Soldiers and the Athlete Triad

Written by Ben Bunting: BA, PGCert. (Sport & Exercise Nutrition) // British Army Physical Training Instructor // S&C Coach.


Low bone mass, menstrual irregularities, and an imbalanced diet can all negatively impact the physical state of soldiers. We look at the athlete triad, how it effects athletes and how this can also relate to soldiers.

What is the Athlete Triad?

The athlete triad is a common problem that can affect athletes. These athletes face a number of psychological problems that require specialized care.

The biggest factor that causes these problems is a lack of energy and calories. Athletes should be advised to increase their calorie intake where needed.

This can help to reduce their energy deficit and increase their performance. However, this can be challenging. 

Soldiers are often compared with athletes because of their high energy requirements alongside extensive mental and physical demands, and often without a dedicated team of nutritionists and other support staff at their disposal.

As such the needs of an athlete often overlap those of the deployed soldier. The American College of Sports Medicine published a position statement defining the athlete triad.

Female athlete triad

In severe cases, the athlete may develop disordered eating habits, such as anorexia nervosa.

Untreated, the disorder can lead to infertility and other health problems. In addition to these issues, the athlete may experience irregular menstrual cycles and decreased bone density. This can lead to stress fractures.

The most common cause of the female athlete triad is an energy imbalance. In female athletes, they may eat less than they expend. This can be on purpose or unintentionally, resulting in excessive fatigue

Screening for the triad should begin with the annual physical exam. In addition to assessing the triad's cardinal signs, health care professionals should educate athletes about the condition.

Moreover, it's crucial to make sure that the athlete feels comfortable with the health care provider. This should be accompanied by an open line of communication so that the problem can be treated early.

If a health care provider suspects any of the three conditions, he or she should perform a thorough evaluation.

Research on the athlete triad has evolved over the last three decades. Researchers have identified the subclinical expressions of each condition, and their relationship with energy deficiency.

They have also been able to investigate the causal effect of energy deficiency on reproductive dysfunction. Some researchers even have conducted randomized controlled trials to help athletes overcome these problems.

Whether you are a male athlete or a female athlete, the athlete triad can be a significant cause of health problems.

While the percentage of female athletes affected by the athlete triad is relatively low, many young women suffer from one or more of its three components. Fortunately, early detection is critical for successful recovery.

Your doctor can help assess whether you are at risk by reviewing your menstrual cycle and hormone levels. In addition, a blood test can check for glucose levels and electrolytes. These tests can give the athlete an idea of any adjustments that may need to be made.

Physiological and biomechanical factors

Physiological and biomechanical factors for soldiers are significant considerations when constructing an effective training program, and something that physical training instructors must be aware of.

Soldiers carry a large load that increases their energy expenditure. The female is particularly at risk due to an energy inbalance caused by not consuming enough foods combined with a high activity level during field tasks. 

The physiology of athletes must be understood to develop effective interventions. This is especially important when addressing the female athlete triad, which can have varying degrees of severity depending on the energy deficit.

Early symptoms may include amenorrhea, while later symptoms can include decreased performance, social isolation, and cardiac instabilities.

The female athlete triad can affect athletes of any sport, but is particularly prevalent among women participating in sports or jobs involving high levels of physical activity and heavy training.

In order to prevent this condition, athletes should embrace nutrition and exercise and develop coping mechanisms.

During a typical training session, soldiers may perform exercises using varying load weights and loads.

In this type of exercise, women are expected to lean forward as their backpack weight increases, which affects their biomechanics further up the spine.

A female athlete's pelvic rhythm is affected by her body's muscle activation, and she may also experience pain in her lower back.

Understanding the Three Components of the Female Athlete Triad

If you're a female athlete, soldier or physical training instructor, it's important to understand the three components of the female athlete trium, or "FAT." The triad includes factors that can affect women's bone health.

These include hormone levels (estrogen, progesterone, and testosterone), menstrual cycle, and bone mineral density.

Early detection of FAT is key to reducing long-term bone damage and improving sports performance.

The triad is often the result of an inadequate caloric intake leading to a inadequate energy balance.

To reduce the risk, female athletes should consult with a team of medical professionals, including a gynecologist, orthopedic surgeon, family physician, and nutritionist.

Increasing intake of high-nutrient foods is often required to meet energy demand.

The female athlete triad is a serious condition with numerous symptoms. One of the most common is energy deficiency, which can be caused by unhealthy eating habits and even severe eating disorders.

The symptoms of FAT include irregular menstrual cycles and amenorrhea (the absence of a menstrual cycle). Additionally, low estrogen can cause loss of bone mass, which increases the risk of stress fractures.

Although FAT is considered a complex syndrome, early treatment is crucial to avoiding serious complications and achieving full recovery.

Treatment should focus on restoring energy balance, restoring normal menstrual cycles, and enhancing bone density. The first step in addressing FAT should include the use of non-pharmacological treatment modalities.

However, the female athlete triad requires an interdisciplinary team approach to the problem.

The triad is preventable and can be treated early. Prevention is key, but many athletes are unaware of its existence.

Fortunately, education can help. Parents, coaches, and teachers are often unaware of its existence, and may encourage maladaptive behavior in diet or exercise.

As a result, these behaviors may be unrecognized until a woman becomes an adult. It's essential for female athletes to seek medical care as soon as possible to prevent serious long-term complications.

Testing for the triad includes blood tests, which can be used to diagnose and treat the condition.

Physicians will look for low levels of vitamin D and anemia which can be caused be inadequate iron intake.

They may also perform a bone density test called a DXA scan. If the results are negative, a physician may recommend further testing for the triad.

If a patient's symptoms persist, an in-depth evaluation is necessary.

Menstrual irregularity

A woman's menstrual cycle can be disrupted due to high levels of physical activity and stress.

The stress of war has been shown to disrupt the menstrual cycle, and women often use menstrual suppressants to avoid having menstruation.

Menstrual suppression has been linked to lowered bone mineral density, but this is a short-term effect, and the effects can be reversed when treatment is stopped.

The menstrual cycles of women are cyclical, allowing a woman to have nine or fewer menstrual cycles within a 12-month period. While secondary amenorrhea is not a condition of menstruation, it is considered an early symptom of a potential medical condition. 

In the military, women often experience menstrual irregularity and secondary amenorrhea. Physical and emotional training, as well as traumatic events, can result in menstrual irregularity. 

In a preliminary study of 32 cadets of the Indonesian Naval Academy, 25 of them (78.1%) suffered from menstrual irregularity.

Furthermore, the relationship between psychological stress and physical activity was looked for. This study also indicated that 89% of the cadets who engage in high levels of physical activity experienced menstrual disorders.

It concluded that physical activity and mental stress are related to menstrual problems.

While menstrual irregularity is often associated with low BMD, it is also a potential risk factor for arterial problems.

Women suffering from FAT have a higher risk of suffering from heart attacks and strokes compared to other menstrual irregularities. The athletes with menstrual irregularity had a higher risk for musculoskeletal injury. 

Low bone mass

Another clinical sign of the triad may be low bone mass. These skeletal abnormalities are often caused by inadequate caloric intake, low calcium or a lack of vitamin D.

In order to treat these conditions, clinicians should initiate nutritional, psychological, and educational interventions. Those with triad symptoms should receive specialized treatment.

They should also be given appropriate physical training and education in the sport they participate in. However, identifying triad patients is not as simple as recognizing the symptoms.

In general, the main goal of treatment is to restore menstrual periods and restore bone mineral density. Unfortunately, no single drug has been proven to improve bone mineral density consistently in this patient group.

Instead, physicians should focus on optimizing energy availability and ensuring sufficient vitamin D and calcium intake. Because these conditions are often interrelated, the triad is best treated with an interdisciplinary team.

In the meantime, prevention is crucial to reduce the risks and complications of the disorder.

In addition to female athletes or soldiers, endurance athletes may also suffer from low bone mass.

This condition is often related to low energy availability, and men who are low in energy are more likely to develop reproductive issues and bonestress injuries.

It is important for athletes and soldiers to be aware of the triad and be aware of the resulting risks. 

In addition to low bone mass, low energy availablility (LEA) may also affect the bone structure.

This condition is accompanied by cortical thinning, which results in reduced bone mass. Thus, it is important to investigate methods that might prevent or treat LEA. 

Future research on LEA should investigate the effects of low-repetition, high-impact interventions, and geometry on bone mass and other markers.

These findings could inform evidence-informed practice and lead to prospective longitudinal studies. It will also be important to evaluate how athletes are able to recover from LEA after injury.

Disordered eating

A recent study reveals that athletes with disordered eating are twice as likely to suffer from musculoskeletal injury as athletes without the disorder.

The findings also show that athletes who are overweight or obese are twice as likely to develop disordered eating.

However, this finding is not yet clinically significant. Further research is needed to determine the exact link between disordered eating and military health. For now, the results suggest that disordered eating is not limited to soldiers.

Another study examined the relationship between the Female Athlete Triad and athletes' health.

The study included elite female athletes aged 18 to 25 years. They completed a questionnaire, which included demographics, body mass index, and sports participation and playing hours.

They were also administered the Eating Aptitude Test-26, which assesses the likelihood of developing disordered eating. The study also included questions about athletes' mental health and family support.

Young athletes are also more likely to develop the disorder. This is because biological changes during puberty and the development of sex-specific fat can result in disorders of the triad.

Young athletes also face pressure to stay thin, and disordered eating often accompanies this unhealthy attempt to stay thin.

Early recognition of young athletes' potential for developing triad disorders is important for developing medical protocols to prevent the disease.

The prevalence of the disordered eating syndrome is particularly high in women serving in the military.

The disordered eating syndrome may be a sign of another problem. Women in the military may be at increased risk of developing osteoporosis or amenorrhea. A study by Hoch et al. showed that women who were enrolled in the study had low bone density.

The study showed that menstruation and osteoporosis were often co-occurring.

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Energy and Nutrient Deficiencies for Soldiers on Deployment

The Department of Defense began developing "Meal, Ready to Eat" (MRE) meals for the armed forces in 1963.

New packaging and modern food preparation techniques enabled lighter rationing of food. These rations now include 24 entrees and 150 food and beverage choices.

In addition to keeping soldiers well-nourished, MREs are developed using the Dietary Reference Intake, a list of recommended daily caloric intakes.

The average military member is advised to consume about 2,400 calories per day, so the idea was to provide soldiers with a meal that would satisfy their needs.

Soldiers on deployment can suffer from energy and nutrient deficiencies. The food they eat must be nutritionally balanced to provide enough energy, proten for muscle recovery and also micronutrients such as electrolytes to help with nerve function. 

Even so, when soldiers are not deployed they are free to eat as they please, but even these choices may not be nutritionally beneficial which can lead to unwanted weight gain and a reduction of physical performance.

Food for Fighter's

The military has been aware of the importance of soldiers' nutrition since the turn of the 20th century.

A well-nourished soldier will be more resilient to illness and strain, as well as be more energetic and cheerful.

Fortunately, NATO militaries have implemented a dietary policies for soldiers on deployment that ensures the best possible nutrition for every soldier.

Military Ration Packs

Over the centuries, military nutrition has improved dramatically. Previously, army personnel were only concerned with staying alive, but new information about nutrition was available that would help soldiers perform better, improve performance and increase their well-being. 

Today, military forces aren't content with providing a large amount of food for their troops; they strive to provide the right food to promote good health and combat fatigue.

The Multi-Climate Ration (MCR) pack utilized by the British Armed forces has an average energy content of 4098 kcal per day, and contains 651 grams of carbohydrate, 130 grams of protein, and 92 grams of fat.

This ration has been evaluated by the Institute for Nutrition and Medicine (INM). It includes a breakfast and main meal, pudding, trail mix, soup, snacks and electrolyte drinks.

The often referred as an operational ration packs (ORPs) are composed of a variety of foods to support soldier performance in the field. The 10-man ORP is designed to feed ten men for twenty-four hours or five men for two days.

It requires field catering equipment and a military field chef with basic catering skills. It is a complex ration, and depends on the military field chef's skill and ability. Fresh food, when available, can supplement the ORP.

There are also other ration packs available for those on exercise and deployments in extreme climates such as the jungle or extreme cold climates.

In these cases there's a slight increase of calories available which is supplemented with additional snacks or a slight variation of the main meals.

Energy balance

Military personnel often face discrepancies in the amount of food they consume. This gap is usually mediated by the amount of time and palatability of the rations.

Only by eating the full amount will the soldier consume enough calories that is required for intense operations, if they don't consume it all, they run the risk of being energy deficient which can negatively effect the soldiers getting all of the nutrients the body needs in high tempo operations.

For this reason, checks on soldiers and education during basic training and peace time is imperative so that all personnel understand the importance of consuming their food.

The provided ration packs to be used on deployments are based on the latest scientific research. It includes information on a number of health problems that soldiers face while deployed.

For example, soldiers who are suffering from iron deficiency may have difficulty concentrating and thinking.

Moreover, they may have difficulty identifying and responding to visual cues and even respond to improvised explosive devices.

The high protein content helps the muscles recover and the high level of carbohydrate provides the body's preferred source of energy to fulfill tasks. 

First Strike Ration

The food components of the First Strike Ration (FSR) used by US forces is designed for short-term consumption, although it could be used over a month, if necessary.

However, the committee does not recommend that soldiers consume more than one serving daily.

This is because the ration's food components are highly processed and may not have the same range of food components as a standard US diet.

The development of the First Strike Ration was inspired by the findings of military studies that indicated the troops were stripping the bulk from their issued ration packs, and keeping the essentials that they liked so they could lessen the weight carried.

This meant that the troops were deducting around 1100kcals from their rations so it was more convenient for them, obvioulsy this can cause many problems for opertional effectiveness.

The First Strike Ration is intended to address this problem by providing more calories in a small package, with a mix of eat-on-the-go and performance-enhancing foods.

The FSR contains the appropriate nutritional content and energy for short-term, highly mobile combat operations.

The First Strike Ration is a lightweight, calorically dense ration for US troops on deployment. It is designed to be consumed by soldiers during the first 72 hours of a conflict and is a viable replacement for Meals Ready-to-Eat (MRE).

The rations are formulated to enhance physical performance, improve mental acuity, and increase mobility, and are easy to carry and consume.

There are different menus providing a variety of energy efficient foods, drinks, gels and drinks to sustain soldiers on deployment. 


The female athlete triad is a condition whereby the female athlete can suffer from menstrual irregularities, poor performance and reduced bone density as a result of poor nutrition and low energy availability.

Female soldiers are also at risk, high physical and emotional stressors couples with a limited knowledge of nutrition place personnel at  alevel similar to their athlete counterparts. 

Furthermore, reduced performance and bone weakening can also be experienced by male endurance athletes or indeed male soldiers who do not meet their nutritional needs.

Fortunately Militaries have been aware of the problems faced by under-nourished soldiers, and have been developing foods to eat and be cooked whilst on operations to minimize any risk of energy and nutritional deficiences. 

They've also taken note of eating habits, to ensure what they provide will be more convenient to carry and consume on the go. Gone are the bulky and heavy caned foods, and now we're seeing more palatable and energy dense gels, snacks and wraps.

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