthy"), but also sufficient fat and protein. Growing girls also need to get at least

1200-1500 mg. of calcium every day. This is most easily obtained from eating 3-5 servings of dairy products, such as yogurt, milk, and cheese. Other calcium-rich foods include leafy green vegetables, such as kale, calcium-enriched juices and cereals, and tofu. A calcium supplement may be warranted if a girl gets insufficient calcium in her diet.

Mick: Are there negative psychological aspects of these disorders?

Dr. Cobb: Beyond the physical problems, disordered eating also has adverse psychological consequences. Even after resuming menses, women recovering from the female athlete triad may still struggle with issues of food and weight. If untreated, women with the female athlete triad may also go on to develop full blown eating disorders, which have a high mortality rate. Therefore, preventing disordered eating altogether is greatly preferable to treatment after the fact.

Mick: OK, Let's talk about PREVENTING the Female Athlete Triad. At what age do prevention efforts need to begin?

Dr. Cobb: Girls can be at risk for developing the female athlete triad at a young age, and prevention efforts should focus on early adolescence. The majority of bone accrual occurs between the ages of 9 and 14 years. This coincides exactly with the time when girls are most at risk for developing disordered eating patterns and eating disorders. Because caloric requirements are highest when children are between 11-14 years old, restricted food intake during this period is more likely to cause energy deficiency.

Bone loss can never be completely reversed, so early diagnosis and intervention is critical. Also, it should be noted, that an analog to the female athlete triad (disordered eating, low sex steroids, and low bone strength) may exist in males, but this has not yet been established.

PREVENTION OF THE FEMALE ATHLETE TRIAD

1. EDUCATION

Education should aim to increase awareness of the female athlete triad and its consequences among coaches, athletes, parents, teachers, and sports physicians. Many young women are unaware of the potential harm of restrictive eating and menstrual irregularities. In one survey of college athletes, seventy percent of the women who were engaging in pathologic weight control behaviors thought this behavior was harmless. Awareness of long-term consequences might prevent girls and women from initiating these behaviors. Young runners may be more motivated by the immediate desire to prevent stress fractures and loss of training time than by the threat of early osteoporosis (which may seem very distant to a young woman).

Pre-pubertal girls should be prepared for the fact that they are going to gain weight and body fat during puberty and that this may initially affect their performance. Education efforts should attempt to dispel the myth that thinner is always better for performance. The optimal weight, for high performance, lies somewhere in between too heavy and too thin.