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.

Increased Female Athlete Triad Knowledge Among Collegiate Dancers Following a Brief Educational Video Intervention.

The female athlete triad (triad) is prevalent among aesthetic athletes, including dancers. However, there is limited research regarding triad knowledge or triad educational interventions among collegiate dancers. This study was intended to help correct that shortage. Participants (N = 24) completed two questionnaires: one assessed demographics, triad risk, and disordered eating (DE) risk; the other measured triad knowledge before and after viewing a 10-minute triad video. Twenty-seven percent of participants were found to be at risk for DE, 27% were at risk for the triad, and 8% were at risk for both. Significant improvements in triad knowledge were observed following the educational video; 4.08 ± 1.83 pre-intervention to 6.75 ± 0.09 post-intervention out of a possible 7, p < 0.001. There were no differences in triad knowledge when comparing freshmen and sophomores to juniors, seniors, and graduate students. This research confirms that triad education should be a continuous component of collegiate dancers' curricula to promote their overall health and wellness, and that the triad video can be an effective educational tool for supporting that goal.

Exploring Health Demographics of Female Collegiate Rowers.

CONTEXT: Limited information exists about health patterns among female rowers at the collegiate level. Furthermore, the element of weight class (lightweights classified as <130 lb [59 kg]) as a factor in the physical and mental health of female collegiate athletes has not been investigated, despite weight requirements in sport being a risk factor for the female athlete triad. OBJECTIVE: To test the hypotheses that (1) components of the female athlete triad were more prevalent in lightweight than in openweight rowers; (2) perceived stress levels were greater in lightweight than in openweight rowers; and (3) rowers who were unable to row due to injury had greater perceived stress levels than uninjured athletes. DESIGN: Cross-sectional study. SETTING: Twelve collegiate women's rowing programs consisting of 6 National Collegiate Athletic Association Division I openweight and 6 Intercollegiate Rowing Association-level lightweight teams. PATIENTS OR OTHER PARTICIPANTS: A total of 158 female collegiate rowers (78 lightweight, 80 openweight). MAIN OUTCOME MEASURE(S): An electronic survey addressing injury history, diet and eating habits and body image (according to the triad screening questionnaire), stress levels (Perceived Stress Scale), and athlete identity (Athlete Identity Measurement Scale) was administered. RESULTS: Lightweight rowers reported limiting or carefully controlling foods more frequently than openweight rowers (41.9% to 29.9%, P = .013). A history of an eating disorder was more prevalent among lightweight than openweight rowers (25.7% to 13.0%, P = .048). Prevalences of stress fractures and menstrual irregularities did not differ between weight classes. Lightweight and openweight rowers' scores on the Perceived Stress Scale (16.0 ± 9.9 and 17.3 ± 6.4, respectively) were not different. Injured rowers scored higher on the Perceived Stress Scale (19.4 ± 7.2) than did uninjured rowers (16.6 ± 5.72). CONCLUSIONS: Weight class did not contribute to differences in the prevalence of female athlete triad components or perceived stress, although lightweight rowers were more likely to have a history of eating disorder. Injury may be a risk factor for increased stress in this population.

Amenorrhea in the Female Athlete: What to Do and When to Worry.

Functional hypothalamic amenorrhea is a diagnosis of exclusion that is common in female athletes, particularly those participating in aesthetic sports (ballet, other dance genres, figure skating, and gymnastics) and endurance sports (cross-country running). Although common, it should be considered abnormal even in the high-level elite athlete. Amenorrhea in combination with low energy availability and low bone density is labeled "the Female Athlete Triad." Studies have demonstrated numerous long-term consequences of athletes suffering from all or a portion of this triad, including increased rate of musculoskeletal injuries, stress fractures, abnormal lipid profiles, endothelial dysfunction, potential irreversible bone loss, depression, anxiety, low self- esteem, and increased mortality. This article provides the clinician with the tools to evaluate an athlete with secondary amenorrhea, reviews the recommended treatment options for affected athletes, and discusses when to return to the activity in an effort to facilitate "healthy" participation.

Eating disorders and their putative risk factors among female German professional athletes.

This study examines putative non-sport-specific and sport-specific risk factors for eating disorders (ED) among groups of professional female athletes versus non-athletes. In detail, societal pressure to be thin, its internalisation, body dissatisfaction, sports pressure and early specialisation were investigated. The cross-sectional study included 46 aesthetic and 62 ball game sports athletes, and 108 age-matched non-athletes. Study methods comprised a clinical interview to detect ED and questionnaires. More athletes from aesthetic (17%) than from ball game sports (3%) and non-athletes (2%) suffered from ED. Aesthetic sports athletes did not differ from non-athletes in non-sport-specific factors but obtained higher levels than ball game sports athletes in sport-specific variables (p < .01). All factors together accounted for 57.3% of variation in disordered eating, with sports pressure and body dissatisfaction as significant predictors. The results confirm ED risk for German aesthetic athletes and indicate the importance of sports pressure and body dissatisfaction in explaining athletes' vulnerability.

Eating disorders in female athletes: use of screening tools.

Screening female athletes for eating disorders is not performed commonly even though the American College of Sports Medicine, National Athletic Trainer Association, and International Olympic Committee have guidelines recommending screening. Eating disorders are more prevalent in the female athlete population than in the general population and carry short-term and long-term consequences that can affect sport performance. There are several screening tools available that have been studied in the general population and fewer tools that were validated specifically in female athletes. Female athletes with eating disorder pathology often have different factors and environmental pressures contributing to their pathology that can be identified best with an athlete-specific screening tool. We will discuss various screening tools available and the evidence for each one. Screening for eating disorders in all female athletes is an important part of the preparticipation examination and should be done using a tool specifically validated for the female athlete.

2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad.

The female athlete triad is a medical condition often observed in physically active girls and women and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with one or more of the three triad components, and early intervention is essential to prevent its progression to serious end points that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement presents a set of recommendations developed following the first (San Francisco, CA) and second (Indianapolis, IN) International Symposia on the Female Athlete Triad. This consensus statement was 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 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.

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.

Changes in energy availability across the season in Division I female soccer players.

Low energy availability [(energy intake--exercise expenditure)/kg lean body mass], a component of the Female Athlete Triad, has been associated with menstrual disturbances and low bone mass. No studies have examined the energy availability of athletes across a season. The purpose of this study was to assess the prevalence of, and what contributes to, low energy availability in Division I female soccer players across a season. Nineteen participants aged 18-21 years (mean [Vdot]O(2max): 57.0 ± 1.0 mL · kg(-1) · min(-1)) were studied during the pre, mid, and post season. Mean energy availability was overall lowest at mid season, and lower at mid than post season (35.2 ± 3.7 vs. 44.5 ± 3.7 kcal · kg(-1) lean body mass, P = 0.009). Low energy availability (<30 kcal · kg(-1) lean body mass) was observed in 5/19 (26.3%), 5/15 (33.3%), and 2/17 (11.8%) of participants during the pre, mid, and post season. Dietary energy intake was lower mid (P = 0.008) and post season (P = 0.022) than it was pre season (pre: 2794 ± 233 kcal · day(-1); mid: 2208 ± 156 kcal · day(-1); post: 2161 ± 143 kcal · day(-1)). Exercise energy expenditure decreased significantly (P ≤ 0.001) over time (pre: 819 ± 57 kcal · day(-1); mid: 642 ± 26 kcal · day(-1); post: 159 ± 28 kcal · day(-1)). Low energy availability was due to lower dietary energy intake at lunch during pre season (P = 0.014) and during lunch and dinner during mid season (P ≤ 0.030). Energy availability was inversely related to body dissatisfaction (r = -0.62, P = 0.017) and drive for thinness (r = -0.55, P = 0.041) during mid season. Although most Division I female soccer players are not at risk for low energy availability, a concerning proportion exhibited low energy availability at pre or mid season. Further studies are needed to explore strategies to prevent and monitor low energy availability in these athletes.

Aspects of disordered eating continuum in elite high-intensity sports.

Dieting is an important risk factor for disordered eating and eating disorders. Disordered eating occurs on a continuum from dieting and restrictive eating, abnormal eating behavior, and finally clinical eating disorders. The prevalence of eating disorders is increased in elite athletes and for this group the cause of starting to diet is related to (a) perception of the paradigm of appearance in the specific sport, (b) perceived performance improvements, and (c) sociocultural pressures for thinness or an "ideal" body. Athletes most at risk for disordered eating are those involved in sports emphasizing a thin body size/shape, a high power-to-weight ratio, and/or sports utilizing weight categories, such as in some high-intensity sports. In addition to dieting, personality factors, pressure to lose weight, frequent weight cycling, early start of sport-specific training, overtraining, injuries, and unfortunate coaching behavior, are important risk factors. To prevent disordered eating and eating disorders, the athletes have to practice healthy eating, and the medical staff of teams and parents must be able to recognize symptoms indicating risk for eating disorders. Coaches and leaders must accept that disordered eating can be a problem in the athletic community and that openness regarding this challenge is important.

The young female athlete.

Participation of adolescents and young women in strenuous sports activity may lead to various metabolic and psychological derangements of clinical relevance to the endocrinologist. The most common manifestations encountered in practice are primary and secondary amenorrhea, reduced bone mineral density and eating disorders. The occurrence of all three together has been named "the athletic triad". The underlying hormonal drivers that lead to some of these manifestations are the reduced leptin level as well as the persistent low grade stress response commonly observed in such females. "Exercise-related female reproductive dysfunction" (ERFRD), can possibly include short-term (infertility) and long-term (osteoporosis) consequences. Functional hypothalamic amenorrhea, a manifestation of ERFRD in adolescence, is an integrated response to the combination of excessive physical and emotional stress, exercise, and/or reduced food intake characterized by decreased endogenous GNRH secretion. The primary aim of treating these athletes should be the prevention of the development of any component of the triad as well as the whole complex by educating athletes, trainers, parents and health care professionals about proper nutrition and safe training. The long term prognosis is good. However, significant long term morbidity may affect these young women later in life.

Characteristics of the female athlete triad in collegiate cross-country runners.

UNLABELLED: The Female Athlete Triad is a life-threatening syndrome defined by disordered eating, amenorrhea, and osteoporosis. OBJECTIVE AND PARTICIPANTS: The author's purpose in this study was to examine female cross-country runners' (N=300) calcium consumption, along with the prevalence of 2 components of the triad: disordered eating and menstrual dysfunction. METHODS: The author used measures including the Orientation to Exercise Questionnaire, Calcium Rapid Assessment Method, and questions related to height, weight, exercise time, perceptions of eating disorders, and menstrual status. Previous or current eating disorders were reported by 19.4% of the women, 23.0% had irregular menstrual cycles, and 29.1% had inadequate calcium intake. RESULTS: Those athletes perceiving a previous/current eating disorder scored higher on the Orientation to Exercise questionnaire than did those who did not perceive such. CONCLUSION: The author recommends educational efforts for the prevention of components of the Female Athlete Triad.