Best practice recommendations for body composition considerations in sport to reduce health and performance risks: a critical review, original survey and expert opinion by a subgroup of the IOC consensus on Relative Energy Deficiency in Sport (REDs).

BACKGROUND: The assessment of body composition (BC) in sport raises concern for athlete health, especially where an overfocus on being lighter or leaner increases the risk of Relative Energy Deficiency in Sport (REDs) and disordered eating. METHODS: We undertook a critical review of the effect of BC on performance (29 longitudinal, prospective or intervention studies) and explored current practice related to BC considerations via a follow-up to a 2013 internationally distributed survey. RESULTS: The review found that a higher level of body fat was negatively associated with endurance performance, while a gain in muscle mass resulted in performance benefits across sports. BC did not contribute to early talent identification, and no unique cut-off to signify a performance advantage for BC was identified. BC appears to be one of an array of variables impacting performance, and its influence should not be overstated. The survey (125 practitioners, 61 sports and 26 countries) showed subtle changes in BC considerations over time, such as an increased role for sport dietitian/nutrition practitioners as BC measurers (2013: 54%, 2022: 78%); less emphasis on reporting of body fat percentage (2013: 68%, 2022: 46%) and reduced frequency of BC assessment if ≥every fourth week (2013: 18%, 2022: 5%). Respondents remained concerned about a problematic focus on BC (2013: 69%, 2022: 78%). To address these findings, we provide detailed recommendations for BC considerations, including an overview of preferable BC methodology. CONCLUSIONS: The 'best practice' guidelines stress the importance of a multidisciplinary athlete health and performance team, and the treatment of BC data as confidential medical information. The guidelines provide a health focus around BC, aiming to reduce the associated burden of disordered eating, problematic low energy availability and REDs.

Sustainable food systems and diets in dietetic training standards: an international content analysis.

BACKGROUND: Low professional confidence and perceived competence create tangible barriers to integrating sustainable food systems (SFS) and diets into dietetic practice. One opportunity to facilitate more systemic integration into dietetic education and training is to include these concepts in professional standards. To better understand the barrier of low professional confidence and perceived competence for engagement with SFS-related practice, the purpose of this research was to investigate dietetic training standards for SFS content and to highlight opportunities for growth within the profession. Questions posed by this research are: (1) how, if at all, are SFS and diets articulated in dietetic training standards, and (2) to what level of cognitive complexity? METHODS: A content analysis of dietetic training standards documents was conducted between 15 April and 15 September 2021. Search terms included 'sustain*' or 'sustainable', 'food systems' and/or 'diets'. Extracted data with applicable SFS content were analysed for level of cognitive complexity requirements. RESULTS: Of 47 National Dietetics Associations, researchers obtained 23 dietetic training standards documents, of which 16 included SFS-related content. The majority of documents used broad descriptors of the concepts, with little granularity and at a lower level of cognitive complexity. CONCLUSIONS: Adoption of more robust frameworks for sustainability with specific learning outcomes that can be adapted to regional contexts would strengthen higher education curricula and thus the profession's ability to contribute more meaningfully to SFSs and diets.

The Environmental Impact of the Athlete's Plate Nutrition Education Tool.

Periodized nutrition is necessary to optimize training and enhance performance through the season. The Athlete's Plate (AP) is a nutrition education tool developed to teach athletes how to design their plates depending on training load (e.g., volume × intensity), from easy (E), moderate (M) to hard (H). The AP was validated, confirming its recommendations according to international sports nutrition guidelines. However, the AP had significantly higher protein content than recommended (up to 2.9 ± 0.5 g·kg-1·d-1; p < 0.001 for H male). The aim of this study was to quantify the environmental impact (EnvI) of the AP and to evaluate the influence of meal type, training load, sex and registered dietitian (RD). The nutritional contents of 216 APs created by 12 sport RDs were evaluated using Computrition Software (Hospitality Suite, v. 18.1, Chatsworth, CA, USA). The EnvI of the AP was analyzed by life cycle assessment (LCA) expressed by the total amount of food on the AP, kg, and kcal, according to the Swiss Agricultural Life Cycle Assessment (SALCA) methodology. Higher EnvI is directly associated with higher training load when the total amount of food on the plate is considered for E (5.7 ± 2.9 kg CO2 eq/day); M (6.4 ± 1.5 kg CO2 eq/day); and H (8.0 ± 2.1 kg CO2 eq/day). Global warming potential, exergy and eutrophication are driven by animal protein and mainly beef, while ecotoxicity is influenced by vegetable content on the AP. The EnvI is influenced by the amount of food, training load and sex. This study is the first to report the degree of EnvI in sports nutrition. These results not only raise the need for sustainability education in sports nutrition in general, but also the urgency to modify the AP nutrition education tool to ensure sports nutrition recommendations are met, while not compromising the environment.

Sustainable Diets for Athletes.

PURPOSE OF REVIEW: Sustainable production and healthy consumption have been the topic of recent publications. Due to the high environmental impact of the current food system, significant changes in how food is produced, distributed, and consumed are needed in all sectors and groups. While most research in sustainable diets has focused on the general population, limited work has involved athletes. The purpose of this review is to summarize the current knowledge on food and sustainability in athletes. RECENT FINDINGS: Meeting but not exceeding protein requirements through flexitarian and plant-based approaches, reducing packaged foods and food waste, and prioritizing seasonal produce were identified as possible mitigation options in athletes. There is urgency for more research on plant-centric, whole food-based strategies for post-exercise skeletal muscle and training adaptation, the effect of sustainable diets on health and performance, and behaviors to reduce packaging and food waste in athletes.

Relative Body Weight and Standardised Brightness-Mode Ultrasound Measurement of Subcutaneous Fat in Athletes: An International Multicentre Reliability Study, Under the Auspices of the IOC Medical Commission.

INTRODUCTION: Fat is a metabolic fuel, but excess body fat is ballast mass, and therefore, many elite athletes reduce body fat to dangerously low levels. Uncompressed subcutaneous adipose tissue (SAT) thickness measured by brightness-mode ultrasound (US) provides an estimate of body fat content. METHODS: The accuracy for determining tissue borders is about 0.1-0.2 mm and reliability (experienced measurers) was within ± 1.4 mm (95% limit of agreement, LOA). We present here inter- and intra-measurer scores of three experienced US measurers from each of the centres C1 and C2, and of three novice measurers from each of the centres C3-C5. Each of the five centres measured 16 competitive adult athletes of national or international level, except for one centre where the number was 12. The following sports were included: artistic gymnastics, judo, pentathlon, power lifting, rowing, kayak, soccer, tennis, rugby, basketball, field hockey, water polo, volleyball, American football, triathlon, swimming, cycling, long-distance running, mid-distance running, hurdles, cross-country skiing, snowboarding, and ice hockey. SAT contour was detected semi-automatically: typically, 100 thicknesses of SAT at a given site (i.e., in a given image), with and without fibrous structures, were measured. RESULTS: At SAT thickness sums DI (of eight standardised sites) between 6.0 and 70.0 mm, the LOA of experienced measurers was 1.2 mm, and the intra-class correlation coefficient ICC was 0.998; novice measurers: 3.1 mm and 0.988. Intra-measurer differences were similar. The median DI value of all 39 female participants was 51 mm (11% fibrous structures) compared to 17 mm (18%) in the 37 male participants. DISCUSSION: DI measurement accuracy and precision enables detection of fat mass changes of approximately 0.2 kg. Such reliability has not been reached with any other method. Although females' median body mass index and mass index were lower than those of males, females' median DI was three times higher, and their percentage of fibrous structures was lower. The standardised US method provides a highly accurate and reliable tool for measuring SAT and thus changes in body fat, but training of measurers is important.

Validation of the Athlete's Plate Nutrition Educational Tool: Phase I.

Nutrition education visual tools are designed to help the general population translate science into practice. The purpose of this study was to validate the Athlete's Plate (AP) to ensure that it meets the current sport nutrition recommendations for athletes. Twelve registered dietitians (RDs; 10 female and 2 male) volunteered for the study. Each registered dietitian was asked to create three real and virtual plates at three different times corresponding to breakfast, lunch, and dinner, and the three different AP training loads, easy (E), moderate (M), and hard (H), divided into two weight categories (male 75 kg and female 60 kg). Data of the real and virtual plates were evaluated using Computrition software (v. 18.1; Computrition, Chatsworth, CA). Statistical analyses were conducted by SPSS (version 23.0; IBM, Armonk, NY) to compare the difference between each training load category (E, M, and H) and the recommendations. No statistically significant differences were found among the created plates and the recommendations for energy, carbohydrates, fat, and fiber for E, M, and H. Protein relative to body mass (BM) was higher than recommended for E (1.9 ± 0.3 g·kg-1 BM·day-1, p = .003), M (2.3 ± 0.3 g·kg-1 BM·day-1, p < .001), and H (2.9+0.5 g·kg-1 BM·day-1, p < .001). No differences were found for the macronutrient distribution by gender when correcting for kilograms of body mass. The authors conclude that the AP meets the nutrition recommendations for athletes at different training intensities for energy, carbohydrates, fat, and fiber, but exceeds the recommendations for protein. Further research should consider this protein discrepancy and develop an AP model that meets, besides health and performance goals, contemporary guidelines for sustainability.

Subcutaneous fat patterning in athletes: selection of appropriate sites and standardisation of a novel ultrasound measurement technique: ad hoc working group on body composition, health and performance, under the auspices of the IOC Medical Commission.

BACKGROUND: Precise and accurate field methods for body composition analyses in athletes are needed urgently. AIM: Standardisation of a novel ultrasound (US) technique for accurate and reliable measurement of subcutaneous adipose tissue (SAT). METHODS: Three observers captured US images of uncompressed SAT in 12 athletes and applied a semiautomatic evaluation algorithm for multiple SAT measurements. RESULTS: Eight new sites are recommended: upper abdomen, lower abdomen, erector spinae, distal triceps, brachioradialis, lateral thigh, front thigh, medial calf. Obtainable accuracy was 0.2 mm (18 MHz probe; speed of sound: 1450 m/s). Reliability of SAT thickness sums (N=36): R(2)=0.998, SEE=0.55 mm, ICC (95% CI) 0.998 (0.994 to 0.999); observer differences from their mean: 95% of the SAT thickness sums were within ± 1 mm (sums of SAT thicknesses ranged from 10 to 50 mm). Embedded fibrous tissues were also measured. CONCLUSIONS: A minimum of eight sites is suggested to accommodate inter-individual differences in SAT patterning. All sites overlie muscle with a clearly visible fascia, which eases the acquisition of clear images and the marking of these sites takes only a few minutes. This US method reaches the fundamental accuracy and precision limits for SAT measurements given by tissue plasticity and furrowed borders, provided the measurers are trained appropriately.

Energy Availability and Dietary Patterns of Adult Male and Female Competitive Cyclists With Lower Than Expected Bone Mineral Density.

The purpose of this study was to assess energy availability (EA) and dietary patterns of 10 adult (29-49 years) male (n = 6) and female (n = 4) competitive (USA Cycling Category: Pro, n = 2; 1-4, n = 8) endurance cyclists (5 road, 5 off-road), with lower than expected bone mineral density (BMD; Z score < 0) across a season. Energy intake (EI) and exercise energy expenditure during preseason (PS), competition (C), and off-season (OS) were estimated from 3-day dietary records, completed once per month, across a cycling season. BMD was measured by DXA at 0 months/5 months/10 months. The Three-Factor Eating Questionnaire (TFEQ) was used to assess cognitive dietary restraint. Seventy percent of participants had low EA [(LEA); < 30 kcal · kg fat-free mass (FFM) (-1) · day(-1)] during PS, 90% during C, and 80% during OS (range: 3-37 kcal · kg FFM(-1) · day(-1)). Ninety percent of cyclists had LEA during ≥ 1 training period, and 70% had LEA across the season. Seventy percent of cyclists were identified as restrained eaters who consciously restrict EI as a means of weight control. Mean daily carbohydrate intake was below sport nutrition recommendations during each training period (PS: 3.9 ± 1.1 g · kg(-1) · day(-1), p < .001; C: 4.3 ± 1.4 g · kg(-1) · day(-1), p = .005; OS: 3.7 ± 1.4 g · kg(-1) · day(-1), p = .01). There were no differences in EA and EI · kg(-1) between male and female cyclists and road and off-road cyclists. Low EI, and specifically low carbohydrate intake, appears to be the main contributor to chronic LEA in these cyclists. Adult male and female competitive road and off-road cyclists in the United States may be at risk for long-term LEA. Further studies are needed to explore strategies to prevent and monitor long-term LEA in these athletes.

Evaluation of food provision and nutrition support at the London 2012 Olympic Games: the opinion of sports nutrition experts.

The aim of this study was to evaluate the food provision and nutrition support at the London 2012 Olympic (OG) and Paralympic Games (PG) from the perspective of sports nutrition experts attending the event. Participants (n = 15) were asked to complete an online survey and rate on a Likert scale menu qualities, food safety, sustainability practices, nutrition labeling, and provision for cultural needs, dietary regimes and specific situations. Open-ended responses were incorporated to explore expert opinion and areas for improvement. Participants rated their overall experience of the food provision as 7.6 out of 10 (range 5 to 10), with the majority (n = 11) rating it greater than 7. The variety, accessibility, presentation, temperature, and freshness of menu items rated as average to good. A below average rating was received for recovery food and beverages, provision of food for traveling to other venues, taking suitable snacks out of the dining hall and provision of food at other venues. However, the variety and accessibility of choices for Ramadan, and provision of post-competition food were rated highly. A number of comments were received about the lack of gluten free and lower energy/fat items. The inclusion of allergens on nutrition labeling was considered more important than nutrient content. While dietetic review of the menu in advance of the OG and PG is clearly a valuable process that has resulted in improvements in the food supply, there are still areas that need to be addressed that are currently not implemented during the event.

Academy of nutrition and dietetics: revised 2014 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in sports nutrition and dietetics.

Sports nutrition and dietetics addresses relationships of nutrition with physical activity, including weight management, exercise, and physical performance. Nutrition plays a key role in the prevention and treatment of obesity and chronic disease and for maintenance of health, and the ability to engage in physical activity, sports, and other aspects of physical performance. Thus, the Sports, Cardiovascular, and Wellness Nutrition Dietetic Practice Group, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, has developed the Revised 2014 Standards of Practice and Standards of Professional Performance as a resource for Registered Dietitian Nutritionists working in sports nutrition and dietetics to assess their current skill levels and to identify areas for further professional development in this emerging practice area. The revised document reflects advances in sports nutrition and dietetics practice since the original standards were published in 2009 and replaces those standards. The Standards of Practice represents the four steps in the Nutrition Care Process as applied to the care of patients/clients. The Standards of Professional Performance covers six standards of professional performance: quality in practice, competence and accountability, provision of services, application of research, communication and application of knowledge, and utilization and management of resources. Within each standard, specific indicators provide measurable action statements that illustrate how the standards can be applied to practice. The indicators describe three skill levels (competent, proficient, and expert) for Registered Dietitian Nutritionists working in sports nutrition and dietetics. The Standards of Practice and Standards of Professional Performance are complementary resources for Registered Dietitian Nutritionists in sports nutrition and dietetics practice.

How to minimise the health risks to athletes who compete in weight-sensitive sports review and position statement on behalf of the Ad Hoc Research Working Group on Body Composition, Health and Performance, under the auspices of the IOC Medical Commission.

A focus on low body weight and body fat content, combined with regulations in some weight-sensitive sports, are considered risk factors for extreme dieting, eating disorders (EDs) and related health consequences among athletes. At present there are, from a health perspective, no generally accepted optimum values for body weight or percentage of fat mass in different sports and there is no 'gold standard' method for body composition assessment in athletes. On the basis of health considerations as well as performance, medical support teams should know how to approach elite athletes who seek to achieve an unrealistic body composition and how to prevent restrictive eating practices from developing into an ED. In addition, these teams must know when to raise the alarm and how to advice athletes who are affected by extreme dieting or clinical EDs. However, there is no consensus on when athletes struggling with extreme dieting or EDs should be referred for specialist medical treatment or removed from competition. Based on the present review, we conclude that there is a need for (1) sport-specific and gender-specific preventive programmes, (2) criteria for raising alarm and 'does not start' (DNS) for athletes with EDs and (3) modifications to the regulations in some sports. Further, the key areas for research identified include the development of standard methods for body composition assessment in elite athletes; screening measures for EDs among athletes; development and testing of prevention programmes; investigating the short and long-term effects of extreme dieting; and EDs on health and performance.

Body composition for health and performance: a survey of body composition assessment practice carried out by the Ad Hoc Research Working Group on Body Composition, Health and Performance under the auspices of the IOC Medical Commission.

BACKGROUND: Successful performers in weight-sensitive sports are characterised by low body mass (BM) and fat content. This often requires chronic energy restriction and acute weight loss practices. AIM: To evaluate current use of body composition (BC) assessment methods and identify problems and solutions with current BC approaches. METHODS: A 40-item survey was developed, including demographic and content questions related to BC assessment. The survey was electronically distributed among international sporting organisations. Frequencies and χ(2) analyses were computed. RESULTS: 216 responses were received, from 33 countries, representing various institutions, sports and competitive levels. Of the sample, 86% of respondents currently assess BC, most frequently using skinfolds (International Society for the Advancement of Kinanthropometry (ISAK): 50%; non-ISAK, conventional: 40%; both: 28%), dual energy X-ray absorptiometry (38%), bioelectrical impedance (29%), air displacement plethysmography (17%) and hydrostatic weighing (10%). Of those using skinfolds, more at the international level used ISAK, whereas conventional approaches were more reported at regional/national level (p=0.006). The sport dietitian/nutritionist (57%) and physiologist/sports scientist (54%) were most frequently the professionals assessing BC, followed by MDs and athletic trainers, with some reporting coaches (5%). 36% of 116 respondents assessed hydration status and more (64%) did so at international than regional/national level (36%, p=0.028). Of 125 participants answering the question of whether they thought that BC assessment raised problems, 69% said 'yes', with most providing ideas for solutions. CONCLUSIONS: Results show high use of BC assessment but also a lack of standardisation and widespread perception of problems related to BM and BC in sport. Future work should emphasise standardisation with appropriate training opportunities and more research on BC and performance.

Body composition in sport: interobserver reliability of a novel ultrasound measure of subcutaneous fat tissue.

BACKGROUND: Very low body mass, extreme mass changes, and extremely low per cent body fat are becoming increasingly common in many sports, but sufficiently reliable and accurate field methods for body composition assessment in athletes are missing. METHODS: Nineteen female athletes were investigated (mean (SD) age: 19.5 (± 3.3) years; body mass: 59.6 (± 7.6) kg; height: 1.674 (± 0.056) m; BMI: 21.3 (± 2.3) kg/m(2)). Three observers applied diagnostic B-mode-ultrasound (US) combined with the evaluation software for subcutaneous adipose tissue measurements at eight ISAK sites (International Society for the Advancement of Kinanthrometry). Regression and reliability analyses are presented. RESULTS: US measurements and evaluation of subcutaneous adipose tissue (SAT) thicknesses (including fibrous structures: D(included); n=378) resulted in an SE of estimate SEE=0.60 mm, R(2)=0.98 (p<0.001), limit of agreement LOA=1.18, ICC=0.968 (0.957-0.977). Similar values were found for D(excluded): SEE=0.68 mm, R(2)=0.97 (p<0.001). D(included) at individual ISAK sites: at biceps, R(2)=0.87 and intraclass-correlation coefficient ICC=0.811 were lowest and SEE=0.79 mm was highest. Values at all other sites ranged from R(2): 0.94-0.99, SEE: 0.42-0.65 mm, and ICC: 0.917-0.985. Interobserver coefficients ranged from 0.92 to 0.99, except for biceps (0.74, 0.83 and 0.87). Evaluations of 20 randomly selected US images by three observers (D(included)) resulted in: SEE=0.15 mm, R(2)=0.998(p<0.001), ICC=0.997 (0.993, 0999). CONCLUSIONS: Subject to optimal choice of sites and certain standardisations, US can offer a highly reliable field method for measurement of uncompressed thickness of the SAT. High accuracy and high reliability of measurement, as obtained with this US approach, are essential for protection of the athlete's health and also for optimising performance.

National Nutritional Programs for the 2012 London Olympic Games: a systematic approach by three different countries.

Preparing a national team for success at major sporting competitions such as the Olympic Games has become a systematic and multi-faceted activity. Sports nutrition contributes to this success via strategic nutritional interventions that optimize the outcomes from both the training process and the competitive event. This review summarizes the National Nutrition Programs involved with the 2012 London Olympic Games preparation of the Australian, British and American sports systems from the viewpoints of three key agencies: the Australian Institute of Sport, the English Institute of Sport and the United States Olympic Committee. Aspects include development of a nutrition network involving appropriately qualified sports dietitians/nutritionists within a multi-disciplinary team, recognition of continual updates in sports nutrition knowledge, and a systematic approach to service delivery, education and research within the athlete's daily training environment. Issues of clinical nutrition support must often be integrated into the performance nutrition matrix. Food service plays an important role in the achievement of nutrition goals during the Olympic Games, both through the efforts of the Athlete Dining Hall and catering activities of the host Olympic Games Organizing Committees as well as adjunct facilities often provided by National Olympic Committees for their own athletes.

Current status of body composition assessment in sport: review and position statement on behalf of the ad hoc research working group on body composition health and performance, under the auspices of the I.O.C. Medical Commission.

Quantifying human body composition has played an important role in monitoring all athlete performance and training regimens, but especially so in gravitational, weight class and aesthetic sports wherein the tissue composition of the body profoundly affects performance or adjudication. Over the past century, a myriad of techniques and equations have been proposed, but all have some inherent problems, whether in measurement methodology or in the assumptions they make. To date, there is no universally applicable criterion or 'gold standard' methodology for body composition assessment. Having considered issues of accuracy, repeatability and utility, the multi-component model might be employed as a performance or selection criterion, provided the selected model accounts for variability in the density of fat-free mass in its computation. However, when profiling change in interventions, single methods whose raw data are surrogates for body composition (with the notable exception of the body mass index) remain useful.

Can alternating lower body negative and positive pressure during exercise alter regional body fat distribution or skin appearance?

The purpose of this study was to determine whether physical activity, with and without lower body pressure, leads to increased regional fat loss in the lower extremities of overweight females. Eighty-six obese women with a female phenotype were randomly assigned into four groups: control group (C), diet only (D), diet plus exercise (DE) or diet, exercise and lower body pressure intervention (DEP). The three treatment groups followed the same diet, the two exercise groups (DE and DEP) additionally followed an endurance training program of 30 min of cycling at 50%VO(2)max three times per week with or without lower body pressure. Body composition and fat distribution were assessed by DXA. Body size circumference measurements were recorded as well as subjective ratings of cellulite and skin appearance. As expected, all test groups (D, DE, DEP) showed a significant decrease (p < 0.05) in total body mass and fat mass. DXA revealed significant differences between the experimental groups and C. The DEP group also lost significantly more body mass and fat mass when compared with D, while no significant difference was observed between the other groups. A similar pattern was seen for circumference measurement data. A significant perceived improvement was made by the DEP group when compared with C, D and DE groups for skin condition and also between the DEP versus C and D groups for cellulite. The combination of diet and exercise is successful for weight reduction. The additional application of lower body pressure especially affects skin appearance.

Nutrition for winter sports.

Winter sports are played in cold conditions on ice or snow and often at moderate to high altitude. The most important nutritional challenges for winter sport athletes exposed to environmental extremes include increased energy expenditure, accelerated muscle and liver glycogen utilization, exacerbated fluid loss, and increased iron turnover. Winter sports, however, vary greatly regarding their nutritional requirements due to variable physiological and physique characteristics, energy and substrate demands, and environmental training and competition conditions. What most winter sport athletes have in common is a relatively lean physique and high-intensity training periods, thus they require greater energy and nutrient intakes, along with adequate food and fluid before, during, and after training. Event fuelling is most challenging for cross-country skiers competing in long events, ski jumpers aiming to reduce their body weight, and those winter sport athletes incurring repeated qualification rounds and heats. These athletes need to ensure carbohydrate availability throughout competition. Finally, winter sport athletes may benefit from dietary and sport supplements; however, attention should be paid to safety and efficacy if supplementation is considered.

Female athlete triad update.

The passage of Title IX legislation in 1972 provided enormous opportunities for women to reap the benefits of sports participation. For most female athletes, sports participation is a positive experience, providing improved physical fitness, enhanced self-esteem, and better physical and mental health. Nonetheless, for a few female athletes, the desire for athletic success combined with the pressure to achieve a prescribed body weight may lead to the development of a triad of medical disorders including disordered eating, menstrual dysfunction, and low bone mineral density (BMD)--known collectively as the female athlete triad. Alone or in combination, the disorders of the triad can have a negative impact on health and impair athletic performance.