As females athletes and recreational exercisers, obtaining adequate nutrition is essential for our bodies to perform and function optimally. We place a high demand on our bodies during training, expending high amounts of energy. As higher performers our goals are to lead a healthy lifestyle. Yet if we are not adequately fueling our bodies we may be placing our own health at risk.
The Female Athlete Triad
In 1992, the Female Athlete Triad was coined to describe the interrelationship between three components: low energy availability, menstrual dysfunction, and bone health. This triad of health conditions exists on a continuum of optimal to dysfunctional bone and menstrual health. The state of their function is based on energy availability. Energy availability is defined as the amount of energy (or calories) left over for biological processes after accounting for exercise energy expenditure. This can occur at any body size, with or without the presence of an eating disorder or disordered eating, though this may place someone at higher risk.
To understand energy availability, for example, let’s say your total energy output for the day is 2500 calories. Of that 2500 calories expended, 900 calories were burned during training and three classes you taught for the day. During the day you only consumed 2000 calories, therefore your energy availability was only 1100 calories. If your resting metabolic rate is 1600 calories, you are 500 calories short of meeting your basic needs for the day. Essentially, low energy availability is a failure to compensate for the increased energy demand for sport and exercise.
Athletes and active women are at greater risk due to the high energy demand placed on their bodies. High energy output coupled with under fueling, whether intentional or unintentional, can lead to low energy availability and therefore dysfunction. While there is limited research on female fitness professionals, a review by Gibbs et al (2012) had shown that the presentation of all three components of the triad exists in up to 15.9% of various athlete groups and up to 60% of athletes have one or two components. These high figures in athlete groups may be of concern to fitness professionals with similar energy outputs.
Biological Mechanisms of the Female Athlete Triad
What are the mechanisms behind the Female Athlete Triad? Inadequate energy availability disrupts the release of luteinizing hormone from the hypothalamus, which may lead to abnormal menstruation and decreased estrogen. Oligomenorrhea (irregular menstruation, cycle >35 days) or amenorrhea (absence of menstruation >90 days) may occur. Both of these are seriously problematic and if you experience either, contact your physician and/or OBGYN.
Low energy availability and menstrual dysfunction impact bone health, likely linked to decreased estrogen. Our bones are dynamic, not stable, meaning they are constantly being resorbed (broken down) and remodeled (rebuilt). Additionally, our bones are actually highly metabolically active, being the site of various biological functions such as the generation of red blood cells.
For women, as we age, we are at greater risk for osteopenia and osteoporosis due to a decrease in estrogen. Low estrogen leads to low bone mineral density, placing us at greater risk for stress fractures, osteopenia and osteoporosis. In addition, low energy availability, independent of low estrogen and menstrual dysfunction, can impact bone metabolism by suppressing bone formation due to a lack of adequate nutrition.
A possible fourth component of the Female Athlete Triad could impact our blood vessels (Barrack et al, 2013) and lead to cardiac issues. A correlation has been shown between menstrual dysfunction and dysfunction in the lining of our blood vessels known as the endothelium. Our blood vessels also have estrogen receptors which aid in increasing blood flow and oxygen throughout the body (Barrack et al, 2013). These receptors have cardio-protective effects such as preventing platelet aggregation and the development of plaque.
Understand and Minimize Your Risk
How do you know if you are at risk? First, it is important that you understand your caloric needs and meet those needs daily. With a tight schedule, you may find it challenging to fuel throughout the day, therefore a plan may be necessary. Additionally, exercise may blunt hunger cues and therefore you may need to fuel even when you are not physically hungry. Ensure that you are consuming adequate protein, carbohydrates, and fats that meet your energy needs, as well as vitamins and minerals that meet current recommendations. If you are unsure about how to measure your needs, working with a Registered Dietitian who specializes in sports and exercise nutrition is ideal to help you determine your needs. A personalized plan can help you stay healthy, energized and performing your best.
Second, monitor your menstrual cycle. There are a variety of apps around to help you do this. One of them is Moody where you can track various symptoms, hunger levels, and emotions. If you notice irregularities in your menstrual cycle contact your physician and/or OBGYN. Lastly, aspects of the female athlete triad can up to double your risk of stress fracture (Abbot et al, 2019). If you have been experiencing stress fractures, this may also be a sign to seek professional help.
The greatest impact you can have on your health is to prioritize nutrition as fuel first, instead of one who eats to primarily support an appearance. Sex sells, and there can be value to looking good. If we can support ourselves by keeping our future selves in mind, considering the impact of our behaviors 10, 20, 30 years from now, we’d be doing some powerful work for ourselves and our community.
Abbott, A., Bird, M.L., Brown, S.M., Stewart, G.m Mulcahey, M.K. (2019). Part I: epidemiology and risk factors for stress fractures in female athletes.Phys Sportsmed, 7(11), 1-8. doi: 10.1080/00913847.2019.1632158.
Barrack, M. T., Ackerman, K. E., & Gibbs, J. C. (2013). Update on the female athlete triad. Current reviews in musculoskeletal medicine, 6(2), 195–204. doi:10.1007/s12178-013-9168-9
Gibbs JC, Williams NI, De Souza MJ. Prevalence of individual and combined components of the female athlete triad. Med Sci Sports Exerc. 2012. doi:10.1249/MSS.0b013e31827e1bdc.