By Jordana Bieze Foster
Authors and Disclosures
June 1, 2009 (Seattle, Washington) — Fewer than one third of physicians can correctly identify all 3 components of the female athlete triad, according to a study presented here at the American College of Sports Medicine (ACSM) 56th Annual Meeting, suggesting that a surprising number of at-risk female athletes might not be receiving the treatment they need.
“There are significant knowledge gaps in terms of both recognition and treatment. We believe these knowledge gaps are based on a lack of education,” Elizabeth Joy, MD, MPH, associate professor of family and preventive medicine at the University of Utah in Salt Lake City, told attendees at the meeting. “There are some real missed opportunities here to intervene before some serious health consequences develop.”
The Utah researchers assessed physicians’ knowledge of the triad using an Internet-based survey. The questionnaire was distributed to 207 physicians identified by researchers as likely to come in contact with female athletes experiencing 1 or more components of the triad: reduced energy availability, menstrual dysfunction, and low bone mineral density. A total of 128 physicians completed the survey, for a 67.7% response rate.
Only 28.6% of respondents correctly identified all 3 triad components. The greatest knowledge gap concerned reduced energy availability, which was identified by only 29.7% of respondents. Physicians were twice as likely to correctly identify menstrual dysfunction (pegged by 66.7%) and low bone mineral density (65.9%).
By comparison, a survey-based study, published in 2006 in the Wisconsin Medical Journal (WMJ. 2006;105:21-24), found that 48% of physicians were able to correctly identify all 3 triad components. However, since that survey was conducted, the American College of Sports Medicine revised its position statement on the triad, replacing “disordered eating” with the broader “reduced energy availability” to reflect that an athlete whose caloric intake does not match her caloric output can be at risk regardless of body image. The Utah survey results suggest that the revised definition, published in 2007 (Med Sci Sports Exerc. 2007;39:1867-1882), has not yet trickled down to the level of the treating physician.
“Reduced energy availability is the central component of the female athlete triad, yet was the least recognized,” Dr. Joy said. “The most striking finding was that only 35.9% of respondents knew that increasing energy intake is the best option for treatment of low bone density.”
More than half of the survey respondents (58.1%) said that they had received no education about the triad during residency, and more than three quarters (79.8%) said that the triad had not been part of their continuing medical education.
Limitations of the Utah study were its small sample size and the fact that it involved only a single institution. Another limitation was that the survey was not as detailed as the researchers would have liked because of the need to keep it a reasonable length to maximize the response rate.
Mitchell J. Rauh, PhD, PT, MPH, who presented a study during the same session on the association between triad symptoms and history of stress fracture in female high-school runners, said that he has observed similar practitioner knowledge gaps but was nonetheless surprised by the figures Dr. Joy reported.
“That 28.6% is a really low number,” said Dr. Rauh, associate professor at Rocky Mountain University of Health Professions in Provo, Utah, and adjunct research professor in the School of Exercise & Nutritional Sciences at San Diego State University in California. “That’s a lot of girls being missed. And these are things we can fix if physicians know about it and can get the girls the right treatment.”
The study did not receive commercial support. Dr. Joy and Dr. Rauh disclosed no relevant financial relationships.
American College of Sports Medicine (ACSM) 57th Annual Meeting: Abstract 793. Presented May 28, 2009.
