Awareness of Triad was first assessed in a study published by Troy and colleagues in 2006 [13]. The researchers found low awareness among the 240 athletic trainers, coaches, medical students, physical therapists, and physicians surveyed. Forty-eight percent of physicians and 32 % of medical students were able to identify the Triad. A mere 9 % of physicians surveyed felt comfortable treating a patient with the disorder. When looking exclusively at pediatricians, 36 % of pediatricians were able to identify the Triad components and only 4 % felt comfortable treating the disorder. This study was limited by sample size [13]. A more recent study from 2014 assessed the ability of 370 US high school nurses to diagnose the three components of the Triad and found that only 19 % were able to do so, but 95 % expressed interest in learning more about the disorder [15].
In a 2006 study assessing coaches’ awareness of the Triad, approximately 43 % of coaches could properly identify the three components, yet only 8 % of coaches reported always assessing menstrual function prior to sport participation [14]. This study had limitations, as well. Most respondents were female, which is not representative of typical coach demographics. Additionally, the response rate was only 30 %, and the sample size was low.
Our findings suggest that slightly more than one third of the residents, fellows, and attending physicians surveyed from the three academic centers have heard of the female athlete triad. Those aware of the Triad scored 71 ± 18 % of a possible 100 % on our questionnaire, which consisted of basic knowledge necessary to properly treat/refer this at risk population. Current residents and fellows have increased odds of having heard of it and properly identifying the three components compared to attending physicians; however, there was not a statistically significant difference in overall awareness score among training levels.
Increasing awareness among health-care providers across specialties is paramount, as one of the primary challenges with the Triad is difficulty in identification. Awareness of the Triad and its components is necessary in order to encourage behavioral changes in these patients. The 2014 Female Athlete Triad Coalition Consensus Statement [11] endorses screening for the Triad as a portion of the preparticipation physical evaluation (PPE) [16–19]. The consensus statement also presents the ‘Female Athlete Triad: Cumulative Risk Assessment’ to provide an objective method of determining an athlete’s risk for the Triad using risk stratification and evidence-based risk factors. Additionally, the International Olympic Committee has recently published a RED-S Clinical Assessment Tool (RED-S CAT) to help identify athletes at risk of low EA. [12] Although there is limited evidence regarding the efficacy of such screening tools, the current standard screening PPE form includes nine questions related to the Triad [20]. Screening is most typically completed for female athletes at the collegiate level but should be done at the high school level as well [11]. This younger age group should be targeted for three main reasons: (1) the declining age of onset of eating disorders; (2) the opportunity to maximize bone accrual during adolescence (greater than 90 % of peak bone mass is attained by 18 years of age with the greatest rate bone mass accrual occurring between ages 11 and 14); and (3) the earlier Triad components are detected, the better they will respond to treatment [21, 22].. Therefore, adolescent female athletes may represent the most important population to target.
Providers should be aware that most patients will only present with one or two components of the Triad, but may be at risk for all three. Schtscherbyna et al. [23] conducted a study in 2009 assessing 78 elite swimmers aged 11–19 years and found that 44.9 % met the criteria for disordered eating, 19.2 % for menstrual irregularity, and 15.4 % for low bone mass. Nichols et al. [4] found that out of 170 high school female athletes, 18.3 % met the criteria for disordered eating, 23.5 % for menstrual irregularity, and 21.8 % for low bone mass. However, of these athletes, only 5.9 % had two components and 1.2 % had all three. Focusing on the three spectra concept of the Triad in future education initiatives will be crucial to optimal physician diagnosis and treatment planning, as many studies have shown that athletes often present with variable severity of the individual components [4, 23, 24].
It is discouraging that our study demonstrates that less than half (47 %) of medicine physicians (including pediatricians, internists, and family medicine physicians) are aware of the Triad. Such physicians should feel comfortable screening and initiating a work-up for each Triad component and potentially developing a multi-disciplinary treatment approach. These medical providers are the ones most often involved in annual health screening, and they should be familiar to Triad risks and consequences when evaluating their athletic patients. Primary care sports medicine physicians are frequently involved in high school and collegiate athlete team coverage. Because there were so few primary care sports medicine physician responders, Triad awareness and knowledge of this subgroup of clinicians was not specifically identified in our survey.
Psychiatrists and psychologists are frequently involved in treatment of female athletes with disordered eating and the mood and anxiety dysfunction that frequently affects females along the Triad spectra. However, this specialty had the poorest Triad awareness in our study. Education should be particularly emphasized in both psychiatry and psychology training programs to help promote early recognition and management of female athletes with the Triad.
It is encouraging that Triad awareness was relatively high among orthopedic surgeons (80 %), as this group of physicians is also frequently involved directly in athletic team coverage and the care of female athletes in clinics and training rooms. Orthopedists who evaluate and treat females for bone stress injuries should be comfortable questioning such patients about the other components of the Triad (e.g., dietary patterns and menstrual history). Ideally, Triad patients are identified prior to the development of stress fracture, which can be a result of low EA, menstrual dysfunction, and decreased bone density [25, 26].
There are limitations to this study. Due to sample size and inconsistent reporting of specific specialties, we were required to combine several specialties for statistical analysis purposes. For example, the “medicine” group includes specialties such as family medicine, pediatrics, general internal medicine, internal medicine specialties, and any of the above who may have also completed a primary care sports fellowship. This survey was administered to three academic teaching hospitals in a large city, which may not be representative of the level of awareness among community physicians at non-academic institutions. Additionally, we had a low response rate of just 23.5 %, questioning the extrapolation of our results to greater populations of clinicians. The survey was e-mailed from an academic attending at each teaching hospital to the attending physicians and house staff of their respective hospitals, with a clear heading of its intent “Survey of Female Athlete Triad Awareness”, with a follow-up reminder e-mail as well. Thus, it is quite likely that many of those with an awareness, interest, or concern for the topic responded. We suspect this would, if anything, result in our over-reporting awareness of the Triad among medical specialties.
