Male Athlete Triad
Sports participation usually offers numerous health benefits to individuals irrespective of gender. But, a subset of the population can also experience adverse effects of sports participation, for example, female athlete triad. The female athlete triad is one of the common syndromes in sports affecting girls and young women. By definition, the female athlete triad is described as a syndrome of three interrelated conditions which include low energy availability (with or without disordered eating), menstrual dysfunction, and low body mass index.
The first publication that identified the Female Athlete Triad in 1992 , also mentioned that some attention should be given to male athletes to determine if a similar model result from the poor energetic status was also apparent in male athletes. In 2019, the Female Athlete Triad Coalition renamed the organization the Female and Male Athlete Triad Coalition to refect upon a similar condition with symptoms including bone stress injuries with a combination of low energy availability, low BMD, and hypogonadotropic hypogonadism, which suggestively is described as male athlete triad parallel to female athlete triad.
Low Energy Availability
Generally, athletes display higher rates of eating disorders as compared to the general population, and eating disorders are more common among those competing in leanness-dependent and weight-dependent sports. However, it is quite notable that across all sport types, the prevalence of male athletes identified as at-risk for an eating disorder, and those with diagnosed eating disorders are lower than female athletes.
Similar to women, low energy availability may have an etiology related to poor eating behaviors, including disordered eating or clinically significant eating disorders. The worrisome symptoms of low energy availability in male athletes are its effects on the hypothalamic-pituitary-gonadal (HPG) axis and on bone health.
Eating Disorders and Disordered Eating
It is reported that since societal and cultural body ideals differ between men and women, it is likely that disordered eating behaviors may differ as well.
The disordered eating behaviors most commonly studied for female athlete triad include high cognitive dietary restraint as measured by the Three-Factor Eating Questionnaire, and high drive for thinness, as measured by the Eating Disorders Inventory, both of which have often been used as measures of energy deficiency and screening tools to identify women at-risk for triad-related conditions. However, there very little information currently available on how cognitive restraint and drive for thinness relates to disordered eating and energy deficiency in exercising men. Drive for thinness, has been applied to both sexes, and, generally, men tend to have a lower drive for thinness subscale scores than women, a report indicates.
It is also suggestive that entirely different subscales may be necessary for the identification of disordered eating behaviors in exercising men. One such tool is the Drive for Muscularity Scale, which represents one’s perception that they are not muscular enough. It was developed and validated by McCreary and Sasse. It can be a valuable screening tool for identifying men at risk of developing eating disorders or disordered eating behaviors.
An interaction between thinness and muscularity in the development of disordered eating (“drive for leanness”), may be relevant to a triad-like condition in men. The mesomorphic body type, which is a combination of muscular and thin, could be most relevant in the development of disordered eating in men.
Summarizing, additional work must be conducted to better understand disordered eating behaviors in men, especially those that are related to restrictive eating patterns and therefore likely contribute to the development of low energy availability.
Due to the absence of an overt clinical sign, such as changes in menstrual cycle frequency, reproductive suppression is more difficult to assess in men than in women. But male sexual function has been related to testosterone concentration and changes in libido is a helpful indicator to identify reproductive suppression secondary to energy deficiency in exercising men. Clinical symptoms of male reproductive dysfunction are few, and evaluation may require sperm and fertility analysis. Cross-sectional reports of hypogonadotropic hypogonadism have been reported in male athletes, particularly in those who participate in endurance sports, and also include evidence of low testosterone, oligospermia, and low libido. Studies suggest that the metabolic and reproductive perturbations observed in men can be recovered by following a reduction in exercise or increased caloric intake.
Low Body Mass Index
Irrespective of gender both men and women must accrue and maintain peak bone mass to optimize bone strength and resistance to fracture. Several factors inﬂuence bone metabolism. Genetics is the strongest factor, although behavioral and environmental inﬂuences, such as diet and exercise, also play a signiﬁcant role. Due to the osteogenic effect of loading forces exerted to the bone during exercise, participation in sports that involve high-impact and multidirectional loading activities promote increased bone mineralization during development, and athletes typically exhibit higher than normal levels of bone mass than non-athlete. Although a representative prevalence of low BMD in male athletics is unknown, current research suggests that the subset of athletes with the highest prevalence of impaired bone health appears to be those participating in endurance and weight-class sports. Evidence suggests that particular subsets of male athletes, such as male distance runners, who are at high risk for having low energy availability are also reported to have low BMD scores and a high prevalence of bone stress injuries .
There is an increasing body of evidence available to date that points to a triad-like syndrome in male athletes, although additional studies are required to fully understand the effects of low energy availability exercising men. The strongest support, for a triad-like syndrome in exercising men, is:
- a higher prevalence of eating disorders and disordered eating behaviors in male athletes, particularly in those who participate in lean sports 
- reproductive suppression - decreased testosterone concentration
- reduced LH pulsatility following periods of energy deficiency and reversal upon increased caloric intake 
- the association of high training volumes with low libido , poor semen quality, and low testosterone 
- low BMD and increased risk of BSI 
- Otis CL, Drinkwater B, Johnson M, Loucks A, Wilmore J. American College of Sports Medicine position stand. The female athlete triad. Medicine and Science in Sports and Exercise. 1997 May 1;29(5):i-x.
- Tenforde AS, Barrack MT, Nattiv A, Fredericson M.Parallels with the Female Athlete Triad in Male Athletes. Journal of Sports Medicine. Review Article 10.1007/s40279-015-0411-y.
- Sundgot-Borgen J, Torstveit MK. Prevalence of eating disorders in elite athletes is higher than in the general population. Clinical journal of sport medicine. 2004 Jan 1;14(1):25-32.
- Murray SB, Nagata JM, Griffiths S, Calzo JP, Brown TA, Mitchison D, Blashill AJ, Mond JM. The enigma of male eating disorders: A critical review and synthesis. Clinical Psychology Review. 2017 Nov 1;57:1-1.
- Scheid JL, Williams NI, West SL, VanHeest JL, De Souza MJ. Elevated PYY is associated with energy deficiency and indices of subclinical disordered eating in exercising women with hypothalamic amenorrhea. Appetite. 2009 Feb 1;52(1):184-92.
- Stunkard AJ, Messick S. The three-factor eating questionnaire to measure dietary restraint, disinhibition and hunger. Journal of psychosomatic research. 1985 Jan 1;29(1):71-83.
- De Souza MJ, Hontscharuk R, Olmsted M, Kerr G, Williams NI. Drive for thinness score is a proxy indicator of energy deficiency in exercising women. Appetite. 2007 May 1;48(3):359-67.
- Garner DM, Olmstead MP, Polivy J. Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. International journal of eating disorders. 1983 Mar;2(2):15-34.
- Smith KE, Mason TB, Murray SB, Griffiths S, Leonard RC, Wetterneck CT, Smith BE, Farrell NR, Riemann BC, Lavender JM. Male clinical norms and sex differences on the Eating Disorder Inventory (EDI) and Eating Disorder Examination Questionnaire (EDE‐Q). International Journal of Eating Disorders. 2017 Jul;50(7):769-75.
- McCreary DR, Sasse DK. An exploration of the drive for muscularity in adolescent boys and girls. Journal of American college health. 2000 May 1;48(6):297-304.
- Klimek P, Murray SB, Brown T, Gonzales IV M, Blashill AJ. Thinness and muscularity internalization: Associations with disordered eating and muscle dysmorphia in men. International Journal of Eating Disorders. 2018 Apr;51(4):352-7.
- Wheeler GD, Wall SR, Belcastro AN, Cumming DC. Reduced serum testosterone and prolactin levels in male distance runners. Jama. 1984 Jul 27;252(4):514-6.
- De Souza MJ, Miller BE. The effect of endurance training on reproductive function in male runners. Sports Medicine. 1997 Jun 1;23(6):357-74.
- Zekarias K, Shrestha RT. Role of Relative Malnutrition in Exercise Hypogonadal Male Condition. Medicine and science in sports and exercise. 2019 Feb 1;51(2):234-6.
- TENFORDE A, SAYRES L, McCURDY MA, SAINANI K, Fredericson M. Identifying sex-specific risk factors for stress fractures in adolescent runners. Medicine & Science in Sports & Exercise. 2013 Oct;45(10):1843-51.
- Friedl KE, Moore RJ, Hoyt RW, Marchitelli LJ, Martinez-Lopez LE, Askew EW. Endocrine markers of semistarvation in healthy lean men in a multistressor environment. Journal of Applied Physiology. 2000 May 1.