Update on the female athlete triad

Disordered eating is not associated with musculoskeletal injury in university athletes

TAKE HOME MESSAGE

Musculoskeletal injuries and disordered eating are prevalent in varsity-level athletes but are not associated in our participants.

Low energy availability reduces bone mass and gonadal function in male mice

INTRODUCTION

In women, the female athlete triad, marked by low energy availability, functional hypothalamic amenorrhea and osteoporosis, is a recognized risk for stress fractures. Stress injuries also occur in men, but by contrast risks and mechanisms underlying them are less characterized.

MATERIALS AND METHODS

5 week-old wild-type male mice were fed ad libitum (ad) or subjected to 60% food restriction (FR) for five weeks. In both groups, some mice were allowed access to an exercise wheel in cages to allow voluntary wheel running (ex) and/or treated with active vitamin D analogues. Mice were sacrificed and analyzed at 10 weeks of age.

RESULT

Male FR mice exhibited significantly reduced testicle weight, serum testosterone levels and bone mass. Such bone losses in FR male mice were enhanced by exercise. Histological analysis revealed that both bone-resorbing and -forming activities were significantly reduced in FR or FR plus exercise (FR + ex) mice, mimicking a state of low bone turnover. Significantly reduced bone mass in FR or FR + ex male mice was significantly rescued by treatment with active vitamin D analogues, with significant restoration of osteoblastic activities. Serum levels of insulin-like growth factor I (IGF-I), which is critical for bone remodeling, were significantly lower in FR versus control male mice.

CONCLUSIONS

Low energy availability puts men at risk for stress injuries as well, and low energy availability is upstream of gonadal dysfunction and osteoporosis in males. Active vitamin D analogues could serve as therapeutic or preventive options for stress injuries in men.

Nutrition Education Curriculum Promotes Adolescent Runners' Self-Efficacy, Knowledge, and Intake of Nutrient-Rich Carbohydrate Foods

BACKGROUND

Endurance runners exhibit an elevated prevalence of low bone mass and characteristics consistent with undernourishment.

OBJECTIVE

This quasi-experimental, pretest-posttest design study evaluated the efficacy of a 4-week nutrition education curriculum to optimize nutrition knowledge, self-efficacy, and the intake of nutrient-rich carbohydrate foods.

METHODS

Forty-eight adolescent endurance runners, age 15.7 ± 1.2 y, from two high schools in Southern California were recruited to complete four, weekly lessons addressing the quantity, quality, and timing of carbohydrate intake. Differences in pre- compared to post-intervention nutrition knowledge and self-efficacy to consume nutrient-rich carbohydrate foods were evaluated using paired samples t-tests. Qualitative coding of open-response questions explored changes in food intake behaviors reported by runners during the intervention.

RESULTS

The percent of nutrition knowledge questions answered correctly increased after Lessons 1 and 2 (59.0% ± 20.0% pre- vs. 81.9% ± 22.8% post-Lesson 1; 44.7% ± 13.7% pre- vs. 74.5% ± 17.4% post-Lesson 2, P<.001) and the number of identified nutrient-rich carbohydrate foods (8.7 ± 2.7 vs. 12.4 ± 2.3, P < 0.001). Self-efficacy scores improved after all lessons (P<.001). After Lesson 2, 84% (n = 27/32) of runners increased the carbohydrate included in a snack or meal; after Lesson 4, 85% (n = 29/34) added a post-exercise snack. Frequent themes identified from questions addressing dietary changes included increasing quantity and quality of carbohydrates in snacks and meals and being more aware of food choices.Conclusions: Findings suggest that the curriculum enhanced nutrition knowledge, self-efficacy, and dietary behaviors related to intake of nutrient-dense carbohydrate foods in adolescent runners.

Prevalence of Risk Factors of the Female Athlete Triad among Young Elite Athletes of Pakistan

BACKGROUND

Female athletes who are not vigilant about their food choices and choose extraneous physical activities may head towards negative health effects.

PURPOSE

The purpose was to determine the prevalence of risk factors that may lead to the Female Athlete Triad among young elite athletes in Pakistan.

STUDY DESIGN & METHODS

A cross sectional questionnaire-based study was conducted in 2018 at Pakistan Sports Board to investigate the risk factors of The Female Athlete Triad among young elite athletes based in national training camps of major metropolitan cities. Trained and professional female elite athletes of age 18 - 25 years, able to comprehend questionnaire in English were included. Athletes completed the questionnaire including demographics, educational qualifications, Body Mass Index, sports participation, and playing hours. The Eating Aptitude Test-26 (EAT-26) and questionnaires on risks of amenorrhea and risks of low bone mineral density were completed. Individual prevalence of the risk factors of three components was assessed. The data were analyzed using SPSS-20 and descriptive statistics applied.

RESULTS

A sample of 60 elite athletes, (23.57 + 2.37 years, BMI 21.97 +1.90) who participated in various sports were included. EAT-26 results indicated that 50% of athletes were at risk of an eating disorder. Disordered Eating behaviors in need of referral were identified in 83.3%. Risks for amenorrhea were identified in 15%, and concerning low Bone Mineral Density, no risks were identified, except the intake of caffeinated beverages in 51.7%.

CONCLUSION

The prevalence of risk for disordered eating was found to be significant among female elite athletes of Pakistan, but risk of amenorrhea and low bone mineral density were not of major concern.

LEVEL OF EVIDENCE

3b.

The female athlete triad

The female athlete triad represents the 3 interrelated components: of energy availability (EA), menstrual function and bone health. Each component exists on a spectrum ranging from optimal health to dysfunction. Screening for the triad during the annual wellness exam, the preparticipation physical evaluation (PPE) or when the athlete presents with any single component can help identify athletes at risk. A multidisciplinary team is helpful in managing the treatment of the Triad which relies on improving EA. Screening, early recognition and aggressive treatment is important, especially in adolescent athletes to optimize bone health.

Eating Disorders in the Adolescent Patient

Eating disorders such as anorexia nervosa, female athlete triad, bulimia nervosa, obesity, and binge eating initially emerge during adolescence. These disorders are present primarily in females, but males may also present with these conditions. Dentistry has a pivotal role in the management of patients with such diet-related disorders. Because dentists examine their patients at frequent intervals and may be the health care professionals with whom patients feel more comfortable discussing eating disorders, dentists must have knowledge of the etiology, diagnostic criteria, systemic effects, and intraoral manifestations of eating disorders. In addition, the dental professional may be the first health care provider to identify the condition and refer the patient appropriately to medical colleagues for subsequent treatment. This chapter provides dentists with current and relevant information to recognize, diagnose, and integrate dental treatment for their adolescent patients who may exhibit manifestations of an eating disorder.

Primary Ovarian Insufficiency in the Prepubertal Adolescent: A Case Report

Although there are many etiologies for delayed puberty in adolescent-aged girls, the pediatric provider should consider primary ovarian insufficiency if estradiol remains undetectable despite elevated levels of gonadotropins. Adolescent girls with this diagnosis will need holistic care from their primary care provider, focusing on both their medical and psychosocial needs. The following case study describes a 14-year-old girl who was referred to pediatric endocrinology for delayed puberty, in the setting of increased gonadotropins and undetectable estradiol. The differential diagnosis, evaluation, and management of primary ovarian insufficiency are reviewed as well as potential long-term health considerations.

Bone mineral density in adolescent elite ballet dancers

BACKGROUND

Data documenting BMD in pre-professional adolescent ballet dancers is limited. This cross-sectional study assesses bone mineral density (BMD) in young adolescent elite ballet dancers and compares BMD values between males and females (with and without normal menarche) and body composition between dancers with and without low Z-score.

METHODS

Cross-sectional study of third year ballet students (female=23; male=15; mean age 14.7 years; SD: 0.5) of The Royal Ballet School of Antwerp (Belgium) training 22 hours a week. They completed questionnaires and underwent dual energy X-ray absorptiometry (DXA) to measure BMD and body composition. Each female participant completed questionnaires assessing menstrual status.

RESULTS

DXA revealed that 12 out of 38 (32%) of the dancers had Z-score <-1. On average, male dancers had a lower BMD compared to an age-matched reference population (mean Z-score -0.9; SD 0.5), with 7 out of 15 having Z-score <-1. Overall, absolute BMD values were highest in the legs, followed by spine and arms. Dancers with Z-score <-1 had a significantly lower total mass. 43% of female ballet dancers had not yet had their first period and 39% had oligomenorrhea, but no significant differences between groups was detected.

CONCLUSIONS

A third of adolescent elite ballet dancers had low to very low Z-score. Nearly 2 out of 3 dancers with a Z-score <-1 were males, showing that low BMD is not limited to female dancers. Among female dancers menstrual dysfunction was frequent, without apparent impact on BMD or body composition in the studied age group.

The Effects of Endurance Sports on Children and Youth

In the United States, youth participation in sports continues to increase yearly. This increase in participation, in conjunction with the trend toward early sports specialization and year round training, has led to a similar increase in athletically developed injuries. These injuries vary in nature and acuity, with the type of injury often related to the athlete's age, sport, and level of training. Endurance athletes are at an elevated risk of injury as they frequently push their body to the limit during their arduous training. Pediatric endurance athletes can be particularly vulnerable, especially to overuse injuries, given their unique and ever-changing physiological state. It is important to understand the specific challenges facing not only the physical, but also the emotional well-being of these pediatric endurance athletes to maximize performance while minimizing injury and potential long-term sequelae.

The Unexplored Crossroads of the Female Athlete Triad and Iron Deficiency: A Narrative Review

Despite the severity and prevalence of iron deficiency in exercising women, few published reports have explored how iron deficiency interacts with another prevalent and severe condition in exercising women: the 'female athlete triad.' This review aims to describe how iron deficiency may interact with each component of the female athlete triad, that is, energy status, reproductive function, and bone health. The effects of iron deficiency on energy status are discussed in regards to thyroid function, metabolic fuel availability, eating behaviors, and energy expenditure. The interactions between iron deficiency and reproductive function are explored by discussing the potentially impaired fertility and hyperprolactinemia due to iron deficiency and the alterations in iron metabolism due to menstrual blood loss and estrogen exposure. The interaction of iron deficiency with bone health may occur via dysregulation of the growth hormone/insulin-like growth factor-1 axis, hypoxia, and hypothyroidism. Based on these discussions, several future directions for research are presented.

Risk and Protective Factors for Middle- and Long-Distance Running-Related Injury

BACKGROUND

Despite a rapidly growing body of research, a systematic evidence compilation of the risk and protective factors for middle- and long-distance running-related injury (RRI) was lacking.

OBJECTIVES

Our objective was to compile the evidence about modifiable and non-modifiable training-related and behavioral risk and protective factors for middle- and long-distance RRI.

METHODS

We searched five databases (PubMed, CINAHL, MEDLINE, SPORTDiscus, and PsycINFO) for the dates 1 January 1970 to 31 December 2015, inclusive, for original peer-reviewed articles. The eligible designs were cross-sectional, case-control, longitudinal observational studies, and randomized controlled trials involving runners competing at distances from ≥800 m to ≤42.2 km. Outcomes were any specific and/or general RRI, and exposures included training-related and behavioral factors. We extracted authors and date, study design, injury type(s), descriptors and comparators for each exposure, and results and measures of association from the selected studies. Methodological quality was independently appraised using two separate checklists: a modified checklist for observational study designs and the Physiotherapy Evidence Database (PEDro) scale for randomized controlled trials.

RESULTS

Among 73 articles eligible for inclusion, 19 (26.0%) and 30 (41.0%) were of high or satisfactory methodological quality, respectively. As a non-modifiable exposure, a history of previous injury was found to be associated with an increased risk of both general and specific RRI. In terms of modifiable exposures, irregular and/or absent menstruation was found to be associated with an increased risk of stress fracture development, whereas the use of oral contraceptives was found to be associated with a decreased risk. High clinical, methodological, and statistical heterogeneity meant it was not feasible to estimate a pooled effect size across similar studies.

CONCLUSIONS

A history of previous injury was associated with an increased risk of both general and specific RRI. The use of oral contraceptives was found to be associated with a decreased risk of skeletal stress fracture. Conversely, irregular and/or absent menstruation was associated with an increased risk. The varied effect directions and/or a number of statistically insignificant results associated with the majority of factors hindered our ability to draw any definitive conclusions about their relationship to RRI risk.

Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport

Low energy availability (EA) is suspected to be the underlying cause of both the Female Athlete Triad and the more recently defined syndrome, Relative Energy Deficiency in Sport (RED-S). The International Olympic Committee (IOC) defined RED-S as a syndrome of health and performance impairments resulting from an energy deficit. While the importance of adequate EA is generally accepted, few studies have attempted to understand whether low EA is associated with the health and performance consequences posited by the IOC.

Objective

The purpose of this cross-sectional study was to examine the association of low EA with RED-S health and performance consequences in a large clinical population of female athletes.

Methods

One thousand female athletes (15–30 years) completed an online questionnaire and were classified as having low or adequate EA. The associations between low EA and the health and performance factors listed in the RED-S models were evaluated using chi-squared test and the odds ratios were evaluated using binomial logistic regression (p<0.05).

Results

Athletes with low EA were more likely to be classified as having increased risk of menstrual dysfunction, poor bone health, metabolic issues, haematological detriments, psychological disorders, cardiovascular impairment and gastrointestinal dysfunction than those with adequate EA. Performance variables associated with low EA included decreased training response, impaired judgement, decreased coordination, decreased concentration, irritability, depression and decreased endurance performance.

Conclusion

These findings demonstrate that low EA measured using self-report questionnaires is strongly associated with many health and performance consequences proposed by the RED-S models.

Knowledge, Attitude, and Skill of High School Coaches with Regard to the Female Athlete Triad

STUDY OBJECTIVE

The purpose of this study was to investigate knowledge high school coaches have about the female athlete triad and to determine if gender differences in knowledge, attitudes, and behaviors exist.

DESIGN

Cross-sectional survey.

SETTING

Twenty-six high schools in and around the vicinity of Cleveland, Ohio.

PARTICIPANTS

Two-hundred currently employed high school coaches.

INTERVENTIONS

Participants completed a 30-question survey used to assess knowledge, attitudes, and behaviors coaches had about the female athlete triad.

MAIN OUTCOME MEASURES

Descriptive statistics (means, SD, frequency) and gender differences in response to triad knowledge, attitude, and behavior questions.

RESULTS

One hundred twenty-three high school coaches completed the survey. Survey respondents were between 25 and 35 years of age, coached for 6-10 years, and coached female athletes 75%-100% of the time. Twenty-four percent reported "having heard of the triad" and 14% (17 of 123) were able to correctly name all of its components. There were no significant differences between gender and the coach's ability to correctly name the 3 triad components (t = 1.47, P = .14). There was no correlation between coach gender (r = 0.13, P = .07), age (r = 0.07, P = .42), number of years of coaching (r = 0.014, P = .88), and coach's knowledge of the triad components, respectively.

CONCLUSION

Female athletes might be at risk for developing the female athlete triad and high school coaches can be instrumental in identifying athletes who are at risk. This study showed that gaps in knowledge about the triad exist and that educating coaches about the condition could serve as an important means of prevention for the condition.

Sport- and sample-specific features of trace elements in adolescent female field hockey players and fencers

Active physical exercises and growth are associated with mineral imbalances in young athletes. The purpose of this study was to examine the impact of sport-related factors on tissue mineral status in adolescent female athletes. Saliva and hair samples were used for the analysis of immediate and more permanent tissue mineral status, respectively. Samples taken from a control non-athletic female group and two groups of female athletes (field hockey and fencing) were analyzed for seven essential minerals: calcium, chromium, iron, potassium, magnesium, selenium and zinc. Inductively-coupled plasma mass spectrometry was used for the quantification of elements having very low concentration range in samples (Se, Cr and Zn) whereas inductively coupled plasma optical emission spectrometry was used for quantification of more ubiquitous elements (Mg, К, Са, Fe). The obtained results for athletic groups were compared with control. Female athletes had increased levels of selenium in both saliva and hair as well as chromium in saliva. Field hockey players had the higher level of zinc in hair whereas fencers had the lower levels of salivary calcium. Strong negative correlation between potassium levels in saliva and hair was identified. Iron and magnesium did not differ between the studied groups. In conclusion, novel sport-specific features of chromium tissue levels in female athletes were found. The studied sport disciplines have different impact on the distribution of osteoporosis-related minerals (calcium and zinc). Our finding can help in the development of osteoporosis preventive trainings and in the proper nutrient supplementation to correct mineral imbalances in female athletes.

Female Athlete Triad: Future Directions for Energy Availability and Eating Disorder Research and Practice

Despite more than 3 decades of research on the Female Athlete Triad, research gaps remain. Although low energy availability (EA) is the key etiologic factor in the Triad and the pathways to low EA are varied, its effects can be modified by several factors. Accurate screening, diagnosis, and treatment of disordered eating are a challenge; however, recent techniques combined with novel educational and behavior interventions prove promising. Recently published practice-based guidelines have helped to translate Triad science and should improve as they are refined. This article identifies the current state of research and distinguishes areas that require further investigation.

Vegetarian, Gluten-Free, and Energy Restricted Diets in Female Athletes

Female athletes who follow a diet that fails to meet energy and nutrient needs are at risk for musculoskeletal injuries, menstrual disturbances, and poor sports performance. Common nutritional concerns for the female athlete include low energy availability (EA) (i.e., energy intake from food remaining for metabolic processes after accounting for energy expended during exercise) and inadequate dietary intakes (i.e., not meeting sports nutrition guidelines) of carbohydrates, protein, essential fatty acids (EFAs), B-vitamins, calcium, iron, and vitamin D. Low EA and the associated nutrient deficiencies are more common in athletes who compete in weight-sensitive sports (i.e., aesthetic, gravitational, and weight category sports) because low body fat and mass confer a competitive advantage. Other athletes at risk for energy and nutrient deficits include athletes following a vegetarian or gluten-free diet (GFD). Careful dietary planning can help an athlete meet energy and nutrient needs. This review covers the nutrition issues associated with low EA and special diets (i.e., vegetarian and GFD) and describes strategies to help female athletes meet their energy and nutrient needs.

Running Injuries During Adolescence and Childhood

The popularity of running among young athletes has significantly increased over the past few decades. As the number of children who participate in running increases, so do the potential number of injuries to this group. Proper care of these athletes includes a thorough understanding of the unique physiology of the skeletally immature athlete and common injuries in this age group. Treatment should focus on athlete education, modification of training schedule, and correction of biomechanical deficits contributing to injury. Early identification and correction of these factors will allow a safe return to running sports.

The Female Athlete Triad

The number of girls participating in sports has increased significantly since the introduction of Title XI in 1972. As a result, more girls have been able to experience the social, educational, and health-related benefits of sports participation. However, there are risks associated with sports participation, including the female athlete triad. The triad was originally recognized as the interrelationship of amenorrhea, osteoporosis, and disordered eating, but our understanding has evolved to recognize that each of the components of the triad exists on a spectrum from optimal health to disease. The triad occurs when energy intake does not adequately compensate for exercise-related energy expenditure, leading to adverse effects on reproductive, bone, and cardiovascular health. Athletes can present with a single component or any combination of the components. The triad can have a more significant effect on the health of adolescent athletes than on adults because adolescence is a critical time for bone mass accumulation. This report outlines the current state of knowledge on the epidemiology, diagnosis, and treatment of the triad conditions.

The Prevalence and Impact of Heavy Menstrual Bleeding (Menorrhagia) in Elite and Non-Elite Athletes

To identify the prevalence and impact of heavy menstrual bleeding (HMB) in exercising females where anemia may have a significant effect on training and performance a ‘Female Health Questionnaire’ was designed incorporating a validated diagnostic HMB series, demographics, exercise ability data, training status, anemia, iron supplementation and whether the menstrual cycle had affected training and performance. The survey was conducted in two stages; initially online, advertised via social media, and then repeated via face-to-face interviews with runners registered for the 2015 London Marathon. 789 participants responded to the online survey, and 1073 completed the survey at the marathon. HMB was reported by half of those online (54%), and by more than a third of the marathon runners (36%). Surprisingly, HMB was also prevalent amongst elite athletes (37%). Overall, 32% of exercising females reported a history of anemia, and 50% had previously supplemented with iron. Only a minority (22%) had sought medical advice. HMB is highly prevalent in exercising females, associated with self-reported anemia, increased use of iron supplementation and a perceived negative impact on performance. Further research is needed to investigate the impact of HMB, iron deficiency and anemia in exercising females.

The Preventive Effect of Calcium Supplementation on Weak Bones Caused by the Interaction of Exercise and Food Restriction in Young Female Rats During the Period from Acquiring Bone Mass to Maintaining Bone Mass

Increasing calcium (Ca) intake is important for female athletes with a risk of weak bone caused by inadequate food intake. The aim of the present study was to examine the preventive effect of Ca supplementation on low bone strength in young female athletes with inadequate food intake, using the rats as an experimental model. Seven-week-old female Sprague-Dawley rats were divided into four groups: the sedentary and ad libitum feeding group (SED), voluntary running exercise and ad libitum feeding group (EX), voluntary running exercise and 30% food restriction group (EX-FR), and a voluntary running exercise, 30% food-restricted and high-Ca diet group (EX-FR+Ca). To Ca supplementation, we used 1.2% Ca diet as "high-Ca diet" that contains two-fold Ca of normal Ca diet. The experiment lasted for 12 weeks. As a result, the energy availability, internal organ weight, bone strength, bone mineral density, and Ca absorption in the EX-FR group were significantly lower than those in the EX group. The bone strength and Ca absorption in the EX-FR+Ca group were significantly higher than those in the EX-FR group. However, the bone strength in the EX-FR+Ca group did not reach that in the EX group. These results suggested that Ca supplementation had a positive effect on bone strength, but the effect was not sufficient to prevent lower bone strength caused by food restriction in young female athletes.

Epidemiology of National Collegiate Athletic Association Men's and Women's Cross-Country Injuries, 2009-2010 Through 2013-2014

CONTEXT

Recent injury-surveillance data for collegiate-level cross-country athletes are limited.

OBJECTIVE

To describe the epidemiology of National Collegiate Athletic Association (NCAA) men's and women's cross-country injuries during the 2009-2010 through 2013-2014 academic years.

DESIGN

Descriptive epidemiology study.

SETTING

Aggregate injury and exposure data collected from 25 men's and 22 women's cross-country programs, providing 47 and 43 seasons of data, respectively.

PATIENTS OR OTHER PARTICIPANTS

Collegiate student-athletes participating in men's and women's cross-country during the 2009-2010 through 2013-2014 academic years.

MAIN OUTCOME MEASURE(S)

Injury rates; injury rate ratios (RRs); injury proportions by body site, diagnosis, and apparatus; and injury proportion ratios were reported with 95% confidence intervals (CIs).

RESULTS

The Injury Surveillance Program captured 216 injuries from men's cross-country and 260 injuries from women's cross-country, leading to injury rates of 4.66/1000 athlete-exposures (AEs) for men (95% CI = 4.04, 5.28) and 5.85/1000 AEs for women (95% CI = 5.14, 6.56). The injury rate in women's cross-country was 1.25 times that of men's cross-country (95% CI = 1.05, 1.50). Most injuries affected the lower extremity (men = 90.3%, women = 81.9%). The hip/groin-injury rate in women (0.65/1000 AEs) was higher than that in men (0.15/1000 AEs; RR = 4.32; 95% CI = 1.89, 9.85). The ankle-injury rate in men (0.60/1000 AEs) was higher than that in women (0.29/1000 AEs; RR = 2.07; 95% CI = 1.07, 3.99). Common diagnoses were strains (men = 19.9%, women = 20.4%) and inflammation (men = 18.1%, women = 23.8%). The majority of injuries were classified as overuse (men = 57.6%, women = 53.3%).

CONCLUSIONS

Consistent with prior research, injury distributions varied between male and female athletes, and the injury rate among females was higher. Understanding the epidemiology of these cross-country injuries may be important for developing appropriate preventive interventions.

Ultra-Marathon Athletes at Risk for the Female Athlete Triad

BACKGROUND

Worldwide female participation in ultra-endurance events may place them at risk for the female athlete triad (FAT). The study objectives were to establish triad knowledge, occurrence of disordered eating and triad risk amongst participants of the 2014 89-km Comrades Marathon event.

METHODS

A survey utilising the Low Energy Availability in Females questionnaire (LEAF-Q) and Female Athlete Screening Tool (FAST) questionnaire was conducted on female participants in order to determine the risk. In addition, seven questions pertaining to the triad were asked in order to determine the athlete's knowledge of the triad. Athletes were requested to complete the anonymous questionnaire after written informed consent was obtained while waiting in the event registration queues. Statistical analyses included Pearson product-moment correlations, chi-square tests and cross-tabulations to evaluate associations of interest.

RESULTS

Knowledge of the triad was poor with 92.5 % of participants having not heard of the triad before and most of those who had, gained their knowledge from school or university. Only three athletes were able to name all 3 components of the triad. Amenorrhoea was the most commonly recalled component while five participants were able to name the component of low bone mineral density. Of the 306 athletes included in the study, 44.1 % were found to be at risk for the female athlete triad. One-third of participants demonstrated disordered eating behaviours with nearly half reporting restrictive eating behaviours. There is a significant association between athletes at risk for the triad according to the LEAF-Q and those with disordered eating (χ²(1) = 8.411, p = 0.014) but no association (or interaction) between triad knowledge and category (at risk/not at risk) of LEAF-Q score (χ²(1) = 0.004, p = 0.949). More athletes in the groups with clinical and sub-clinical eating disorders are at risk for the triad than expected under the null hypothesis for no association.

CONCLUSIONS

Only 7.5 % of the female Comrades Marathon runners knew about the triad despite 44.1 % being at a high risk for the triad. Therefore, education and regular screening programmes targeting these athletes are overdue. Postmenopausal athletes are at particularly high risk for large losses in bone mass if they experience chronic energy deficiency and hence require special focus.

Comparison of disordered eating symptoms and emotion regulation difficulties between female college athletes and non-athletes

The purpose of the study was to compare the prevalence of disordered eating between female college athletes and non-athletes and explore emotion regulation as a potential mediator of the link between participation in athletics and disordered eating symptoms. Data for this cross-sectional study came from 527 college students in a mid-western state of the USA in fall of 2013 (376 non-athletes and 151 athletes). Disordered eating symptoms and emotion regulation were assessed utilizing the Eating Attitudes Test and the Difficulties with Emotion Regulation Scale in a survey-based format. The prevalence of disordered eating was higher in non-athletes (16.5%, vs. 6.6%; X(2)=62.8; p<.05). Non-athletes reported more signs and symptoms of disordered eating than athletes (p<.01). A linear regression approach indicated a statistically significant indirect effect (0.63, CI95=0.18, 1.20) of athletic-status on disordered eating via emotion regulation; however, this effect did not reach practical significance. Our findings show that female athletes in our sample were somewhat protected from disordered eating compared to non-athletes, but the mechanism of this relationship is unclear. A further in-depth examination of other factors, such as self-esteem and body satisfaction, that may have contributed to this finding is warranted utilizing a large sample of female college students and athletes representing a variety of sports.

The Interaction of Voluntary Running Exercise and Food Restriction Induces Low Bone Strength and Low Bone Mineral Density in Young Female Rats

There is a concern that the combination of exercise with food intake reduction has a risk of reducing bone strength and bone mass in young female athletes. We examined the influence of the interaction of voluntary running exercise and food restriction on bone in young female rats. Seven-week-old female Sprague-Dawley rats were divided into four groups: the sedentary and ad libitum feeding group (SED), voluntary running exercise and ad libitum feeding group (EX), sedentary and 30 % food restriction group (SED-FR), and voluntary running exercise and 30 % food restriction group (EX-FR). The experiment lasted 12 weeks. Statistical analysis was carried out by two-way analysis of variance with exercise and restriction as the between-subjects factors. As a result, there were significant interactions of running and restriction on energy availability, breaking force, breaking energy, and bone mineral density (BMD). Breaking force and energy in the EX group were significantly higher than in the SED group; breaking force and energy were significantly lower in the EX-FR group than in the EX group, and breaking force in the EX-FR group was significantly lower than that in the SED-FR group. BMD in the EX-FR group was significantly lower than in the EX and SED-FR groups. These results suggest that food restriction induced low bone strength in young female rats engaging in voluntary running exercise. Also, through the interaction of exercise and food restriction, voluntary running exercise combined food restriction, unlike ad libitum feeding conditions, induced low bone strength, and low BMD in young female rats.

Design, validation, and reliability of survey to measure female athlete triad knowledge among coaches

The purpose of this study was to design and to test the validity and reliability of an instrument to evaluate coaches' knowledge about the female athlete triad syndrome and their confidence in this knowledge. The instrument collects information regarding: knowledge of the syndrome, components, prevention and intervention; confidence of the coaches in their answers; and coach's characteristics (gender, degree held, years of experience in coaching females, continuing education participation specific to the syndrome and its components, and sport coached). The process of designing the questionnaire and testing the validity and reliability of it was done in four phases: a) design and development of the instrument, b) content validity, c) instrument reliability, and d) concurrent validity. The results show that the instrument is suitable for measuring coaches' female athlete triad knowledge. The instrument can contribute to assessing the coaches' knowledge level in relation to this topic.

Identifying sex-specific risk factors for low bone mineral density in adolescent runners

BACKGROUND

Adolescent runners may be at risk for low bone mineral density (BMD) associated with sports participation. Few prior investigations have evaluated bone health in young runners, particularly males.

PURPOSE

To characterize sex-specific risk factors for low BMD in adolescent runners.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Training characteristics, fracture history, eating behaviors and attitudes, and menstrual history were measured using online questionnaires. A food frequency questionnaire was used to identify dietary patterns and measure calcium intake. Runners (female: n = 94, male: n = 42) completed dual-energy x-ray absorptiometry (DXA) to measure lumbar spine (LS) and total body less head (TBLH) BMD and body composition values, including android-to-gynoid (A:G) fat mass ratio. The BMD was standardized to Z-scores using age, sex, and race/ethnicity reference values. Questionnaire values were combined with DXA values to determine risk factors associated with differences in BMD Z-scores in LS and TBLH and low bone mass (defined as BMD Z-score ≤-1).

RESULTS

In multivariable analyses, risk factors for lower LS BMD Z-scores in girls included lower A:G ratio, being shorter, and the combination of (interaction between) current menstrual irregularity and a history of fracture (all P < .01). Later age of menarche, lower A:G ratio, lower lean mass, and drinking less milk were associated with lower TBLH BMD Z-scores (P < .01). In boys, lower body mass index (BMI) Z-scores and the belief that being thinner improves performance were associated with lower LS and TBLH BMD Z-scores (all P < .05); lower A:G ratio was additionally associated with lower TBLH Z-scores (P < .01). Thirteen girls (14%) and 9 boys (21%) had low bone mass. Girls with a BMI ≤17.5 kg/m(2) or both menstrual irregularity and a history of fracture were significantly more likely to have low bone mass. Boys with a BMI ≤17.5 kg/m(2) and belief that thinness improves performance were significantly more likely to have low bone mass.

CONCLUSION

This study identified sex-specific risk factors for impaired bone mass in adolescent runners. These risk factors can be helpful to guide sports medicine professionals in evaluation and management of young runners at risk for impaired bone health.

Recommendations for Healthy Nutrition in Female Endurance Runners: An Update

The purpose of this review is to present the basic principles of a healthy nutrition in female endurance runner enriched by the latest scientific recommendations. Female endurance runners are a specific population of athletes who need to take specifically care of daily nutrition due to the high load of training and the necessity to keep a rather low body mass. This paradoxical situation can create some nutritional imbalances and deficiencies. Female endurance athletes should pay attention to their total energy intake, which is often lower than their energy requirement. The minimal energy requirement has been set to 45 kcal/kg fat free mass/day plus the amount of energy needed for physical activity. The usual recommended amount of 1.2–1.4 g protein/kg/day has recently been questioned by new findings suggesting that 1.6 g/kg/day would be more appropriate for female athletes. Although a bit less sensitive to carbohydrate loading than their male counterparts, female athletes can benefit from this nutritional strategy before a race if the amount of carbohydrates reaches 8 g/kg/day and if their daily total energy intake is sufficient. A poor iron status is a common issue in female endurance runners but iron-enriched food as well as iron supplementation may help to counterbalance this poor status. Finally, they should also be aware that they may be at risk for low calcium and vitamin D levels.

Epidemiology of stress fracture injuries among US high school athletes, 2005-2006 through 2012-2013

BACKGROUND

High school athletes in the United States sustain millions of injuries annually, approximately 10% of which are fractures. However, there is no clear estimate of the number of stress fractures sustained by high school athletes annually despite reports that stress fractures account for 0.7% to 20% of injuries seen in sports medicine clinics. This suggests a high utilization of resources for a potentially preventable injury. In addition, stress fractures have been associated with low energy availability and disordered eating in young athletes, highlighting the importance of early recognition and intervention.

PURPOSE

To investigate stress fracture rates and patterns in a large national sample of US high school athletes.

STUDY DESIGN

Descriptive epidemiologic study.

METHODS

Data from High School RIO (Reporting Information Online), a national sports injury surveillance study, were analyzed to describe rates and patterns of stress fracture injury sustained from 2005-2006 through 2012-2013, across sports and by sex.

RESULTS

From 2005-2006 through 2012-2013, a total of 51,773 injuries were sustained during 25,268,873 athlete-exposures, of which 389 (0.8%) were stress fractures, resulting in an overall stress fracture rate of 1.54 per 100,000 athlete-exposures. Rates per 100,000 athlete-exposures were highest in girls' cross country (10.62), girls' gymnastics (7.43), and boys' cross country (5.42). In sex-comparable sports, girls sustained more stress fractures (63.3%) than did boys (36.7%) and had higher rates of stress fracture (2.22 vs 1.27; rate ratio, 1.75; 95% CI, 1.38-2.23). The most commonly injured sites were the lower leg (40.3% of all stress fractures), foot (34.9%), and lower back/lumbar spine/pelvis (15.2%). Management was nonsurgical in 98.7% of the cases, and 65.3% of injuries resulted in ≥3 weeks of time loss, medical disqualification, or an end to the season before athletes could return to play.

CONCLUSION

Although a rare injury, stress fractures cause considerable morbidity for high school athletes of both sexes. Future research should evaluate risks of stress fractures to drive development of targeted prevention efforts.

Associations between the female athlete triad and injury among high school runners

PURPOSE/BACKGROUND

During the 2013-14 school year, over 763,000 female athletes participated in interscholastic running sports in the United States. Recent studies have indicated associations between the female athlete triad (Triad) and stress fracture or other musculoskeletal injuries in elite or collegiate female running populations. Little is known about these relationships in an adolescent interscholastic running population. The purpose of this study was to determine the associations between Triad and risk of lower extremity musculoskeletal injury among adolescent runners.

METHODS

Eighty-nine female athletes competing in interscholastic cross-country and track in southern California were followed, prospectively. The runners were monitored throughout their respective sport season for lower extremity musculoskeletal injuries. Data collected included daily injury reports, Eating Disorder Examination Questionnaire (EDE-Q) that assessed disordered eating attitudes/behaviors, a questionnaire on menstrual history and demographic characteristics, a dual-energy x-ray absorptiometry scan that measured whole-body bone mineral density (BMD) and body composition (lean tissue and fat mass), and anthropometric measurements.

RESULTS

Thirty-eight runners (42.7%) incurred at least one lower extremity musculoskeletal injury. In the BMD Z-score ≤ -1 standard deviation (SD) adjusted model, low BMD relative to age (BMD Z-score of ≤ -1SD) was significantly associated (Odds Ratio [OR]=4.6, 95% confidence interval [CI]: 1.5-13.3) with an increased occurrence of musculoskeletal injury during the interscholastic sport season. In the BMD Z-score ≤ -2 SDs adjusted model, a history of oligo/amenorrhea was significantly associated (OR=4.1, 95% CI: 1.2-13.5) with increased musculoskeletal injury occurrence.

CONCLUSION

Oligo/amenorrhea and low BMD were associated with musculoskeletal injuries among the female interscholastic cross-country and track runners.

CLINICAL RELEVANCE

Regular, close monitoring of adolescent female runners during seasonal and off-season training may be warranted, so that potential problems can be recognized and addressed promptly in order to minimize the risk of running injury.

LEVEL OF EVIDENCE

2.

Current perspectives on the etiology and manifestation of the "silent" component of the Female Athlete Triad

The Female Athlete Triad (Triad) represents a syndrome of three interrelated conditions that originate from chronically inadequate energy intake to compensate for energy expenditure; this environment results in insufficient stored energy to maintain physiological processes, a condition known as low energy availability. The physiological adaptations associated with low energy availability, in turn, contribute to menstrual cycle disturbances. The downstream effects of both low energy availability and suppressed estrogen concentrations synergistically impair bone health, leading to low bone mineral density, compromised bone structure and microarchitecture, and ultimately, a decrease in bone strength. Unlike the other components of the Triad, poor bone health often does not have overt symptoms, and therefore develops silently, unbeknownst to the athlete. Compromised bone health among female athletes increases the risk of fracture throughout the lifespan, highlighting the long-term health consequences of the Triad. The purpose of this review is to examine the current state of Triad research related to the third component of the Triad, ie, poor bone health, in an effort to summarize what we know, what we are learning, and what remains unknown.

2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, CA, May 2012, and 2nd International Conference held in Indianapolis, IN, May 2013

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves 3 components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with 1 or more of the 3 Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement represents a set of recommendations developed following the first (San Francisco, California) and second (Indianapolis, Indianna) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad Expert Panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts. This consensus paper has been endorsed by The Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians, and other health care professionals, the American College of Sports Medicine, and the American Medical Society for Sports Medicine.

Female athlete triad for the primary care pediatrician

PURPOSE OF REVIEW

Female participation in athletics has increased significantly over the past several decades. For most young women, participation in sport fosters self-confidence, positive relationships with peers, and good physical health. However, with growing female representation in athletics, the sport community has become increasingly aware of the syndrome known as 'female athlete triad,' which describes the interplay between low energy availability (LEA), menstrual disturbances, and decreased bone mineral density (BMD). This review aims to discuss the definition and prevalence of the triad and prevention, detection, and treatment strategies.

RECENT FINDINGS

Current research has elucidated the importance of identifying and treating the triad in young athletes, as adolescence is a critical time for bone development and failure to intervene can lead to long-term problems. First defined in 1992, full characterization of the triad in adolescents has been elusive because of difficulties in diagnosing low BMD in this population and reliance on self-report for menstrual disturbances and LEA. A 2007 reformulation of the triad incorporated research demonstrating that the full deleterious triad is rare and emphasized that its components exist on a spectrum. Removal of the stigma from the triad has the potential to allow earlier detection and treatment, thereby improving outcomes.

SUMMARY

The female athlete triad is a problem with important long-term consequences. Education should be geared toward athletes as well as coaches, athletic trainers, school nurses, primary care providers, and others involved in female athletics to allow early identification and intervention.

Sport specificity of mental disorders: the issue of sport psychiatry

The prevalence of psychiatric conditions among elite athletes is still under debate. More and more evidence has accumulated that high-performance athletes are not protected from mental disorders as previously thought. The authors discuss the issue of the sport specificity of selected mental diseases in elite athletes. Specific aspects of eating disorders, exercise addiction, chronic traumatic encephalopathy and mood disorders in the context of overtraining syndrome are examined. In particular, the interrelationship between life and work characteristics unique to elite athletes and the development of mental disorders are reviewed. Differences of clinical presentation and some therapeutic consequences are discussed. The authors suggest that the physical and mental strains endured by elite athletes might influence the onset and severity of their psychiatric disorder. Beside the existing research strategies dealing with the amount of exercise, its intensity and lack of recreation experienced by athletes, further research on psycho-social factors is needed to better understand the sport-specific aetiology of mental disorders in high-performance athletes.