Greeshma Prabhu, B.P.T., M.S.
Several decades ago, the US Government passed the Title IX of the Education Amendments of 1972, which eliminated sex discrimination in any education program or activity receiving Federal aid. This law led to a rise in the female participation in sports over time, up to more than 150,000 women playing sports today.
The “female athletic triad” is a term given to the presence of three conditions, namely disordered eating, osteoporosis, and amenorrhea, which adversely affect the overall health of the female athlete. The prevalence of this triad is found more in sports that lay more emphasis on the body’s aesthetic appeal, such as gymnastics, figure-skating, ballet, swimming etc. since these sports require low body fat percentages. The findings of Beals et al related to disordered eating identified other common characteristics in female athletes with subclinical eating disorders, including preoccupation with food, energy intake, and body weight; distorted body image; and body weight dissatisfaction . Athletes fitting this pattern tend to adopt harmful dietary habits like binge eating and purging to achieve the desired body image and fat percent.
The remaining two conditions tend to result from the disordered eating. Osteoporosis is defined as the loss of bone mineral density, which leads to an elevated risk of fractures and bone injuries. Amenorrhea, or absence of menstruation, related to athletic training occurs due to weight fluctuations, stress and low body fat percentages. It can be classified as primary or secondary.
Coaches and trainers spend more time with the athletes than do other individuals. It is essential for coaches and trainers to recognize the tell-tale signs of the athletic triad. The Position stand paper published by the American College of Sports Medicine recommends short-term amenorrhea to be considered as a warning signal or a red flag for the female athletic triad. An athlete who presents with one component of this triad must be screened for the other two also.
Management of the triad requires careful interventions designed to prevent or treat each component. Healthy eating habits are necessary to optimize overall nutritional status to prevent nutrient deficiencies and/or low energy availability, which leads to reproductive dysfunction and impairment of skeletal muscle function. Hence the first step to be taken in the treatment of this triad is to ensure a nutrient-balanced diet with adequate caloric intake by increasing energy availability and/ or decreasing energy expenditure thus restarting the menstrual cycle. Nutritional counseling and dietary intervention by a dietitian is necessary. Nichols et al state that female athletes have been advised to consume the same amount of calcium as the general female population (1000-1300mg/day), however, it has yet to be determined if they need additional calcium. In addition to calcium, Vitamin D and protein intake of the athletes should be monitored. Athletes who do not comply with the nutritional recommendations may require cognitive, behavioral and supportive therapy.
The ACSM gives excellent guidelines on the treatment of the triad according to the category or severity, which can be found at
- Beals et al. Understanding the female athlete triad: eating disorders, amenorrhea, and osteoporosis. Journal of School Health, Vol. 69 Issue 8, p337-340, 1999.
- Nichols et al. Bone density and young athletic women-An update. Sports Med 37(11): 1001-1014, 2007.
- Beals et al. Behavioral, psychological and physical characteristics of female athletes with sub-clinical eating disorders. Int J Sports Med Exer Metab; 10:128-143,2000.