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The Female Athlete Triad: Fueling for Health and Performance

Any active girl or woman can develop the condition known as the female athlete triad, but some are at higher risk than others. What are the factors that elevate the risk? What can athletes do to fuel for health and performance—and prevent the triad?

In some physically active girls and women, menstrual periods skip a month or two, or even stop altogether. Because menstrual abnormalities can cause low estrogen, and low estrogen contributes to weak bones, these athletes have a higher chance of stress injuries to their bones. At their worst, these injuries sideline athletes with painful stress fractures, often in connection with the repeated impacts that are a part of sports.

Decades of research point to the culprit behind both the menstrual and the bone problems. In a word, it’s calories—calories too few to stock the energy stores a female athlete needs to run, jump, dive or dance.

Alone or together, low energy stores, abnormal menstrual cycles and low bone mass make up the female athlete triad. The key to preventing the triad is eating enough food to replenish the calories and nutrients burned in exercise. An athlete may train for hours a day and not develop low energy stores—as long as she is consuming enough calories and key nutrients.

However, doing this is not always easy in sports cultures that prize appearance over health.

Who is at risk of the triad?

Athletes in certain sports seem to be more likely to develop the triad, says Dr. Elizabeth Joy, a family physician at Intermountain Healthcare in Salt Lake City and past president of the American College of Sports Medicine.

“We tend to see [the triad] particularly among athletes who participate in sports where leanness confers a competitive advantage,” she says.

These girls and women include long-distance runners who want a very lean appearance because they believe their success hinges on carrying less weight over distance. Athletes in “aesthetic” sports such as gymnastics, figure skating, diving and ballet are also at risk. “They tend to wear more revealing costumes or revealing uniforms, and as such may have more body consciousness,” explains Joy.

How does low energy availability occur?

Experts have noticed eating and exercise patterns that are common to athletes who develop low energy stores and other elements of the triad. They include:

  • Dieting or restricting how much they eat
  • Limiting the types of food they eat
  • Frequent weight cycling (weight loss and weight gain)
  • Receiving critical comments about eating or weight from a parent, coach or teammate
  • Being pressured to lose weight
  • Overtraining or exercising for long periods

“When energy availability is low, it could be because you’re not taking in enough calories,” says Joy. “It could be because you’re exercising a whole lot. Those probably are the components that affect the energy availability equation the most.”

Inadequate calorie intake may or may not be intentional. “There’s quite a spectrum that can affect the energy availability equation,” says Joy.

  • The triad often starts with dieting. “It can be that somebody is intentionally restricting their dietary intake as a strategy to change their body composition. That could be at the extreme end, and may actually be an eating disorder like anorexia nervosa.”
  • The cause could be disordered eating, a less dangerous situation when people are “misinformed about what their energy needs are,” explains Joy. “They’re still intentionally restricting calories, but it does not rise to the diagnostic level of an eating disorder.”

Research suggests that harmful eating behaviors and sometimes-fatal eating disorders are more likely to occur in girls and women who are perfectionists or obsessive, or who suffer from depression, low self-esteem, family dysfunction or abuse.

  • Finally, the cause of low energy availability could be “lazy” eating. Lazy eaters rise late, drink a cup of coffee, have a salad for lunch, “don’t want to eat too much before practice,” and grab a quick bite in the evening, says Joy. “They inadvertently don’t get enough calories in. They’re not intentionally trying to restrict their energy intake, but they’re still not meeting their energy needs.”

Promoting the whole athlete, preventing eating problems

Joy says the triad has its roots in a complex mix of social, sports and personal issues. At the heart of the problem is “the messages that women get, that in order to be successful in sport—for that matter, in order to be successful in life—you have to achieve a certain appearance,” she suggests.

“If our goal is to support the healthiest athlete possible, then we are more likely to succeed in preventing the female athlete triad. Let’s talk less about how much she weighs, and talk more about how well she trains—and how well she is caring for herself in terms of sleep and dietary intake and stress management,” advises Joy.

Early recognition is important. Know the early warning signs of dietary restriction and excessive exercise. Pay attention to comments about body image, she says. “You know, ‘Do you think I’ve gained weight?’ ‘I’m feeling kind of fat.’ ‘I don’t think I’ll have the mashed potatoes for dinner tonight.’ ‘Guess what? I’m not eating fat anymore.’ ‘I couldn’t possibly have dessert.’ ”

Joy advises parents, athletes, coaches, athletic directors and others to support a culture that promotes the value of food as fuel. “In order to perform optimally, you have to fuel your body optimally. We need to emphasize function over form. Athletes can be successful at lots of different sizes and body weights and body compositions. There is no ideal form for success.”