APU Health & Fitness Original

Female Athlete Triad and the Risks for Female Competitors

By Daniel G. Graetzer, Ph.D.
Faculty Member, School of Health Sciences

and Kristjana Cook, M.S. 
2022 Master’s Degree Graduate, Sports and Health Sciences

Female Athlete Triad is increasingly being diagnosed in girls and women heavily involved in both recreational and competitive sports, according to the American College of Pediatrics. This is not surprising, because we live in a culture that glorifies thinness and beauty, as well as the sacrifices needed to achieve a slim body.

As a result, an obsession with diet and exercise often grips young female athletes and compels them to do whatever it takes to mold their bodies into often unrealistic ideals, based on the images that saturate the media. The drive to be and look the best has the potential to wreak havoc on these young women, and the health consequences of Female Athlete Triad affect nearly every system of the body and extend far into adulthood.

What Is the Female Athlete Triad?

Female Athlete Triad is a cause for concern due to its effects on the body. It is typically characterized by three interlinking variables:

female athlete triad 2
Female Athlete Triad can lead to severe eating disorders such as anorexia and bulimia.
  • An energy imbalance with or without an eating disorder
  • Amenorrhea (the absence of a monthly period)
  • Decreased bone mineral density (with or without osteoporosis, which is often not identified until a bone stress injury occurs)

Weight loss due to decreased caloric intake and excessive exercise (with both possibly becoming obsessions) are often the first signs of possible progression into a full-blown eating disorder. These eating disorders can include anorexia or bulimia. 

RELATED: How Warmups and Stretches Can Affect Athletic Performance

How Are Young Girls and Women Affected by the Triad?

Young female athletes are often overly concerned about their personal body weight and shape. As a result, they may feel the need to drastically restrict their eating and lose weight to achieve a physical ideal.

This desire to be thin is often influenced by images they see in social media. Essentially all social media platforms show photographs of professional athletes and fitness models with extremely low body fat, toned muscles, and visible bones. However, the common practice of using digital photoshopping to create these “ideal” bodies is something most people often conveniently ignore, according to More Than a Body.

Low-calorie diets, especially those which lack sufficient protein, calcium and Vitamin D may lead to amenorrhea (the absence of a monthly period) as the body begins to shut down nonessential functions to conserve available energy. This conservation process frequently triggers a reduction of estrogen production, which contributes to low bone density, a higher risk of bone stress injury and fractures, and possibly early-onset osteoporosis (which increases bone fragility).  

An almost morbid fear of gaining weight is more common than many parents and coaches would like to believe. Many young girls competing in timed, weight-bearing sports such as running and aesthetic sports such as dancing, gymnastics, and figure skating may be willing to do anything it takes to be as thin as possible.

What’s more, some of these athletes believe that losing their period is a sign that they are training at their peak. They imagine that amenorrhea speaks to their dedication and commitment to their sport, and they like the convenience of not having to navigate a monthly menstrual cycle during competition.

A restricted pattern of eating, however, leads to dangerously low intakes of vitamins and vital nutrients such as iron, calcium, and zinc. Elimination diets, a popular way to disguise disordered eating, makes excluding whole macronutrients such as carbs or fats seem wholesome, according to Global Autoimmune Institute.

Similarly, extremely low-protein vegan diets may also seem virtuous, says WebMD. But eliminating dairy products drastically reduces calcium and vitamin D intake, which are essential for a robust musculoskeletal system. 

The Female Athlete Triad is also closely associated with a reduction in the body’s supply of estradiol (the primary form of the hormone estrogen), which increases a female’s risk for amenorrhea and other menstrual irregularities in addition to bone mineral, according to News Medical. Although low body weight alone is generally not enough to explain the loss of menstrual periods, insufficient nutrition relative to the amount of exercise contributes strongly to low bone density.

Teenage girls who fall into the Female Athlete Triad spectrum have an increased risk for broken bones (ballet dancers and runners are particularly prone to stress fractures), which is another sign that more serious problems might follow. According to Dr. Sara Forsyth, the critical years for building bone mass are from onset of adolescence to about age 25. Insufficient fueling to support exercise and the increased caloric demands of growth during puberty essentially robs the skeleton of the very minerals it requires. 

RELATED: Strength Training for Young Athletes: What Is Appropriate?

How Can Female Athlete Triad Be Avoided?

Young women can optimize bone mass through proper diet and exercise during childhood to adulthood, giving them the greatest potential protection against osteoporosis later in life. Once a female nears the end of her reproductive years and enters the menopause transition, estrogen levels naturally begin to decline, according to the Cleveland Clinic. Bone tissue begins to break down faster than new bone can be formed as the body begins to deplete the “bone bank” established during the peak growing years.

Ideally, healthcare providers, coaches and parents should be aware of the symptoms, causes, and health risks associated with the Female Athlete Triad. Educating young female athletes on the importance of maintaining a healthy diet, especially during the teen years, is the best strategy for reducing risk of future osteoporosis. 

Fortunately, Female Athlete Triad is both preventable and treatable if it is addressed early and appropriate interventions are put into place, according to Family Doctor. Reducing the stigma associated with talking openly about menstrual cycles will help young women to realize the importance of a balanced diet that contains adequate calories to support training and essential nutrients such as calcium and vitamin D.

Also, teaching parents and coaches to recognize the warning signs of eating disorders and body dysmorphia can change the way young women define a healthy body. Hopefully, the dissemination of Female Athlete Triad information will aid a new generation of female athletes who will be able to participate and thrive in sports throughout their lifespans. 

About the Authors 

Daniel G. Graetzer, Ph.D., received his B.S. from Colorado State University/Fort Collins, MA from the University of North Carolina/Chapel Hill, and Ph.D. from the University of Utah/Salt Lake City and has been a faculty member in the School of Health Sciences, Department of Sports and Health Sciences, since 2015. As a regular columnist in encyclopedias and popular magazines, Dr. Graetzer greatly enjoys helping bridge communication gaps between recent breakthroughs in practical application of developing scientific theories and societal well-being. 

Kristjana Cook, M.S., earned a bachelor’s in anthropology from The George Washington University in 1996. In 2022, she earned her master’s in health sciences with a concentration in exercise science and human performance from American Public University, maintaining a 4.0 GPA. Her capstone project, written under the direction of Dr. Graetzer, was “Reframing the Female Athlete Triad and Reconsidering Mindsets and Training Methods for Female Distance Runners Across the Lifespan.” Kristjana is an American Council on Exercise (ACE) Certified Personal Trainer and a certified Road Runners Club of America (RRCA) Level 1 Running Coach. She has also been a participant in the Boston Marathon multiple times.

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