Not enough calories

Energy deficiencies that trigger health problems can be caused in different ways. “Some people rush out the door; they skip breakfast, rush through their school day, grab an energy bar at 3:00, go to practice, and finally have dinner at 7:30. In these cases, it is not deliberate that they are under fueled,” said De Souza.

Most athletes facing the problems of the Female Athlete Triad, however, display disordered eating behavior. This usually occurs if athletes feel dissatisfied with their bodies, have a high drive for thinness, or deliberately restrict their food intake when they are hungry. Disordered eating can be triggered by external pressures like a demanding coach or internal pressures like the desire to excel.

“We consider disordered eating a very serious red flag because it can precede more serious eating disorders,” De Souza continued.

The problems of energy deficiency and disordered eating are not unique to women. In the general public, between three and five percent of the population develop an eating disorder. Around four percent of male athletes will suffer from an eating disorder. Among female athletes, the number soars to over 20 percent; one in five women who exercise regularly will develop an eating disorder.

“Athletes in sports that emphasize leanness or aesthetics are especially at risk,” Williams said. “If it is a sport where leanness is valued or the aesthetics are being judged, like diving or gymnastics, then the incidence is typically higher than sports like soccer or basketball where the emphasis is on performance. But eating disorders can occur in any group of athletes or any nonathlete as well.”

Despite the danger of eating disorders, the researchers say that knowledge can effectively combat the problem for many people.

 “Education about the importance of a proper diet is critical for everyone, especially athletes,” said De Souza. “Additionally, coaches and parents need to be educated about how to encourage healthy eating and not pressure athletes to be thin. By raising awareness, we can enable more women to reap the benefits of exercise without harming themselves.

Reversibility

One of the reasons De Souza and Williams have dedicated their careers to this issue is that some of the health problems associated with the Female Athlete Triad are irreversible. Though menstrual cycles will usually recommence once the body receives enough energy, studies on restoring bone density are less promising.

“Can you recover bone after going through a long experience with insufficient energy intake?” De Souza asked rhetorically. “The answer is: we don’t think so. When girls and women are training to reach their athletic goals, it is not the training that is the problem. It’s the eating, the nutrition. When they expose their bodies to years and years of energy deficiency and estrogen deficiency, it has long-term impacts on bone health.”

Williams and De Souza recently conducted a year-long trial on female athletes who lost bone density due to the deficiencies of the Female Athlete Triad. The researchers provided a higher calorie and nutrient diet to the women for a year. Though they found that menstrual cycles could be restarted by a modest increase of calories in the diet, the same was not true of bone loss. The researchers found no improvement in the women’s bone mineral density. This is the strongest scientific evidence to date that the problem may be irreversible.

Looking ahead

In the future, the Women’s Health and Exercise Lab will include more male athletes in their studies. Though these problems affect fewer men, they are serious, and most of the research on the Triads has centered around women.

“Exercise and sports have so many benefits for boys, girls, men, and women,” Williams said. “No one should learn about the Triad and think that decreasing exercise is the answer. When people are in tune with their body and accepting of their body, and when they eat enough, exercise can help them lead richer, happier, healthier lives. That is what we want for everyone, whether they are an athlete or not.”