To date, only one study has examined the prevalence of the Triad components amongst the non-athletic population. This is surprising given that the ACSM position stand [2
] clearly states that all women are 'at risk' of its development. Although the control population was included predominantly to assess nutrition knowledge, it is interesting to examine differences in Triad risk behaviour compared to the athletic sample. EAT-26 scores ≥ 20 were attained by 3.1% and 8.3% of controls and athletes respectively. Amongst the athletic sample, menstrual dysfunction was significantly higher (p
< .05), however of the 21 (43.8%) who were considered to be 'at risk', only one was also considered as 'at risk' of either disordered eating or low bone mineral density.
Initially these results may be of little concern, however it is important to consider that the Triad occurs on a continuum. Bearing in mind the detrimental physiological effects induced by the occurrence of any one component, a respondent is clearly putting themselves at increased risk of developing other aspects of the Triad. For this reason, Torstveit and Sungot-Borgen [26
] classified those 'at risk' as respondents meeting any one of the criteria. This results in 42.4% of athletes and 12.5% of controls in the present study being 'at risk' of the Female Athlete Triad based on proxy measures for the three components. This is in keeping with studies conducted by Torstveit and Sungot-Borgen [26
] who classified 60.4% of athletes 'at risk' of the triad, including the BMI < 18.5 criterion.
Results of this study show significantly higher nutrition knowledge amongst athletes compared to the normal population. Following basic guidelines for healthy eating is the most important dietary consideration for elite athletes [27
]. The questionnaire covered these guidelines thus elevated scores imply better understanding of dietary needs and consequently improved eating behaviour. However, overall results from this study do not indicate this. 'At risk' EAT-26 scores were present in 10.2% of athletes (controls = 3.1%) and 16.7% had previously been diagnosed with either anorexia nervosa or bulimia nervosa compared to 3.1% of controls. This conclusion supports findings of previous research showing that athletes may know what the advisable behaviour is regarding eating and nutrition but tend not to follow these guidelines if it was not practical [28
]. Studies regarding the effectiveness of nutrition education showed that while improvement in knowledge occurred, there was no difference observed in eating behaviour [25
The reasons underlying the disordered eating despite the high level of nutrition knowledge may be both cognitive and motivational. People may have inert knowledge
, which can be cited or recalled on a test but not applied to problems [30
] or behavioural decisions. Alternatively, information may be available but consciously ignored or overwritten by reasons with higher priority (i.e. keeping weight unreasonably low for aesthetic or performance reasons). Individuals may possess the relevant information but they only use what is important to them [14
Having the knowledge of health recommendations but not followed can be considered a form of risk taking [31
]. Cook and Bellis showed that knowledge of health risks and risk-taking behaviour were peculiarly related: those with precise risk assessment were high risk takers whilst those who repeatedly over-estimated the risks exhibited low level of risk-taking behaviour [32
]. Better than average nutrition knowledge does not necessarily have a positive effect on individual health. Athletes with heightened awareness may engage in risk taking behaviour by making excessive efforts to reduce calorie intake in order to stay lean, with negative consequences on performance and ultimately on health. Athletes may justify their unhealthy eating habits as being controlled, temporal and goal oriented behaviour. In a sporting arena where leanness often equates to success, daily decisions about what and how much to eat are a constant challenge to the female athlete. This phenomenon can be explained by the perceived sense of control over the risks. For example, decision in a simulated situation (i.e. driving), people with control (drivers) were more comfortable taking high level of risk than those who had no control (passengers) [33
]. Additionally, in case of deliberate acts, motives for a given behaviour exert influence on the perceived control over the behaviour [34
] and risks taken. The deliberately low daily energy intake (cognitive dietary restraint) is also likely to be reinforced by the subculture where low body weight is desirable and restricted eating is the perceived norm. Further research is needed to investigate the applicability of these explanations of the seemingly deliberate unhealthy dieting observed among female athletes.
Decisions about whether to engage in risky behaviour, e.g. restrictive eating, and the subsequent impact on health can be serious. Although some dispute the seriousness of the Triad [35
], it is possible that this underestimation of the cumulative effects of one's behaviour is relevant to the Female Athlete Triad. Athletes scored significantly higher than controls in all nutrition knowledge topic areas, yet no relationship was observed between higher nutrition knowledge and decreased EAT-26 scores or vice versa. This suggests that 'at risk' taking behaviour, i.e. cognitive dietary restraint, is present.
The majority of female endurance athletes (88%) are consuming less than the minimum amount of energy recommended when training (45 kcal/kg/day) [25
]. This may represent a chronic, low level stressor instigating cortisol release. High cortisol levels have been associated with reproductive disturbances and are known to have a direct effect on bone mineral density [37
]. Numerous studies have shown that these sub-clinical disorders occur more frequently in women with high levels of cognitive dietary restrain [38
] indicating that nutrition intervention programmes should focus on behavioural and psychosocial changes alongside nutritional awareness, particularly as disordered eating patterns, once established, are difficult to relinquish [14
This study is considered explorative for a number of reasons. A large percentage of respondents were self-selected. Those with experience of the Triad disorders or a particular interest in nutrition or health issues may be more inclined to respond resulting in a known volunteer effect. Self-selection also meant the standard of athletes was not as 'elite' as desired. Even though criteria were set in order to filter out the 'recreational athlete', it was concluded that a broad range of abilities was included in the athletic sample.
Identification of 'at risk' factors is essential in the evaluation of the Triad [26
]. It is therefore important to stress that this study examined 'at risk' behaviour of the Triad rather than the occurrence of the disorders themselves. To achieve this, cut-off points were designated for each component, thus borderline respondents may have been categorised incorrectly. However, because of the assessment criteria in each element of the Triad, such a 'close miss' could only happen regarding the disordered eating assessment, where the measurement was taken on a quasi-continuous scale (see Figure ). Further research involving clinical interviews and dual energy x-ray absorptiometry (DXA) is required to assess the existence of one or more elements of the Triad accurately. Energy intake and expenditure should also be calculated and taken into account.
Suggestions for future research
A number of studies have reported an inverse relationship between CDR and either menstrual dysfunction or low bone mineral density [36
]. To date, no research has examined the direct relationship of CDR with the occurrence of disordered eating among athletes. Thus, to extend the work of this study, future research should focus on CDR measurement to identify potentially serious problems and consequences associated with poor nutrition choices despite good nutritional awareness. Food diaries, clinical assessment and interviews of those considered 'at risk' would provide a useful insight to the athlete's reasoning for dietary behaviour or restraint. Future studies should incorporate other potentially important factors, such as genetics, desired weight change and perceived pressure to lose weight, perceived health risk and predisposition to risk taking. Special attention should be given to athletes' participation in sports where leanness is considered advantageous.