Female Athlete Triad in Runners

August 24, 2023

Female Athlete Triad in Runners

Female Athlete Triad (FAT)….do you know what it is or what the potential health and running performance implications are of this syndrome? You are not alone…many runners, and athletes in general, have very little knowledge of FAT and how nutrition and energy availability may impact its development. So, here we update you on the current research into FAT syndrome and outline some recommended nutritional approaches to help reduce the risk of it becoming a concern for you!

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Female Athlete Triad in Runners


Outlining WHY we are talking about this subject:

  1. FAT is a syndrome that is known to be prevalent in runners
  2. To educate our listeners and followers on this condition and the signs and symptoms to observe for, in themselves or in fellow runners, so they can take action
  3. FAT focuses on JUST the female athlete…therefore research is carried out on female athletes only, which is rare!
  4. To highlight a 2022 research paper, which focuses on aspects of FAT in RECREATIONAL female runners, which is also rare!


Defining FAT, which is a syndrome that was first acknowledged in 1992. At this time, it was understood to be a condition found in girls and women and consisting of THREE interrelated conditions:

  • Disordered Eating
  • Amenorrhoea (Menstrual dysfunction)
  • Osteoporosis (Low bone mineral density (BMD)

The athlete’s health is said to move along a spectrum depending on diet and exercise behaviours.

In 2007 the ACSM (American College of Sports Medicine) updated the definition to reflect the interdependence of LEA (low energy availability) with the conditions associated with FAT.

Then, in 2014, the IOC (International Olympic Committee) reported on the syndrome known as RED-S (Relative Energy Deficiency in Sport). The IOC Report recognised FAT as one of the outcomes of LEA in the RED-S model…as well as recognising that male athletes may also suffer from many of the symptoms outside of menstrual related symptoms.


Outlining some of the key findings from recent research into FAT Syndrome. Some of the observations include:

Low energy availability could occur intentionally or unintentionally

Early recognition of LEA in female athletes and an understanding of FAT syndrome and its progression. This is really paramount in preventing the short- and longer-term health consequences of it

It is now being suggested that only one component of the Female Athlete Triad needs to be evident in order for FAT to be established. Previously it was two or more


Outlining the highlights from the 2022 research paper looking at FAT in recreational runners, all of which were related to menstruation.

The researchers found that female recreational runners:

  • Had fewer regular monthly cycles per year
  • Their menstrual bleeding was shorter
  • They had slightly more spotting between menstrual periods
  • They had cycles every 24 days (which was more than the control group experienced)

The researchers concern was around the luteal phase of the cycle and whether it was shortened. This is because a reduced luteal phase of the menstrual cycle is associated with an increased risk of infertility and habitual spontaneous abortion due to inadequate progesterone production. An area for future research!



See Below


Highlighting some dietary and nutritional observations from the 2022 research paper on female recreational runners:

  • Recreational runners following a “special diet” for example; paleo, ketogenic, vegetarian showed higher incidence of amenorrhoea (absence of menstrual cycle) besides those following a “normal” diet
  • This data was suggesting that female recreational runners following a “special diet” may have a lack of knowledge about the specific dietary needs of a runner
  • This lack of knowledge could lead to a lack of understanding of the need to replace a potential energy deficit from their run training, which in turn could lead to a disorder of the menstrual cycle and the development of FAT syndrome

Information from additional research into FAT syndrome highlighted that many female athletes have a “fear of carbohydrates” because they worry about body image, body composition and weight gain

Also, this fear could be exacerbated by external factors and influences such as social media and potentially training coaches too


Looking at ideas and strategies to put into place to help limit the risk of FAT Syndrome becoming a concern for you including:

Think about the following questions:

  • Do you frequently train and forget to eat immediately afterwards?
  • Do you restrict your caloric intake to try and attain/maintain a lean physique?
  • Are you under pressure to keep below a certain weight for your sport?
  • Do you frequently skip meals but train hard?

If you have answered ‘yes’ to any of these questions you may be at increased risk of suffering from LEA and falling within the realms of the FAT diagnosis.

Our advice is to work with a sports nutrition professional who can guide you regarding nutrient intake to support your goals whilst still ensuring sufficient energy for your running training.

But some general advice to consider to ensure you are eating enough for your training includes:

  • Remember to eat if you feel hungry, do not go hungry for long periods of time – it seems obvious but true hunger is sometimes neglected or ignored
  • Think about the food choices you make; are they nutrient dense? CHO is important in the prevention of LEA, however the other macros (PRO & FAT) and the micronutrients (vitamins and minerals) are also essential for running performance
  • Eat sufficient carbohydrates to fuel your running – follow our Athlete’s Plate concept. If you would like to know more about this concept, listen to Ep137 Athlete’s Plates in Practice
  • Remember to ALWAYS eat Before During and After long training runs
  • You could run in the fasted state up to 90 minutes but eat immediately afterwards and ensure that your food choices are nutrient dense
  • Rather than being scared of carbs, see them as an important nutrient for running performance. Use them strategically alongside your training


Female Factors

Female Athlete Triad in Runners

The only observation the 2022 research paper mentioned was that:

    1. Older runners are less likely to experience menstrual disorders besides their younger counterparts
    2. The difference was quite significant at 67% of younger runners vs only 9% of older runners experiencing menstrual disorders
    3. The study did not state at what age the participants were recognised as “old” but the oldest participants were approx. 40yrs of age


Female Athlete Triad in Runners

  1. Just as a reminder; Female Athlete Triad (FAT) is defined as a syndrome where there is an interdependence of low energy availability (LEA) with amenorrhea, decreased bone mineral density, and osteoporosis – with LEA being evident either with or without the presence of any eating disorders
  2. LEA may occur intentionally or unintentionally. Despite this, early recognition of LEA and the FAT in a runner is paramount to prevent the short…and long-term…health consequences of it
  3. Different components of FAT may occur with a different intensity and could appear at different times depending on a runner’s diet and training load. As a result, only one aspect of this syndrome needs to be apparent in order for FAT to be established
  4. Current research suggests that within the recreational running community there is a general lack of knowledge about the specific dietary needs of a runner and the need to replace a potential energy deficit from their run training This lack of knowledge could potentially lead to the inadvertent development of FAT
  5. We highly recommend you work with a sports nutrition professional as they can guide you regarding nutrient intake to support your goals whilst also ensuring you are eating appropriately to fuel your running training and void LEA and the development of FAT
  6. Finally, consider using our Athlete’s Plate Concept as a tool to guide your food intake, especially your carbohydrate intake to help maintain energy balance for your running

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The suggestions we make during this episode are for guidance and advice only, and are not a substitute for medical advice or treatment. If you have any concerns regarding your health, please contact your healthcare professional for advice as soon as possible.

Remember we are available to support you if required contact us at hello@ runnershealthhub.com

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