Saudi Journal of Sports Medicine

: 2019  |  Volume : 19  |  Issue : 2  |  Page : 56--61

An incidence survey of the female athlete triad in school and college level female athletes in Dakshina Karnataka, India

Keerthika Veer Ranji1, Joseph Oliver Raj Alexander2, Kshama Susheel Shetty1,  
1 Alva's College of Physiotherapy, Dakshina Kannada, Karnataka, India
2 Alva's College of Physiotherapy, Dakshina Kannada, Karnataka; Vinayaka Mission's College of Physiotherapy, Vinayaka Mission's Research Foundation (Deemed to be University), Salem, Tamil Nadu, India

Correspondence Address:
Prof. Joseph Oliver Raj Alexander
Alva's College of Physiotherapy, Moodabidri, Dakshina Kannada, Karnataka


Introduction: The female athlete triad (FAT) being a major health concern received global recognition, but not much effort has been put in this direction in India. Aim and Objective: The aim of this study is to determine the incidence of the FAT, in school and college level professional female athletes in Dakshina Karnataka, India. Materials and Methods: Survey was conducted using a cluster sampling technique on 64 female athletes between the age group of 15 and 22 years, actively involved in any sports for at least 2 years. The three components of the triad were assessed using standardized, valid, and reliable tools of assessment. Eating disorders were assessed using Eating Attitude Test-26 Scale. Peripheral ankle dual-energy X-ray absorptiometry used to assess bone mineral density. Menstrual abnormalities were assessed based on the predetermined set of questions. Data Interpretations and Results: Descriptive statistics revealed that 6% of the sample studied suffers from FAT, 19% have two components, and 33% have one component positive, that is, they are at high risk of the positive triad. Conclusion: The incidence of the FAT is low, but a significant proportion of the studied sample is at high risk for the triad.

How to cite this article:
Ranji KV, Alexander JO, Shetty KS. An incidence survey of the female athlete triad in school and college level female athletes in Dakshina Karnataka, India.Saudi J Sports Med 2019;19:56-61

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Ranji KV, Alexander JO, Shetty KS. An incidence survey of the female athlete triad in school and college level female athletes in Dakshina Karnataka, India. Saudi J Sports Med [serial online] 2019 [cited 2020 Aug 11 ];19:56-61
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Physical training, workout, and participation in sports are essential for a disease-free and balanced living. The participation of the female population in sports has increased tremendously. This upward trend has seen a 20% increase in the past 50 years and the figure is expected to increase with each passing year.[1] Several factors have contributed to this rise, the most important being allowing the participation of women in the Olympics that happened in 1912.[2] This legally opened the door to the participation of females in sports.

Active participation in sports greatly benefits women. It significantly promotes improved physical fitness and reduced susceptibility to depression and substance abuse.[3] Consequently, it leads to enhanced overall physical, psychological, and emotional well-being. However, there has always been a persistently alarming question in the minds of coaches, parents, and the female athlete themselves, that is, “should women be trained like men?” The prime reasons being that when women are involved in sports, several issues need to be considered that are not a problem when men take part in sports training.

Although a majority of women receive significant health benefits from physical activity and sports participation, there are also reports of increased health-related problems associated with it.[4],[5] One of the primary concerns for women in sports is that of the “Female Athlete Triad” (FAT).

The term had been initially coined by the American College of Sports Medicine in the year 1992 at the Triad Consensus Conference[4] after numerous studies reported a significant number of female athletes do have eating disorders, menstrual abnormality, and osteoporosis. It identified these three major problems and their interrelationship.[4],[5],[6] A policy statement on the FAT was published by the American Academy of Paediatrics in the year 2000 to concentrate on the growing concerns regarding adolescent female athletes.

The term eating disorders was replaced as being on a spectrum from “optimal energy availability” to “low energy availability with or without an eating disorder,” menstrual abnormalities on a spectrum from “eumenorrhea” to “functional hypothalamic amenorrhea” and osteoporosis on a spectrum from “optimal bone health to osteoporosis.”[7]

Previously as per the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) criteria of the American Psychiatric Association, the term “eating disorder” was used for the clinical diagnosis of anorexia nervosa and bulimia nervosa. However, numerous athletes though exhibiting pathogenic weight control behavior did not satisfy all the criteria of the DSM IV for eating disorders. Hence, they coined “disordered eating” to take account of pathogenic eating behaviors that fail to fulfill the strict DSM IV requirements. Disordered eating is described as a spectrum of behaviors that could range from an athlete avoiding consumption of sufficient food to suffice the energy requirements to being preoccupied with eating accompanied by the fear of turning obese due to which they incorporate the use of laxatives, diet pills, diuretics, and food restrictions.

The term energy availability that is “dietary energy intake minus energy expenditure,” is used for athletes showing some eating and weight concerns; however, do not exhibit “significant psychopathology” and do not fulfill criteria for disordered eating.[7]

The term menstrual dysfunction is used to describe the spectrum from eumenorrhea to amenorrhea. This allows clinicians to find athletes exhibiting low estrogen levels, but still experiencing menstruation. It encompasses oligomenorrhea, primary and secondary amenorrhea, luteal suppression, and anovulation. Physicians are cautioned that all other causes of menstrual dysfunction should be ruled out through complete investigation before attributing menstrual dysfunction to low estradiol levels arising due to reduced energy availability. Osteoporosis in a young athlete is alarming as it points toward a decline in bone density. Bone quality and bone mineral density (BMD) are the two important components of bone health. Several factors determine bone quality, such as the bone turnover rate, microarchitecture, maturation time of new bone matrix and bone size and geometry. Dual-energy X-ray absorptiometry (DEXA) scan provides a quantitative measure of bone health. T scores from the BMD report are used for the diagnosis of osteopenia and osteoporosis.

These problems of FAT have received wide recognition across the world due to its debilitating consequences.[4] There is a lack of epidemiological data assessing the prevalence and causes of FAT in the Indian context.[8]

Thus, this study aims at exploring the incidence of FAT in school and college level female athletes in Dakshina Karnataka, India.

 Materials and Methods

Sample size

A total of 64 subjects participated through the cluster sampling technique.

Selection criteria

Inclusion criteria

Female athletes in the age group of 15–22 yearsFemale athletes actively involved in any outdoor sport for at least the past 2 years.

Exclusion criteria

Subjects unwilling to participate in the study due to reasons not stated by themSubjects with a history of menstrual, dietary, and musculoskeletal abnormalities due to causes other than their participation in athletics.

Materials used for the study

Eating Attitudes Test (EAT) 26– scaleAn assessment form for assessing menstrual abnormalitiesDual Energy X-ray absorptiometry (DEXA) machine/ instrument machine/instrumentRecording sheets.


Prior informed consent was obtained from participating female athletes. The Institutional Ethics Committee of Alva's College of Physiotherapy, Moodbidri, provided the ethical clearance for the study. The participants were assured that the data would be kept confidential, and the nature and purpose of this study were explained. Adequate care was taken to avoid any kind of bias.

All three components of the FAT that is eating disorders, menstrual dysfunction, and osteoporosis were assessed to determine the incidence of the triad. The initial interview was conducted by the researcher in English using a self-administered assessment questionnaire to obtain the demographic data. This was followed by the assessment of the triad components.

Eating disorders were assessed using the EAT-26, which is a valid and reliable tool to assess eating disorders.[9] This test is a short form of the EAT-40. The scale consists of 26 items. The replies given by the subjects were rated on a scale ranging from never through rarely, sometimes, often, usually to always. A score of zero is given for answers marked as “never, rarely and sometimes;” score of one is given for “often,” two for “usually,” and three for “always.” The last item on the test is reverse coded. Subjects who scored 20 or greater were considered as suffering from eating disorder/positive for eating disorders. The test was administered to the participants by the researcher, and the results thus obtained revealed the presence or absence of eating disorders in the participants.

Menstrual dysfunction was assessed based on the answers given by the participants in response to a predetermined set of questions relevant to menstrual history. Questions were aimed at obtaining information pertaining to the age of menarche, the average duration of the menstrual cycle, any changes in the menstrual pattern after the commencement of sports training, and changes in sports performance during menses, consumption of pills or any medications to alter menses during sports events, history of ovarian or uterine diseases, consumption of any other medications such as antipsychotic drugs or on hormonal therapy. The questions were close-ended; that is, the answer was sought in terms of “Yes/No.” The presence or absence of menstrual disorders was determined as per the operational definition of menstrual disorders stated later.

Osteoporosis was assessed by estimation of BMD using the DEXA scan. Peripheral DEXA was performed at the ankle by a certified technician using a portable DEXA instrument. The value of BMD was reported in terms of the T scores based on which it was determined whether or not the participant suffered from osteoporosis or decreased BMD.

The grading used for the T score as per the World Health Organization criteria is as follows:[10]

>−1 = normal−1 to −2.5 = osteopenia

The data obtained were then subjected to statistical analysis to determine the incidence of the FAT in the population studied.

 Data Interpretations and Results

Descriptive statistics

Analysis of the data was performed to determine the percentage of subjects suffering from the FAT and those at high risk for the triad.

Eating disorders

The scores of the EAT–26 test was used to determine if the subjects suffered from eating disorders. Subjects having a score of 20 or greater was considered as suffering from eating disorder/positive for eating disorders.

<20 = normal20 or <20 = eating disorder present.

Menstrual abnormality

Operational definition/working definition: subjects who reported medically diagnosed menstrual abnormality and or changes in menstrual pattern, irregular cycles, scanty bleeding oligomenorrhea, missing of periods, polymenorrhea (frequent menstruation), dysmenorrhea (excessive pain during menstruation), and reduced duration of menstrual cycle secondary to sport training were considered as having menstrual abnormality.


DEXA scan used to determine the presence of osteoporosis. The results were classified as follows:

Female athlete triad

Subjects having all three components positive were considered/diagnosed as positive for the FAT. Those having one or two components positive were classified as being at high risk for FAT.

Six percent of the studied population is positive for FAT, 19% have 2 components positive and 33% have one component positive. The subjects having either one or two components positive are at high risk for developing the triad.


Each of the components has been assessed using standardized, valid, and reliable tools of assessment. The EAT – 26, which is the short version of EAT – 40 has been used to assess eating disorders. Menstrual abnormality has been assessed based on subjective information collected through a questionnaire. Portable ankle DEXA has been used to determine the BMD.

Results reveal that the incidence/prevalence of the triad is low (6%) [Table 1] and [Figure 1], but prevalence for an individual component of the triad is high. The highest prevalence is that of menstrual abnormality (44%) [Table 2] and [Figure 2], followed by an eating disorder (14%) [Table 3] and [Figure 3], and the least is for osteoporosis (5%) [Table 4] and [Figure 4]. Although the proportion of subjects suffering from osteoporosis is low; a considerable fraction (27%) are osteopenic.{Table 1}{Figure 1}{Table 2}{Figure 2}{Table 3}{Figure 3}{Table 4}{Figure 4}

Furthermore, a substantial proportion of the studied population suffers from one or more components of the triad (33% have one component positive and 19% have two components positive), which places them in the high-risk category for developing the triad in future.

The presence of greater proportion of menstrual abnormality (44%) [Table 2] and [Figure 2] (dysmenorrhea, oligomenorrhea and missing of menstrual period, scanty menstrual flow, irregularity of the cycles and reduced duration of the menstrual period as per operational definition) was initially explained by restrictive eating behavior or excessive training. This causes an energy deficit; that is an imbalance between energy intake and energy expenditure. The energy deficit leads to disruption of hypothalamic-pituitary – ovarian axis causing reduced gonadotropin-releasing hormone (GnRH) pulsatility and decreased luteinizing hormone (LH) and follicle-stimulating hormone.[11] This, in turn, leads to low estrogen levels.[12]

The current explanation for menstrual abnormality is based on the “energy availability” theory which states that when the central nervous system detects that dietary energy intake is not sufficient to support both exercise and other physiologic functions; it reduces energy expenditure by suppressing reproductive function. This includes loss of LH pulsatility resulting in low estrogen levels and a hypogonadal state.

A red flag for detecting the triad is menstrual dysfunction, as it is easier to recognize than the other two components of the triad.[12]

The hormone leptin is secreted by adipocytes. Lower levels of leptin have been observed in amenorrhea and infertility, which shows that leptin is an important mediator for reproductive function.[13] Hypothalamic neurons controlling GnRH pulsatality have shown the presence of leptin receptors.

Of the population studied, 14% have eating disorder [Table 3] and [Figure 3], which is considered to be the central component of the Triad. Studies have shown that among all the three components of the FAT; the most rampant is an eating disorder. The majority of the coaches and athletes maintain that low body weight is the key to an improved and better athletic performance.[12] Emotional stress can also lead to disordered eating and overtraining.[3]

Energy deficit that occurs when the energy expenditure exceeds the dietary energy intake was the initial explanation for the FAT.[3] There occurs a reduction in body weight due to restrictive eating behavior and excessive energy expenditure. This caloric restriction also leads to changes in cardiovascular, muscular-skeletal, thermoregulatory, and endocrine systems and reduces the metabolic rate.[12] The Position Stand on the FAT by the International Olympic Committee Medical Commission Working Group states that although the athlete might be eating normally she must be unintentionally consuming inadequate calories to meet her energy needs of the sport. This leads to decreased energy availability due mismatch between the energy required for daily living, that necessary for exercise and sport and energy expended for growth.[14] Although it is the central component of the FAT, the identification of the presence of eating disorders, or the risk factors for eating disorders is almost always delayed. Coaches always stress athletes to maintain low body weight, which they believe is extremely important for improved performance.[15],[16] The athletes themselves have the notion that this would give them an edge for performance, whereas in fact, it is detrimental to their health and well-being.[15],[16] Constant stress and pressure from parents, coach, low self-esteem, competitive fear, and urge to perform better than peers lead the athlete to behaviors such as dieting, binging, starvation, abuse of laxatives, and use of saunas, etc.[16] Furthermore, media reports and publications combined with the athlete's drive for perfection and success; add fuel to the fire.

Only a small proportion of the sample (5%) suffered from osteoporosis [Table 4] and [Figure 4], but a substantial proportion (27%) was osteopenic; that is they had a low BMD. Though not detectable at early stages, with the passage of time gradual loss of bone mass occurs. This can be attributed to the decreased energy availability and endogenous estrogen, which in turn suppress bone formation.[14] Thus, weakening and deterioration of the microarchitecture of the bone occur, which makes the skeletal system fragile, thereby increasing the risk of fractures and injury.[14] Over time this imbalance can lead to microarchitectural deterioration and increased skeletal fragility placing the athlete at an increased risk for fractures.

The decrease in estrogen production, which causes menstrual dysfunction, leads to calcium resorption and impairs bone health.[11] The termination of menstruation makes women more vulnerable to calcium loss and decreased BMD as the protective effect of estrogen on bone no longer exists.[17]

Another mechanism which explains the occurrence of reduced BMD is the presence of leptin receptors in the bone that are important for osteoblastic function.[13] Leptin secreted by the fat cells functions independently as a regulator of metabolic rate. Leptin levels are lower in athletes who have low body fat, exercise excessively, and in those who fast.[13] Furthermore, dietary restriction indirectly reduces the calcium intake, which manifests as reduced BMD, leading to osteoporosis resulting in an increased incidence of falls.

All the three components of the FAT are interrelated. One leads to another. Disordered eating is the initiating factor in the majority of the cases; however, this is not mandatory. The detrimental effects of the Triad manifest not immediately unless severe. Thus, the emphasis is now laid on early identification of the Triad components, which is possible with the preparticipation physical examination and screening.[18],[19],[20],[21] Efforts should also be directed toward increasing the awareness of the FAT among athletes, coaches, and all those who are associated with the athlete and the sport.[16],[22],[23],[24],[25] This facilitates prompt treatment measures to be instituted so that the health and well-being of the athlete is not compromised.


Incidence of the FAT is low, but the incidence of an individual component of the triad is high, that is, a significant proportion of the studied population suffers from one or more components of the triad although the proportion that suffers from all the three components of the triad is low.

The results of this study lead us to the conclusion that the FAT is prevalent in Dakshina Karnataka. Thus, appropriate measures should be undertaken to improve their health status, thereby preventing the occurrence of the FAT and also optimum therapy for the same should be made available to the female athletes.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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