October 2012 Issue

The Female Athlete Triad — What Sports RDs Should Know About This Prevalent Condition
By Christin L. Seher, MS, RD, LD
Today’s Dietitian
Vol. 14 No. 10 P. 68

Women’s athletics recently has enjoyed the spotlight with the anniversary of Title IX and the London 2012 Summer Olympics, which showcased the finest athletes from around the world.

Amid the talk about training and sacrifice, what’s gone unspoken are the challenges female athletes face when it comes to fueling their bodies for competition—which, if done incorrectly, can lead to more than just decreased performance. It can lead to what’s called the Female Athlete Triad (Triad), a condition in which female athletes experience low energy availability, disrupted menstrual function, and diminished bone mineral density.1 For many women, the Triad presents another obstacle to conquer on their path to success.

This article will discuss the Triad, its causes, who’s at risk, and the role dietitians can play in counseling female athletes.

What Causes the Triad?
The Triad results from low caloric availability, defined as the amount of energy accessible to the body after accounting for physical activity and training demands. Often the energy deficit underlying the Triad results from the athlete’s disordered eating behaviors (eg, food restriction, selective avoidance of food groups, binge eating) or dysfunctional eating patterns such as fasting and skipping meals. It’s important to note that while disordered eating can be severe enough to meet clinical diagnostic criteria, an eating disorder such as anorexia or bulimia isn’t a required component of the Triad diagnosis.

Kristy Morrell, RD, a sports dietitian at the University of Southern California (USC), frequently sees examples of disordered eating among athletes she counsels. The most common include cycles of food restriction and binge eating, preoccupation with weighing, measuring, calorie counting, or following a rigid, “clean” diet consisting of only the healthiest foods.

While low energy availability is attributed to disordered eating behaviors in some athletes, many others are simply undereating, consuming fewer calories than necessary to sustain the rigorous demands placed on their bodies during competition and training. An energy deficit can occur unknowingly if an athlete is misinformed about her caloric needs or energy expenditure or knowingly if she’s trying to lose weight, body fat, or achieve a desired physique.

Regardless of how the athlete becomes energy deficient, the adverse effects are similar, as a calorie deficit can trigger a cascade of physiologic changes that place female athletes at risk of other health problems such as amenorrhea (the absence of menstruation for more than three months) and low bone density. Adequate energy intake is necessary to maintain sufficient estrogen production to promote normal menstruation; amenorrhea results from an inadequate hormonal balance.1 Moreover, normal menstruation sustains bone mineral density, whereas the absence of menstruation, triggered by low estrogen levels, can lead to lower bone mineral density than what’s appropriate for chronological age, osteoporosis, or increased risk of stress fractures.1

Who’s at Risk?
The Triad affects athletes involved in all types of competitive sports; however, components of the Triad occur more frequently in those participating in activities that emphasize leanness, such as gymnastics and dancing, or that promote a desired body shape or size.1 Vegetarian athletes who remove entire food groups from their diets, who are food insecure, or compete in multiple sports are of particular concern for low energy intake. Morrell has witnessed this while working with athletes, noting that sprinters, swimmers, divers, and rowers also are at risk because of the weight restrictions and the fact they believe being leaner will improve performance.

Prevalence estimates of the Triad vary widely. Lack of awareness and screening, nonstandard diagnostic criteria, and various methodological problems in research have contributed to the rudimentary understanding of its pervasiveness. Most studies have examined only a single component of the Triad; a handful of studies have investigated the occurrence of all three components but not without limitations and the use of strict diagnostic criteria.

Not surprisingly then, prevalence rates of the Triad are low. However, one study of high school athletes found individual components of the Triad were relatively common, with 18.2% demonstrating disordered eating behaviors, 23.5% reporting menstrual irregularities, and 21.8% exhibiting low bone mass. Six percent met the criteria for two components of the Triad, and only 1% met all three.2 Another study of collegiate athletes estimated the prevalence of the Triad is only 2.7%.3

However, according to experts, aspects of the Triad exist along a continuum, from optimal to pathological, making recognition of subclinical signs and symptoms critical.1 The presence of just one aspect of the Triad places athletes at risk for health problems. Recent studies show that more than three-fourths of high school athletes exhibit one component of the Triad, indicating a need for action.4

Asking the Right Questions
To prevent the Triad, the implementation of universal screening measures to identify at-risk athletes is necessary. Morrell has helped develop screening methods at USC that ensure all athletes are asked about dietary behaviors and menstrual regularity so she can make a note of athletes who might need additional follow-up and counseling.

Amy Goodson, MS, RD, CSSD, LD, a sports dietitian for collegiate and professional teams in Texas, suggests RDs ask simple questions to help them assess an athlete’s risk for the Triad. “Asking if they cut out entire food groups, have weight-loss goals when there isn’t a need, or if they have interesting eating patterns, such as skipping meals, avoiding going out to eat, or not eating postworkout, can help determine if an athlete exhibits disordered eating,” she says. It’s also important to ask about stress fractures or bone breaks to give insight into other aspects of the Triad, she adds.

Treatment Options
What’s unique about working with athletes is that their performance-driven, people-pleasing mindset makes them more motivated than other clients, according to Morrell. “Most of them are trying to do what’s best. They have good intentions, but they may have let it go too far,” she says. Dietitians can tap into athletes’ competitive natures to facilitate the treatment process by working in tandem with coaches and trainers.

Educating athletes about increasing caloric intake is the critical component. Dietitians can perform individual assessments of the athletes, taking into account type of exercise, duration, frequency, and intensity as well as age, body size, and fat-free mass (FFM). Ideally, determining caloric needs involves measuring basal or resting metabolic rate to estimate total energy expenditure. Validated predictive equations or metabolic equivalents can be used as secondary options when access to equipment, which can provide individualized data (eg, a metabolic cart), is limited. In the absence of such personalized assessments, 30 kcal/kg of FFM/day is the least women athletes should consume to maintain energy availability.5

High-quality protein foods, such as low-fat dairy products, eggs, and lean meats, are especially useful as calorie sources in ameliorating Triad symptoms because they help reestablish hormonal concentrations that promote bone health. Protein recommendations vary by individual athlete, but they generally fall within 1.2 to 1.4 g/kg/day in endurance athletes (eg, distance runners, cyclists, swimmers), and 1.2 to 1.7 g/kg/day in strength/resistance athletes (eg, weightlifters).5 When combined with nutrition timing strategies pre-, peri-, and postworkout, high-quality protein foods or supplements also can assist in recovery, muscle development and preservation, increased glycogen storage, decreased inflammation, and immunological benefits.

What Can RDs Do?
To help raise awareness of the Triad, Goodson suggests dietitians talk to teams, coaches, and athletic trainers and educate them about sports nutrition and the importance of fueling the body. It’s ideal for everyone, including parents, “to send a consistent message about food, energy balance, body image, and performance,” she says.

Morrell agrees, explaining that coaches can be either a big obstacle or an invaluable resource, depending on the language they speak. Helping those in the sports community recognize the importance of food as fuel is a good place to start.

— Christin L. Seher, MS, RD, LD, is founder of Strategic Health Solutions, LLC, serving northeastern Ohio.


The NCAA has published a handbook to help coaches understand, screen for, and participate in the treatment of the Female Athlete Triad. Access it online at www.femaleathletetriad.org/wp-content/uploads/2008/10/NCAA-Managing-the-Female-Athlete-Triad.pdf.


1. Nattiv A, Loucks AB, Manore MM, et al. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc. 2007;39(10):1867-1882.

2. Nichols JF, Rauh MJ, Lawson MJ, Ji M, Barkai HS. Prevalence of the female athlete triad syndrome among high school athletes. Arch Pediatr Adolesc Med. 2006;160(2):137-142.

3. Beals KA, Hill AK. The prevalence of disordered eating, menstrual dysfunction, and low bone mineral density among US collegiate athletes. Int J Sport Nutr Exerc Metab. 2006;16(1):1-23.

4. Hoch AZ, Pajewski NM, Moraski L, et al. Prevalence of the female athlete triad in high school athletes and sedentary students. Clin J Sport Med. 2009;19(5):421-428.

5. Rodriguez NR, DiMarco NM, Langley S, et al. Position of the American Dietetic Association, Dietitians of Canada, and the American College of Sports Medicine: nutrition and athletic performance. J Am Diet Assoc. 2009;109(3):509-527.