What is the Male Athlete Triad?

For a long time, the research efforts of Coalition members focused on the health consequences of energy deficiency/low energy availability in females, but in 2017, a Triad-like syndrome that affects men was introduced at a round-table discussion of key researchers and clinicians and which has been the focus of recent reviews [1, 2] and an upcoming Consensus Statement. The Male Athlete Triad refers to three health problems that are related to each other: energy deficiency (“under-fueling”), reproductive suppression, and poor bone health. Reproductive suppression includes low testosterone, oligospermia (irregular and low sperm count), and reduced sex drive (libido). The Triad exists on a spectrum, and men do not need to have all three components of the Triad to experience the negative repercussions. Low energy levels drive the Triad and are often accompanied by disordered eating behaviors, or excessive exercise levels. It is important for all male athletes, especially if involved in a sport that highlights leanness, to be aware of the Triad to hopefully prevent serious reproductive and bone health problems from occurring. 

Components of the Triad

Compared to women, men seem to require a more severe energy deficit to induce Triad-related effects. In the two short duration experimental studies where men were prescribed low energy availability over 5 days, metabolic hormones leptin and insulin were reduced in one study [3] but not the other [4], and neither produced reductions in the hormones total triiodothyronine (TT3), insulin-like growth factor-1 (IGF-1), or testosterone. It seems that a longer duration, or more severe, energy deficit is necessary to see reductions in body composition (body weight, fat mass), TT3, IGF-1 and luteinizing hormone (LH) [5]. When you aren’t consuming enough calories each day to match your level of physical activity, your body can develop a state of energy deficiency (energy intake

Sometimes, athletes slip into this under-fueled state by: 

      • Inadvertent Under-eating: some men simply do not realize how much energy they burn during workouts and they don’t eat enough to maintain a healthy weight
      • Disordered eating/ Eating disorders: Some men try to lose too much weight or lose it too quickly in order to look or perform better. Some men may under-eat by skipping meals, avoiding all foods that contain fat, or eliminating many foods without making healthy substitutions. While disordered eating and eating disorders may contribute to energy deficiency/low energy availability in both sexes, as the prevalence in athletes are higher than the general male and female populations [6], the specific eating behaviors may differ.  In men, eating behaviors may be more related to a high drive for muscularity and/or leanness [7-10] rather than thinness.
      • Exercising too much relative to their caloric intake in order to lose weight quickly, which can create an excessive energy deficit.

In men, reproductive suppression resulting from energy deficiency/low energy availability is referred to as hypogonadotropic hypogonadism and can present as reduced LH [5, 11, 12], low testosterone levels [13-16], abnormal sperm production [17-19], and reduced sex drive [20, 21]. In these men, testosterone is most often in the subclinical range, but can be clinically low in some cases [14].

The recovery of the metabolic and reproductive consequences of energy deficiency appear to recover faster in men than women. Following an intensive multistressor military training environment, all metabolic and reproductive hormones quickly returned to normal, with most recovering within one week [5]. After acute endurance events, several investigators reported testosterone concentration returning to normal concentrations within 12-72 hours after the event [22-24].

Bone health consequences remain the most severe clinical endpoint of the Triad in men, with male athletes presenting with low BMD [25-28] and high prevalence of bone stress injuries [29, 30] that, similarly to women, could put them at risk for fracture and osteoporosis later in life.

What are the risk factors for developing the Triad?

There are many factors that put someone at risk for the Triad. Being aware of these risk factors allows you to stay ahead of the Triad and aid in prevention.

  • Dieting at an early age

  • Disordered eating habits (such as skipping meals)

  • Being unhappy with your body type

  • Perfectionism

  • Believing that losing weight (or body fat) at any cost will improve performance

  • Frequent weight cycling

  • Extremely high training volumes

  • “Extreme” weight control behaviors (vomiting, saunas)

Who is at risk for the Triad?

The Triad most commonly affects men involved in weight-class sports, sports that emphasize leanness or muscularity, and endurance sports. All athletes can be at risk for the Triad, regardless of competition level.

Athletes in sports that emphasize leanness, or are based on aesthetics

    • Diving
    • Gymnastics
    • Ice Skating
    • Dance

Athletes who participate in weight class sports

    • Wrestling
    • Boxing
    • Rowing

Athletes in gravitational sports

    • Running
    • Ski Jumping
    • High Jump
    • Pole Vault 
    • Cycling

How is the Male Athlete Triad treated?

Treatment will look different for every individual, but we have collected a few tips on how exercising men who are experiencing the Triad can reach out to medical professionals to get the help they need:

  • Seek a team of experts who provide medical care and nutritional counseling

  • See a psychologist or other counselor to seek help for any disordered eating thoughts or anxiety

  • Educate yourself on how to maintain a healthy lifestyle by eating enough calories to cover the amount of energy expended through exercise

Even More Important- How can we prevent the Triad?

The Triad is completely preventable with the right knowledge. Read below for our tips on how to prevent the Triad.

  • Use online resources — These resources can help you estimate how many calories you need per day to maintain your current body weight.

  • Eat every three to four hours — Three meals a day and at least two snacks. Have a daily eating plan for when to eat to best fuel and re- cover from exercise. For example, competitive athletes often need to carry snacks around during the day and eat before, as well as right after practices.

  • Treat snacks as mini-meals — Choose foods that are nutritious, taste good and fit your lifestyle. For example, healthy “fast foods” like a bowl of instant oatmeal with raisins, a peanut butter sandwich or crackers with peanut butter, a low-fat milk shake or fruit smoothie, or a micro- waved baked potato topped with cheese, fit the bill.

  • Track how much you exercise in a day — accounting for time, type and intensity of exercise. Adjust your food intake to account for the increased expense of energy. For example, if you weigh 150 pounds and you add a 2 hour vigorous volleyball practice to your daily activities, you will burn approximately 1100 calories in addition to your nor- mal requirements. There are many online sources to calculate how many calories are needed by an athlete who performs a wide variety of sports.

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