The Male Athlete Triad Syndrome

The "female athlete triad," a concept that began to be elaborated by researchers in 1992, has been officially defined by the American College of Sports Medicine as a clinical entity consisting of the following three features: (i) low energy availability defined as energy intake minus exercise energy expenditure (with or without an eating disorder); (ii) menstrual dysfunction; and (ii) low bone mineral density. Each component of the triad exists on a spectrum ranging from health to disease.

This definition was developed because several studies documented the presence of an increased risk of fractures and reproductive disorders in female athletes who consume more energy than they introduce with food. Some studies have also found that energy deficit in athletes can also have negative effects on mood tone and cardiovascular functioning.

One reason that led to the name "female athlete triad" was to focus the attention of researchers, clinicians, and coaches on this issue to prevent it and treat it quickly by helping the athlete eat according to their physiological needs. However, the adjective "female" has diverted attention from the fact that this syndrome can also occur in males. Indeed, some clinical reports have reported that it is not uncommon to observe male athletes who have a persistent energy deficit, with or without an eating disorder, which is associated with loss of bone mass, decreased testosterone levels and impotence and, in some cases, marked bradycardia, hypothermia, decreased strength and depression.

Currently, the few available data on athlete males come mainly from cross-sectional studies. A study, for example, found that jockeys who intentionally maintain a low weight have a lower bone mass than boxers. Another study noted that bone mass at the lumbar spine level may be low in endurance running and cycling athletes. In addition, adverse effects on sperm production and reduction of testosterone levels have been found in male athletes practicing endurance sports; however, no cases of bone fractures have been reported. A couple of controlled longitudinal studies also found a reduction in testosterone levels in some athletes, but the duration of this research was too short to document the development of bone fractures. Finally, more research is needed to assess the effects of other hormones in men, such as insulin and IGF1.

The interest in complications related to energy deficit in male athletes is not only academic because it can affect the way clinicians and coaches assess athletes. Indeed, if we are not aware that there is a problem, we do not go looking for it. For this reason, it might be appropriate to remove the term "female" from the athlete's triad, to avoid focusing only on female athletes or, as suggested by the 2014 consensus document of the International Olympic Committee replace the term "triad of the female athlete" with "Relative Energy Deficiency in Sport (RED-S)”. In this document, it was also pointed out that the syndrome can affect both females and males and that it is not a triad because it causes many other damages such as alterations in immunity, protein synthesis, and cardiovascular system.

While waiting for a consensus that eliminates the gender problem in defining the athlete's triad, the evaluation of a male athlete who has lost a lot of weight should be performed by a multidisciplinary team including a physician and a registered dietitian, and, for athletes with suspected eating disorders, also a mental health practitioner. The assessment should include questions about his eating behavior and attitudes, changes in mood tone, libido and sport performance, and history of bone fracture. If some of these features are reported by the athlete, the evaluation should be integrated with the assessment of testosterone, 25-hydroxy vitamin D, white blood cells and glucose metabolism concentrations levels, the dual-energy x-ray absorptiometry for low bone mineral density and eating disorder psychopathology with appropriate diagnostic questionaries or interviews (e.g., the Eating Disorder Examination Questionnaire or Eating Disorder Examination interview).

Referral to a registered dietitian with a background in sports nutrition is recommended for athletes participating in sports emphasizing leanness or who show some features of the athlete triad. The dietitian should counsel athletes on their caloric and macronutrient intake needs specific for their sport and exercise energy expenditure. In most cases, increasing energy intake and/or reducing energy expenditure is recommended over the use of hormonal therapy, although integration of the diet with an adequate amount of calcium and vitamin D may be recommended.

Convincing athletes to eat more, however, is not always easy, especially if they have to stay within a weight category, such as wrestlers, or if they benefit from being lighter, like jumpers and jockeys. One strategy that often works is to emphasize that proper nutrition and good nutritional status improve athletic performance. However, if the presence of the eating-disorder psychopathology is confirmed, the athlete should be referred to clinicians specialized in the management of eating disorders.

In my long clinical practice, I have treated with cognitive behavior therapy several athlete males with an eating disorder who, after the remission of their eating-disorder psychopathology, returned to the sports competition with a marked improvement of their physical performance, physical health, and psychosocial functioning.