Despite allegations that the triad is just a ''myth'' [4,5], and that researchers have grossly overestimated the extent of the problem [4-6], scientific data and anecdotal evidence indicate that the triad does exist and can have devastating consequences for female athletes [7-10]. Perhaps one of the reasons for the contradictory opinions regarding the magnitude of the problem stems from the dearth of solid data documenting the prevalence of the triad among female athletes. To date, only three studies have examined all three disorders of the triad using direct measures of BMD (ie, dual-energy x-ray absorptiometry [DXA]) in female athletes [7,10,11].
Beals and Hill  examined the prevalence of disordered eating, menstrual dysfunction, and low BMD among 112 US collegiate athletes representing seven different sports. Disordered eating and menstrual dysfunction were assessed by a validated health, weight, dieting, eating disorder, and menstrual history questionnaire, and BMD was determined via DXA. Although only one athlete met the criteria for all three disorders of the triad (using a Z-score <—2.0), two additional athletes qualified when using a less conservative and more frequently used criterion for low BMD (ie, a Z-score <—1.0). In addition, 28 athletes met the criteria for disordered eating, 29 athletes met the criteria for menstrual dysfunction, and 2 athletes had low BMD (using a Z-score <—2.0). Ten athletes met the criteria for two disorders of the triad using the more conservative BMD criterion, and this prevalence was increased to 13 athletes when the less conservative BMD criterion was used.
In a similar study, Nichols and colleagues  examined the prevalence of the triad of disorders among 170 high school athletes representing eight different sports. Disordered eating behaviors and attitudes were measured via the Eating Disorder Examination Questionnaire (Fairburn and Belgin, 1994), menstrual dysfunction was determined from a preparticipation examination questionnaire, and BMD was assessed via DXA (with a Z-score of <—1 or <—2 indicative of low BMD). Although only 2 athletes met the criteria for all three components of the triad, 10 girls met the criteria for two components; 18.2%, 23.5%, and 21.8% of the athletes met the criteria for disordered eating, menstrual dysfunction, and low BMD.
Using the entire population of elite Nowegian female athletes, Torstveit and Sundgot-Borgen  compared the prevalence of the triad among athletes with that of a nonathletic control group in a three-phase study design. In phase one, all athletes (n = 930) and all controls (n = 900) completed a detailed menstrual, weight, diet history, eating, and activity patterns questionnaire, which also included body dissatisfaction and drive for thinness subscales of the Eating Disorder Inventory (Garner et al, 1983). Based on data from phase one, a random sample of 300 athletes and 300 controls was selected and invited to complete a BMD test (phase two) and a clinical interview to ascertain eating disorder and disordered eating prevalence (phase three). A total of 186 athletes and 145 controls completed all three phases of the study, and of these, just 3 athletes and 3 controls presented with the full-blown triad. Compared with controls, a significantly greater percentage of athletes showed disordered eating and menstrual dysfunction (3.4% versus 10.8%; P < .01), whereas the opposite was found for menstrual dysfunction combined with low BMD (2.2% athletes versus 6.9% controls; P < .05).
These prevalence studies indicate that the number of athletes with all three disorders of the triad simultaneously is relatively small. Nonetheless, from a health and performance perspective, any occurrence, no matter how small, deserves attention. The percentage of athletes in all three studies with disordered eating and menstrual dysfunction was substantial and warrants concern. The finding that fewer female athletes have low BMD should not be surprising. First, as described in greater detail later, exercise, particularly that of a high-impact or bone-loading nature, has been shown to provide a protective effect on bone even under conditions of menstrual dysfunction or disordered eating [12-15]. Second, declines in BMD, particularly in the age groups of the female athletes routinely studied (ie, 13-25 years), can take a substantial amount of time to become apparent. Finally, research suggests that BMD may not be the best measure of bone ''health,'' thus, currently available research may not accurately reflect the impact of disordered eating or menstrual dysfunction on bone health.
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