In my early 20s, I took the notion of exercising as a hobby to another level. I generally ran during morning hours, averaging in excess of 60-70 miles a week. My evening hours were spent in the gym, during which time I engaged in highly intense bouts of weight training. In addition to my extreme exercise habits, I was also a strict vegan, avoiding any and all foods of animal origin.

Needless to say, I was quite thin, even though I naturally have a larger frame.

After almost two years of living this way, my periods started to become few and far between. Eventually, I lost them all together, a condition known as amenorrhea. Coupled with the fact that I was always getting sick, I knew exactly what was happening. As an exercise physiologist, who regularly worked with athletes, I’d seen this happen to many other young women before.

My symptoms were classic signs of the female athlete triad.

If you aren’t familiar with the term, the ‘female athlete triad’ is a syndrome, that’s most common among young women who participate in sports that require a thin or lean physique like competitive swimming, long-distance running, and gymnastics. The syndrome itself is linked to three symptoms:

  1. Nutritional imbalances (malnutrition) due to excessive dieting and disordered eating;
  2. Amenorrhea and other forms of menstrual dysfunction; and
  3. Low bone mass, which ultimately increases the risk of osteoporosis and bone injuries.

Since I was all-too familiar with these symptoms, I immediately set out to reverse them, mainly by paying closer attention to my diet and eventually reintroducing animal-based foods into my regimen. I still exercised a lot—It was still a hobby of mine. Truth is, though extreme, my exercise habits weren’t the primary culprit.

My symptoms were largely driven by an utter lack of adequate nutrition to support my extreme workouts.

More women than ever before are taking up vigorous and competitive exercise. And, I’m all for this as exercise in general has powerful protective effects against chronic diseases. Problem is, when coupled with excessive dieting and inherent social pressures to be thin, too much of a good thing can undoubtedly become a bad thing.

Related Article: Nutrition Strategies for Women Trying to Bulk Up

This is evidenced by the still increasing prevalence of the female athlete triad. Indeed, in recent years, many women have shared stories of amenorrhea and other symptoms with me; all of whom combined excessive dieting with highly intense exercise patterns over the course of several years. So, I felt a pressing need to address this topic here.

Obviously, this triad can be quite dangerous if left unchecked. I can attest to this on both a personal and professional level. So, if you’re a woman who also happens to be an athlete, bodybuilder or even a highly-active fitness enthusiast, here are some key strategies for avoiding it.

Eat Regularly and Every Day

This might sound like a silly suggestion but it’s a necessary one. Unbeknownst to many, intense exercise has powerful appetite-suppressing effects—So powerful that you’ll often have to remind yourself to eat. Now, if you’re trying to maintain a high level of thinness, you may view this as a winning strategy—Exercise at extreme levels and eat less.

I’m here to tell you that this is not at all a good approach, particularly over the long-term.

Restricting calories while exercise intensely can greatly increase your risk of amenorrhea, as you’re simply not taking in enough calories to maintain a normal menstrual cycle. Amenorrhea can lead to a host of adverse effects including infertility, reduced bone density, and, over time, osteoporosis.

Related Article: Osteoporosis: What It Is and How to Prevent and Treat It

Therefore, it’s especially important to eat regularly and every day so that you’re taking in enough calories to support your workouts and, more important, your vital functions. Most athletic women require a minimum of 2,200-2,400 calories per day. These calories should come from all essential macronutrients, which include carbohydrates, fat, and protein.

If you regularly participate in any endurance sport that burns a sizeable number of calories in a single session (distance running, cycling or swimming) it’s especially important that you watch what you’re eating to ensure you’re taking in the calories needed to achieve proper balance. In some cases, you may have to up your overall calorie intake by eating more.

Related Article: Estimating Your Metabolic Rate and Daily Calorie Needs

Consume a Diet Rich in Iron

Iron is a vital mineral that’s critical for healthy production of red blood cells. It’s specifically a chief component of hemoglobin, which is the protein responsible for transporting oxygen from the lungs to the cells, tissues and organs of the body. Obviously, if you regularly engage in highly intense exercise, adequate iron intake is crucial, as working muscles require a constant oxygen supply.

Moreover, neglecting to meet your body’s iron needs will inherently increase your risk of deficiency (anemia).

Unfortunately, iron-deficiency anemia is already quite common among women due to menstrual blood loss. The risk is further magnified among women who generally shy away from eating red meat and other iron-rich animal-based foods out of a fear of gaining weight.

Related Article: Red Meat: Nutritional Friend or Foe?

Among athletic and highly active women, this form of anemia is generally associated with extreme weakness, fatigue, and, ultimately, declines in exercise performance, as it can significantly impair the body’s ability to transport oxygen to exercising muscles. Other common symptoms include shortness of breath, dizziness, headache, and coldness in the hands and feet.

Women generally require at least 15 milligrams of iron each day. In addition to eating meat, you can up your intake by consuming a wide array of whole soy foods, dark leafy green vegetables, legumes, nuts and seeds. Soybeans, spinach, lentils, olives and sesame seeds are among the richest plant-based sources of iron.

But, it’s important to understand that the type of iron housed in plant-based foods (non-heme iron) is not as readily absorbed as that contained in animal-based foods (heme-iron). So, if you’re at increased risk, supplements might be necessary.

Related Article: Supplements Are No Substitute for Good Nutrition

Up Your Intake of Calcium and Vitamin D

Calcium intake is important throughout life, as this mineral plays a key role in a lot of vital functions like muscle contraction, heartbeat maintenance, proper nerve function, and blood clotting. Since 99% of the body’s calcium is naturally stored in bone, regular intake is especially critical for preserving the strength and integrity of this hard and rigid tissue.

Related Article: The Importance of Getting Enough Dietary Calcium

But, it doesn’t stop there!

For proper absorption and metabolism of calcium, vitamin D is also needed.

Unfortunately, due to excessive dieting and disordered eating patterns many female athletes and fitness enthusiasts are especially vulnerable to calcium deficiency. Prolonged calcium deficiency can accelerate reductions in bone density and mass leading to premature bone loss, fractures and, ultimately, osteoporosis.

These are classic symptoms of the female athlete triad.

And even when calcium intake is adequate, low levels of vitamin D can cause problems so adequate intake of both is important.

Women generally require about 1,000 milligrams of calcium a day. However, those exhibiting symptoms of the triad may require as much as 1,500 milligrams. Dairy foods contain the most concentrated amounts of calcium and those low in fat (low-fat or fat-free milk, yogurt, and cheese) provide slightly more than their full fat counterparts.

In addition to dairy foods, adequate amounts of calcium can be obtained from dark leafy green vegetables, whole soy foods, and fortified beverages (soymilk and rice milk). But, the calcium housed in some of these foods isn’t as readily absorbed by the body so there’s often a need to take in a lot more to match that which is contained in dairy foods.

And when it comes to vitamin D, women should consume at least 600 international units (IU) of vitamin D daily from food sources. Foods containing vitamin D include fortified milk, oily fish, egg yolks, and butter. Vitamin D synthesis is also triggered when the skin is exposed to ultraviolet rays from direct sunlight.

Related Article: Vitamin D: Why You Need it and How to Get It

In addition to the strategies I’ve mentioned here, sufficient protein intake is extremely important, as it’s critical for preserving muscle and maintaining the metabolic rate, which inherently supports healthy weight management.

This is especially beneficial for athletes, bodybuilders, and highly active fitness enthusiasts who are generally seeking to maintain a certain level of leanness.

It’s best, to choose high-quality protein sources that contain all essential amino acids such as lean meats, skinless poultry, fish and seafood, eggs, dairy foods, and whole soy foods. Other potentially good sources of high-quality protein include whey, egg white, casein and plant-based supplements.

For maximum protection against the female athlete triad, highly active women should consume at least 0.5 grams of protein for each pound of body weight.

Related Article: Nutrition Basics: Your Daily Protein Intake

To close, I’d like to clarify that women who engage in moderate intensities of exercise are generally not as prone to the female athlete triad. Problems arise when exercise patterns become extreme or highly intense.

But, again, the exercise itself isn’t the primary culprit.

Poor nutrition is the most common cause.

This is why women with eating disorders or those who severely restricted food intake are also at increased risk—Even in the absence of extreme exercise behaviors.

At the end of the day, the female athlete triad is best avoided by eating a healthy, well-balanced diet that contains enough calories. By incorporating these tips, vulnerable women can avoid this triad and easily meet their unique dietary needs in a healthy way.

Related Article: A Simple Guide to Eating Sensibly