Performance Enhancement & Health 1 (2012) 10–27 Contents lists available at SciVerse ScienceDirect Performance Enhancement & Health jou rnal h omepa ge: www.elsevier.com/locate/peh Review Expanding the Female Athlete Triad concept to address a public health issue Sean Wheatley a , Saira Khan a , Andrea D. Székely b , Declan P. Naughton a , Andrea Petróczi a,∗ a School of Life Sciences, Kingston University, Kingston upon Thames, Surrey KT1 2EE, UK b Department of Anatomy, Histology and Embryology, Semmelweis University of Medicine, Budapest IX, Tüzoltó utca 58, H-1450, Hungary a r t i c l e i n f o Article history: Received 8 August 2011 Received in revised form 20 March 2012 Accepted 27 March 2012 Keywords: Female Athlete Triad energy deficiency disordered eating menstrual dysfunction perfectionism over-exercise a b s t r a c t Research into the Female Athlete Triad (FAT) often posits that the condition is one of the unwanted consequences of increased physical activity and the prevailing preference for a lean body among female athletes; as well as the result of mounting pressure for constant performance improvement, which is often coupled to a misconception that low body weight would help to achieve this goal. This paper challenges the prevailing concept of the FAT for being inexact and over-specific, giving the impression that only athletes are affected by this condition, whilst the narrow focus on the co-occurrence of disordered eating–amenorrhea–osteoporosis can potentially lead to incorrect diagnoses of females suffering from, or at risk of developing, the condition. As the common underlying factor in athletes and non-athlete females suffering from FAT conditions is chronically low energy availability (via increased physical activity and/or disordered or restricted eating), we propose a unified framework that focuses on this common characteristic. Under the umbrella term ‘Female Energy Deficiency’ (FED), the expanded FAT and related concepts such as Anorexia Athletica and atypical eating disorder may be reconciled. The suggested framework can facilitate the understanding of this convoluted field within and outside the athletic community and offers flexibility for future developments. To support our proposition, we discuss the: i) expansion of the components to capture the extent and depth of this health condition, ii) expansion of the ‘at risk’ population, and iii) effective prevention, along with the need for early diagnosis and treatment. © 2012 Elsevier Ltd. All rights reserved. Contents 1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.1. Prevalence of the FAT components among athletes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.2. Practitioners’ knowledge about the FAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1.3. Aims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2. The Female Athlete Triad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2.1. Relationship between disordered eating, menstrual dysfunction and low bone mineral density . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2.2. The relationship between the FAT and other related disturbances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2.3. Factors associated with the development of the FAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 2.4. Pathological vs. behavioural disordered eating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 3. The need to reconsider the Female Athlete Triad Concept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 3.1. The prevalence of FAT components among non-athletes: the need for expanding the ‘at risk’ population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 3.2. Progression of the FAT components to a ‘triad’ and beyond: The need to expand the components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 3.3. Disordered eating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3.4. Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3.5. Hypothalamic control over gonadal functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3.6. Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3.7. Leptin levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3.8. Bone density loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3.9. Gastrointestinal problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 ∗ Corresponding author. E-mail address: A.Petroczi@kingston.ac.uk (A. Petróczi). 2211-2669/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.peh.2012.03.001