Content notice: eating disorders.

“Have you ever heard of the Female Athlete Triad?”

I know what my new doctor’s about to say as soon as I hear the words “female athlete.” Having struggled with the ghosts of an eating disorder throughout my twelve-year running history, I get asked if I’m aware of the world’s best-named collection of ailments at least once a year by medical professionals. I’m quick to cut them off––it’s embarrassing for me that they’d even suggest it, since I’m not as thin as I feel I should be to even invite the possibility.

“Yup, no, I’m fine––I haven’t been underweight since I was a teenager. I had an eating disorder, and I got treated for it, and no problems since then, and I eat enough, and my weight is in the normal range,” I recite with boredom, ready to move on to a relevant topic and just a little annoyed that with my winter clothes on I was 5 pounds heavier on the doctor’s scale than my actual weight.

My doctor blinks a couple of times before responding. It’s the same expression I’m pretty sure I have on my face when someone asks me to recommend a “sweet dry wine.”

“Yeah, ok, you don’t know what the Female Athlete Triad is.”

I’m startled. She goes on. “The Female Athlete Triad has nothing to do with being thin. It’s about not eating enough calories to sustain your activity level.”

Now I’m just confused. “Wouldn’t I be… losing weight? If that was the case?”

“Nope. You’d be getting injured a lot.” She’s been eyeing my chart, on which for the first time in my life I listed the last five years of my medical history in one place: arthroscopic surgery for shoulder tear. Severe fingernail breaks, one way too gnarly to recount here but requiring emergency treatment. Shin splints (ten years into running, not as a newbie). Two stress fractures in the last two years (my first and favorite one, Tibia 2011, is pictured above).

“Have you ever wondered why you keep getting all these sports injuries? Your body is breaking down bone and muscle tissue to compensate for a calorie deficit. That’s why you’re not losing fat. What do you eat, 1600 calories a day?” I nod slowly, creeped out that she guessed accurately, and halfheartedly offer that I’m just following MyFitnessPal’s recommendations. “Well, I don’t know what your little ‘fitty thing’ is telling you, but you probably have the metabolism of an inactive 70-year-old.”

Well then. I thought of my last several years of training: martial arts, three marathon seasons, several half marathons. Nearly every year I’ve gotten sidelined with an injury, always two steps back to ruin my progress despite taking rest days, following training plans from expert sources, and cross training for strength. I always just wrote it off as “injury proneness” or “bad luck.” The knowledge that it might be my fault was horrifying.

When my doctor informed me that I needed to be eating much, much more than I currently am, I found myself on the verge of a panic attack. She told me of her days as a young athlete (her background is in sports medicine, which is why I requested her as a primary-care physician; the fact that she’s kind of an awesome smartass was a bonus) dealing with frequent injuries. A nutritionist advised her to bump her diet to double her current intake. “I was sure I’d gain weight, but instead, I got healthier, and stopped getting injured,” she told me. “You need to see a nutritionist.” [EDIT: Though it’s common to use the terms “nutritionist” and “dietician” interchangeably, or use “nutritionist” as an umbrella term, they are not the same; I will be seeing a registered dietician with approved medical credentials. Thanks to those who reminded me of this important point.]

I’ll be seeing one a week from today, and I’m terrified. Here I am, unable to run or ride my bike for 12 weeks due to an unhealed stress fracture and bone edema (swelling) that’s making my hip feel like someone’s drilling a hole in it after just a mile or two. Six months ago I was running 40-50 miles a week and biking everywhere. I was considering training for an Ironman. Now, just a short walk to the bus stop is all I can manage.

How much fitness would I lose? How would I keep from losing total control of my life––control that, I realized, has always revolved around food? What the hell was I supposed to eat now that I was inactive? And how could I stop this from happening again? Filled with trepidation, I retreated to the traditional anxiety coping mechanism of obsessive Googling.

For starters, my doctor was right. (A note here: The literature I found on this topic addresses people who menstruate, which, of course, doesn’t include all women and includes people who don’t identify as women; I did find this helpful information on osteoporosis risks for trans* people taking hormone replacement.) The Female Athlete Triad doesn’t necessarily present as severe thinness, and that misconception is a dangerous one: just as people who don’t fit the eating disorder “mold” (deathly thin, female) can easily go untreated or even be denied treatment coverage and suffer severe consequences, people who don’t fit that mold can suffer the consequences of the Triad simply because their bodies are scrounging extra fuel from their bone and muscle tissue rather than causing them to lose weight. The Triad can occur at any size and weight.

Often, and unfortunately, stress fractures are the first medical indication that something is wrong. You don’t even need to exhibit symptoms of an eating disorder––well-known symptoms like hair loss, sore throats from bingeing, and obsessive recipe collecting––for your bones to be suffering the effects of depletion. The NCAA coaches’ guidebook article on the Triad, written by Roberta Sherman, Ph.D., FAED, and Ron Thompson, Ph.D., FAED, co-chairs of the Athlete Special Interest Group of the Academy of Eating Disorders, points out, “The term “disordered eating” is used rather than eating disorders because the athlete’s eating does not have to be disordered to the point of a clinical eating disorder (i.e., anorexia nervosa or bulimia nervosa) in order for the other two components of the Female Athlete Triad — amenorrhea and osteoporosis — to occur.”

Here’s how it works: thanks in part to a mainstream culture of dieting, stick-thin stock photos (including those in the NCAA’s Triad booklet, ironically) and models in women’s fitness magazines as images of “health,” and a culture of competitiveness and pushing ones’ self to the limit within the athletic world, female athletes––especially those in sports like running and gymnastics, where thinness is typically seen as a goal––are prone to calorie restriction. This puts bone growth at a disadvantage. Low calorie and fat intake, high levels of exercise, and stress can simultaneously lead to amenorrhea, the cessation of menstrual periods. “Bone growth and health involve the opposing, but balanced, processes of bone building and bone resorption (tearing down),” says the NCAA guide. “Estrogen is necessary for the building of bone, but can be unavailable due to amenorrhea. In the absence of estrogen, loss of bone mass occurs because bone growth is decreased while resorption continues at a higher rate. At a time when the athlete should be building bone mass, she is losing it.”

Amenorrheic athletes can lose up to five percent of their bone mass in just one year, increasing the risk of stress fractures. Some of this loss is irreversible even when estrogen levels are returned to normal (oral contraceptives, which I’ve taken since my initial eating disorder treatment, may be helpful here, but more research is needed, and not everyone wants to or is able to go on the pill). And if the athlete continues to have disordered eating, inadequate vitamin D and calcium levels will prevent adequate recovery. The result? More fractures, and eventually, osteoporosis––the deterioration of bone mass and tissue to the point of fragile, easily breakable bones. If you’ve had a loved one with osteoporosis, as I have, you know how scary, painful, and debilitating this disease is.

It’s all rather frightening, and I’m angry with myself for the damage I’ve caused my body. But there are already such rampant misconceptions about eating disorders and what they look like, and I wanted to share this misunderstanding on my part because I’ve lived my adult life by the principle that I was okay as long as my weight stayed in the “healthy” range. “The focus in working with the student-athlete who is affected by DE [disordered eating] or has other symptoms of the Triad should be more on her health and nutrition, and less on her weight,” the NCAA guide recommends. “This approach has sometimes been criticized by athletes and coaches, who claim that a de-emphasis on weight is apt to result in a decrease in athletic performance. However, athletic performance is like most human behaviors; it is multidimensional and probably determined by multiple factors.” Coaches need to be aware that fatphobic or fat-shaming attitudes and pressuring athletes to lose weight are not just damaging psychologically; they could be causing them to ignore serious symptoms of health problems in their athletes, or indeed causing the problems themselves.

Part 2 of this post will go up after I talk to my nutritionist, and it will discuss steps for resolving the Triad and preventing future fractures as well as dealing with psychological barriers to increasing my calorie intake. I’m scared out of my mind. It’ll be fun!