Rauh MJ, Nichols JF, Barrack MT.

School of Exercise & Nutritional Sciences, San Diego State University, CA, USA. mrauh@rmuohp.edu

J Athl Train. 2010 May-Jun;45(3):243-52.

In this prospective study by Rauh and colleagues, the relationship among disordered eating, menstrual dysfunction, and low bone mineral density (BMD) and musculoskeletal injury among girls in high school sports was evaluated. 163 female athletes from 8 sports completed daily injury reports, the Eating Disorder Examination Questionnaire (EDE-Q) that assessed disordered eating attitudes and behaviors, a dual-energy x-ray absorptiometry (DXA) scan that measured BMD and lean tissue mass, anthropometric measurements, and a questionnaire on menstrual history and demographic characteristics. 90 injuries occurred in 61 athletes (37.4%). Using a model with z score ≤ -1 SD, a history of oligomenorrhea/amenorrhea in the past year and low BMD were associated with the occurrence of musculoskeletal injury. Disordered eating (Eating Disorder Examination Questionnaire score ≥ 4.0), a history of oligomenorrhea/amenorrhea during the past year, and a low BMD were associated with musculoskeletal injury occurrence when using a z-score of of ≤ -2 SDs. This study further proves that this unhealthy Triad increased one’s risk of injury. This information can be used to further promote screening, prevention, and adequate treatment in at-risk female athletes.

Doyle-Lucas AF, Davy BM.

Department of Dance, The Ohio State University, Columbus, Ohio, USA.

J Dance Med Sci. 2011;15(2):65-75.

Prevention is the best treatment for the Triad and disordered eating. This purpose of this study by Doyle-Lucas and Davy was to develop, implement, and evaluate a theoretically based nutritional education intervention through a DVD lecture series (three 30-minute classes) in summer intensive programs for pre-professional, adolescent ballet dancers. The goals were to increase knowledge of basic sports nutrition principles and the Female Athlete Triad and promote self-efficacy for adopting healthier dietary habits. Dancers ranging from 13 to 18 years old who were attending summer intensive programs affiliated with professional ballet companies were recruited. Group One (n = 231) participated in the nutrition education program, while Group Two the control participants (n = 90) did not. Assessments of the participants’ dietary status consisted of a demographic questionnaire, a Sports Nutrition Knowledge and Behavior Questionnaire, and a Food Frequency Questionnaire. The intervention group was assessed at baseline, immediately post-program, and at six weeks post-program. The control group was assessed at baseline and at six weeks post-baseline. The intervention program was effective at increasing nutrition knowledge, perceived susceptibility to the Female Athlete Triad, and self-efficacy constructs. Improvements in dietary intake were also observed among intervention group participants, which makes this a very promising educational tool. To improve overall health and performance nutrition education should be incorporated into the training regimens of adolescent dancers. This potentially replicable DVD-based program may be an effective, low-cost mechanism for doing that.

Becker CB, McDaniel L, Bull S, Powell M, McIntyre K.

Department of Psychology, Trinity University, One Trinity Place, San Antonio, TX 78212-7200, United States.

This study was done to further investigate a crucial issue in the female athlete triad-that of education. Becker and colleagues evaluated whether two peer-led interventions could have a positive effect on athletes eating disorder (ED) risk factors. Athletes were randomly assigned to athlete-modified dissonance prevention or healthy weight intervention (AM-HWI). ED risk factors were assessed pre/post-treatment, and 6-week and 1-year follow-up. Results (analyzed sample, N=157) indicated that both interventions reduced thin-ideal internalization, dietary restraint, bulimic pathology, shape and weight concern, and negative affect at 6 weeks, and bulimic pathology, shape concern, and negative affect at 1 year. Unexpectedly we observed an increase in students spontaneously seeking medical consultation for the triad. Qualitative results suggested that AM-HWI may be more preferred by athletes.

By Kathryn E. Ackerman, Taraneh Nazem, Dorota Chapko, Melissa Russell, Nara Mendes, Alexander P. Taylor, Mary L. Bouxsein, and Madhusmita Misra in J Clin Endocrinol Metab, 2011.

In a recent cross-sectional study published in the Journal of Clinical Endocrinology and Metabolism, Ackerman and colleagues from Massachusetts General Hospital and Harvard Medical School examined the bone mineral density (BMD) and bone microarchitecture in 34 young (15-21yr) amenorrheic (AA) and eumenorrheic athletes (EA) compared to 16 age-matched nonathletes (NAC). BMD was measured using dual energy x-ray absorptiometry (DXA) and bone microarchitecture was determined using high-resolution peripheral quantitative computed tomography (pQCT). The purpose of the study was to determine whether impaired bone microarchitecture is an independent determinant of fracture risk in AA, which to date has not been evaluated. There were no significant differences between groups for chronological age, bone age, BMI, or vitamin D levels. Age of menarche did not differ between athletic groups, but was significantly higher in the AA compared to the NAC (14.2±2.5yr vs. 12.1±1.7yr, p=0.006). Lean body mass was significantly higher in the EA vs NAC (46.7±15.5kg vs. 39.8±4.5, p=0.009); whereas, percent body fat was significantly lower in AA vs. NAC (21.4±4.5% vs. 25.6±4.9%, p=0.03). Estradiol was significantly suppressed in AA to confirm amenorrheic status. The EA group demonstrated significantly greater femoral neck and hip BMD Z-scores (0.21±1.14 and 0.80±1.09 respectively); whereas, lumbar BMD and bone mineral apparent density (BMAD) Z-scores were higher in EA and NAC vs. AA (-0.62±1.05 vs. -0.36±1.26 vs. -1.66±1.10). Both athletic groups had significantly greater total area, trabecular area, and cortical perimeter at the tibia compared to NAC. Cortical density was lower in AA vs. NAC. After controlling for bone age, both athletic groups were significantly lower than NAC. Trabecular density was lower at the radius in AA compared to EA and NAC. Regression modeling demonstrated that later menarcheal age was an important determinant of impaired bone microarchitecture. After controlling for covariates, subject grouping explained 18-24% of the variance in tibial trabecular number and separation. In conclusion, amenorrhea was an important determinant of lower trabecular bone density of the radius, lower total density and greater trabecular separation at the tibia. Subject grouping explained the greatest amount of variance in trabecular number and separation at the tibia. Therefore, bone microarchitecture is a valuable bone health parameter to measure in amenorrheic athletes independent of bone mineral density and may represent important information relative fracture risk.

Jeanne F. Nichols, PhD; Mitchell J. Rauh, PhD, PT, MPH; Mandra J. Lawson, MS, RD; Ming Ji, PhD; Hava-Shoshana Barkai, MS. Arch Pediatr Adolesc Med. 2006; 160:137-142

As of recent years, most literature surrounding the female athlete triad subsisted solely in collegiate female athletes. Data regarding high school-aged athletic females was severely lacking. In 2006, Nichols et al performed an observational cross-sectional study to estimate the prevalence of the female athlete triad among high school athletes. One-hundred-seventy female athletes representing eight sports from six high schools in southern California were included in the analysis to determine prevalence of the three aspects of the triad: disordered eating, menstrual status and bone health. Disordered eating and menstrual status were determined by interviewer-assisted questionnaires. Bone mineral density was determined via dual-energy x-ray absorptiometry (DXA) at the spine (L1-L4), hip and total body. Among athletes, 18.2% met criteria for disordered eating, 23.5% met criteria for menstrual irregularity and 21.8% met criteria for low bone mass. Ten of the 170 girls studied (5.9%) met criteria for 2 of the 3 components of the triad and 2 girls (1.2%) met criteria for all 3. In comparison to eumenorrheic athletes (regular menstrual cycles), oligomenorrheic (cycle length of 36-90 days) and amenorrheic (no menses for ≥ 90 days) athletes presented with high dietary restraint (the ability to restrict food intake) and Eating Disorder Examination Questionnaire global scores. As well, in comparison to eumenorrheic athletes, and after controlling for age, age at menarche, BMI, race/ethnicity and sport type, athletes with oligomenorrhea/amenorrhea had lower bone mineral densities at the trochanter (hip). In conclusion, the prevalence of the female athlete triad in high school-aged female athletes showed to be substantial illustrating that these women are at risk for one or more of the components of the triad. Long-term health consequences may be associated with the disordered eating, menstrual irregularities and poor bone health seen in this population. Preparticipation screening to identify these components should be encouraged as a preventive approach to identify high-risk athletes.

September 2011

S. E. Tomten, A. T. Høstmark in Scand J Med Sci Sports 2006: 16:127–133

Exercising female athletes create an energy deficit with exercise for which they require an increase in energy intake to match expenditure and remain in a state of energy balance.  However, reported daily intake is often similar to, or even lower than sedentary women; which creates an energy deficit leading to menstrual dysfunction and related complications such as poor bone health.   In a study by Tomten and Hostmark, energy balance, nutritional intake, training activity and total energy expenditure were assessed in female athletes both with and without menstrual dysfunction.  Energy balance and nutritional adequacy were assessed in a group of runners with irregular menstrual function (IR, n=10) as well as a group of runners with normal menstrual function (R, n=10).   Daily training-related excess energy expenditure and total energy expenditure (TEE) were not different between groups.  Daily energy intake (EI) was, however, significantly lower in IR athletes than in the R athletes.  EI and TEE were in balance in R athletes; however, a significant negative energy balance was observed in IR athletes. The energy deficit observed in the IR athletes was corroborated by significantly lower levels of free thyroxine in IR athletes, which may indicate a depressed BMR in IR athletes.  Mean intakes of carbohydrates and protein were close to recommended guidelines and were not significantly different between groups. The key difference in macronutrient intake was observed in dietary fat that was significantly lower in the IR athletes.  Though all athletes were weight stable, an energy deficit was observed in IR athletes, and not in R athletes, primarily due to a lower intake of dietary fat.  Fear of gaining weight has been widely accepted as a probable cause for a sub-optimal EI in athletes who depend on a low body mass for success.  Decreasing dietary fat intake has been one method by which female athletes lower their EI to maintain low body weights.  They may be reluctant to increase food intake in fear of a possible weight gain, even though a higher EI may seem to improve the reproductive function, it may also increase body weight and fat mass.

By Noel Pollock, Claire Grogan, Mark Perry, Charles Pedlar, Karl Cooke, Dylan Morrissey, and Lygeri Dimitriou in International Journal of Sports Nutrition and Exercise Metabolism, 2010, 20 419-426.

In a recent cross-sectional study by Pollock and colleagues, the associations between bone mineral density (BMD), menstrual status, disordered eating, and training volume were explored in 44 elite female endurance runners with a mean age of 22.9 years. Seven runners were followed longitudinally and this investigation represents one of the few studies with follow-up data in this subgroup of elite-level athletes. Bone density measurements were completed using DXA. Training and menstrual history were obtained using in-house questionnaires. The Three Factor Eating Questionnaire (TFEQ) was completed to assess eating behavior. For the longitudinal analysis, a follow-up DXA scan was completed 6-14 months from baseline. The investigators demonstrated that menstrual dysfunction, disordered eating, and low BMD were coexistent in 15.9% of the runners. However, there were no significant relationships (p>0.05) between BMD and menstrual status, disordered eating, and training volume, respectively. Interestingly, a significant positive association was found between a reduction in BMD at the lumbar spine and training volume (p=0.026). Therefore, these findings indicate that Triad-related complications exist in elite female endurance runners and furthermore, that low BMD and osteoporosis are prevalent. Pollock and colleagues also found that normal menstrual status did not significantly relate to normal BMD. To this end, it is notably imperative that female endurance athletes complete a DXA amongst their pre-participation screening. Furthermore, future research should investigate this association between high training volume, potential menstrual dysfunction, and reductions in lumbar BMD in larger populations of female endurance athletes. Based on these findings, it is indirectly suggested that a negative energy balance is a contributing factor to bone loss in these athletes.

By Michelle T. Barrack, Marta D. Van Loan, Mitchell J. Rauh, and Jeanne F. Nichols in MSSE, 2011.

To date, few studies have investigated whether low bone mass in adolescence increases the risk of low peak bone mineral density (BMD) in adulthood in female endurance runners. In a study by Barrack and colleagues, 40 adolescent runners aged 15.9 years were evaluated on two occasions, approximately 3 years apart, to measure bone mass and determine the factors associated with long-term changes. Particularly, these investigators were interested in determining whether those female athletes with low bone mass during adolescence demonstrated “catch-up” bone accrual in comparison to their normal bone mass counterparts. Data collection included baseline measurements of menstrual status, training volume, and sports participation via questionnaire and bone mass via dual energy x-ray absorptiometry (DXA). Participants were categorized as low bone mass for age if their lumbar spine and/or total body values were below a cut-off z-score (age-matched, gender-specific reference data) of -1 or -2. All measures were repeated approximately 3 years later. At the follow-up visit, runners were 18.7±0.2 yrs old and height, body weight, BMI, and percent body fat had increased by 0.9±0.2 cm, 4.7±0.7 kg, 1.5±0.2 kg/m2, and 5.6±0.6%, respectively, from baseline. The prevalence of menstrual irregularity was 28.2% and 25.6% at baseline and follow-up, respectively. Notably, 87% of participants with low bone mass at baseline had low BMD at follow-up. Those who demonstrated a low bone mass at baseline had significant lower adjusted total body, total hip, and lumbar spine BMC values. Training volume, menstrual function, age, developmental stage, and change in body mass explained a significant amount of variability in BMC change (29%-54%). In conclusion, it appears as though female adolescent runners with low bone mass are more likely to have low BMD after a 3 year follow-up. Thus, “catch-up” growth from adolescence to adulthood does not necessarily occur and the importance of adequate bone mineral accrual during early adolescent years is underscored.

As an athletic trainer you are certified and trained to prevent and treat injury. Only a trained professional that is certified in strength training and conditioning (National Strength and Conditioning Association’s Certified Strength and Conditioning Specialist or USA Weightlifting are great examples) should be training athletes in sport-specific strength training or conditioning (e.g. plyometrics or speed/agility drills). You are right; strength training has very positive effects on bone health. However, there are specific recommendations to how much and how often athletes should be conditioning off the competitive field and it varies greatly between sports. These types of certifications teach a strength coach proper technique in all areas of strength and conditioning, and about the unique balance between time spent engaging in athletic practice/competition and time spent conditioning off the field. Also, training information on how to tailor workouts to maximize performance in each sport would be valuable. It is a real concern that without being taught these skills in advance, you may over train/injure your athletes. It would be in your and your athletes’ best interests if someone that is certified as a strength coach would train them, or you could seek out a certification yourself. There is more information about the certifications mentioned at www.nsca-lift.org or http://weightlifting.teamusa.org/.

Yes, there are other reasons why your daughter may not be getting her period. These reasons include polycystic ovarian syndrome or PCOS, and chronic diseases, such as thyroid disease, diabetes, or hyperprolactinemia (high levels of prolactin). However, you should first confirm she is not pregnant. Once pregnancy is ruled out, you should contact your primary care physician for an evaluation for your daughter to see if she has any of these conditions and find out the cause of her missing period.