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What to Know About the Male Athlete Triad

The Female Athlete Triad–a trifecta of low energy availability, menstrual irregularities, and impaired bone health–has been well documented for the last 30 years, but there is growing evidence a similar syndrome in male athletes exists. A decline in athletic performance accompanied by low energy availability, low testosterone, and poor bone health constitutes the Male Athlete Triad (MAT). While the decline in athletic performance is immediately troubling, MAT can also have long-term, irreversible consequences, so it’s important athletes, parents, coaches, health care providers understand the triad, who is at risk, and how to prevent it. 


What is MAT?

The precise physiologic mechanisms are not completely understood, but it is agreed upon that low energy availability (LEA) drives hormonal suppression and impaired bone health. Simply put the athlete isn’t eating enough calories to meet the athletic demands so the body shunts resources away from reproduction and bone maintenance in favor of more vital functions. This leads to low testosterone, bone stress injuries, and/or impaired bone health.  


Low Energy Availability

Because low energy availability both drives the triad and identifies male athletes at risk, it’s worth fully understanding how it comes about. Low energy availability means energy expenditure exceeds intake. This could be unintentional, associated with the sport’s culture, or an active process (see table). For example, a marathoner increases his mileage in preparation for an ultramarathon but does not increase his caloric intake, a body builder fasts to keep his lean appearance in front of the judges, or a middle school wrestler goes on a sweat run to “make weight.” In all these examples the athlete isn’t eating enough to sustain the demands of the exercising body. 


Special Population: Male Youth Athletes & MAT

Youth male athletes face an additional challenge. Not only must they eat for a functioning, exercising body, but also a growing body! This puts youth male athletes at higher risk for low energy availability. 

The impact of LEA in male adolescents is of greater consequence too because it can delay puberty and lower peak bone mass development. Peak bone mass is a threshold, when bones are at their greatest strength and density, and does not significantly increase after age 20. In fact, 90% of peak bone mass is accrued by age 20. Higher peak bone mass is protective against osteopenia and osteoporosis. In their lifetime, more than 1 in 10 men will have an osteoporotic fracture. Therefore, adolescence is a critical time to build bone for present and future skeletal health.


Call to Action: Preventing MAT

Because of sex-specific differences, men are less likely to experience the triad than women and recover faster when nutritional deficit is restored. Preventing MAT involves identifying risk factors for LEA, ensuring proper nutrition, and diversifying exercise. More specifically –  

  • Focus on adequate nutrition that is balanced with a wide variety of nutrient dense foods like fruit, vegetables, daily, fish, poultry, meat, beans, nuts. This can be facilitated by a dietician. 
  • Coaches and parents avoiding negative comments and training practices that impact the athlete and emphasizing nutrition and health rather than weight.
  • Adequate vitamin D (600 IU daily)
  • Adequate vitamin C intake
    • 1,300mg daily if between 9-18 years old
    • 1,000mg daily if between 19-50 years old
    • 1,500mg daily if an athlete
  • Adequate magnesium intake 
    • 410m daily if 14-18 years old
    • 400mg daily if 19-30 years old
    • 420mg daily if 31+ years old
  • Weight bearing sports with multi-directional loading like: baseball, basketball, soccer, volleyball, martial arts. 
    • Male youth between 13-15 years old should participate in weight bearing, multidirectional exercise or resistance training for a minimum of 4 hours per week for at least 2 years 
    • Athletes in non-weight bearing sports should participate in weight bearing exercise 2-3 days/week

In summary, it is important for athletes and coaches to be aware of MAT because of its negative impact on athletic performance in the short term and potential for delayed puberty, stress fractures, and osteoporosis in the long term. Athletes at risk for MAT are those with low energy availability, but it can be prevented with proper nutrition; adequate intake of vitamin C, vitamin D, and magnesium; a training program that includes multi-directional weight bearing; and the support of a sports medicine physician.