The Female Athlete Triad and Relative Energy Deficiency in Sport Components of the Triad
The term “female athlete triad” (or, the “Triad”) was first coined in 1992, and since that time diagnosis of this medical condition has evolved into a complex interaction of different indexes of health. The three components that comprise the Triad are (1) low EA with or without disordered eating; (2) menstrual dysfunction; and (3) low bone mineral density (BMD). It is now understood that low EA underpins the other two components. Thus, it is essential to have an understanding of EA. The Triad is most commonly seen in athletes who participate in the weight-sensitive sports outlined earlier, probably as a result of the relative importance of leanness in these sports.
Energy Availability: The Underlying Cause
EA is the amount of dietary energy remaining after exercise training for all other physiological functions each day (De Souza et al. 2014). EA = Energy Intake (EI) in kcal minus the energy cost of exercise (kcal) relative to FFM in kg. Simplified, EA (kcal/kg FFM/day) = [EI (kcal/day) – exercise EE (kcal/day)]/kg FFM. A total of 45 kcal/kg FFM/day is considered to be sufficient for meeting the physiological needs of the body once the energy demands of training have been accounted for. Low EA is considered to be 30 kcal/kg FFM/day or less, as this is the threshold below which harmful changes occur in reproductive, metabolic, and bone health. Disordered eating and eating disorders are not always the cause of low EA, since inadequate EI may merely be due to a lack of understanding by the athlete as to their actual energy needs. However, it is more commonly the case that there are disordered eating practices underlying low EA.
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In between 30 and 45 kcal/kg FFM/day represents suboptimal intake that may result in hormonal, metabolic, and functional perturbations, though in this range there are less likely to be clinical manifestations. It should be noted that these values are not clear-cut; different physiological functions (hormonal responses and markers of bone formation) will respond differently at different EA levels, and there will be interindividual variations in response to low EA. Thus, values of 45 kcal/kg FFM/day and 30 kcal/kg FFM/day should be viewed as estimates to approximate EA adequacy.
Low EA is thought to contribute to the Triad, particularly menstrual and bone health. Low EA plays a causal role in menstrual disturbances. Whereas adequate EA supports eumenorrhea, low EA may result in menstrual disturbances such as luteal phase defects and anovulation, as well as oligomenorrhea, primary amenorrhea, or secondary amenorrhea. Essentially, low EA disrupts an important hormonal cascade of the hypothalamus that alters menstrual functioning. This is known as functional hypothalamus amenorrhea. For a clinician to ascertain if low EA is at the root of menstrual dysfunction, other potential etiologies need to be ruled out.
Low EA by itself, and through its causal role in low estrogen l evels (hypoestrogenism), has negative musculoskeletal effects through its disruption of bone remodeling. This can result in bone stress injuries, including stress fractures, and ultimately can increase the risk for low BMD. Unfortunately, depending upon the extent of damage, these effects may be irreversible.
A recent effort has been made to shift from using the term Female Athlete Triad, to using “Relative Energy Deficiency in Sport” (RED-S). Relative energy deficiency connotes that low EA can occur even when there is no energy deficit; that is, EI and total energy expenditure are “balanced” (Mountjoy et al. 2014). RED-S proponents believe that use of the term Triad results in a more limited view of low EA, and instead of just a triad of three entities, this clinical phenomenon is a medical syndrome affecting many aspects of functioning. There is also concern that the Triad fails to capture the negative effects of energy deficiency in males, and that using the term “Athlete” in the Female Athlete Triad may restrict other active individuals from being included. It has yet to be seen if RED-S will replace the Triad terminology, though there are some concepts that should be considered.
There are indeed other effects of low EA than just the impact on bone and menstrual health (and the Triad proponents agree with this), including detriments to metabolic health, immunity, protein synthesis, cardiovascular and psychological health (Mountjoy et al. 2014), all which need to be addressed in athletes exhibiting low EA. Additionally, while there is a paucity of research, there is some support for low EA in male athletes and evidence that it impairs endocrine and bone health. However, as of yet, research has not delineated the cut-off values for low EA in men due to lack of sufficient evidence. Thus, given the potential consequences it has on overall health, weight loss experts need to be able to identify and treat both males and females with low EA.
Practitioners should also be familiar with and able to identify athletes at risk for muscle dysmorphia. Muscle dysmorphia is a specific type of body dysmorphia most commonly seen among male athletes and is characterized by a fear of being too small; these individuals often perceive themselves to be smaller than they actually are. There is often a hypervigilance to even small deviations from their perceived ideal (typically a large, muscular figure), and they may ignore feedback that their body image is not consistent with reality. While it is outside of the scope of this text to go into further treatment recommendations, these individuals should be referred to a mental health professional as would anyone dealing with diagnosed eating disorders. Because of their drive to increase muscle mass at all costs, these individuals are at greater risk for substance use and excessive exercise. This needs to be addressed to avoid potential negative effects to their health.
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