Association of Diabetes Care & Education Specialists


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The Female Athlete Triad and Diabulemia

Jun 21, 2010

I recently presented to athletic trainers about “Athletes with Diabetes” and “The Female Athlete Triad.” They were intended to be two separate topics. But, there is a connection. As a segue between the two topics, I included a slide about Diabulemia, describing when a person with diabetes, typically type 1, can decrease or omit insulin to lose weight; a method of purging. Have you worked with patients that do this?

I was interested to see some of the changes in how the Female Athlete Triad is now viewed. It brought my attention to some things we should consider when working with people with diabetes.

The ironic acronym “FAT” is no longer used; it has been replaced by the “Triad.” When the Triad was originally described, it included anorexia nervosa, amenorrhea, and osteoporosis. Intervention was considered when a person had all 3 components.

This diagram shows the current thinking. One end describes a healthy person with optimal energy availability, eumenorrhea, and optimal bone health and the other end shows a person with the Triad including low energy availability, functional hypothalamic amenorrhea, and osteoporosis. There is a continuum between the two ends. It is important to watch for signs suggesting any deviation from healthy for intervention.

Decreased energy availability can be due to decreased dietary energy intake (intentional or not), excessive energy expenditure (lots of activity), or some combination, creating a mismatch resulting in weight loss. A risk factor for low energy availability is restricted dietary intake. With diabetes, people often pay close attention to food and may restrict some foods, making them more susceptible to this. Originally, it was accepted that the decreased energy availability part of the Triad was due to intentional weight loss as part of anorexia nervosa, always with a psychological component. This is no longer a given. However, if a person does have signs or symptoms of an eating disorder, they should be referred for psychological intervention; the sooner, the better for best results.

The Triad occurs more frequently in athletes in sports emphasizing leanness (i.e., dancing, diving, gymnastics, distance running, wrestling). It is more common in females, teens/young adults, and athletes. But, there are many that don’t fall into the stereotypical categories: non-athletes, older adults, men (obviously without the amenorrhea component), and those who are overweight (may binge and purge).

Interactions with people with diabetes can give us clues about the Triad. If we suspect a person is eating too little, exercising too much, omitting or decreasing insulin; presents with stress fractures, recurrent injury or illness; or amenorrhea/oligomenorrhea, further investigation is warranted. A person doesn’t need to have all 3 components of the Triad to bring concern; any of the 3 warrants intervention.

Diabetes educators have an opportunity to catch some of these problems early. Treatment is better when started early before full-blown problems arise.

Have you had situations where you have intervened when a person has some of these issues? I am especially interested to hear from educators working with teens. Tell us what you know!

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