The Examination of the Knowledge Level of Young Papuan Female Athletes about Female Athletes Triad (FAT) Gambaran Pengetahuan Atlet Remaja Putri Papua mengenai Female Athletes Triad (FAT)

Background: Female Athletes Triad (FAT) is a syndrome characterized by impaired energy availability, menstrual dysfunction, and low bone density. FAT might interfere with the health and performance of young female athletes in training and competition, which causes a decrease in achievement. Research on FAT is still limited in Indonesia, especially on indigenous Papuans. Objectives: To obtain a description of young Papuan female athletes' knowledge of FAT, including the three main components of FAT: danger, impacts, and risk factors for FAT. Methods: The total sample was 61 young female athletes with a convenience sampling technique. The survey method used a questionnaire consisting of questions related to athlete characteristics (age, ethnicity, training duration, and sports) and eight questions about FAT knowledge; it includes the three main components of FAT (osteoporosis, menstrual disorders, eating disorders), dangers and impacts, and the risk factors (age and physical activity). Results: Young Papua female athletes


INTRODUCTION
In recent years, several factors have been found to significantly contribute to the history of sport in Indonesia, including the surge in Indonesian female athletes participating in various sporting activities.This situation marked a significant shift from when women's involvement in sports was limited.Currently, the number of female athletes engaging in sports has increased 1 , fostering an environment where both males and females have the same potential to excel in national and international events.This positive change resulted in a viral trend of "celebrity athletes," thus leading to the perception that being an athlete is a promising career choice.In 2021, Indonesian female athletes gained welldeserved recognition for their impressive achievements.A touching moment during the 2020 Tokyo Olympic Games was when Greysia Polii and Apriyani Rahayu proudly raised the flag of Indonesia, symbolizing their success and dedication to the respective sports they were engaged in.
Recently, the president of Indonesia approved Papua as a sports province in the country.This was primarily because of the successful hosting of the area's 20th National Sports Week (PON XX Papua 2021).Papua was successful as an organizer and in terms of sports achievement.The province ranked 4th in the championship, securing an impressive medal tally of 93 gold, 66 silver, and 102 bronze medals 2 .This triumph was a historic moment for the region with around 923 Papuan athletes, including 387 female athletes, specifically indigenous Papuan female athletes 2,3 .

The Examination of the Knowledge Level of Young Papuan Female Athletes about Female Athletes Triad (FAT)
The recognition of Papua as a sports province showcases its significant progress, even though the area is undeveloped in Indonesia.The area has abundant natural resources, featuring unique landscapes with beaches, valleys, lakes, and hills.Furthermore, intertwined with nature, the Papuan lifestyle promotes physical activity and fosters physical strength and the natural talent for sports among its people 4 .The geographical and ecological aspects of the area have undoubtedly contributed to nurturing the innate sports talents of its indigenous, making sports an integral part of their lives.Accordingly, it is evident that the successful PON XX Papua further accelerated the development of sports potential in the region 3 .
This region has a rich heritage of producing remarkable athletes, as evidenced by historical records.These athletes have consistently achieved notable success at both national and international levels, particularly in football, athletics, and rowing 4 .Additionally, it is imperative to cultivate sports talent from an early age by leveraging sports sciences, including medicine, physiology, nutrition, biomechanics, psychology, coaching, and research 5 to facilitate optimal development.Regardless of the potential and achievements of female athletes, they usually face unique challenges.These challenges include complex nutritional and health issues arising from excessive exercise, commonly known as Female Athletes Triad (FAT) 6,7 .
FAT is characterized by impaired energy availability, menstrual dysfunction, and decreased bone density 6,8 .Globally, the syndrome is often found in active adolescent girls with a prevalence rate of 40-60% 6,9 .Desai & Prajal (2020) discovered that 49.5% of female athletes in India were not aware of the syndrome 10 .Although data on FAT in Indonesia remains limited, several research reports reported tendencies ranging from 1.1% to 11.54% in the high category and >11.54% in the very high category 11,12 .Understanding that research on Papuan female athletes is still limited is expedient.Most of this research focused primarily on general aspects such as physical and psychological conditions 13,14 , personality traits 15 , the mentality of the athletes 16 , psychological profile 17 , and anxiety and aggressiveness 18 .Therefore, information regarding young female athletes is unavailable.
Given its significant impact on female athletes, the syndrome can impede training and performance, leading to a decrease of approximately 9.8% in different competitive individuals.Managing FAT is a complex task requiring the collaboration of the athletes with various sports sciences professionals, such as doctors, nurses, nutritionists, coaches, and psychologists, through personalized approaches and early treatment 6,19,20,21 .This syndrome, if not addressed, will hamper sports coaching programs that demand substantial investments and potentially hinder the development of natural athletic talent in Papuan.Therefore, this research aims to obtain a comprehensive description of the knowledge level of young Papuan female athletes regarding FAT.It serves as a crucial initial step for preventing, detecting, and treating FAT in Papua.Furthermore, the results can contribute valuable insights to address research gaps and aid in planning achievement development programs for the athletes, specifically those belonging to the indigenous community.

METHODS
This observational research was conducted using a cross-sectional survey design in Jayapura City, Papua.Furthermore, it involved a total sample size of 61 young Papuan female athletes selected from the Student Sports Education and Training Center of Papua Province (PPLP) and various sports clubs.The athletes were selected from a diverse range of games, such as hockey, outdoor volley, football, basketball, tennis, cycling, rowing, weightlifting, and athletics, as well as martial sports such as judo, martial arts, wrestling, boxing, karate, and taekwondo.As mentioned earlier, a convenience sampling technique was used to select the participants from the two locations where most young female athletes trained.Data were collected using a questionnaire adapted from research conducted by Jafar (2021).The questionnaire comprised eight questions that focused primarily on assessing the knowledge level of the athletes about the three main components of FAT (osteoporosis, menstrual disorders, and eating disorders), its impacts, and the associated risk factors 22 (intensive physical activity, age, and stress fracture).To determine the knowledge category of each participant, this research employed the classification method proposed by Budiman and Riyanto (2013).Using this method, the data on the knowledge level obtained were divided into two categories, namely "good knowledge" and "lack of knowledge"."Good knowledge" was assigned when the total score exceeded the median, while "lack category" was designated when the score was less than or equal to the median.Furthermore, the data related to the athletes' knowledge was analyzed using descriptive statistics with univariate analysis.In this situation, the SPSS program was used to determine the mean, standard deviation, and frequency.The categorical data were then presented in the form of frequency and proportion.It is crucial to note that this research has been approved by the Health Research Ethics Committee at the Health Polytechnic of Jayapura with Ethical Clearance number 125/KEPK-J/VII/2022.

RESULTS AND DISCUSSION
This research comprised 61 young Papuan female athletes actively training at various sports clubs in Jayapura City and PPLP in Papua Province.Data collection for the research was carried out over a period spanning from August 3 to September 30, 2022.Accordingly, the collected data underwent descriptive analysis to provide comprehensive insights, and the detailed results are presented below.

Characteristics of Subjects
The research samples comprised young female athletes who were part of PPLP in Papua Province.The samples' characteristics include age, ethnicity, training duration, and sports, as shown in Table 1.  1 shows a comprehensive overview of each respondent's average age, ethnicity, and length of practice.It also presents the distribution of sports among a total of 61 athletes.The average age of respondents was 14.74±1.84years old, with the youngest being ten and the oldest 20 years old.Regarding ethnicity and training duration, approximately 86.89% of the athletes were Papuan, while 50.82% had trained for less than one year.Only nine athletes had undergone training for three or more years.Furthermore, when examining the distribution of sports among the samples, the athletes involved in athletics held the highest percentage (19.67%).

Description of Knowledge of FAT
The knowledge assessment on FAT consisted of 3 main components: the associated dangers, impacts, and risk factors.In this situation, participants were asked eight questions, each with a dichotomous response format of "yes" or "no" and "true" or "false".Table 2 presents the detailed questions included in the knowledge assessment.

Abbreviation: FAT = Female Athletes Triad
Table 2 presents the knowledge assessment results regarding FAT among young Papuan female athletes.The results showed that approximately 80.33% of participants were unaware of the syndrome.Following this, only 8.20% correctly acknowledged that bone fracture is an occurrence associated with FAT.Regarding the dangers posed, about 65.57% of the athletes agreed that the syndrome is dangerous and a serious problem, acknowledging its potential implications on health and performance.It was also observed that approximately 62.30% of the athletes believed that women over 25 years were not at risk of FAT, and 68.85% stated that the syndrome persists even after an infected person stops being an athlete.Furthermore, 75.41% answered correctly that eating disorders are part of this condition, indicating a better understanding of this aspect.Apart from the results, it is crucial to note that most respondents provided incorrect answers about the highrisk group (81.97%) and the main components of FAT (88.52%), highlighting the need for improved knowledge in these areas.

FAT Knowledge Category
The knowledge score for each participant was determined by assigning points based on their responses to the eight questions related to FAT.For each correct answer, a certain number of points were allocated, and all the obtained points from every question were summed up.After calculating the total score for each participant, the scores were categorized into two main groups, namely "good knowledge" and "lack of knowledge".The table above shows that approximately 80.33% of the athletes lacked knowledge about FAT, while only 19.67% indicated accurate knowledge of the subject matter.This research aimed to examine the knowledge level of Papuan female athletes concerning FAT.Accordingly, the obtained results showed that most participants lacked awareness and understanding of the syndrome, with more than half indicating total unawareness, highlighting a significant knowledge gap.
Specific aspects of FAT were examined, and the following results were obtained.First, only 8.20% of the athletes correctly answered questions related to fracture occurrence in FAT, and merely 9.84% could accurately identify all three syndrome components.Furthermore, 18.30% of the participants recognized the risk associated with high physical activity in athletes, and only 37.70% could correctly answer questions related to age and its relation to FAT.
Regarding sample characteristics, this research involved predominantly (86.89%) indigenous Papuan athletes with an athletic background.The average age of the participants was 14.74 years old, and they mostly had a training duration of less than one year.FAT is characterized by three interrelated conditions, namely menstrual disorders, eating disorders, and osteoporosis.It is crucial to understand that several risk factors are associated with various syndrome components, including the type of exercise, psycho-social problems, dietary and nutritional issues, body image, and training regimen, as described in multiple evidence-based reviews of medical history 23 .Accordingly, research in other regions showed that elite female athletes in Pakistan had a high risk of experiencing eating disorders 18,21 , and endurance athletes aged 18 to 38 years were reported to experience the totality of the syndrome 23 .
Female athletes across various sports and levels of competition are at risk of FAT syndrome, with those engaging in endurance sports having the highest risk.Aesthetics sports athletes, particularly those focusing on leanness, are also prone to FAT due to concerns about shape and weight.This leads to abnormal eating habits and potential deviations in eating behavior, resulting in decreased bone mass and an increased risk of bone fracture.While the role of ethnicity and race in contributing to the occurrence of FAT is still debated, previous research showed that low energy availability was found both in African-black and African-American athletes 24 .Moreover, Caucasian athletes have been found to have a higher risk of menstrual dysfunction and energy deficiency 25 .
The results showed that the majority of female athletes lacked knowledge about FAT, and this was consistent with previous research showing poor knowledge among athletes and coaches 26,27,28 .General knowledge about nutrition among athletes, coaches, and sports specialists had also been reported to be inadequate ,29,30 possibly due to the limited access to research-based nutrition information, specifically when licensed sports nutritionists were not available as part of the sports science team.The athletes must have a good understanding of FAT components as this will enable early recognition of the syndrome and foster the immediate action of appropriate prevention measures 31 .
The results also showed that a significant portion of the athletes, approximately 80.33%, were unaware of FAT.Additionally, most participants failed to identify the main component of FAT and the associated risk factors.The results align with previous research conducted among sports students 28,31 and athletes 26,22,32 , indicating limited awareness of FAT-related aspects.While the majority of the respondents correctly recognized the dangers of FAT and the presence of eating disorders, it is expedient to understand that inadequate nutritional knowledge and understanding of good eating habits and nutrient benefits could lead to intelligence and productivity issues.Research conducted by Nugroho & Purwanto (2020) on sports students also highlighted a notable risk of experiencing the syndrome and a lack of knowledge and information 33,34 .
The global prevalence of FAT syndrome in female athletes was reported to be relatively high, ranging from 40 to 60%.This prevalence could be attributed to the lack of knowledge about FAT, as observed from the research on female swimmers in KwaZulu-Natal 27 .The research also found that athletes in various sports had limited access to appropriate healthcare choices, pinpointing the necessity to initiate further evaluation and preventive measures to address metabolic progression and decline associated with FAT 6 .According to Lawrence Green's theory, knowledge is one of the perceived factors that can be targeted to deal with health problems related to health behavior 34 .Therefore, interventions aimed at improving sports nutrition knowledge and behavior in female endurance athletes with relative energy deficiency in sports have shown positive results 35 .Previous research showed that collaboration with policymakers in health education or dissemination was beneficial in increasing health knowledge and awareness while minimizing the consequences of the syndrome 36 .
Eating disorders are closely related to health behavior, and they can manifest in the form of anorexia and bulimia nervosa 37 .Combat sports athletes, in particular, have a higher risk of developing FAT due to severe weight-cutting behaviors 38 .Various research showed that female athletes often struggle to meet their nutritional and energy needs both from macronutrients and micronutrients, and this has led to health problems related to low energy availability and poor performance (EA) 19 .It is crucial to understand that adequate nutrition is vital for adolescent growth and optimal performance in sports 39,40 .FAT is dangerous, and each of its components has significant health implications, among which are morbidity and mortality 38 .Moreover, nutritional knowledge among athletes is crucial as it influences food selection, eating frequency, habits, and body weight control, ultimately affecting physical condition, fitness, and optimal performance 41 .
FAT has an impact not only on sports performance but also on daily life activities and mental health.The collected data underwent descriptive analysis to provide comprehensive insights.The detailed results are presented below.Additionally, FAT can have a detrimental impact on the mental health of the athletes, leading to stress and pressure from coaches and their social environment during training and competition.This situation also has the potential to affect their dietary intake 42 .The consequences of the syndrome include eating disorder patterns, mental health-related conditions, osteoporosis 43 , and potential effects on future pregnancy 44 .

CONCLUSIONS
In conclusion, the results showed that young Papuan female athletes had a significant lack of knowledge regarding FAT, with the majority unaware of its existence.Moreover, many of the athletes failed to accurately identify the components of the syndrome and its associated risk factors.To address this issue and promote early prevention and management of FAT, it was crucial to implement educational initiatives targeted at young Papuan female athletes, coaches, and parents.To gain further insights and advance knowledge in the area, it was recommended that future research should be conducted using a larger sample.They can also explore additional aspects, such as signs and symptoms of FAT in athletes, variables related to physical activities, and anthropometric data.

Table 1 .
Characteristics of Subjects

Table 3 .
FAT Knowledge Category