The Female Athlete Triad: Not As Fun As it Sounds

Content notice: eating disorders.

“Have you ever heard of the Female Athlete Triad?”

I know what my new doctor’s about to say as soon as I hear the words “female athlete.” Having struggled with the ghosts of an eating disorder throughout my twelve-year running history, I get asked if I’m aware of the world’s best-named collection of ailments at least once a year by medical professionals. I’m quick to cut them off––it’s embarrassing for me that they’d even suggest it, since I’m not as thin as I feel I should be to even invite the possibility.

“Yup, no, I’m fine––I haven’t been underweight since I was a teenager. I had an eating disorder, and I got treated for it, and no problems since then, and I eat enough, and my weight is in the normal range,” I recite with boredom, ready to move on to a relevant topic and just a little annoyed that with my winter clothes on I was 5 pounds heavier on the doctor’s scale than my actual weight.

My doctor blinks a couple of times before responding. It’s the same expression I’m pretty sure I have on my face when someone asks me to recommend a “sweet dry wine.”

“Yeah, ok, you don’t know what the Female Athlete Triad is.”

I’m startled. She goes on. “The Female Athlete Triad has nothing to do with being thin. It’s about not eating enough calories to sustain your activity level.”

Now I’m just confused. “Wouldn’t I be… losing weight? If that was the case?”

“Nope. You’d be getting injured a lot.” She’s been eyeing my chart, on which for the first time in my life I listed the last five years of my medical history in one place: arthroscopic surgery for shoulder tear. Severe fingernail breaks, one way too gnarly to recount here but requiring emergency treatment. Shin splints (ten years into running, not as a newbie). Two stress fractures in the last two years (my first and favorite one, Tibia 2011, is pictured above).

“Have you ever wondered why you keep getting all these sports injuries? Your body is breaking down bone and muscle tissue to compensate for a calorie deficit. That’s why you’re not losing fat. What do you eat, 1600 calories a day?” I nod slowly, creeped out that she guessed accurately, and halfheartedly offer that I’m just following MyFitnessPal’s recommendations. “Well, I don’t know what your little ‘fitty thing’ is telling you, but you probably have the metabolism of an inactive 70-year-old.”

Well then. I thought of my last several years of training: martial arts, three marathon seasons, several half marathons. Nearly every year I’ve gotten sidelined with an injury, always two steps back to ruin my progress despite taking rest days, following training plans from expert sources, and cross training for strength. I always just wrote it off as “injury proneness” or “bad luck.” The knowledge that it might be my fault was horrifying.

When my doctor informed me that I needed to be eating much, much more than I currently am, I found myself on the verge of a panic attack. She told me of her days as a young athlete (her background is in sports medicine, which is why I requested her as a primary-care physician; the fact that she’s kind of an awesome smartass was a bonus) dealing with frequent injuries. A nutritionist advised her to bump her diet to double her current intake. “I was sure I’d gain weight, but instead, I got healthier, and stopped getting injured,” she told me. “You need to see a nutritionist.” [EDIT: Though it’s common to use the terms “nutritionist” and “dietician” interchangeably, or use “nutritionist” as an umbrella term, they are not the same; I will be seeing a registered dietician with approved medical credentials. Thanks to those who reminded me of this important point.]

I’ll be seeing one a week from today, and I’m terrified. Here I am, unable to run or ride my bike for 12 weeks due to an unhealed stress fracture and bone edema (swelling) that’s making my hip feel like someone’s drilling a hole in it after just a mile or two. Six months ago I was running 40-50 miles a week and biking everywhere. I was considering training for an Ironman. Now, just a short walk to the bus stop is all I can manage.

How much fitness would I lose? How would I keep from losing total control of my life––control that, I realized, has always revolved around food? What the hell was I supposed to eat now that I was inactive? And how could I stop this from happening again? Filled with trepidation, I retreated to the traditional anxiety coping mechanism of obsessive Googling.

For starters, my doctor was right. (A note here: The literature I found on this topic addresses people who menstruate, which, of course, doesn’t include all women and includes people who don’t identify as women; I did find this helpful information on osteoporosis risks for trans* people taking hormone replacement.) The Female Athlete Triad doesn’t necessarily present as severe thinness, and that misconception is a dangerous one: just as people who don’t fit the eating disorder “mold” (deathly thin, female) can easily go untreated or even be denied treatment coverage and suffer severe consequences, people who don’t fit that mold can suffer the consequences of the Triad simply because their bodies are scrounging extra fuel from their bone and muscle tissue rather than causing them to lose weight. The Triad can occur at any size and weight.

Often, and unfortunately, stress fractures are the first medical indication that something is wrong. You don’t even need to exhibit symptoms of an eating disorder––well-known symptoms like hair loss, sore throats from bingeing, and obsessive recipe collecting––for your bones to be suffering the effects of depletion. The NCAA coaches’ guidebook article on the Triad, written by Roberta Sherman, Ph.D., FAED, and Ron Thompson, Ph.D., FAED, co-chairs of the Athlete Special Interest Group of the Academy of Eating Disorders, points out, “The term “disordered eating” is used rather than eating disorders because the athlete’s eating does not have to be disordered to the point of a clinical eating disorder (i.e., anorexia nervosa or bulimia nervosa) in order for the other two components of the Female Athlete Triad — amenorrhea and osteoporosis — to occur.”

Here’s how it works: thanks in part to a mainstream culture of dieting, stick-thin stock photos (including those in the NCAA’s Triad booklet, ironically) and models in women’s fitness magazines as images of “health,” and a culture of competitiveness and pushing ones’ self to the limit within the athletic world, female athletes––especially those in sports like running and gymnastics, where thinness is typically seen as a goal––are prone to calorie restriction. This puts bone growth at a disadvantage. Low calorie and fat intake, high levels of exercise, and stress can simultaneously lead to amenorrhea, the cessation of menstrual periods. “Bone growth and health involve the opposing, but balanced, processes of bone building and bone resorption (tearing down),” says the NCAA guide. “Estrogen is necessary for the building of bone, but can be unavailable due to amenorrhea. In the absence of estrogen, loss of bone mass occurs because bone growth is decreased while resorption continues at a higher rate. At a time when the athlete should be building bone mass, she is losing it.”

Amenorrheic athletes can lose up to five percent of their bone mass in just one year, increasing the risk of stress fractures. Some of this loss is irreversible even when estrogen levels are returned to normal (oral contraceptives, which I’ve taken since my initial eating disorder treatment, may be helpful here, but more research is needed, and not everyone wants to or is able to go on the pill). And if the athlete continues to have disordered eating, inadequate vitamin D and calcium levels will prevent adequate recovery. The result? More fractures, and eventually, osteoporosis––the deterioration of bone mass and tissue to the point of fragile, easily breakable bones. If you’ve had a loved one with osteoporosis, as I have, you know how scary, painful, and debilitating this disease is.

It’s all rather frightening, and I’m angry with myself for the damage I’ve caused my body. But there are already such rampant misconceptions about eating disorders and what they look like, and I wanted to share this misunderstanding on my part because I’ve lived my adult life by the principle that I was okay as long as my weight stayed in the “healthy” range. The focus in working with the student-athlete who is affected by DE [disordered eating] or has other symptoms of the Triad should be more on her health and nutrition, and less on her weight,” the NCAA guide recommends. “This approach has sometimes been criticized by athletes and coaches, who claim that a de-emphasis on weight is apt to result in a decrease in athletic performance. However, athletic performance is like most human behaviors; it is multidimensional and probably determined by multiple factors.” Coaches need to be aware that fatphobic or fat-shaming attitudes and pressuring athletes to lose weight are not just damaging psychologically; they could be causing them to ignore serious symptoms of health problems in their athletes, or indeed causing the problems themselves.

Part 2 of this post will go up after I talk to my nutritionist, and it will discuss steps for resolving the Triad and preventing future fractures as well as dealing with psychological barriers to increasing my calorie intake. I’m scared out of my mind. It’ll be fun!

Julia Burke

Julia is a wine educator with an interest in labor and politics in the wine industry. She has also written about fitness and exercise science, mental health, beer, and a variety of other topics for Skepchick. She has been known to drink Amaro Montenegro with PB&J.

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  1. Thanks for sharing this. It’s extremely useful and I look forward to Part 2 (and maybe more?)

    1. There will be at least a part 2, and probably more––the response to this has indicated that a lot of people are dealing with this and/or dealing with the myths surrounding it. I may do a “Why are you injured?” series; might as well use my bad habits for SCIENCE!

  2. I like your doctor. Too many health professionals zero in on that magical BMI number and see literally nothing other than that. Your shopping around for a doctor who would not do that was very wise.

    This would be good information for folks like the ones who were all over this post: and elsewhere across the internet, implying that one’s weight is easy to alter with willpower and/or that a person’s moral upstandingness can be inferred from that person’s apparent weight. You are practically the poster child for Eat Less Move More, and yet your weight was steady.

    I wish you good luck with your dietician and I look forward to part 2.

    1. I had a doctor tell me I was “overweight” once early in college, at 130 pounds and 5’5 and 3/4″, because the proper height for 130 pounds is 5’6″. No discussion of the fact that I was lifting four days a week––or the fact that having one arbitrary number as the goal for everyone at a certain height is completely ridiculous.

  3. I am doing research in nitric oxide physiology, which is extremely important in regulation of things like healing. Exercise per se does not increase strength or endurance. It is the remodeling of physiology that occurs during the rest that follows exercise that causes the increased strength and increased endurance.

    During acute exercise is a terrible time to try and build-up strength. You are pushing yourself to a limit. Your body doesn’t have spare metabolic capacity to use for rebuilding damaged stuff (bones and muscle), those are actually shut down so the energy they normally consume can be diverted elsewhere.

    I am pretty sure that the euphoria of the “runner’s high” is from the same physiology as the euphoria of the stimulant drugs of abuse, of solvent huffing, of autoerotic asphyxiation. It is an “emergency” system that kicks in so that you can run yourself to death trying to escape from a bear (if you needed to). That state has to be euphoric because you have to be able to ignore pain and life-threatening bodily damage (muscles dying from necrosis due to overwork), but it is worth it if you can escape from the bear. If you can’t escape, then it doesn’t matter.

    I am pretty sure that overuse injuries and the damage associated with stimulant drugs of abuse (cocaine heart, amphetamine brain, and so on) are from the same types of physiology going on. The shutting down of normal ongoing “housekeeping” and repair to divert ATP to immediate consumption. Stress can do that all by itself.

    1. Very interesting stuff. Can you differentiate between “acute” exercise and weight training? What, in your opinion, is a good way to go about building general fitness, as in a combination of endurance and strength, while avoiding the problems you mentioned––or is that an inappropriate goal?

  4. Low fat (especially vegetarian) eating, calorie restriction, excessive exercise volume with little emphasis on strength and coordination, emphasis on passive flexibility rather than active range of motion. etc. etc. etc.

    A recipe for disaster that seems deeply entrenched in in women’s media, including supposedly feminist sources. Thanks for the attention. It is probably going to become more important every year as new cohorts of young women are mislead by the fitness and weight loss industry.

    1. Absolutely. And the vegetarian thing is a good point; protein and calcium aren’t emphasized nearly as much in women’s mainstream fitness literature as they should be. It’s always “You don’t need protein! Psh!” Just because the Western diet includes an excess of protein does not mean that the athlete should restrict protein. I have found this a huge challenge. Not impossible on a vegetarian diet to get 100g of protein a day, but it definitely requires a lot more planning.

  5. No kidding about the nutritionist/dietician thing. My GP actually made me go to the in-house nutritionist (who has minimal qualifications) and it was the most horrific waste of time…she did nothing flog high-school level food-pyramid stuff from the 80s (and looked mystified when I brought up research literature contesting some of the medical folk wisdom on offer).

    More annoyingly, she refused to believe that I eat a healthy diet (presumably based on my being somewhat overweight and having low energy levels) until I proved as much by logging every damned thing I ate for three weeks. At which point she (unhelpfully) just kept on with the same old advice…showing portion sizes with plastic food like I was a kindergartner incapable of using a kitchen scale. At that point I just gave up on the whole thing.

    Not really on topic but I felt like a rant…

    1. Also only semi-related, my boyfriend told me they had just one nutrition class in med school, and the “nutritionist” told them that drinking Coke is a good thing. So doctors don’t necessarily know much about nutrition either. Plenty of misinformed “professionals” in all kinds of disciplines…

      1. Ha, that reminds me (totally unrelated). When we were on hols in the US my wife got some food jammed in her esophagus just before our flight home (this happens to her from time to time and usually needs a gastroenterologist to clear the blockage with an endoscope). The condition is painful and lasts for hours if not treated.
        With no other option, an open clinic was found where we were made to pay $300 up front.
        The treatment was “Drink this can of Sprite!”
        “But that never works”
        “Do it anyway”
        It worked, for the first time ever.
        So, that was the story of the $300 can of soda. The moral is, drinking Coke may well be a good thing!
        From the stories told by Marilove and others, we got off lightly!

        Thanks to Julia for this article, and for the excellent link to the distinction between nutritionist and accredited dietician.

    1. Well, not necessarily, though it’s certainly a good sign. I get periods every month because I’m on the pill, but the last time I stopped taking it, they stopped too. You should also monitor your energy levels, sleep quality, and injury rate/recovery time when assessing your intake. Of course, a sports medic and/or dietician can asses your specific situation, and I always recommend seeing a therapist if you suspect you have disordered eating habits; too often these issues go on too long without being addressed. This is a great resource:

    1. “‘…the athlete’s eating does not have to be disordered to the point of a clinical eating disorder (i.e., anorexia nervosa or bulimia nervosa) in order for the other two components of the Female Athlete Triad — amenorrhea and osteoporosis — to occur.’”

      It’s called a Triad because it refers collectively to those three related but separate issues: disordered eating, amenorrhea, and osteoporosis.

  6. “…who claim that a de-emphasis on weight is apt to result in a decrease in athletic performance” This I find such a bizarre objection. Surely injury and illness, including broken bones, damaged tendons, muscles and ligaments, and osteoporosis all result in a decrease in athletic performance? Or maybe this view just reveals the truth that nobody really cares about the health or longevity of an athlete.

    Quite apart from which, eating enough, recovering properly, and being “adequately fueled” for your sport surely results in better athletic performance than being three pounds lighter? I’d rather be able to run faster because I felt strong and robust, than because I felt a fraction lighter than normal.

  7. Hello, Julia. Thank-you for a very interesting article, and I will be interested to read Part 2. You say that you had an eating disorder that you have recovered from: are you aware that it appears to still be running your approach to fitness / weight / health / food? I quote, “How much fitness would I lose? How would I keep from losing total control of my life––control that, I realized, has always revolved around food? What the hell was I supposed to eat now that I was inactive?”. Please, I am not trying to be mean, but that sentence just about made my hair stand on end, and I wondered if you realized how close you still seem to be mentally to the eating disorder mindset? Anyway, wishing you all the best and a speedy and uncomplicated recovery from your injury.

    1. Joannah, I am very aware; thanks. Part of the purpose of this post was to make the point that I’m not as “recovered” as I thought when I originally made that claim to my doctor. I apologize if my language was upsetting; I always post content notices when I discuss disordered eating to try to avoid that.

  8. Thank you for writing this. As someone who also considers herself recovered from years of eating disorders in my teens and early twenties, I strongly identify with this post. Ghosts of eating disorders past definitely do not disappear overnight. I eat plenty now, mostly healthy, but a fair amount of not so healthy thrown in, and generally do not think too much about my eating. I do not count calories (purposefully). Exercise is a different story. I LOVE working out, but there is a somewhat obsessive side to it, as I cannot stand to miss a workout. I am very into heavy weightlifting now at least, which has a nice focus on building instead of losing. It’s all part of the journey to find our healthiest, happiest selves and I wish you luck in yours! Thank you again for sharing.

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