By BUILD Sports Performance Lab and Physical Therapy / July 28, 2022

The Male Athlete Triad: Part 1

Part 1

By Evan Culbert, PT, DPT

What is the Male Athlete Triad?

Over the past 30 years, research has developed our understanding of the Female Athlete Triad. More recently, research has shed more light on The Male Athlete Triad, a similar condition affecting men. While awareness about the Female Athlete Triad has grown in the endurance community, many are unfamiliar with The Male Athlete Triad.
Each of these conditions fall under the umbrella of Relative Energy Deficiency in Sport, or RED-S, a broader condition affecting both women and men. These are problems related to prolonged training in an energy deficient state, aka a state of low energy availability in the body.
Imagine the energy your body uses as money. This money is energy availability. For the sake of the metaphor, let’s call this, “energy dollars.” Eat breakfast? That’s a direct deposit of energy dollars into your body’s energy availability checking account. Going for a run? Time to make a withdrawal.
This is how our body works (albeit very oversimplified). You wake up and eat a bagel. Boom, 5 energy dollar deposit – you have energy available and are ready to run. Your run costs you 3 energy dollars. Your body makes physiological adaptations and you become a little faster.
Let’s say after you eat your bagel ($5 deposit), you go for a long run that costs 6 energy dollars and overdraft your checking account. That’s okay, your body can take out an energy dollar from your savings account – energy stored elsewhere in the body. Afterwords, you refuel, and your body builds back stronger. 
But let’s say you don’t refill your accounts. And you do this day after day. Your checking and savings accounts are running dry, you’ve spent all your energy dollars and you go into energy debt. You are training in a state of low energy availability. Let’s step away from this kooky metaphor for a minute to look at a study:
In this study, runners reduced energy intake 50% of daily needs and ran 60 minutes on a treadmill every day for 3 days. This caused a 15% decrease in bone formation. In just 3 days! When we continue training in an energy deficient state, with an empty energy availability bank account, our body shuts down other critical processes in our body because there just aren't the funds for it. We have no resources to direct towards building back bone or recovery because in our low energy availability state, everything we have is going towards training. The longer we train with improper fueling, the more these effects are compounded. This is the root of Relative Energy Deficiency Syndrome, or RED-S, and it can manifest in dysfunction of metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular health, and other bodily systems.
The Male and Female Athlete Triad’s each involve 3 interrelated conditions secondary to training in an energy deficient state. The Female Athlete Triad was coined prior to RED-S over 30 years ago. It consists of low energy availability, altered bone mineral density, and menstrual dysfunction. Increased research in recent years on the Male Athlete Triad has furthered our understanding of the condition, and like The Female Athlete Triad it is important to know how to recognize and address it.
What is the Male Athlete Triad?
3 interconnected conditions make up the triad:
1) Low energy availability (EA) – put simply, more energy is going out than coming in. To return to our metaphor, the body is operating without energy dollars in the bank and is paying for activity with credit – other bodily functions are suppressed as the athlete continues to train in an energy deficient state. Low EA can be present with or without disordered eating. 
2) Impaired Bone Health – as illustrated by the study mentioned above, operating in an energy deficit has significant impact on the body’s bone health. Low bone mineral density is present in a bigger proportion of lean-sport athletes like runners, swimmers, jockeys, and cyclists. 
3) Suppression of hormone function – Specifically, the hypothalamic-pituitary gonadal (HPG) function, resulting in decreased testosterone concentrations and decreased sex drive.
It is important to note that the male athlete triad is a continuum. There is no exact threshold value of energy availability that once crossed leads to metabolic changes and dysfunction. Instead, we see a spectrum: on one end we see optimal energy availability, bone health, and hormonal function, and on the other severely low energy availability, osteoporosis/possibly bone stress injuries, and Hypogonadaropic Hypogonadism (negative hormonal changes). These changes happen over time when training with low EA. When caloric intake is not enough to fulfil the cost of training load, athletes begin to go into “energy debt.” Initially, athletes may be able to perform well in a state of low EA, but it is not sustainable as they will continue to move towards the unhealthy end of the spectrum. 
Athletes with or without disordered eating can experience the Male Athlete Triad. 8% of male athletes develop eating disorders, and this number is higher among “leanness sports” like running, swimming, and cycling. Unintentional undereating can also lead to low energy availability. However, it is not always a simple equation of caloric intake equaling energy expended during training to avoid going into energy debt. Oftentimes athletes fail to consider the impact of being a human being and dealing with the daily stressors of life! Life load and the stresses that come along with it can have an impact on our energy availability. Jobs, school, relationships, sleep, stress, quality of food, and difficult life events are all important parts of the equation that demand energy, and are important for any coach, athlete and clinician to remember. 
Male athletes that continue to train with energy debt, aka in an energy deficient state, begin to demonstrate objective changes that indicate long term energy deficiency. This is as a result of not having energy remaining after the cost of exercise for the body’s basic processes, and includes:

  • Changes in metabolic hormones (i.e., decreased testosterone)
  • Lower resting metabolic rate (RMR) - the body suppresses the energy directed towards basic bodily processes to conserve energy
  • Changes in body weight and composition
Subjective indicators and symptoms are also important to monitor and can warrant further screening. Examples include:
  • Persistent fatigue and lethargy – this one can be tricky. For many endurance athletes, fatigue is a part of training. We all know the feeling of being in the middle of a training block and feeling tired just walking up a flight of stairs. Fatigue is a part of endurance sports. However, concerning signs may include feeling fatigued after appropriate rest days, when expected to be relatively fresh for intense training sessions, or fatigue that carries through tapering.
  • Decreased libido and the absence of morning erections
  • Decreased beard growth – needing to shave less often
  • Negative performance changes in their sport
  • Mood changes that are unaccounted for
  • Getting sick more often than normal
  • Recurring injuries
These can occur over weeks to months of training in a depleted state. It is important to evaluate these changes and symptoms in conjunction with one another. Low BMI for example is a common characteristic among runners but alone does not mean an athlete has low energy availability. One indicator is not enough to diagnose RED-S or the Male Athlete Triad; it is a multifactorial condition and should be evaluated and treated as such. Keep an eye out for a part two on this topic with information on how to screen for, evaluate, and manage athletes experiencing The Male Athlete Triad.

Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine 2014;48:491-497. 
Nattiv A, De Souza MJ, Koltun KJ, Misra M, Kussman A, Williams NI, Barrack MT, Kraus E, Joy E, Fredericson M. The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part 1: Definition and Scientific Basis. Clin J Sport Med. 2021 Jul 1;31(4):335-348. doi: 10.1097/JSM.0000000000000946. PMID: 34091537.
Fredericson M, Kussman A, Misra M, Barrack MT, De Souza MJ, Kraus E, Koltun KJ, Williams NI, Joy E, Nattiv A. The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part II: Diagnosis, Treatment, and Return-To-Play. Clin J Sport Med. 2021 Jul 1;31(4):349-366. doi: 10.1097/JSM.0000000000000948. PMID: 34091538.
Raj MA, Creech JA, Rogol AD. Female Athlete Triad. 2021 Aug 14. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 28613538.

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