Women and Sport Nutrition The Female Athlete Triad

Sports and exercise are healthy activities for girls and women of all ages. Occasionally, a female athlete who focuses on being thin or lightweight may eat too little or exercise too much. Doing this can cause long-term damage to health, or even death. It can also hurt athletic performance or make it necessary to limit or stop exercise. Three interrelated illnesses may develop when a girl or young woman goes to extremes in dieting or exercise. Together, these conditions are known as the "Female Athlete Triad”.

The Three Conditions of ‘Female Athlete Triad’

Disordered eating

Abnormal eating habits (i.e., crash diets, binge eating) or excessive exercise keeps the body from getting enough nutrition.

Menstrual Dysfunction

Poor nutrition, low calorie intake, high-energy demands, physical and emotional stress, or low percentage of body fat can lead to hormonal changes that stop menstrual periods (amenorrhea). 

Premature Osteoporosis (Low Bone Density for Age)

Lack of periods disrupts the body's bone-building processes and weakens the skeleton, making bones more likely to break.

In 2007, the American College of Sports Medicine broadened the criteria — it now includes low-energy availability (with or without eating disorders), disturbed menstruation (including amenorrhea) and bone mineral density (BMD) decline, an osteoporosis precursor.

What are the risk factors for developing the Triad? 

Thoughts, beliefs or behaviours that lead to low energy availability or energy deficiency might be considered a risk factor for developing the Triad. For example: dieting at an early age; chaotic eating habits (such as skipping meals), being unhappy with your body type, perfectionism; or believing that losing weight (or body fat) at any cost will improve performance. Taking part in sports that favour a lean body size or shape (like gymnastics, figure skating or long-distance running) or sports that have weight classes (like rowing) or revealing uniforms (like swimsuits or volleyball uniforms) can also lead some girls and women to unhealthy eating habits.

What are the signs of the Triad?

In the early stages, workouts and performances may not be adversely affected and standard blood test results are typically normal. Frequent or deliberate attempts to lose weight or decrease body fat quickly or to look “more toned” or “like an athlete should” often result in chaotic eating patterns and under-fueling. Possible indicators of the Triad that need to be evaluated by a sports-minded health professional include: irregular or absent periods (or difficulty becoming pregnant); stress “reactions” or fractures; a preoccupation with weight or body size and shape that interferes with normal eating habits; noticeable weight loss; and excessive or compulsive exercise habits.  

What are the consequences of the Triad?

The Triad can affect every aspect of life. Eating too few calories and nutrients can quickly lead to dehydration and electrolyte imbalances and leaves a woman feeling more tired, anxious and irritable than usual. It may find it harder to concentrate and feel less motivated to do things normally liked. Athletes report that they feel as if they are training harder but their performances don’t improve, or may even get worse. Over time, the Triad increases the risk of suffering a stress fracture or an “overuse” injury and then makes it harder to train successfully.

Diagnosis of the Triad typically includes blood and urine tests especially for estrogen. Also, a bone density scan and an EKG.

Treatment is based on the following:

• Adequate protein. Typically, a person is burning protein for energy by conversion to sugar. This should be replenished. A 120-pound athlete should target 60 to 90 grams of protein each day.
• At least 20% of calories should derive from health fats – vegetable saturated fats such as coconut oil, monoglycerides like olive, avocado or walnut oil.
• Replenish deplete calcium by supplementation. Calcium citrate, citrate-malate or calcium chelate all being easily available.
• Vitamin D supplementation which is typically deficient. Along with calcium this addresses the osteoporotic factors.

The Female Athlete Triad is a serious matter and requires the attention of a physician and often a nutritionist as well. Counselling is also recommended.

Select references:

The Female Athlete Triad, Taraneh Gharib Nazem, BA and Kathryn E. Ackerman, MD, MPH, Sports Health. 2012 Jul; 4(4): 302–311.doi:  10.1177/1941738112439685

Female Athlete Triad, Updated: Apr 28, 2017 Author: Laura M Gottschlich, DO; Chief Editor: Craig C Young, MD http://emedicine.medscape.com/article/89260-overview

Treatment of the Female Athlete Triad, Written by: Elizabeth Joy, MD, MPH, FACSM, National Collegiate Athletic Association  http://www.ncaa.org/health-and-safety/nutrition-and-performance/treatment-female-athlete-triad