CLINICAL SCIENCES Clinical Investigations The Female Athlete Triad Exists in Both Elite Athletes and Controls MONICA KLUNGLAND TORSTVEIT 1 and JORUNN SUNDGOT-BORGEN 1,2 1 The Norwegian University of Sport and Physical Education, Oslo, NORWAY; and 2 The Norwegian Olympic Training Centre, Oslo, NORWAY ABSTRACT TORSTVEIT, M. K., and J. SUNDGOT-BORGEN. The Female Athlete Triad Exists in Both Elite Athletes and Controls. Med. Sci. Sports Exerc., Vol. 37, No. 9, pp. 1449 –1459, 2005. Purpose: To examine the prevalence of the female athlete triad (the Triad) in Norwegian elite athletes and controls. Methods: This study was conducted in three phases: (part I) screening by means of a detailed questionnaire, (part II) measurement of bone mineral density (BMD), and (part III) clinical interview. In part I, all female elite athletes representing the national teams at junior or senior level, aged 13–39 yr (N = 938) and an age group–matched randomly selected population-based control group (N = 900) were invited to participate. The questionnaire was completed by 88% of the athletes and 70% of the controls. Based on data from part I, a stratified random sample of athletes (N = 300) and controls (N = 300) was selected and invited to participate in parts II and III of the study. 186 athletes (62%) and 145 controls (48%) participated in all parts of the study. Results: Eight athletes (4.3%) and five controls (3.4%) met all the criteria for the Triad (disordered eating/eating disorder, menstrual dysfunction, and low BMD). Six of the athletes who met all the Triad criteria competed in leanness sports, and two in nonleanness sports. When evaluating the presence of two of the components of the Triad, prevalence ranged from 5.4 to 26.9% in the athletes and from 12.4 to 15.2% in the controls. Conclusion: Our results support the assumption that a significant proportion of female athletes suffer from the components of the Triad. In addition, we found that the Triad is also present in normal active females. Therefore, prevention of one or more of the Triad components should be geared towards all physically active girls and young women. Key Words: EATING DISORDERS, MENSTRUAL DYSFUNCTION, AMENORRHEA, OSTEOPENIA, BONE MINERAL DENSITY F or most women, participation in physical activity contributes to significant health benefits, overall well- being and improved physical fitness. Furthermore, sports performance may lead to high self-esteem, healthy body image, and positive health status (24). However, ac- cording to the 1997 ACSM position stand on the female athlete triad (21), physically active girls and women partic- ipating in a wide range of physical activities may be at risk for developing the female athlete triad (the Triad), a syn- drome consisting of three components: disordered eating, amenorrhea, and osteoporosis. These three medical prob- lems are interrelated with respect to etiology, pathogenesis, and consequences and can alone, or in combination, nega- tively affect health and, for athletes, impair athletic perfor- mance (21). Several factors may contribute to the development of the Triad. Pressure to excel in sports, be thin and/or achieve a low body weight, or insufficient energy availability in gen- eral, may lead to disordered eating, and/or menstrual dys- function, and subsequently loss of BMD potentially result- ing in osteopenia or osteoporosis (21). The existence of the Triad is implied in studies that establish a relationship between disordered eating and/or energy deficit and menstrual dysfunction (2,9,35) and be- tween menstrual dysfunction and low BMD (9,25,34,35). It is also possible that disordered eating /eating disorders and/or energy deficit may be directly linked to low BMD (35). Recently, it has been suggested that each component of the Triad develops on a continuum (8,27), suggesting that there might be Triad “stages.” If early stages are not treated properly, they can progress toward the extremes of the Triad (8,27). The continuum model of disordered eating ranges from abnormal eating behaviors to clinical eating disorders such as anorexia nervosa and bulimia nervosa (27). Athletes with disordered eating attempt to lose weight or body fat by inducing a negative energy balance and/or employing a Address for correspondence: Monica Klungland Torstveit, The Norwegian University of Sport and Physical Education, PO Box 4014, Ullevaal sta- dion, 0806 Oslo, Norway; E-mail: monica.torstveit@nih.no. Submitted for publication April 2004. Accepted for publication April 2005. 0195-9131/05/3709-1449/0 MEDICINE & SCIENCE IN SPORTS & EXERCISE ® Copyright © 2005 by the American College of Sports Medicine DOI: 10.1249/01.mss.0000177678.73041.38 1449