Natalie Digate Muth by Natalie Digate Muth

ImbalanceParticipation in ample physical activity and consumption of a nutrient-dense and healthful diet are defining features of a healthy lifestyle.  Oftentimes athletes are the model citizens of excellent health; however, a sizeable number of athletes have taken healthful habits to an extreme such that they become pathologic and detrimental to overall health and well being.  Whether done inadvertently or purposefully, somewhere around 25% of elite female athletes in endurance sports, aesthetic sports, and weight-class sports suffer from disordered eating and some variation of the female athlete triad.

The female athlete triad is characterized by amenorrhea (at least three months without a menstrual period), osteoporosis (weakened bones and increased risk of fracture), and disordered eating.   The path from optimal health to full manifestation of the triad exists along a continuum.  That is, an athlete’s eating and activity habits can range from optimal health to severe anorexia nervosa.  Her bones can be incredibly strong to extremely frail and fracture prone.  She may have regular, monthly menstrual periods to prolonged amenorrhea. The three components of irregular periods, weakened bones, and disordered eating are intimately related.  Even if an athlete does not necessarily exhibit the full manifestation of the female athlete triad, she may still be at-risk for negative health and performance consequences.

The triad results when an athlete burns more calories than she consumes, creating a state of decreased energy availability.  This can happen when an athlete increases her physical activity without appropriately increasing caloric intake or if she restricts her caloric intake.  When this happens, the body attempts to restore energy balance by using less energy for growth, reproduction, and various other important bodily functions.  Menstruation halts and hormonal imbalance ensues which often leads to decreased bone strength and increased risk of fracture.  Athletes at highest risk for low energy availability and manifestation of the triad are those who restrict caloric intake, exercise for prolonged periods, are vegetarian, and limit the types of foods that they will eat.  Other risk factors include sport-specific training at an early age, dieting, sports injury, and sudden increase in training volume.

Typically, sport participation requires a pre-participation physical exam.  During this exam the physician should ask the appropriate questions to elicit whether the athlete has any signs of the female athlete triad.  If she does, a multidisciplinary team including a physician, a registered dietitian, and, if the athlete is thought to have an eating disorder such as anorexia or bulimia, a mental health professional, will work together to help the athlete regain her health.  The athlete’s coach, an exercise physiologist, a certified athletic trainer, parents and other family members also play an important role in her recovery. If you suspect a friend or teammate has disordered eating or any one of the components of the female athlete triad and you are concerned that she may respond defensively if you mention your concerns,  consider helping with use of the “CONFRONT” approach advocated by the National Association of Anorexia Nervosa and Related Disorders (ANAD) (

C – Concern.  Share that the reason you are approaching the individual is because you care about his or her mental, physical, and nutritional needs.

O – Organize.  Prepare for the confrontation.  Think about who will be involved, where is the best place, why you are concerned, how you plan to talk to the person, and the most appropriate time.

N – Needs.  What will the individual need after the confrontation?  Have referrals to professional help and/or support groups available should the individual be ready to seek help.

F – Face the confrontation.  Be empathetic but direct.  Be persistent if the individual denies having a problem.

R – Respond by listening carefully.

O- Offer help and suggestions. Be available to talk and provide other assistance when needed.

N – Negotiate. Agree upon another time to talk and a time frame in which to seek professional help, preferably from a physician who specializes in eating disorders as well as an experienced psychologist.

T – Time. Remember that the individual will not be “fixed” overnight.  Recovery takes time and patience.

You can learn more about the female athlete triad at the Female Athlete Triad Coalition website.

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