The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part 1: Definition and Scientific Basis.

ABSTRACT: The Male Athlete Triad is a syndrome of 3 interrelated conditions most common in adolescent and young adult male endurance and weight-class athletes and includes the clinically relevant outcomes of (1) energy deficiency/low energy availability (EA) with or without disordered eating/eating disorders, (2) functional hypothalamic hypogonadism, and (3) osteoporosis or low bone mineral density with or without bone stress injury (BSI). The causal role of low EA in the modulation of reproductive function and skeletal health in the male athlete reinforces the notion that skeletal health and reproductive outcomes are the primary clinical concerns. At present, the specific intermediate subclinical outcomes are less clearly defined in male athletes than those in female athletes and are represented as subtle alterations in the hypothalamic-pituitary-gonadal axis and increased risk for BSI. The degree of energy deficiency/low EA associated with such alterations remains unclear. However, available data suggest a more severe energy deficiency/low EA state is needed to affect reproductive and skeletal health in the Male Athlete Triad than in the Female Athlete Triad. Additional research is needed to further clarify and quantify this association. The Female and Male Athlete Triad Coalition Consensus Statements include evidence statements developed after a roundtable of experts held in conjunction with the American College of Sports Medicine 64th Annual Meeting in Denver, Colorado, in 2017 and are in 2 parts-Part I: Definition and Scientific Basis and Part 2: The Male Athlete Triad: Diagnosis, Treatment, and Return-to-Play. In this first article, we discuss the scientific evidence to support the Male Athlete Triad model.

The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part II: Diagnosis, Treatment, and Return-To-Play.

ABSTRACT: The Male Athlete Triad is a medical syndrome most common in adolescent and young adult male athletes in sports that emphasize a lean physique, especially endurance and weight-class athletes. The 3 interrelated conditions of the Male Athlete Triad occur on spectrums of energy deficiency/low energy availability (EA), suppression of the hypothalamic-pituitary-gonadal axis, and impaired bone health, ranging from optimal health to clinically relevant outcomes of energy deficiency/low EA with or without disordered eating or eating disorder, functional hypogonadotropic hypogonadism, and osteoporosis or low bone mineral density with or without bone stress injury (BSI). Because of the importance of bone mass acquisition and health concerns in adolescence, screening is recommended during this time period in the at-risk male athlete. Diagnosis of the Male Athlete Triad is best accomplished by a multidisciplinary medical team. Clearance and return-to-play guidelines are recommended to optimize prevention and treatment. Evidence-based risk assessment protocols for the male athlete at risk for the Male Athlete Triad have been shown to be predictive for BSI and impaired bone health and should be encouraged. Improving energetic status through optimal fueling is the mainstay of treatment. A Roundtable on the Male Athlete Triad was convened by the Female and Male Athlete Triad Coalition in conjunction with the 64th Annual Meeting of the American College of Sports Medicine in Denver, Colorado, in May of 2017. In this second article, the latest clinical research to support current models of screening, diagnosis, and management for at-risk male athlete is reviewed with evidence-based recommendations.

Disordered Eating, Development of Menstrual Irregularity, and Reduced Bone Mass Change After a 3-Year Follow-Up In Female Adolescent Endurance Runners.

This prospective study evaluated the 3-year change in menstrual function and bone mass among 40 female adolescent endurance runners (age 15.9 ± 1.0 years) according to baseline disordered eating status. Three years after initial data collection, runners underwent follow-up measures including the Eating Disorder Examination Questionnaire and a survey evaluating menstrual function, running training, injury history, and prior sports participation. Dual-energy X-ray absorptiometry was used to measure bone mineral density and body composition. Runners with a weight concern, shape concern, or global score ≥4.0 or reporting >1 pathologic behavior in the past 28 days were classified with disordered eating. Compared with runners with normal Eating Disorder Examination Questionnaire scores at baseline, runners with disordered eating at baseline reported fewer menstrual cycles/year (6.4 ± 4.5 vs. 10.5 ± 2.8, p = .005), more years of amenorrhea (1.6 ± 1.4 vs. 0.3 ± 0.5, p = .03), and a higher proportion of menstrual irregularity (75.0% vs. 31.3%, p = .02) and failed to increase lumbar spine or total hip bone mineral density at the 3-year follow-up. In a multivariate model including body mass index and menstrual cycles in the past year at baseline, baseline shape concern score (B = -0.57, p value = .001) was inversely related to the annual number of menstrual cycles between assessments. Weight concern score (B = -0.40, p value = .005) was inversely associated with lumbar spine bone mineral density Z-score change between assessments according to a multivariate model adjusting for age and body mass index. These finding support associations between disordered eating at baseline and future menstrual irregularities or reduced accrual of lumbar spine bone mass in female adolescent endurance runners.

An Investigation of Habitual Dietary Supplement Use Among 557 NCAA Division I Athletes.

Background: Supplements may expose athletes to dangerous ingredients, banned substances, toxins or contaminants; however, few investigations assess use among collegiate athletes in the U.S.Objective: This cross-sectional study evaluated habitual dietary supplement intake, defined use ≥2 days/week over the past year, in NCAA Division I athletes.Methods: Male and female members of a NCAA Division I team, at two universities in southern California completed a 13-item survey. Among 705 eligible participants, 596 submitted surveys (84.5% response rate), 557 surveys included complete data. Chi-square (χ2) analyses evaluated differences among athletes based on sex, weight status, year in college, and sport-type. Independent t-test or ANOVA evaluated mean differences for continuous variables.Results: A total of 45.2% athletes (n = 252) reported taking supplements (≥2 days/week over the past year). Vitamin/minerals (25.5%, n = 142), protein/amino acids (24.6%, n = 137) were used most frequently. Male, vs female athletes, took more supplements overall (1.2 ± 0.1 vs 0.8 ± 0.1, p = 0.004) and indicated higher use of protein/amino acid products (34.2% vs 13.5%, p < 0.005), whereas, females reported higher use of vitamin/minerals (30.5% vs 21.1%, p < 0.05). Higher supplement use was also reported by athletes with BMI ≥ 30.0 kg/m2 (vs <30 kg/m2, 1.9 ± 0.3 vs 1.0 ± 0.1, p = 0.02), and athletes in ≥ third college year (vs first or second year, 1.2 ± 0.1 vs 0.9 ± 0.1, p = 0.03).Conclusions: Nearly half of NCAA athletes reported habitual supplements use, with significant variation in patterns based on sex, sport-type, year in college, and weight status.

Disordered Eating Among a Diverse Sample of First-Year College Students.

OBJECTIVE: A cross-sectional study of first-year college students was conducted to identify the prevalence and predictors of disordered eating (DE). METHODS: College freshmen students, aged 18 years, (n = 106) completed the Eating Disorder Examination Questionnaire (EDE-Q) and a supplemental survey. A subset of the sample (n = 77) underwent measurements of height, weight, and body composition. DE was defined as an elevated (3) weight, shape, eating concern, or dietary restraint EDE-Q subscale score. RESULTS: The sample, consisting of 56.6%, 15.1%, 11.3%, and 11.3% Latino/a, Asian, African American, and Caucasian students, respectively (37% male), reported a 31.1% prevalence of DE. The current desire to lose weight was the strongest predictor of DE (odds ratio = 15.3; 95% confidence interval = 2.8, 82.5). Other variables linked to DE or elevated EDE-Q subscale scores included body mass index (BMI) 25.0 kg/m2, vegetarianism, weight loss in the past year, female gender, and eating breakfast < 5 d/wk. Participants with BMI 25.0 kg/m2 and the current desire to lose weight (n = 23) or following a vegetarian diet (n = 5) exhibited the highest prevalence of DE (78.3% and 80.0%, respectively). A higher proportion of Latinas reported binge episodes compared to female Caucasian, Asian, and African American students (36.4% vs. 0.0%, 6.7%, and 28.6%, respectively, p = 0.056, χ2 = 7.6). Males, versus females, were more likely to report excessive exercise (56.4% vs. 37.3%, p = 0.056, χ2 = 3.6). CONCLUSIONS: This study adds to the current body of literature on DE by providing a diverse sample and potentially novel predictors and risk factors for DE.

Bone stress injuries in male distance runners: higher modified Female Athlete Triad Cumulative Risk Assessment scores predict increased rates of injury.

OBJECTIVES: Bone stress injuries (BSI) are common in runners of both sexes. The purpose of this study was to determine if a modified Female Athlete Triad Cumulative Risk Assessment tool would predict BSI in male distance runners. METHODS: 156 male runners at two collegiate programmes were studied using mixed retrospective and prospective design for a total of 7 years. Point values were assigned using risk assessment categories including low energy availability, low body mass index (BMI), low bone mineral density (BMD) and prior BSI. The outcome was subsequent development of BSI. Statistical models used a mixed effects Poisson regression model with p<0.05 as threshold for significance. Two regression analyses were performed: (1) baseline risk factors as the independent variable; and (2) annual change in risk factors (longitudinal data) as the independent variable. RESULTS: 42/156 runners (27%) sustained 61 BSIs over an average 1.9 years of follow-up. In the baseline risk factor model, each 1 point increase in prior BSI score was associated with a 57% increased risk for prospective BSI (p=0.0042) and each 1 point increase in cumulative risk score was associated with a 37% increase in prospective BSI risk (p=0.0079). In the longitudinal model, each 1 point increase in cumulative risk score was associated with a 27% increase in prospective BSI risk (p=0.05). BMI (rate ratio (RR)=1.91, p=0.11) and BMD (RR=1.58, p=0.19) risk scores were not associated with BSI. CONCLUSION: A modified cumulative risk assessment tool may help identify male runners at elevated risk for BSI. Identifying risk factors may guide treatment and prevention strategies.

Prevalence and Predictors of Higher-Risk Supplement Use Among Collegiate Athletes.

Sassone, J, Muster, M, and Barrack, MT. Prevalence and predictors of higher-risk supplement use among National Collegiate Athletic Association Division I athletes. J Strength Cond Res 33(2): 443-450, 2019-This study aimed to identify the prevalence and predictors associated with the use of higher-risk dietary supplements, defined as supplements containing herbal ingredients, caffeine, or those classified for weight loss, muscle-building, or as a preworkout supplement, among 557 National Collegiate Athletic Association Division I male and female collegiate athletes. Although 252 (45.2%) athletes reported the use of a dietary supplement on ≥2 days per week over the past year, 46 (8.3%) athletes met criteria for higher-risk supplement use. Twenty (3.6%) athletes reported the use of herbal, 1 (0.2%) caffeinated, 5 (0.9%) weight loss, 28 (5.0%) preworkout, and 1 (0.2%) muscle-building supplements. Body mass index status (BMI ≥30 kg·m), sport-type (sports using the phosphocreatine energy system), and college year (≥4th year) were associated with the use of preworkout, muscle-building, or herbal supplements. A multiple regression analysis identified predictors of higher-risk supplement use including the number of dietary supplements used in the past year (odds ratio [OR] = 2.1, 95% confidence interval [CI] = 1.7-2.7, p < 0.001), the reported motivation of taking dietary supplements to gain muscle and lose body fat (OR = 3.5, 95% CI = 1.1-11.7, p = 0.04), and the motivation to increase athletic endurance (OR = 3.5, 95% CI = 4.0, 95% CI = 1.6-9.9, p < 0.005). These factors may be considered as a part of a screening process to evaluate athletes with an increased risk of higher-risk supplement use and potential consequences to health or eligibility status.

Evidence of a cumulative effect for risk factors predicting low bone mass among male adolescent athletes.

BACKGROUND: Limited research has evaluated risk factors for low bone mineral density (BMD) in male adolescent athletes. AIMS/OBJECTIVES: To evaluate predictors of low BMD (defined as BMD Z-score <-1.0) in a sample of male adolescent distance runner and non-runner athletes. METHODS: Male adolescent athletes completed a survey characterising sports participation, nutrition, stress fracture history, dual energy X-ray absorptiometry (DXA)-measured BMD and body composition. Independent t-tests and analysis of covariance (ANCOVA) evaluated group differences; logistic regression evaluated low BMD risk factors. RESULTS: Runners (n=51) exhibited a lower body weight (p=0.02), body mass index (BMI) (kg/m2) (p=0.02), per cent expected weight (p=0.02) and spine BMD Z-score (p=0.002) compared with non-runners (n=18). Single risk factors of low BMD included <85% expected weight (OR=5.6, 95% CI 1.4 to 22.5) and average weekly mileage >30 in the past year (OR=6.4, 95% CI 1.5 to 27.1). The strongest two-variable and three-variable risk factors included weekly mileage >30+ stress fracture history (OR=17.3, 95% CI 1.6 to 185.6) and weekly mileage >30+<85% expected weight + stress fracture history (OR=17.3, 95% CI 1.6 to 185.6), respectively. Risk factors were cumulative when predicting low BMD (including <85% expected weight, weekly mileage >30, stress fracture history and <1 serving of calcium-rich food/day): 0-1 risk factors (11.1%), 2 risk factors (42.9%), or 3-4 risk factors (80.0%), p<0.001). CONCLUSIONS: Male adolescent runners exhibited lower body weight, BMI and spine BMD Z-score values. The risk of low BMD displayed a graded relationship with increasing risk factors, highlighting the importance of using methods to optimise bone mass in this population.

Body Mass-Related Predictors of the Female Athlete Triad Among Adolescent Athletes.

Early detection of the female athlete triad is essential for the long-term health of adolescent female athletes. The purpose of this study was to assess relationships between common anthropometric markers (ideal body weight [IBW] via the Hamwi formula, youth-percentile body mass index [BMI], adult BMI categories, and body fat percentage [BF%]) and triad components, (low energy availability [EA], measured by dietary restraint [DR], menstrual dysfunction [MD], low bone mineral density [BMD]). In the sample (n = 320) of adolescent female athletes (age 15.9± 1.2 y), Spearman's rho correlations and multiple logistic regression analyses evaluated associations between anthropometric clinical cutoffs and triad components. All underweight categories for the anthropometric measures predicted greater likelihood of MD and low BMD. Athletes with an IBW >85% were nearly 4 times more likely to report MD (OR = 3.7, 95% CI [1.8, 7.9]) and had low BMD (OR = 4.1, 95% CI [1.2, 14.2]). Those in <5th percentile for their age-specific BMI were 9 times more likely to report MD (OR 9.1, 95% CI [1.8, 46.9]) and had low BMD than those in the 50th to 85th percentile. Athletes with a high BF% were almost 3 times more likely to report DR (OR = 2.8, 95% CI [1.4, 6.1]). Our study indicates that low age-adjusted BMI and low IBW may serve as evidence-based clinical indicators that may be practically evaluated in the field, predicting MD and low BMD in adolescents. These measures should be tested for their ability as tools to minimize the risk for the triad.

Epidemiology of injuries in U.S. high school track and field throwing events from 2008 to 2019.

BACKGROUND: Injury characteristics of high school track and field throwing athletes in the United States are not well studied. Understanding epidemiology of injuries is important to identify treatment and prevention strategies. OBJECTIVE: To describe injury rates and patterns in U.S. high school track and field throwing events from a longitudinal national sports injury surveillance system. DESIGN: Descriptive epidemiology study. SETTING: Data were provided by the National High School Sports Related Injury Surveillance System, High School RIO (Reporting Information Online). METHODS: Athletic trainers reported injury and exposure data through the High School RIO website on a weekly basis. An athlete exposure (AE) was defined as one athlete participating in one school-sanctioned practice or competition. Throwing events of discus, shot put, and javelin were analyzed in this study. MAIN OUTCOME MEASURES: Injury rate, rate ratios (RR), injury proportion ratios (IPR). PARTICIPANTS: U.S. high school athletes. RESULTS: A total of 267 track and field throwing injuries occurred during 5,486,279 AEs. Overall, the rate of injuries in competition was higher than in practice (RR 1.35, 95% confidence interval [CI] 1.01-1.80). In practice, the rate of injuries was higher for girls than boys (RR 1.53, 95% CI 1.12-2.08). The most frequently injured body part was the shoulder (21.7%), followed by the ankle (16.5%) and knee (12.0%). The most common types of injury were muscle strains (26.14%) and ligament sprains (25%). Recurrent injuries accounted for a higher proportion of chronic injuries compared to new injuries (IPR 1.85, 95% CI 1.16-2.97). CONCLUSION: This study described injury characteristics of high school track and field throwing athletes from 2008 to 2019. Based on our results, injury prevention may be particularly important for female throwers with prior injury.

International society of sports nutrition position stand: ketogenic diets.

POSITION STATEMENT: The International Society of Sports Nutrition (ISSN) provides an objective and critical review of the use of a ketogenic diet in healthy exercising adults, with a focus on exercise performance and body composition. However, this review does not address the use of exogenous ketone supplements. The following points summarize the position of the ISSN.1. A ketogenic diet induces a state of nutritional ketosis, which is generally defined as serum ketone levels above 0.5 mM. While many factors can impact what amount of daily carbohydrate intake will result in these levels, a broad guideline is a daily dietary carbohydrate intake of less than 50 grams per day.2. Nutritional ketosis achieved through carbohydrate restriction and a high dietary fat intake is not intrinsically harmful and should not be confused with ketoacidosis, a life-threatening condition most commonly seen in clinical populations and metabolic dysregulation.3. A ketogenic diet has largely neutral or detrimental effects on athletic performance compared to a diet higher in carbohydrates and lower in fat, despite achieving significantly elevated levels of fat oxidation during exercise (~1.5 g/min).4. The endurance effects of a ketogenic diet may be influenced by both training status and duration of the dietary intervention, but further research is necessary to elucidate these possibilities. All studies involving elite athletes showed a performance decrement from a ketogenic diet, all lasting six weeks or less. Of the two studies lasting more than six weeks, only one reported a statistically significant benefit of a ketogenic diet.5. A ketogenic diet tends to have similar effects on maximal strength or strength gains from a resistance training program compared to a diet higher in carbohydrates. However, a minority of studies show superior effects of non-ketogenic comparators.6. When compared to a diet higher in carbohydrates and lower in fat, a ketogenic diet may cause greater losses in body weight, fat mass, and fat-free mass, but may also heighten losses of lean tissue. However, this is likely due to differences in calorie and protein intake, as well as shifts in fluid balance.7. There is insufficient evidence to determine if a ketogenic diet affects males and females differently. However, there is a strong mechanistic basis for sex differences to exist in response to a ketogenic diet.

Comparative analysis between a brief nutrition screening survey and validated food frequency questionnaire among physically active college students.

OBJECTIVE: To evaluate the agreement between a 61-item Nutrition Screening Survey (NSS) and 127-item validated Food Frequency Questionnaire (FFQ). PARTICIPANTS: Forty-seven college students (male, n = 29; female, n = 18), age 21.7 ± 0.4 years, BMI of 23.5 ± 0.4 kg/m2. METHODS: Participants completed the NSS, Block FFQ, and anthropometric measurements. Pearson's correlation, paired sample t test, and Bland-Altman plot evaluated agreement between the assessments. RESULTS: Moderate to strong associations between assessments (0.61-0.89, p < 0.001) were identified for meals/day, snacks/day, calories, carbohydrate, fiber, grains, non-starchy vegetables, potatoes, legumes, fruit, yogurt, cheese, and eggs. Mean daily meals/day, calories, fat, fiber, grains, fruit, milk, and eggs did not significantly differ between surveys. The Bland-Altman plot analyses indicated no proportional bias for calories, fat, fiber, grains, fruit, milk, and eggs. CONCLUSIONS: The NSS and Block FFQ display reasonable agreement, supporting use of the NSS for evaluating a range of dietary components among physically active college students.

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.

Support for inadvertent undereating in female adolescent athletes with clinical indicators of low energy availability.

OBJECTIVES: This study evaluated pathways to low energy availability in a sample of female adolescent athletes (n = 464). DESIGN: Cross-sectional. METHODS: Participants (age 13-18 y) underwent assessments for height, weight, eating attitudes and behaviors, and menstrual function. Bone mineral density and body composition were evaluated by dual-energy x-ray absorptiometry in a subset of participants (n = 209). Athletes were classified with clinical indicators of low energy availability if they met criteria for 1) primary or secondary amenorrhea or 2) clinical underweight status (body mass index-for-age < 5th percentile). Disordered eating was assessed using the Eating Disorder Examination Questionnaire. RESULTS: Thirty (6.5%) athletes exhibited clinical indicators of low energy availability, with higher estimates in leanness than non-leanness sports (10.9% vs. 2.1%, p < 0.005). Among athletes with clinical indicators of low energy availability, 80% (n = 24) did not meet criteria for disordered eating, eating disorder, or report the desire to lose weight. Athletes with (vs. without) clinical indicators of low energy availability exhibited lower lumbar spine (-1.30 ±â€¯1.38 vs. -0.07 ±â€¯1.21, p < 0.001) and total body (-0.30 ±â€¯0.98 vs. 0.53 ±â€¯0.97, p < 0.006) bone mineral density Z-scores. CONCLUSIONS: A majority of female adolescent athletes with clinical indicators of low energy availability did not exhibit characteristics consistent with intentional dietary restriction, supporting the significance of the inadvertent pathway to low energy availability and need for increased nutrition education in this population.

Healthy Runner Project: a 7-year, multisite nutrition education intervention to reduce bone stress injury incidence in collegiate distance runners.

Objectives: We evaluated the effect of a nutrition education intervention on bone stress injury (BSI) incidence among female distance runners at two NCAA Division I institutions. Methods: Historical BSI rates were measured retrospectively (2010-2013); runners were then followed prospectively in pilot (2013-2016) and intervention (2016-2020) phases. The primary aim was to compare BSI rates in the historical and intervention phases. Pilot phase data are included only for descriptive purposes. The intervention comprised team nutrition presentations focused on optimising energy availability plus individualised nutrition sessions for runners with elevated Female Athlete Triad risk. Annual BSI rates were calculated using a generalised estimating equation Poisson regression model adjusted for age and institution. Post hoc analyses were stratified by institution and BSI type (trabecular-rich or cortical-rich). Results: The historical phase included 56 runners and 90.2 person-years; the intervention phase included 78 runners and 137.3 person-years. Overall BSI rates were not reduced from the historical (0.52 events per person-year) to the intervention (0.43 events per person-year) phase. Post hoc analyses demonstrated trabecular-rich BSI rates dropped significantly from 0.18 to 0.10 events per person-year from the historical to intervention phase (p=0.047). There was a significant interaction between phase and institution (p=0.009). At Institution 1, the overall BSI rate dropped from 0.63 to 0.27 events per person-year from the historical to intervention phase (p=0.041), whereas no decline was observed at Institution 2. Conclusion: Our findings suggest that a nutrition intervention emphasising energy availability may preferentially impact trabecular-rich BSI and depend on team environment, culture and resources.

Restoration of menses with nonpharmacologic therapy in college athletes with menstrual disturbances: a 5-year retrospective study.

BACKGROUND: Functional hypothalamic amenorrhea is common among female athletes and may be difficult to treat. Restoration of menses (ROM) is crucial to prevent deleterious effects to skeletal and reproductive health. OBJECTIVES: To determine the natural history of menstrual disturbances in female college athletes managed with nonpharmacologic therapies including increased dietary intake and/or decreased exercise expenditure and to identify factors associated with ROM. STUDY DESIGN: A 5-yr retrospective study of college athletes at a major Division I university. METHODS: 373 female athletes' charts were reviewed. For athletes with menstrual disturbances, morphometric variables were noted. Months to ROM were recorded for each athlete. RESULTS: Fifty-one female athletes (19.7%) had menstrual disturbances (14.7% oligomenorrheic, 5.0% amenorrheic). In all, 17.6% of oligo-/amenorrheic athletes experienced ROM with nonpharmacologic therapy. Mean time to ROM among all athletes with menstrual disturbances was 15.6 ± 2.6 mo. Total absolute (5.3 ± 1.1 kg vs. 1.3 ± 1.1 kg, p < .05) and percentage (9.3% ± 1.9% vs. 2.3% ± 1.9%, p < .05) weight gain and increase in body-mass index (BMI; 1.9 ± 0.4 kg/m2 vs. 0.5 ± 0.4 kg/m2, p < .05) emerged as the primary differentiating characteristics between athletes with ROM and those without ROM. Percent weight gain was identified as a significant positive predictor of ROM, OR (95% CI) = 1.25 (1.01, 1.56), p < .05. CONCLUSIONS: Nonpharmacologic intervention in college athletes with menstrual disturbances can restore regular menstrual cycles, although ROM may take more than 1 yr. Weight gain or an increase in BMI may be important predictors of ROM.

Dietary Supplement Intake and Factors Associated with Increased Use in Preadolescent Endurance Runners.

BACKGROUND: The prevalence of dietary supplement intake among preadolescent endurance runners is currently unknown. OBJECTIVE: Our aim was to describe use of dietary supplements, higher-risk supplements, and sport foods among preadolescent endurance athletes and identify associated characteristics of dietary supplement users in this population. DESIGN: This was a retrospective, cross-sectional study. PARTICIPANTS/SETTING: Participants were 2,113 preadolescent endurance runners (male: n = 1,255, female: n = 858; mean age ± standard deviation = 13.2 ± 0.9 years). MAIN OUTCOME MEASURES: Use of dietary supplements, higher-risk dietary supplements, and sport foods on 2 or more days per week during the past year. STATISTICAL ANALYSES PERFORMED: Mann-Whitney U tests, χ2 tests, univariate and multivariate analyses. RESULTS: Twenty-six percent (n = 551) of preadolescent runners used dietary supplements on 2 or more days per week during the past year; 1.3% (n = 27) reported taking higher-risk supplements. Compared with male runners, female runners reported higher use of 1 or more supplements (32.5% vs 21.7%; P < .001) and 4 or more supplements (4.0% vs 1.9%; P = 0.005), multivitamin/minerals (24.2% vs 14.4%; P < .001), vitamin D (12.4% vs 5.6%; P < .001), calcium (8.9% vs 4.8%; P < .001), iron (3.1 vs 1.1%; P < .001), probiotic supplements (8.2% vs 1.3%; P < .001), and diet pills (0.5% vs 0.0%; P = .02). Male runners reported higher use of creatine (1.3% vs 0.0%; P < .001) and sport foods, including protein bars and drinks (19.5% vs 8.4%; P < .001), energy bars (23.5% vs 9.7%; P < .001), and carbohydrate-electrolyte drinks (27.9% vs 13.3%; P < .001) than female runners. Factors independently associated with a higher likelihood for dietary supplement use included weight loss in the past year, female (vs male) gender, following a vegetarian diet, skipping meals, attempting to gain weight, and history of a running-related bone stress injury. CONCLUSIONS: More than one-quarter of preadolescent runners regularly consumed dietary supplements. Behaviors consistent with dietary restriction and history of bone stress injury were associated with higher likelihood for supplement use. Further work to understand supplement use patterns and potential value for nutrition education is advised to optimize health of preadolescent runners.

Adolescent Endurance Runners Exhibit Suboptimal Energy Availability and Intakes of Key Nutrients.

Backgroud: Despite the evidence of an elevated prevalence of low bone mass in adolescent endurance runners, reports on dietary intake in this population is limited.Objectives: This study aimed to evaluate energy availability (EA) and dietary intake among 72 (n = 60 female, n = 12 male) high school cross-country runners.Methods: The sample consisted of a combined dataset of two cohorts. In both cohorts, the Block Food Frequency Questionnaire (FFQ; 2005 & 2014 versions) assessed dietary intake. Fat free mass was assessed using dual-energy x-ray absorptiometry or bioelectrical impedance analysis.Results: Mean EA was less than recommended (45 kcal/kgFFM/day) among male (35.8 ± 14.4 kcal/kg FFM/day) and female endurance runners (29.6 ± 17.4 kcal/kgFFM/day), with 30.0% of males and 60.0% of females meeting criteria for low EA (<30 kcal/kgFFM/day). Calorie intake for male (2,614.2 ± 861.8 kcal/day) and female (1,879.5 ± 723.6 kcal/day) endurance runners fell below the estimated energy requirement for "active" boys (>3,100 kcal/day) and girls (>2,300 kcal/day). Female endurance runners' relative carbohydrate intake (4.9 ± 2.1 g/kg/day) also fell below recommended levels (6-10 g/kg/day). Male and female endurance runners exhibited below-recommended intakes of calcium, vitamin D, potassium, fruit, vegetables, grains, and dairy. Compared to male endurance runners, female endurance runners demonstrated lower relative intakes of energy (kcal/kg/day), protein (g/kg/day), fat (g/kg/day), fiber, vegetables, total protein, and oils.Conclusion: This study provides evidence of the nutritional risk of adolescent endurance runners and underscores the importance of nutritional support efforts in this population.