Higher Triad Risk Scores Are Associated With Increased Risk for Trabecular-Rich Bone Stress Injuries in Female Runners.

OBJECTIVE: Bone stress injuries (BSIs) in trabecular-rich bone are associated with greater biological risk factors compared with cortical-rich bone. We hypothesized that female runners with high Female Athlete Triad (Triad)-related risk would be at greater risk for trabecular-rich BSIs than runners with low Triad-related risk. DESIGN: Prospective cohort study. SETTING: Two NCAA institutions. PARTICIPANTS: Female runners were followed prospectively for up to 5 years. INTERVENTION: The intervention consisted of team nutrition presentations focused on optimizing energy availability plus individualized nutrition sessions. Triad Cumulative Risk Assessment (CRA) categories were assigned yearly based on low-energy availability, menstrual status, age of menarche, low body mass index, low bone mineral density, and prior BSI. MAIN OUTCOME MEASURES: The outcome was the annual incidence of trabecular- and cortical-rich BSI. Generalized Estimating Equations (GEE, to account for the correlated nature of the observations) with a Poisson distribution and log link were used for statistical modeling. RESULTS: Cortical-rich BSI rates were higher than trabecular-rich BSI rates (0.32 vs 0.13 events per person-year). Female runners with high Triad-related risk had a significantly higher incidence rate ratio of trabecular-rich BSI (RR: 4.40, P = 0.025) and cortical-rich BSI (RR: 2.87, P = 0.025) than women with low Triad-related risk. Each 1-point increase in Triad CRA score was associated with a significant 26% increased risk of trabecular-rich BSI ( P = 0.0007) and a nonsignificant 14% increased risk of cortical-rich BSI ( P = 0.054). CONCLUSIONS: Increased Triad CRA scores were strongly associated with increased risk for trabecular-rich BSI. Incorporating Triad CRA scores in clinical care could guide BSI prevention.

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.

The Path Towards Progress: A Critical Review to Advance the Science of the Female and Male Athlete Triad and Relative Energy Deficiency in Sport.

Energy status plays a key role in the health of athletes and exercising individuals. Energy deficiency/low energy availability (EA), referring to a state in which insufficient energy intake and/or excessive exercise energy expenditure has resulted in compensatory metabolic adaptations to conserve fuel, can affect numerous physiological systems in women and men. The Female Athlete Triad, Male Athlete Triad, and Relative Energy Deficiency in Sport (RED-S) models conceptualize the effects of energy deficiency in athletes, and each model has strengths and limitations. For instance, the Female Athlete Triad model depicts relationships between low EA, reproductive, and bone health, underpinning decades of experimental evidence, but may be perceived as limited in scope, while the more recent RED-S model proposes a wider range of potential health effects of low EA, though many model components require more robust scientific justification. This critical review summarizes current evidence regarding the effects of energy deficiency on athlete health by addressing the quality of the underlying science, the strengths and limitations of each model, and highlighting areas where future research is needed to advance the field. With the health and wellness of athletes and exercising individuals as the overarching priority, we conclude with specific steps that will help focus future research on the Female and Male Athlete Triad and RED-S, and encourage all researchers, clinicians, and practitioners to collaborate to support the common goal of promoting the highest quality science and evidence-based medicine in pursuit of the advancement of athletes' health, well-being, and performance.

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.

Sexual violence in sport: American Medical Society for Sports Medicine Position Statement.

The American Medical Society for Sports Medicine (AMSSM) convened a group of experts to develop a Position Statement addressing the problem of sexual violence in sport. The AMSSM Sexual Violence in Sport Task Force held a series of meetings over 7 months, beginning in July 2019. Following a literature review, the Task Force used an iterative process and expert consensus to finalise the Position Statement. The objective of this Position Statement is to raise awareness of this critical issue among sports medicine physicians and to declare a commitment to engage in collaborative, multidisciplinary solutions to reduce sexual violence in sport.

Dietary Supplement Use According to Sex and Triad Risk Factors in Collegiate Endurance Runners.

ABSTRACT: Barrack, MT, Fredericson, M, Dizon, F, Tenforde, AS, Kim, BY, Kraus, E, Kussman, A, Singh, S, and Nattiv, A. Dietary supplement use according to sex and Triad risk factors in collegiate endurance runners. J Strength Cond Res 35(2): 404-410, 2021-This cross-sectional study evaluated the prevalence in the use of dietary supplements among elite collegiate runners among 2 NCAA Division I cross-country teams. At the start of each season from 2015 to 2017, male and female endurance runners were recruited to complete baseline study measures; the final sample included 135 (male n = 65, female n = 70) runners. Runners completed a health survey, web-based nutrition survey, and Triad risk assessment. The prevalence of dietary supplement use and Triad risk factors, including disordered eating, low bone mass, amenorrhea (in women), low body mass index, and stress fracture history, was assessed. A total of 78.5% (n = 106) runners reported taking 1 or more supplements on ≥4 days per week over the past month, 48% (n = 65) reported use of ≥3 supplements. Products used with highest frequency included multivitamin/minerals 46.7% (n = 63), iron 46.7% (n = 63), vitamin D 34.1% (n = 46), and calcium 33.3% (n = 45). More women, compared with men, used iron (61.4 vs. 30.8%, p < 0.001) and calcium (41.4 vs. 24.6%, p = 0.04); men exhibited higher use of amino acids and beta-alanine (6.2 vs. 0%, p = 0.04). Runners with bone stress injury (BSI) history, vs. no previous BSI, reported more frequent use of ≥3 supplements (61.5 vs. 32.8%, p = 0.001), vitamin D (49.2 vs. 19.4%, p < 0.001), and calcium (47.7 vs. 19.4%, p = 0.001). Low bone mineral density was also associated with higher use of vitamin D and calcium. Most runners reported regular use of 1 or more supplements, with patterns of use varying based on sex, history of BSI, and bone mass.

Sexual Violence in Sport: American Medical Society for Sports Medicine Position Statement.

The American Medical Society for Sports Medicine (AMSSM) convened a group of experts to develop a position statement addressing the problem of sexual violence in sport. The AMSSM Sexual Violence in Sport Task Force held a series of meetings over 7 months, beginning in July 2019. Following a literature review, the task force used an iterative process and expert consensus to finalize the position statement. The objective of this position statement is to raise awareness of this critical issue among sports medicine physicians and to declare a commitment to engage in collaborative, multidisciplinary solutions to reduce sexual violence in sport.

Sexual Violence in Sport: American Medical Society for Sports Medicine Position Statement.

The American Medical Society for Sports Medicine (AMSSM) convened a group of experts to develop a Position Statement addressing the problem of sexual violence in sport. The AMSSM Sexual Violence in Sport Task Force held a series of meetings over 7 months, beginning in July 2019. Following a literature review, the task force used an iterative process and expert consensus to finalize the position statement. The objective of this position statement is to raise awareness of this critical issue among sports medicine physicians and to declare a commitment to engage in collaborative, multidisciplinary solutions to reduce sexual violence in sport.

Sexual Violence in Sport: American Medical Society for Sports Medicine Position Statement.

The American Medical Society for Sports Medicine (AMSSM) convened a group of experts to develop a Position Statement addressing the problem of sexual violence in sport. The AMSSM Sexual Violence in Sport Task Force held a series of meetings over 7 months, beginning in July 2019. Following a literature review, the task force used an iterative process and expert consensus to finalize the Position Statement. The objective of this Position Statement is to raise awareness of this critical issue among sports medicine physicians and to declare a commitment to engage in collaborative, multidisciplinary solutions to reduce sexual violence in sport.

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.

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.

2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management.

Eating disorders, such as anorexia nervosa and bulimia nervosa, can have devastating effects on both the health and performance of athletes. Compared to non-athletes, both female and male athletes are at higher risk of developing an eating disorder. This is especially true for athletes participating in sports where low body weight or leanness confers a competitive advantage. Screening for disordered eating behaviours, eating disorders and for related health consequences should be a standard component of preparticipation examinations, and team physicians should be knowledgeable of the updated diagnostic criteria for eating disorders in the Diagnostic and Statistical Manual-V. Athletes with eating disorders should undergo thorough evaluation and treatment by an experienced multidisciplinary team. Team physicians play a critical role in decision-making on clearance for participation and return to play. Using evidence-based guidelines for clearance and return to play encourages transparency and accountability between the sports medicine care team and the athlete. Efforts to prevent eating disorders should be aimed at athletes, coaches, parents and athletic administrators, and focused on expanding knowledge of healthy nutrition in support of sport performance and health.

Parallels with the Female Athlete Triad in Male Athletes.

Participation in sports offers many health benefits to athletes of both sexes. However, subsets of both female and male athletes are at increased risk of impaired bone health and bone stress injuries. The Female Athlete Triad (Triad) is defined as the interrelationship of low energy availability (with or without disordered eating), menstrual dysfunction, and low bone mineral density. The Triad may result in health consequences, including bone stress injuries. Our review presents evidence that an analogous process may occur in male athletes. Our review of the available literature indicates that a subset of male athletes may experience adverse health issues that parallel those associated with the Triad, including low energy availability (with or without disordered eating), hypogonadotropic hypogonadism, and low bone mineral density. Consequently, male athletes may be predisposed to developing bone stress injuries, and these injuries can be the first presenting feature of associated Triad conditions. We discuss the evidence for impaired nutrition, hormonal dysfunction, and low bone mineral density in a subset of male athletes, and how these health issues may parallel those of the Triad. With further research into the mechanisms and outcomes of these health concerns in active and athletic men, evidence-based guidelines can be developed that result in best practice.

Health Considerations in Female Runners.

Female participation in running is at a historical high. Special consideration should be given to this population, in whom suboptimal nutritional intake, menstrual irregularity, and bone stress injury are common. Immature athletes should garner particular attention. Advances in the understanding of the Triad and Triad-related conditions have largely informed the approach to the health of this population. Clinicians should be well versed in the identification of Triad-related risk factors. A multidisciplinary team may be necessary for the optimal treatment of at-risk runners. Nonpharmacologic strategies to increase energy availability in athletes should be used as first-line treatment.

Bone density in premenopausal women and men under 50 years of age with cerebral palsy.

OBJECTIVE: To determine bone mineral density (BMD) z scores in adults with cerebral palsy (CP), an understudied population. DESIGN: Cross-sectional. SETTING: Medical facility. PARTICIPANTS: Adults (N=48; mean age, 34.3±5.8y; range, 25-46y) with CP. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: BMD z scores at the lumbar spine and hip using dual-energy x-ray absorptiometry, Gross Motor Function Classification System (GMFCS), body mass index (BMI), and ambulatory status. RESULTS: Mean BMD z scores were -1.40 for the lumbar spine, -1.36 for the total hip, and -1.02 for the femoral neck. The z scores were significantly lower for the nonambulatory group at all 3 sites (P<.05). Significant differences were found among GMFCS levels for the lumbar spine and total hip z scores (P<.05). For the lumbar spine, the mean z scores for level V (the lowest mobility level) were significantly lower than the mean for levels I/II (P=.001), III (P=.002), and IV (P=.013). For the total hip, the mean z scores for level V were significantly lower than the mean for levels I/II (P=.045). A significant positive relationship between the z scores and age was found for the lumbar spine (Spearman ρ=.40, P=.005). Significant positive relationships between BMI and z scores were found for all sites (P<.05). CONCLUSIONS: This study contributes to the sparse literature about bone health in adults with CP. In contrast with pediatric data, z scores did not decrease as a function of age in this adult cohort. This information is important for clinicians considering treatment options for this population.