female athlete triad

runner sillouette[source]

If you’re a female athlete you’ve probably heard of the female athlete triad – even if you didn’t know that’s what it was called. The female athlete triad is a combination of the following:

1. eating disorders or disordered eating

2. low bone mineral density

3. menstrual irregularity

There are varying degrees of each of the above and an athlete with the triad may display one condition more than another, but all three are closely related (1). Although female athletes from any sport can exhibit the triad, it is most common in sports that emphasize leanness or a low body weight for performance – gymnastics, ballet, distance running, and weight class sports.


In competitve sport environments, the pressure to perform can lead athletes to develop disordered eating behaviors. In fact, traits that make good athletes are also often the same as those the put one at risk for an eating disorder – perfectionism, high achievement orientation, and obsessive-compulsive tendencies (2,3). Disordered eating is different from a diagnosed eating disorder and can include things like avoiding certain foods/food groups, severely limiting calories to achieve a desired weight or body composition, and skipping meals. While many athletes may not meet all of the specific criteria for an eating disorder, a large number display disordered eating behaviors.

Some athletes may not even intend to alter their eating behaviors but, due to large training volumes, fail to meet their energy requirements and end up in an energy deficit, meaning they aren’t consuming enough calories to meet thier energy needs for daily life and training (4,5,6). Most websites and fitness apps do not provide reliable health and nutrition information, especially for an athlete training at a high level. Working with a sports dietitian is the best way to ensure that you’re meeting your specific energy requirements.


Whether intentional or unintentional, consuming fewer calories than your body requires forces your body to make several changes in order to survive. Processes that your body doesn’t feel are necessary for survival are essentially cut out in order to save energy for processes that are required for survival (7). This is why many female athletes struggle with menstrual irregularity or complete absence of the menstrual cycle (called amenorrhea). Reproductive function isn’t absolutely necessary for survival, so the body decides to take the energy that would usually be spent on normal menstrual function and use it elsewhere.

Although this may sound rather convenient, the hormones associated with normal menstrual function serve several other functions in the body, like normal bone and cardiovascular health (1,8). An abnormal menstrual cycle in the teens and early 20s when bones are still developing can lead to weak bones, stress fractucres, or even osteoporosis.


Hormone replacement therapy is often prescribed to athletes struggling with menstrual irregularity, but research suggests that this is not enough to overcome the hormal imbalance caused by inadequate energy intake and protect against bone loss or other detrimental effects (1, 9, 10, 11, 12, 13). The preferred method of treatment is increasing energy intake (1, 14, 15). However, for an athlete with an eating disorder, this is much easier said than done. If you or someone you know struggles with an eating disorder, seek help from medical professionals. A doctor, psychologist, and registered dietitian are all important parts of the team in helping an athlete overcome an eating disorder.

Although the main focus here is on females, male athletes can also suffer from disordered eating/eating disorders and, as a result, poor effects on their health. Recently, relative energy deficiency syndrome (RED-S) was proposed as a new way to describe the effects of not consuming enough calories to support physical activity as a way to recognize that males can suffer from the consequence of under fueling as well (16).


1. Nattiv A, Loucks A, Manore M, Sanborn C, Sundgot-Borgen J, Warren M. The female athlete triad. Med Sci Sports Exerc 39: 10: 1867-1882, 2007.

2. Thompson R, Sherman R. “Good Athlete” Traits and Characteristics of Anorexia Nervosa: Are They Similar? 7: 3: 181-190, 1999.

3. Leon G. Eating disorders in female athletes. 12: 4: 219-27, 1991.

4. Loucks A. Low energy availability in the marathon and other endurance sports. 37: 4-5: 348-52, 2007.

5. King N, Lluch A, Stubbs R, Blundell J. High dose exercise does not increase hunger or energy intake in free living males. Eur J Clin Nutr 51: 7: 478-83, 1997.

6. Hubert P, King N, Blundell J. Uncoupling the effects of energy expenditure and energy intake: appetite response to short-term energy deficit induced by meal omission and physical activity. Appetite 31: 1: 9-19, 1998.

7. Wade G, Schneider J, Li H. Control of fertility by metabolic cues. Am J Physiol -Endocrinol Metab 270: 1: E1-E19, 1996.

8. Hoch A, Dempsey R, Carrera G, Wilson C, Chen E, Barnabei V, Sandford P, Ryan T, Gutterman D. Is there an association between athletic amenorrhea and endothelial cell dysfunction? Med Sci Sports Exerc 35: 3: 377-383, 2003.

9. Cobb K, Bachrach L, Sowers M, Nieves J, Greendale G, Kent K, Brown Jr B, Pettit K, Harper D, Kelsey J. The effect of oral contraceptives on bone mass and stress fractures in female runners. Med Sci Sports Exerc 39: 9: 1464-1473, 2007.

10. Braam L, Knapen M, Geusens P, Brouns F, Vermeer C. Factors affecting bone loss in female endurance athletes – A two-year follow-up study. Am J Sports Med 31: 6: 889-895, 2003.

11. Keen A, Drinkwater B. Irreversible bone loss in former amenorrheic athletes. Osteoporosis Int 7: 4: 311-315, 1997.

12. Warren M, Brooks-Gunn J, Fox R, Holderness C, Hyle E, Hamilton W, Hamilton L. Persistent osteopenia in ballet dancers with amenorrhea and delayed menarche despite hormone therapy: a longitudinal study. Fertil Steril 80: 2: 398-404, 2003.

13. National Institutes of Health Consensus Development Panel. Osteoporosis prevention, diagnosis, and therapy. 285: 6: 785-795, 2001.

14. Arends J, Cheung M, Barrack M, Nattiv A. Restoration of Menses With Nonpharmacologic Therapy in College Athletes With Menstrual Disturbances: A 5-Year Retrospective Study. Int J Sport Nutr Exerc Metab 22: 2: 98-108, 2012.

15. Mallinson R, Williams N, Olmsted M, Scheid J, Riddle E, De Souza M. A case report of recovery of menstrual function following a nutritional intervention in two exercising women with amenorrhea of varying duration. J Int Soc Sport Nutr 10: 34, 2013.

16. Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. The IOC consensus statement: beyond the Female Athlete Triad-Relative Energy Deficiency in Sport (RED- S). Br J Sports Med 48: 7: 491-+, 2014.



This week has some great make-ahead meals. Being prepared is one of the main keys for success when you’re trying to eat healthy! Enjoy!

a great grilled veggie sandwich to make use of all those summer veggies [which could definitely be grilled ahead of time]

have a homemade mid-day pick-me-up with these strawberry chia jam bars

flourless peanut butter + chocolate chip cookies also make a healthy but sweet snack…or dessert!

why not take full advantage of the beautiful weather & grill breakfast on the weekend too? especially when it’s grilled peach french toast!

it’s never too hot for tortilla soup

kale is sturdy enough to stand up to sitting in a dressing for awhile, making it a super easy [and healthy] make ahead lunch or side salad

mango and red pepper orzo salad and green rice salad are also perfect make-ahead meals.

mango soft serve is a healthier and lower calorie alternative to ice cream. you could make it with any other fruit you like too

the summer colors in this basil chicken curry are incredible

some people don’t like the flavor of fish, but when you marinate or season it like this caribbean jerk salmon, you get an incredibly flavorful AND healthy meal



deceptive labeling

grocery b+w[source]

Going to the store with the intention of eating healthy can be a huge challenge for so many reasons, not the least of which is the huge variety of products. When you’re trying to change your eating habits and make healthier choices, it can be hard enough to walk by those cookies or chips without them “jumping” into your cart. You shouldn’t also have to navigate the confusing packaging and labeling that companies use to make their products look healthier when, in fact, they are not. Although grocery store tours with people are my favorite way to answer these questions as we go aisle-by-aisle, I’ll try to clear up some of the most confusing packaging and labeling on the shelves in this post so it’s easier to make good choices.


As I’ve mentioned before, a gluten-free diet is a very necessary part of life for someone with Celiac disease. It is currently the only treatment and consuming even small traces of gluten can cause serious damage to the intestines that can lead to nutrient deficiencies and malnutrition. However, as I’m sure you’re aware, gluten-free has become something of a fad diet in recent years. While this has dramatically increased the number and availability of gluten-free products for those who do live with Celiac, others have become convinced that these products are automatically a healthier option. In reality, gluten-free products are often highly processed and have far more ingredients than their conventional counterparts in order to achieve a similar taste and texture. This doesn’t include naturally gluten-free foods like grains (quinoa, millet, etc.), meats, fruits, and veggies, all of which are certainly healthy and just happen to be gluten-free as well. A gluten-free cookie is still a cookie. Of course, all foods can fit into a healthy, balanced diet but if you don’t have Celiac and can safely consume gluten, you aren’t getting any kind of health benefit by eating a gluten-free cookie (or other item) over a regular one.

all natural

“All natural” seems to be slapped on just about every package these days. The major thing to keep in mind is that all natural is NOT a regulated term. It can be put on pretty much any product and is often found on foods that actually contain quite a few ingredients that many wouldn’t consider “natural”. If you want a product that is truly all natural, take a look at the ingredients panel for things that you could use in your very own kitchen to prepare the same product. If you don’t recognize an ingredient or couldn’t easily buy it to use in your own kitchen, it’s probably not natural. For things like meats and eggs, it’s best to research the farm or company to see what their individual practices are for producing a product that is “natural”.



I’ve covered organic before but the main takeaway here is similar to the above points – just because a product says it is organic doesn’t mean it’s healthy. Organic just refers to the growing or production practices of the product and it’s ingredients. Organic desserts are just like regular desserts, except with organic butter, sugar, flour, etc.

green packaging

Although not a labeling term, I think this point fits in well with the previous two. Many people associate the color green with a healthy choice and food companies take advantage of this. Don’t assume that just because your frozen pizza comes in a green, “healthy-looking” box that it is a healthy choice. Healthier, less processed products often do have green packaging, but check the nutrition facts panel and ingredients list for the full story before tossing it in your cart.


low fat or fat free

These became a trend around the early 90s but these products are still around. There are a few reasons why these aren’t the best choice:

1) Fat is a huge part of the flavor and texture of many products and, when it is removed, something has to be put in it’s place or no one would want to eat it. This is often extra sugar, meaning these products are no healthier than the original version.

2) Fat is a necessary nutrient! Saturated fats should be limited and trans fats avoided due to their negative impact on heart health but unsaturated fats (found in nuts, fish, avocados, some oils) are a beneficial and necessary part of the diet. Salad dressings are a great example – salads often contain lots of vegetables with fat soluble vitamins, meaning they need fat to be absorbed. A low fat salad dressing isn’t really doing you any favors in this case!

3) Fat contributes to satiety, or feelings of fullness. When you eat a lower fat item, you’re likely to feel less satisfied afterwards and may then end up consuming more calories than you otherwise would have in an attempt to fill up.

I’ve actually seen low fat brownie mixes with far more sugar and calories than the original version! Some products are naturally low in fat or fat free and the pacakge will often claim this since people view it as a benefit. The ones you need to look out for are low fat versions of other products. I can’t think of many situations in which the lower fat version would be a better/healthier choice (except dairy!).

low calorie

Similar to above, your best bet if you’re looking for a low calorie option is to stick with foods that are naturally low in calories, like fruits and vegetables. Other products are probably highly processed and less satisfying.

hormone free

Finally, hormone free is seen on many meat and dairy products these days. While useful in some circumstances, the USDA does not allow administration of hormones to any poultry or hogs so the designation of “hormone free” on these products doesn’t really mean anything special. If you are looking for a farm or company that humanely treats their animals, it is best to check out their website and do a little homework on their practices.


lots of great veggie filled recipes this week! many would make perfect leftovers for lunches. just make a big batch of something like the easy pasta salad or chickpea and mozzarella salad, portion into individual containers, and healthy, affordable lunches will be the easy choice all week long. Enjoy!

coconut basil chicken with brown rice looks AMAZING.

ginger garlic steak tacos with pineapple pico de gallo are perfect for summer

add those delicious fresh blueberries to a fresh blueberry lemonade

toss some potatoes and carrots on the grill – the herb feta pesto would be perfect on grilled meats too

vegetarians sometimes get stuck with a plate of baked beans or pasta at cookouts – serve these grilled portabellos for a nice change!

cherries are at their prime right now (and super cheap). if you can avoid eating them all fresh, throw some on the grill for this grilled cherry milkshake

another easy summer pasta salad. you can never have too many! it makes a perfect healthy, no-fuss lunch for the rest of the week too

take a trip to Morocco from your own kitchen with this vegetarian tagine

toss your next grain salad with some pesto for great flavor – like this chickpea, tomato, and mozzarella salad


I hope you’re inspired by some of the recipes below to get in the kitchen (or out to the grill) this week. Enjoy!

roasted red pepper almond dip is the perfect way to add flavor to sandwiches, veggies, and meats

avoid artificial sweetners and colors in your summer drinks by making your own blackberry cherry lemonade

tabbouleh is a light, healthy grain salad that makes a great side dish. add chickpeas or grilled chicken to make it a filling meal all on its own

with whole wheat crust, veggies, and mozzarella (which is relatively low in fat), this stromboli is a delicious, healthy dinner you can have on the table in no time. who says healthy food can’t taste good??

if you’re tired of the same old granola bar snack every day, these caprese bites might be the perfect way to change it up this summer

zucchini pasta with homemade sauce is fast, easy, healthy, and makes use of the amazing summer produce available right now. real food at its finest.

this taco salad looks great but I think I’m most excited about that avocado lime dressing!

I’ve shared a lot of easy homemade popsicle recipes in these posts lately but if you just don’t want to make your own, these are some great guidelines for the best ones to purchase

why choose seasonal?


You hear it often these days, but why exactly is it best to purchase fruits and vegetables that are in season? Here are the 3 main reasons:

1. Cost

Perhaps first on the minds of many grocery shoppers is price and in-season fruits and vegetables are the best value. Produce that is in season in your area likely won’t have to travel as far to get to your grocery store and you can likely enjoy even greater savings by purchasing straight from the farmers themselves. When not in season, produce has to be shipped from parts of the world where it is in season and this raises the cost.

2. Nutrients

Produce that has traveled a great distance to reach you also has fewer nutrients. As soon as a fruit or vegetable is harvested, it begins to lose nutrients. A tomato picked from your garden before dinner will have more nutrients than one picked in a greenhouse 3 weeks ago, shipped to your grocery store, and placed on a shelf for 4 days before you purchased it in the middle of January. Some nutrients deteriorate faster than others but seasonal and close to home are always better. [frozen and canned fruits and vegetables are often packaged very soon after harvesting in order to preserve their nutrients]

3. Flavor

There is nothing worse than a flavorless tomato or strawberry in the dead of winter to turn someone off of eating fresh fruits and vegetables. In their prime season, fruits and vegetables grow and taste their best. If you have ever compared the taste of an early spring peach to a late summer peach, you know what a huge difference it makes to wait until a fruit is in season!

So, with grocery stores that stock everything all the time, how do you know what’s seasonal?? One good indication is cost – there tend to be pretty good sales on items that are in season. Many stores also have tags now that indicate if a product is local and if they have produce from your local area, it’s in season.

Seasonality can also vary slightly based on what region of the country you live in. California, for example, enjoys longer seasonality of many fruits and vegetables because of the warmer climate. Epicurious has a great map that allows you to choose the month and the state you live in to find out what’s in season. You can check seasonality in neighboring states too because “local” often includes products from neighboring states.

ScreenHunter_69 Jul. 07 14.07

Cooking Light is also another great resource because they not only tel you what’s in season, but allow you to search recipes so you know what to do with it! This is an especially great place to go if you get a weekly or monthly CSA box from a local farm. A CSA (community supported agriculture) is something you sign up for with a local farm [search for one in your area here!]. They fill a box for all “subscribers” with whatever they harvested that week and you can pick it up at a designated time/location. It’s pretty cost effective and a great way to support local farms and try new things because it’s likely that you’ll get at least one item you’ve never tried before.

What fruits and vegetables do you anxiously await to come into season? I LOVE strawberry, sweet corn, and peach season!!

all about protein

With all of the protein bars, powders, and shakes crowding the store shelves these days, not to mention cereals, granola bars, breads, and even water with added protein, I think there is a lot of misinformation about the role of protein in our daily diets and how much is necessary.


Here are 4 things I think are important to know about protein:

1. Not all protein is created equal

You’ve probably heard about complete and incomplete proteins at some point in your life. Basically, complete proteins contain all of the essential amino acids, which are building blocks of protein that your body can’t make on its own. Complete proteins include animal products like meat, fish, soy, and dairy products.

Incomplete proteins are missing one or more of the essential amino acids and, if your body doesn’t have all of the amino acids required to build a certain protein, it doesn’t get built. That’s a pretty big deal when  you consider all of the parts of your body that are made up of protein – muscles, parts of cells, enzymes, etc. Many non-animal foods like grains, beans, fruits, and vegetables provide incomplete proteins. It used to be thought that you needed to eat complimentary proteins (2 incomplete protein sources that, together, contain all of the essential amino acids – for example: rice and beans) together at the same meal to get a complete protein. However, now we know that, as long as you eat a variety of foods that contain all of the different amino acids throughout the day, you’re good to go.

Now, that’s just real food sources of protein. Protein supplements are a whole different story, but are also not created equal. Whey protein isolate is your best choice, with some new research suggesting a blend of dairy and soy protein is most effective, but that’s a topic for a whole other blog post and brings me to my next point……


2. You don’t need a supplement

That’s right. I know you see all those huge guys at the gym carrying around giant tubs of protein powders but it’s honestly not necessary. Your body can’t really store excess protein, so anything that it doesn’t use right away for rebuilding proteins in the body is just excreted in the urine. What’s more is that several research studies in recent years have show that your body only utilizes about 20-30g of protein at a time to maximally stimulate muscle protein synthesis. Now, it is thought that this amount could vary slightly based on body size so more research is needed, but the main point is that downing a protein shake with 60g of protein is likely just resulting in some expensive urine.

This point doesn’t just apply to athletes who load up on supplements. A typical American diet is very light on protein early in the day and heavy on protein in the evening. By spreading protein intake evenly throughout the day, you can stay fuller longer (because protein helps with satiety) and get the maximum benefit from the protein you consume.

For example, a healthy 140 pound woman needs about 50-65g of protein per day to meet her basic protein requirements. Getting 20g of protein at each meal would easily meet these needs, and that doesn’t even include snacks! It may look something like the sample day below, which actually includes just over 80g of protein – more than enough to meet our example woman’s needs!

ScreenHunter_69 Jun. 27 13.30

3. More protein does not equal bigger muscles

Going back to that image of protein shakes in the gym – simply consuming more protein will not result in bigger muscles. First, you must be doing some kind of resistance training to increase muscle mass. Second, you must be consuming not only enough calories to allow for muscle building, but you also need adequate carbohydrates so that you have enough fuel to perform the exercise and the protein you consume can be used for muscle building instead of being converted into fuel. Weight loss and muscle building can’t happen at the same time because weight loss requires a calorie deficit and muscle building requires a calorie surplus, not to mention that weight loss involves loss of both muscle and fat mass. Working with a dietitian is the best way to set up a plan that helps you achieve your goals if you are looking to alter your body composition because each person requires an individualized plan that considers a variety of factors in order to be successful.

4. Yes, even vegetarians can easily get enough protein from foods

All of this brings me to my last point and a question that I’m certain every vegetarian or vegan has heard numerous times – “But where do you get your protein??” As I demonstrated above, it is relatively easy to get an adequate amount of protein through a regular, balanced diet and the same is true for vegetarians.  Vegan diets require a little more planning in general, but can also include an adequate amount of protein without expensive supplements. Whole, unprocessed soy (edamame, tofu, etc.), beans, nuts, seeds, whole grains, and eggs/dairy (for vegetarians who include these items) can all help vegetarians and vegans meet their protein needs for the day.