A Triple Threat : Eating disorders, osteoporosis and more. The Female Athlete Triad affects thousands of active and competitive girls and women. And the physical damage can be lasting.

A star soccer player, wanting to run a little faster and play a little better, cuts down on her eating and throws up after every meal. Five months later she is hospitalized with medical complications from an eating disorder.

A national-class distance runner goes more than 10 years without having a regular menstrual cycle.

A college swimmer fractures two ribs while coughing during an asthma attack.

Three athletes, three different ailments, but one thing in common--the Female Athlete Triad.

The triad is a chain-link series of disorders that affects tens of thousands of women, according to experts. June marked the fifth anniversary of the identification of the triad, but there still is only limited information available for athletes, coaches and administrators.

The triad is a continuum that generally begins with disordered eating, a serious and widespread ailment that by itself can lead to a host of life-threatening health problems. Doctors have discovered that if left untreated, disordered eating also can cause amenorrhea (the absence of a regular menstrual cycle). Amenorrhea, considered a red flag for the triad, also is a sign of increased risk for osteoporosis, a condition researchers are finding is permanent. The presence of any one disorder puts an athlete in the triad and she should be screened promptly for the other two ailments.

Many female athletes suffering from these disorders face a fundamental paradox: Intense pressure to excel sometimes leads to behavior that causes health risks, making success more difficult and dangerous to achieve. This balancing act between health and athletic success can create conflicts for coaches as well.

“It’s not necessarily true that being a world-class athlete or being an elite athlete is the best thing for your body,” New York City nutritionist Ellie Krieger said. “It may actually be in conflict with your body. When an athlete is driven to be world-class, it may actually be in conflict with your physical well-being.”

Or, as University of Connecticut team physician Jeffrey Anderson asked, “Are optimal performance and optimal health mutually exclusive?”

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The triad ailments--particularly disordered eating--are not uncommon in the general female population, which already is under pressure from a society obsessed with weight and appearance. But experts say that athletes, faced with the physical demands of training and subjected by their sports to even more pressure to stay thin, are especially vulnerable. Often, some of the very traits that make a great athlete--competitiveness, stubbornness and perfectionism--also make a woman more susceptible to the triad.

For the past 18 months, Newsday has examined the many issues of the Female Athlete Triad. The investigation included interviews with more than 80 health care professionals, athletes and athletic officials, as well as more than 800 questionnaires answered by high school and college athletes and athletic directors.

Responses from all of the groups make one thing clear: As the number of serious female athletes grows, so does concern about the triad.

“We can’t wait for data,” said Carol Otis of the American College of Sports Medicine, the group that first defined the triad. “We have people dying. We have people being permanently harmed.”

“There is a relative ignorance in the population about it being widespread,” said Tina Huffman, an elite gymnast from Connecticut who quit the sport at 15. At that point, Huffman already was restricting what she ate, purging occasionally and exercising compulsively--all forms of disordered eating--to retain the small physique demanded by her coaches.

Eventually, she became anorexic. Huffman battled the disease for nearly 15 years, and was amenorrheic most of that time. She almost went into kidney failure, had an irregular heartbeat and was hospitalized many times, once after dropping to 65 pounds. Although she is in recovery, her bone density is 70% of normal and her risk of fracture is considered “moderate to marked.”

For Huffman, the need to stay small overwhelmed any concern about medical consequences.

“The long-term effects don’t matter,” said Huffman, now 32 and doing her residency in medical physics at an Atlanta-area hospital. “You’re told you can die from this, but that’s not reality at this moment. The short-term benefits outweigh the long-term costs.”

That was the case for Michelle, a 20-year-old woman from Long Island, N.Y., who just completed her junior year of college. Michelle requested anonymity for this story.

A standout soccer player, Michelle has battled eating disorders since her junior year of high school. Her problem peaked in college, when she decided to lose weight in an effort to increase her speed. After five months of cutting back on food, throwing up and abusing laxatives, she lost 45 pounds and had to be hospitalized.

“If there was some way to let each person know: No boyfriend, no sport, nothing is worth putting your body through this. You’re so much more important than that,” Michelle said.

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In May, the American College of Sports Medicine issued its official stand on the Female Athlete Triad.

Among the group’s conclusions:

* The triad is a “serious syndrome” that can result in death.

* The triad often is denied and underreported by sufferers and not recognized by sports medicine professionals.

* Research on the triad and its prevalence is urgently needed.

* There is a compelling need to educate athletes, coaches and the public on the nature of the disorder and its ramifications.

“We’re in a new era of numbers of women participating in sports,” said Otis, chairwoman of the task force that issued the report. More than 2.36 million girls participate in high school sports, compared with 300,000 in 1972. Similarly, there are 123,207 female college athletes; in 1972, there were 31,852.

“It’s more widespread now,” Otis said. “There are more women participating and the stakes are higher. . . . People are training younger and longer. We are witnessing a new phenomenon in the way women train.”

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Although there are no studies documenting the prevalence of the triad, Otis said that out of the more than 3 million girls and women who play junior high, high school, college and professional sports, tens of thousands may suffer from one of the triad disorders and therefore are at risk for developing all three.

“It’s like heart disease,” Otis said. “We don’t know how many people age 30 will have a heart attack, but we know how many of you are at risk.”

Otis, formerly a team physician at UCLA and one of the nation’s leading authorities on the triad, said that as many as 30% of female athletes in sports such as gymnastics, long-distance running and figure skating suffer from one or more of the triad disorders.

“The magnitude of the problem, we’re only now starting to get a grip on,” said Dan Benardot, co-director of the Laboratory for Elite Athlete Performance in Atlanta and nutritionist for the U.S. gymnastics team. “Clearly, it’s a problem which can be fatal in its extreme. In its less extreme form, it’s probably a huge number of people who are involved in the Female Athlete Triad. Huge.”

Women’s-sports advocates and researchers strongly warned against using the triad as a reason for women to avoid sports. Sports creates an environment of risk but does not cause the triad, Otis said. Women should continue to play, but they should know about those risks, just as football players are warned about the possibilities of concussions.

“We have to balance the danger that it is pervasive and that women who enter sports are in danger,” said Donna Lopiano, executive director of the Women’s Sports Foundation in Nassau County, N.Y. “Participation in sports far outweighs any of the negatives in terms of increased risk for the Female Athlete Triad.”

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The key, experts say, is to understand the syndrome. It usually begins with disordered eating, ranging in severity from anorexia or bulimia to common chronic dieting. Poor or inadequate nutrition, combined with the intense training done by many female athletes, can cause “energy deficit.” This occurs when the energy expended is greater than the energy taken in.

Energy deficit causes the body to shut down production of several hormones necessary to make estrogen. The lack of estrogen, in turn, triggers amenorrhea. This happens, on average, when a woman’s body fat drops below 17% to 18%. (By contrast, experts say, a male’s body fat can fall to 1% with very little medical consequence.)

The lack of estrogen in an amenorrheic athlete, combined with the lack of calcium in many women’s diets, results in loss of bone density. If the bones deteriorate enough, the result is osteoporosis, often called “brittle bone disease.” The condition is found more commonly in older women after they have gone through menopause.

Doctors, however, have found the disorders of the triad occurring with increasing frequency among much younger women--athletes in college, high school and even junior high school.

Ellen Wilson was a healthy 12-year-old in New Jersey when she said her swimming coach told her she had to “slim down” to stay competitive.

That remark, she said, touched off two bouts with anorexia--one at that time and another last year, when she was a sophomore at Washington University in St. Louis. Wilson, who just finished her junior year, has been amenorrheic on and off for years and has been told by doctors her bones are brittle--she recently fractured two ribs while coughing during an asthma attack.

“Coaches and parents of female athletes need to be well-informed about the triad,” said Wilson, now 20.

In the meantime, medical professionals continue researching the triad. Despite strong anecdotal evidence of the pervasiveness of the triad’s disorders, researchers still do not know precisely how many women suffer from the triad and cannot get funding to develop mechanisms for tracking its prevalence. Doctors do not know the rates at which women with disordered eating develop amenorrhea, and they have only limited data on the rates at which amenorrheic women develop osteoporosis.

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But much has been learned about other aspects of the triad, including the following:

* Various surveys have found that as many as six in 10 college female athletes in some sports practice forms of disordered eating. Similarly, as many as two-thirds of college athletes have some form of amenorrhea, depending on the sport and the level of competition.

* Although the triad may be more commonly found among elite athletes and in certain sports, it is found to some degree at all levels of competition and in every women’s sport.

Research indicates the triad occurs most often in sports and activities that are scored subjectively (gymnastics, figure skating, diving, dance); in endurance sports that emphasize a low body weight (distance running, cycling, cross-country skiing); in sports that require clothing that reveals body contour (volleyball, swimming, diving, track, cheerleading); in sports with weight classifications (crew, horse racing, wrestling); and in sports that emphasize a childlike figure for success (figure skating, gymnastics, diving).

The American College of Sports Medicine indicated that “potentially all physically active girls and women could be at risk for developing one or more components of the triad.”

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The medical consequences of the Female Athlete Triad can be permanent. Recent research on osteoporosis suggests that bone density lost as a result of the triad’s disorders is never regained, meaning the victim will have weaker bones and an increased risk of fractures for the rest of her life.

As for other long-term consequences, no one knows for sure. Randa Ryan has studied the triad as director of the Performance Team, a group of medical professionals at the University of Texas that researches health issues in women’s sports.

Said Ryan: “We might be creating a generation of hunchbacked women down the road because we just didn’t know.”

Athletes, as they are traditionally defined, are not the only women affected by the Female Athlete Triad. In fact, some experts prefer the name “Female Triad,” which recognizes that non-athletes subjected to pressures from the fashion, advertising and entertainment worlds often develop the triad disorders.

But additional tensions endemic to sports cause researchers such as Otis to say that athletes are more at risk for developing the triad disorders than non-athletes.

Often, the same psychological factors that allow women to become top athletes contribute to the development of the triad disorders, in particular disordered eating.

“The very thing that makes a great athlete or a great student or a great businessperson already predisposes them to be obsessive,” said Cathy Rigby, a two-time Olympic gymnast who was hospitalized twice with life-threatening symptoms during a 12-year battle with bulimia. “Add on top of that that the sport demands you to be young, demands you to be thin, and where perfection is the name of the game. . . . If she happens to have a coach that is demanding, that very thing that makes her coachable can lead to a problem.”

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Nearly 30 years later, doctors are just beginning to understand the triad.

“The triad was only described five years ago, so our learning curve is tremendous,” said Lisa Callahan, former team physician at Stanford University and member of the women’s sports medicine program at the Hospital for Special Surgery in New York City.

“In the last couple of years, people have started to say, ‘If you have a stress fracture, you have to check for amenorrhea, you have to check for osteoporosis.’ We’re on the cutting edge.”

Callahan said many of her peers lag behind that curve and still do not know anything about the triad: “Half of the doctors I know didn’t know about it until they knew me.”

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The good news is, some organizations are beginning to take action. In 1990, the U.S. Olympic Committee and the NCAA began disseminating information on eating disorders. The National Federation of State High School Assns. made disordered eating the topic of a 1996 teleconference.

And the Corel Women’s Tennis Assn., whose chief medical advisor is Otis, raised its initial participation age to 14, with restrictions on play to age 18, and instituted yearly physical exams for its athletes and education for players, parents and coaches.

USA Gymnastics, the national governing body of a sport with a large statistical problem with the triad, has made the most progress. The organization is implementing a series of programs designed to educate its constituency.

The problem in educating anyone, Otis said, is dissemination: How do researchers reach a cross-country runner, a swimmer and a gymnastics coach?

No one would argue, however, that word needs to spread.

“Why did we make such a big stink about it?” Otis asked. “Because we heard what young women were telling us about it. Women told us and women died and we said we’re not going to stay quiet any longer.”