Female athletes have unique nutritional needs, and not meeting them can have real consequences for their health and performance. Our partners at Children's Hospital Colorado break down the Female Athlete Triad and relative energy deficiency in sport (REDs), what they are, who is at risk, and how to recognize the signs early.
Proper nutrition and fueling are important for all athletes. Certain sports require more energy output, such as gimnasia, fútbol or track, and require rigorous training schedules that demand the right foods to keep the body at its peak.
Female athletes may underestimate the calories they need to perform and stay healthy. While that can be due to participating in sports that promote a slimmer physique, the presence of disordered eating or a lack of nutritional knowledge, can lead to health and performance consequences including the Female Athlete Triad and relative energy deficiency in sport (REDs).
What is the female athlete triad?
The female athlete triad is a syndrome that consists of three interrelated conditions: low energy availability, menstrual dysfunction and low bone mineral density. It occurs when an athlete’s caloric intake doesn’t cover the energy spent during exercise and disrupts typical hormonal and physical health. The triad is a spectrum and can range from a mild imbalance to a severe dysfunction. The triad can include low energy availability which leads to the loss of menstrual periods and osteoporosis at the condition’s most serious.
What is low energy availability?
Low energy availability happens when someone does not eat enough to support all the energy they are burning through exercise and the energy the body needs to stay healthy. This is more likely to happen in athletes who are training and competing on a regular basis. For example, if a soccer player doesn’t eat breakfast and has too small of a lunch before a long after-school practice, it will impact their available energy. Low energy availability can occur unintentionally, but it can also be due to disordered eating (problematic eating behaviors) or an eating disorder (a diagnosable mental health condition), which can be influenced by societal pressures that tend to commonly impact female athletes.
What is menstrual dysfunction?
It’s not normal for female athletes to miss periods or lose their menstrual cycle entirely (also known as amenorrhea). Having regular periods indicates that the body has enough energy to support hormonal and menstrual health. Persistent or severe low energy availability can decrease the hormone levels that are necessary for the menstrual cycle, and if an athlete is having irregular periods or missing periods, it can be a sign of low energy availability.
The American College of Obstetrics and Gynecology considers menstrual periods as an additional vital sign. Just like a typical heart rate and blood pressure, having regular periods indicates the body is healthy. Although there can be many causes of menstrual pattern changes, and any persistent change warrants additional evaluation.
Some common signs of menstrual dysfunction include:
- Having more time between periods resulting in less than 8 periods in one year (irregular periods)
- More than three months between periods (secondary amenorrhea)
- Not starting periods by age 15 (primary amenorrhea)
What is bone mineral density?
Most bone accrual happens during adolescence, from ages 10 to 25, making youth a critical time to optimize bone health and decrease the risk for osteoporosis (a disease characterized by weak bones, making them vulnerable to fractures) in adulthood. Low bone density can lead to an increased risk of bone injuries, such as bone stress injuries, hip/femoral fractures and vertebral fractures. Low bone mineral density can increase the risk of recurrent bone stress injuries and fractures. Having adequate energy availability and regular menstrual cycles is very important to optimize bone health both in adolescence and for the future.
Female athlete triad vs. REDs
The female athlete triad describes the connection between low energy availability, menstrual dysfunction and poor bone health in female athletes. Relative energy deficiency in sport (REDs) expands this concept, recognizing that low energy availability can affect additional body systems, athletic performance and athletes of any sex and gender.
Additional health consequences that may occur due to low energy availability include:
- Nutritional deficiencies like iron deficiency anemia
- Declines in metabolism
- Mood and dormir disturbances
- Gastrointestinal dysfunction
- Delays in growth and development
REDs can also impact athletic performance resulting in delayed recovery, poor training response, and declines in strength, power and endurance. However, weight loss or low body weight/body mass index are not necessary to make the diagnosis of the triad or REDs.
Signs and symptoms of the female athlete triad and REDs
Any athlete can develop the triad or REDs if they are not eating enough to meet their energy needs. However, athletes in endurance sports, such as running, cycling and swimming, weight-based sports like wrestling or rowing, and aesthetic sports like gymnastics, dance and figure skating may be more at risk. Coaches, parents and athletic trainers should keep an eye out for the sign and symptoms, including:
- Fatiga
- Decrease in performance
- Preocupación por la comida, la pérdida de peso o la imagen corporal
- Frequent stomach upset
- Missed or irregular periods
- Frequent injuries or recurring stress fractures
- Depression, anxiety or irritability
If an athlete is showing any of these symptoms or a change in behavior, it’s important to recommend an evaluation with a healthcare professional.
How to prevent and treat the female athlete triad and REDs
Early recognition is the key to treatment. Prioritizing proper nutrition supports health, injury prevention and athletic performance to help manage the female athlete triad and REDs. Athletes can follow the athlete plate model to build healthy lunches and meals, and should prioritize eating at least three meals alongside two to three snacks per day. Each meal and snack should incorporate a wide variety of foods and be eaten before and after workouts, with supplemental nutrition during longer training sessions or games.
“Though making changes to nutrition and overall energy balance can be really challenging and frustrating, it is worth it,” says Lauryn Roth, MD, pediatric gynecologist. “Making changes to nutrition and overall energy balance has the potential to improve athletic performance, minimize risk of injury and bring back regular menses (indicating return of healthy reproductive hormonal levels). These things are obviously important right now, but they are also incredibly important for future health as well.”
At the Centro de Medicina Deportiva, our Female Athlete Program provides interdisciplinary care with sports medicine physicians, sports nutrition experts and gynecologists to ensure proper diagnosis and treatment of the female athlete triad or REDs. We offer individualized treatment to help athletes build and maintain healthy relationships with food, their bodies, and sport, and identify factors that may be preventing optimal health and performance.
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