New research shows that men can suffer the devastating consequences of a male version of the female athlete triad, as Peta Bee reports

We have recently covered issues surrounding the female athlete triad, or relative energy deficiency in sport (RED-S). This complex interplay of menstrual dysfunction, low energy availability (with or without an eating disorder), and decreased bone mineral density is alarmingly common within sport. Energy deficiency – a result of imbalances between the amount of energy consumed and the amount of energy expended during training – is the main underlying cause of the syndrome. But is there a male equivalent of the triad?

Drawing parallels

This question was the focus of a paper published last year in the journal Sports Medicine in which Dr Adam Tenforde, assistant professor of physical medicine and rehabilitation at Harvard Medical School and Sports Medicine Physician at the Spaulding National Running Centre, and his colleagues proposed that a similar condition affects male athletes.

Their early research suggests “that a subset of male athletes may experience adverse health issues that parallel those associated with the triad,” Tenforde said, experiencing changing levels of hormones, coupled with undereating and resulting injuries. While not yet formally recognised as a medical syndrome, the male athlete triad is to be a subject discussed by an expert panel at the American College of Sports Medicine annual conference in 2018.

“It’s likely the term ‘male athlete triad’ will be used,” says Dr Mary Jane De Souza, a professor of kinesiology and physiology at the Pennsylvania State University in University Park and a leading researcher on the subject who will be on the ACSM panel.

How it affects men

In women, the triad is linked to a sharp drop in levels of the female hormone oestrogen which causes the cessation of the menstrual cycle and a related weakening of bone mass. Tenforde, a former elite athlete himself, became interested in investigating the male version  of the syndrome after noticing “a subset of male athletes I cared for, mostly endurance athletes like runners and cyclists, with a history of stress fractures”.

He suspected that these athletes were under-fueling and wondered whether hormone levels were also off kilter. Upon examination, he found that the male athletes with repeated injuries often had “low testosterone levels and low bone-mineral levels on their DEXA [bone] scans”. It means that these male athletes may be predisposed to developing bone stress injuries, an early sign of triad symptoms.

Nothing new

Several studies have shown male endurance athletes to be at a higher risk of undereating to the point that their calorie intake does not meet the demands of their sport. As far back as 2004, the former Commonwealth 1500m champion Michael East spoke about the fact that many of his male contemporaries had developed a dangerous obsession with undereating that took its toll on their bodies as well as affecting their performance on the track.

“It used to be just women, but more and more men are obsessed with how much they weigh and what’s on their plate,” East said at the time. “They think they’ll get quicker if they get thinner, but they are grasping at straws. These people aren’t stupid. But it’s such a mental issue and I’m banging my head against a wall trying to get through to them it’s not right.”

One and the same?

Some experts argue that, specific hormones aside, there is little difference between male and female triad symptoms. “I am not sure why there is a need to separate the genders if the underlying issue addresses both genders,” says Margo Mountjoy, an associate professor of family medicine at McMaster University in Hamilton, Ontario, Canada, who was lead author of a 2014 consensus statement by the International Olympic Committee in which the term RED-S was adopted in place of the female athlete triad. Yet, the male triad is a new area of study and many experts believe that more investigation is needed to determine any differences between the male and female syndromes.

As De Souza points out, little is known about the threshold at which reduced levels of body fat begins to affect hormonal balance in male athletes. She says that more work is needed to find out how training and undereating affect testosterone, but also other male hormones, such as insulin and insulin-like growth factor 1.

What to do

Coaches and parents of male athletes should be aware of unexplained and repeated stress fractures or injuries to the pelvic bone in male athletes. Tenforde suggests they undergo tests for endocrine hormones, thyroid function, testosterone levels, and vitamin D deficiency.

If a male athlete does present with very low testosterone he might be prescribed a form of hormone therapy that “is very similar to what was previously prescribed for female athletes who had amenorrhea”. However, all experts stress that the underlying issue need to be addressed. Carefully increasing calorie intake is a crucial step.

Research presented by De Souza at the 2017 American College of Sports Medicine annual meeting outlined a treatment plan, called REFUEL, for female athletes with triad symptoms of amenorrhea and excessive exercise. It showed that when women consumed more calories in their daily diet they recovered their menstrual cycles that had been suppressed by extreme exercise. More than half the women diagnosed with female athlete triad began menstruating in the year after a caloric increase that was 20-30% of baseline energy expenditure.

In most cases this involved an increase by up to 580 calories a day which was achieved with power bars for some women while others worked with the researchers to change the foods they normally ate. Pilot studies had shown that the women would find it “extremely difficult” just to add the calories through eating more food, Dr De Souza said. Indeed, such was their relationship with food that some women said they couldn’t eat a whole power bar in one sitting, so the researchers cut the bars into thirds so that they could eat portions every few hours. It’s an approach that is also applicable to male athletes.