For a long time, the message to female athletes has been to ‘train harder’, ‘train longer’, and to ‘train until you think you can practice with the men’. Not only does society shame female athletes for not being as ‘talented’ or as ‘interesting’ as men’s sports, but research is only beginning to understand how sports and nutrition affect a woman’s body, notably, her fertility and regular menses. It’s time to open the conversation about the condition that is quietly sidelining female athletes — Female Athlete Triad — the one that stands in the way of our success in sports and long term consequences associated with it.
Female Athlete Triad Definition - What Is It?
Chances are, you’ve never heard of female athlete triad. In fact, even more possible, you may have experienced it and never even known it. The female athlete triad is a devastating health problem that female athletes face, notably involving, nutritional deficits, lack of menstruation, infertility, and issues with bone health.
Not long ago, in 1997, the American College of Sports Medicine defined the Triad as “interrelationships among energy availability, menstrual function, and bone mineral density, which may have clinical manifestations including eating disorders, functional hypothalamic amenorrhea, and osteoporosis.” [R]
Female Athlete Triad Syndrome:
- Disordered Eating
- Amenorrhea (absent mensuration and periods)
- Osteoporosis
The problem with this description of the female athlete triad? For a while, a full-blown clinical diagnosis of the three conditions of the triad needed to be met. As more researchers jumped in the pot to study female athletes and their bodies, the more nuances they discovered. [R]
The Three Components of The Female Athlete Triad Syndrome
Typically speaking, the triad can manifest itself in three main ways that are measured across a spectrum from healthy to unhealthy:
-
Low Energy With/Without Disordered Eating
Any type of energy disturbance associated with nutritional intake is classified in this category. Notably, patterns of obsessive eating, dieting, and/or poor nutritional habits. This can be moderate to severe, even in the presence of a clinically diagnosed eating disorder. The issue? Poor nutrient delivery and low caloric intake can result in extreme fatigue and poor energy level production. [R]
-
Loss of Period/Menstrual Disturbances
Whether it’s an irregularity with menstrual cycles or the complete absence of a cycle for six or more months (amenorrhea), these symptoms often go unreported and not taken seriously enough. There are long-term consequences to this, such as infertility. This often goes undiscussed between athletes-trainers due to the stigma, nature, and privacy of the topic altogether. [R]
-
Low Bone Mineral Density/Osteoporosis
Poor bone mineral density is the most dangerous component of the Female Athlete Triad. Not only can weaker bones lead to osteopenia (and osteoporosis later in life), but it can lead to short term consequences such as stress fractures and major injuries to female athletes. Specifically associated with the triad, female athletes can see low bone density and injuries manifest themselves in both the hips and vertebral columns. [R]
Of these presenting symptoms, researchers estimate that as many as 60% of women who are fairly active exercisers may experience one of the Triad components. That number reduces to about 27% for those who may experience two of the Triad components. The amount of women who may present in all three of the Triad components drops even further to a staggering 16%. [R]
Who Is At Risk For Female Athlete Triad?
As formerly mentioned, female athletes at the recreational, collegiate, elite and professional levels who’s lower body weight and body fat percentage are the main groups susceptible to the triad. Some of the main sports include endurance and strength sports, such as high-intensity functional training, running, weightlifting, cross country, biking, swimming, figure skiing, gymnastics, ballet, and diving, to name a few. [R]
Additionally, the societal pressures and expectations of what a woman’s body should look like can contribute to negative body issues and physical health associated with the female athlete triad. To take this a step further, the scrutiny, the negative body issues, self-esteem pressure to compete and excel, and image issues associated with the sport can perpetuate a toxic environment that may unintentionally increase a female athlete’s risk for developing the Triad. [R]
Female Athlete Triad Symptoms
It’s important to keep in mind that not all items on the triad criteria ‘checklist’ need to be met in order to be clinically diagnosed with the Triad. Common symptoms of the Triad, even if not all conditions of the triad are met, should be taken just as seriously as often they manifest the disorder and other behaviors as part of the syndrome. [R]
- Irregular or absent periods
- Recurring sports-related injuries (stress fractures, bone breakages)
- Eating issues such as disordered eating habits, lack of eating, underrating, obsessive eating, obsessive dieting, and severe weight loss
- Poor energy levels, intense fatigue, excessive tiredness, problems sleeping
- Physical changes: hair loss, dry/flaky skin, cold extremities, poor immune health function, or illnesses and infections
How Many Female Athletes Are Affected?
While there is no way to know the exact number of female athletes who experience the Triad, there are researchers dedicated to conducting research to further data collections. As presented by research published by Medicine and Science in Sports and Exercise who examined 669 elite-level female athletes, they found that over 60% of the women were classified ‘at risk of the Triad’ because of presenting symptoms. Of that same group, low bone mineral density was noted in 34% of the athletes and osteoporosis in 33%. Of that same group, menstrual dysfunction and disordered eating presented in 16% of the athletes. [R]
Similarly, a study in the Journal of American College Health reported findings in elite endurance female runners to be along the same lines as those in the study we just reviewed. They found that Previous or current eating disorders were reported by 19.4% of the women, 23.0% had irregular menstrual cycles, and 29.1% had inadequate calcium intake. Of that same group, 34.2% had low bone mineral density in the spine, osteoporosis was present in 33% of the sampled female athletes. [R]
The Female Athlete Triad is not only a growing problem for female collegiate, elite, or professional athletes but recreational female athletes as well. It’s an alarming condition that leaves athletes either sidelined in their sport or sidelined when they’re trying to start a family and the worst part? It’s not being talked about. Despite emerging evidence, Female Athlete Triad symptoms and diagnoses linger on the sidelines of many sports, contributing to the stigma and judgment of eating disorders and menstrual health.
Screening For The Female Athlete Triad
Even if clinical manifestations of the main three components of the female athlete triad are not presented, a female athlete can still be affected by the condition, regardless of body build or sport. When an athlete visits the obstetrician-gynecologist, their physician has an opportunity to screen a female athlete for components of the female athlete triad at comprehensive visits for preventative care.
It is recommended that an athlete is questioned about her weight, menstrual history and pattern, satisfaction with body image, exercise regime, current and past medications, eating habits, diet history, history of eating disorders, laxative or diet pill use, sexual history, substance abuse, and symptoms of depression. [R]
Other important screening questions should be focused around disordered eating, as it’s an important aspect of treatment in the female athlete triad. Information collected is related directly to dietary practices, exercise type and amount, weight fluctuations, restriction/purging of food, overall body image satisfaction, fear of weight gain or fat consumption, as well as other psychological problems associated with disordered eating. [R]
Management of Female Athlete Triad
The goal of treatment for any athlete who is diagnosed with the female athlete triad is the restoration of regular menses as a clinical marker of the reestablishment of energy balance and enhancement of bone mineral density levels. [R]
It’s important to note that not all athletes who experience symptoms or who are diagnosed with the triad need pharmacologic treatment, and many can find great improvement and success with nonpharmacologic interventions for disordered eating, image issues, and expectations. [R]
That being said, not all have disordered eating, either. Some athletes are not aware of energy needs and/or lack the appetite required to deliver adequate levels of nutritional consumption. Working with athletes from a sports nutritionist or coach standpoint can help focus on the quality of food consumption, quantity, energy input, and dietary supplementation.
Female Athletes and Energy Intake - Preventing The Female Athlete Triad
It’s frequently reported in research that female athletes have a hard time matching energy intakes relative to their high levels of energy expenditures. However, that being said, female athletes also face the pressure of low body fat and desired body size, despite high-energy needs. [R] Here’s where we run into trouble - poor nutrient intake is directly correlated with poor health and performance, and in more extreme cases, leads to the female athlete triad and what is called “low energy availability” [R] or “relative energy deficiency in sport (RED-S)”. [R]
Relative Energy Deficit (RED-S) Syndrome In Female Athletes
The term ‘Relative Energy Deficiency in Sport’ (RED-S) refers to the impaired psychological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular health caused by relative energy deficiency — the balance (or imbalance) of dietary energy intake and energy expenditure required for health, activities of daily living, and sporting activities. While the RED-S phenomenon is not a ‘triad’ of the three entities of the female athlete triad, it is rather a syndrome associated with it. [R]
The underlying cause of RED-S is low energy availability (EA). As you can see, there is so much more happening than just a lack of menstrual cycle or disordered eating patterns, which is why the female athlete triad has gained attention and research funding and awareness from organizations, even the International Olympic Committee (IOC), to share the severity and seriousness of this condition. [R]
Long Term Consequences of The Female Athlete Triad
Since first introduced in 1992, the female athlete triad has been researched and studies have been published with regard to the identification, management, and prevention of this condition. More recently, the women who were originally studied in the 1990s have aged into their late 30s and 40s. Women who have been diagnosed with the triad are now seeing advancements in low bone density, fractures, osteoporosis, osteopenia, poor fertility, lack of fertility, and menstrual disturbances. [R]
Nutritional Considerations for Female Athletes To Avoid The Triad
A lack of appropriate nutritional intake could be intentional or unintentional in female athletes that present with poor energy and symptoms/conditions of the triad. They could be a result of purposeful energy or food restrictions, illness, injury, loss of appetite due to training, or even dieting or specific dietary practices (e.g. vegan, gluten-free, etc.). [R]
Other factors to note may be poor food selection or food groups, limited food availability/eating patterns, or inability to buy a sufficient amount of food due to income issues. When female athletes reach a certain, peak level of performance in their sport, this is where the biggest damage is done, if the triad isn’t addressed. This is where the long-term damage can begin.
Macronutrient Recommendations
Macronutrient focuses should focus on the quality of food as well as the appropriate quantity. Without them, one may see significant changes in energy balances and energy availability, compromising bodily function for performance. If the bodily function is compromised for performance, the safety mechanisms of the athlete are compromised along with it. While the athlete may see peak performance values, their body is going down like a sinking ship.
CARBOHYDRATES
Carbohydrates are needed to replenish liver and muscle glycogen following exercise and it’s recommended that athletes who train at a high-elite level consume between 6-12g carbohydrate/kg body weight per day. [R] Focus on whole, minimally processed sources of carbohydrates that pack lots of nutrition and fiber, and include a mix of starches and colorful fruits.
- Steel-cut, rolled, and/or old-fashioned oats
- Whole or sprouted grain bagels, bread, muffins, pasta and wraps
- Sweet Potatoes
- Yams
- Greek Yogurt
- Fresh & Frozen Fruit
- Dried Fruit w/ no added sugar
- Corn
- CLEAN CARBS
PROTEIN
The most at-risk group of female athletes for low protein intakes are those who follow specific dietary preferences, such as vegan, vegetarian, gluten-free and energy-restricted diets, and/or females athletes who are dieting for weight loss while still performing athletically. [R] The general recommendation for protein intake for female athletes that are weight stable is to consume 1.2-2.0g protein/kg body weight per day. [R] Not only that, but the primary focus needs to be on a constant delivery and replenishment of high-quality protein spread out across the day. [R]
- Eggs and egg whites
- Fish
- Shellfish
- Chicken
- Duck breast and thighs
- Turkey
- Lean Beef
- Bison
- Lamb
- Pork
- Wild Game
- Greek Yogurt
- Cultured Cottage Cheese
- Lentils & Beans (for plant-based eaters)
- Whey Protein Isolate
TOTAL FAT & ESSENTIAL FATTY ACIDS
While most of the conversation of energy sufficient foods is around the adequate intake of carbohydrates and protein, it’s important to note that sufficient intakes of total fat and essential fatty acids also be included in the female athlete diet. Female athletes who have been studied with low EA levels have reported to also have fat intakes below, or far below, the Dietary Reference Intake of 20-35% of energy intake. [R]
Dietary fat levels that make up less than 15% of energy intake can increase the probability of EFAs (linoleic acid and alpha-linolenic acid (ALA)), especially ALA. If the conversation of ALA to eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) is low, then the attenuation of inflammation, [R] numerous biological functions, and brain health [R], especially in sports of activities at high risk for concussion and brain injury, can all suffer. [R] Aim for a mix of whole-food fats (like nuts and seeds), blended whole foods (like nut butters), and pressed oils (like olive and avocado).
- Oils (extra virgin olive, walnut, avocado)
- Marinades and dressings with healthy oils
- Cheese aged 6+ months
- Egg yolks
- Seeds (chia, flax, hemp, pumpkin, sesame)
- Nuts (cashew, pistachio, almond, brazil, pecan, peanut)
- Nut butters
- Olives
- Pesto
- Fresh coconut (unprocessed)
- Krill Oil
Supplement Recommendations
Despite the numerous positive health benefits of physical activity in female athletes, without the proper nutrition to fuel activities, the female body suffers. If energy intakes from food do not match the high level of energy expenditure, the athlete can suffer, sacrificing health and performance. Elite athletes need elite level supplements to bridge the gaps in their nutrition and fuel intense training.
The following supplement recommendations are based on the research presented over the last 20 years. This research supports the use of supplements for athletes who perform at higher levels so that they can get the adequate amount of nutrients they need to fuel a happy, healthy, vibrant body, as well as performance.
**The products mentioned below are not meant to replace any medical regimen or medically recommended treatment for anyone experiencing the Female Athlete Triad, nor are they meant to replace whole food nutrition. They are only meant to be ‘supplementary’ to a healthy lifestyle and training regimen.**
Clean Carbs
It is well documented that carbohydrate is important for exercise performance and to replenish liver and muscle glycogen stores following exercise. [R] It is generally recommended that athletes training very hard consumes between 6-12 g carbohydrate/kg body weight/d. [R] Depending on body size and energy needs of the female athlete, this level of carbohydrate intake can be difficult for some to consume, especially if unprocessed, low energy-dense carbohydrates are being consumed (e.g., whole fruits and vegetables, whole wet grains). [R]
Supplementing with Swolverine’s CLEAN CARBS is an efficient way to bridge the energy-gaps from nutrition while on the go, before, during, and/or after training. CLEAN CARBS is easy to drink and mix powder form of Sweet Potatoes, Yams, Oats and Blueberries. It’s available in 45 servings from Swolverine.
RECOMMENDED PRODUCT Clean Carbs
Whey Protein Isolate
The primary focus of protein consumption and supplementation should be to get adequate amounts of high-quality protein spread out across the day. [R] Current recommendations are that weight stable athletes consume 1.2-2.0g protein/kg body weight per day. [R] There is also supporting evidence that the intake of both carbohydrates and protein post-workout preserve lean muscle tissue and glycogen replacement, contributing to increases in strength and faster recovery times. [R]
In order to achieve consistent delivery of protein throughout the day, we recommend eating nutrient-dense sources of meat in conjunction with supplementing Whey Protein Isolate from Swolverine in-between meals and post-workout. Whey Isolate is one of the highest forms of protein powder available and it has less than 1% lactose. Swolveirne’s Whey Isolate also has added digestive enzymes to increase the rate of digestion and absorption. For athletes, we recommend combining Whey Isolate with CLEAN CARBS after training sessions to replenish glycogen and to maintain/build lean muscle mass.
RECOMMENDED PRODUCT Whey Protein Isolate
Multivitamin
Micronutrient intakes shouldn’t be overlooked in female athletes, either. Similar to their macronutrient counterparts, micronutrient intakes (vitamins/minerals) can become low if food groups are eliminated, a special diet is followed, if an athlete has an eating disorder or disordered eating, and if there are any health issues with absorption. [R] Some key nutrients for female athletes to avoid anemia are iron, zinc, vitamin b-12, vitamin D, magnesium, b-vitamins, and folate. When food isn’t enough, this is where a good, low-dose multivitamin can come into play.
Swolverine’s Multivitamin provides a wide variety of vitamins and minerals crucial to an athlete’s health and development. Unlike most multivitamins on the market, Swolverine’s is designed to help bridge the gaps in your nutrition, not replace it altogether. Just 1 tablet a day can boost your nutrition efforts, helping you reach your daily intake of key nutrients in order to avoid a compromise in performance. Because Swolverine doesn’t use any proprietary blends, you can view each ingredient and the amount on the back of the label to gauge if it’s right for you and your nutrient needs.
RECOMMENDED PRODUCT Once Daily Multivitamin
Vitamin D3 & Calcium
Every athlete needs vitamin D and calcium to support healthy functioning. Some athletes may spend more time indoors than others or they may have dietary preferences that prevent them from getting adequate amounts of vitamin D on a daily basis. If sun exposure is low, then chances are vitamin D levels are low, too. Either taken on a preventative level, or taken when a female athlete has bone loss as a result of the triad, supplementation can really improve bone density, hormone balance, injury prevention, reduction of stress fractures, infection, and inflammation. [R]
Optimizing calcium and vitamin D intake is an important part of treatment; significantly more athletes with stress fractures have low calcium and vitamin d intakes than do athletes without stress fractures. [R] Swolverine’s Vitamin D tablets are available in 1,5000 IUs. [R] We recommend having your vitamin D levels measured regularly with your physician.
RECOMMENDED PRODUCT Vitamin D3 Tablets
Krill Oil Omega 3
Although most research focuses on and emphasizes the delivery of sufficient carbohydrates and protein, it’s important to note the role of total fat and essential fatty acid consumption for athletes. In the past, thanks to the stigma around fat in our society, many female athletes avoid dietary fat, especially those who were interested in weight loss and/or maintaining low body weight or body fat percentage. [R]
While it’s recommended to get high-quality sources of fat from food such as dark leafy vegetables, flaxseed/oils, and nuts, supplementation of omega-3s can work to bridge the gaps in an athlete's nutrition. However, because our bodies do not efficiently produce some omega-3 fatty acids from marine sources, it is necessary to obtain adequate amounts through marine products, such as Krill Oil. [R]
Supplementation of Krill Oil can provide consistent delivery of essential fatty acids that are converted (ALA) into eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which together can help a female athlete improve overall health, function, and performance, as well as avoid the female athlete triad. [R] Female athletes who do not get a sufficient amount of nutrients from their food or who follow restrictive diets where marine sources of healthy fats are not available (vegan, vegetarian, etc.) may also find themselves with low intakes of essential fatty acids, especially ALA. [R] Emerging research has linked the importance of these two fatty acids for the attenuation of inflammation [R] and to brain health [R] especially in sports or activities at high risk for concussion and brain injury. [R]
Swolverine’s Krill Oil contains EPA, DHA, Phospholipids and a powerful antioxidant Astaxanthin. One 500mg soft gel taken daily can provide an athlete with a host of benefits, including a reduction in inflammation, improvement in joint health, immune system function, effects of aging, and potential increases in brain function.
RECOMMENDED PRODUCT Krill Oil
Zinc
Zinc is a component of over 300 enzymes, some involved in functions important to physical performance such as muscle energy production and protein synthesis. [R] Zinc is crucial for successful muscle growth and health, dopamine is produced during high-stress levels (ex. HIIT) and is a huge component of prostate health and mind stimulation/focus. Studies also suggest that Zinc supplementation increases total and free testosterone without preventing the inhibition of testosterone concentration* [R]
We recommend supplementing with ZMT, Swolverine’s zinc supplement designed to help athletes sleep better, recover faster, and perform better.
RECOMMENDED PRODUCT ZMT
Magnesium
Magnesium is a component in over 300 enzymes, some involved in the regulation of muscle contraction, oxygen delivery, and protein synthesis. [R] In athletes, magnesium relaxes muscles so that muscles can build during your workout. Coupled with calcium it helps to regulate protein synthesis, muscle and nerve function, and blood glucose control - reducing the negative effects of soreness, cramps, tension, and muscle fatigue. Research suggests that magnesium exerts a positive influence on anabolic hormonal status, including Testosterone* [R]
We recommend supplementing with ZMT, Swolverine’s magnesium supplement designed to help athletes sleep better, recover faster, and perform better.
RECOMMENDED PRODUCT ZMT
Summary – The Female Athlete Triad
Many athletes, from recreational, everyday athletes, to elite level and professional athletes, may find themselves at risk for developing the Female Athlete Triad due to an improper balance of nutrient delivery and performance demands. While a number of nutrition and energy imbalances may arise throughout a female athlete’s journey, if an athlete can become more aware of them and know how to more accurately deliver nutrients on a consistence basis, the issues associated with the Female Athlete Triad can effectively be avoided.
If you find yourself relating to this article in more ways than one, we recommend consulting your primary care physician, trainer, gynecologist, and/or nutritionist to discover ways in which you can improve your nutrition to reflect your training, energy, and performance demands.
By opening the discussion, breaking down the stigma, and providing scientifically supported solutions from a food-first approach, female athletes can stay in the game and not be sidelined by the Triad and nutritional deficiencies long before they arise.
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