The significance of energy deficiency as a cause of Female Athlete Triad–related menstrual disruptions and bone loss is now more apparent than ever. Research has determined that one of the primary causes of Triad-related health problems like menstrual abnormalities and bone loss is a chronic energy deficiency. The amount the athlete eats is simply not enough to meet the caloric (energy) demands of their daily exercise training. In other words, energy deficiency occurs when there is a negative imbalance between food intake and energy expenditure through exercise — it doesn’t matter if the imbalance is due to an intentional caloric restriction or an increase in exercise. Because an athlete’s energy supply can be purposely manipulated (unlike bone density and menstrual regularity), it warrants a special comment.
It is clear that in many cases of Female Athlete Triad, there is some form of disordered eating behavior that contributes to the energy deficiency. The disordered eating can present in a variety of ways; the athlete’s constant drive to be thin or achieve an inappropriately low body weight can lead to poor body image or purposeful restriction of calories. These behaviors cause a chronic energy deficiency.
It is also noteworthy to remember that some athletes can experience an energy deficiency even if they’re not consciously restricting their food intake at all. These individuals simply do not eat enough food to fuel their exercise energy expenditure. A busy class schedule, travel, stress, and other factors can hinder female athletes from maintaining an adequate diet for training. Thus, some athletes who do not present with disordered eating symptoms or behaviors are often overlooked in discussions of Female Athlete Triad.
Recent studies have attempted to define a threshold of energy below which the body attempts to suppress menstrual function, but no firm conclusion has been reached. Some research suggests that if an athlete eats “normally” (the average amount for her body weight), she should be able to perform the equivalent of running up to eight miles per day without compromising menstrual function. However, other studies have shown menstrual irregularities in recreationally active women who run only 7.5 miles per week, which most people would not consider intense training. In those studies, the women’s diets did show some evidence of restriction, which further reinforces the idea that nutrition plays a key role in triggering Triad-related problems; on the other hand, this means good nutrition is key in preventing the condition.
For good reason, then, most educational efforts aimed at preventing Female Athlete Triad focus on nutrition and disordered eating. A comprehensive approach should include not only clinically recognized eating disorders, such as anorexia nervosa and bulimia nervosa, but also subclinical disordered eating behaviors, such as caloric restriction. The subclinical category includes many athletes who fail to meet the criteria for an eating disorder, but display a preoccupation with body weight and a poor body image.
