THE FEMALE ATHLETE TRIAD REVISITED

Dear Editor-in-Chief: We read with interest the article by Torstveit and Sundgot-Borgen (5) published recently in Medicine & Science in Sports & Exercise®. The authors posed the question of whether elite athletes are at increased risk of the female athlete triad (FAT) compared with nonathletes. From one of the more descriptive and generalizable studies to address this issue to date, we now are able to conclude that athletes assume no greater risk of the FAT than do nonathletes—in fact, they are much better off! The authors report that, overall, a lower proportion of elite athletes (60%) were considered at risk of the Triad relative to nonathletes (69%; P < 0.01), and even among the purported highest risk athletes (those competing in leanness sports) athletes were at no greater risk of the Triad than nonathletes (70 vs 69%). Moreover, elite athletes and nonathletes were similar with regard to the prevalence of underweight (BMI ≪ 18.5 kg·m−2) and of self-reported eating disorders (18 vs 21%, respectively); however, more nonathletes than elite athletes reported use of pathogenic weight control methods (37 vs 20%; P < 0.001). Women aged 20–29 yr are considered by some to be the most vulnerable age group with regard to the long-term health consequences (e.g., osteoporosis) associated with underweight or amenorrhea. Yet when these data were stratified by age group, nonathletes aged 20–29 yr were at higher risk of the FAT compared with elite athletes of the same age (74 vs 59%; P < 0.0001). The authors also observed no increased risk with higher volume of training or level of physical activity, suggesting no dose–response relationship between level of exercise and syndrome risk. These exciting new findings suggest that being an athlete is protective with regard to the FAT (although this sadly contradicts the general tone of the paper’s conclusion). So why do the authors continue to single out the female athlete? Presumably, most women and many men living in the United States (active and inactive) meet at least one of the criteria listed in this article for being at risk of the FAT. Logically then, we are all at risk for the “life-threatening health consequences of inadequate energy intake and excessive exercise habits” proposed by these authors. Rigorous experimental work by Loucks, et al. (3,4) has, indeed, identified low energy availability as an agent in the reproductive alterations observed among women. Interestingly, however, low energy intake is also strongly related to survival in a number of species, including rats, mice, fish, flies, worms, and yeast (see (2) for review). In any case, one can barely argue that a chronic negative energy balance prevails among the majority of our modern-day society (1). There is no doubt that a very small proportion of the general population exhibits true psychiatric dysfunction that may be expressed as clinically diagnosed eating disorders, excessive exercise, or other behaviors related to obsessive-compulsive disorder. Perhaps as a college, however, we should be addressing the more pressing public health concerns of excessive energy availability combined with low energy expenditure. Loretta Di Pietro Nina Stachenfeld John B. Pierce Laboratory and Department of Epidemiology & Public Health, Yale University School of Medicine, New Haven, CT