1
|
Mountjoy M, Ackerman KE, Bailey DM, Burke LM, Constantini N, Hackney AC, Heikura IA, Melin A, Pensgaard AM, Stellingwerff T, Sundgot-Borgen JK, Torstveit MK, Jacobsen AU, Verhagen E, Budgett R, Engebretsen L, Erdener U. 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med 2023; 57:1073-1097. [PMID: 37752011 DOI: 10.1136/bjsports-2023-106994] [Citation(s) in RCA: 47] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2023] [Indexed: 09/28/2023]
Abstract
Relative Energy Deficiency in Sport (REDs) was first introduced in 2014 by the International Olympic Committee's expert writing panel, identifying a syndrome of deleterious health and performance outcomes experienced by female and male athletes exposed to low energy availability (LEA; inadequate energy intake in relation to exercise energy expenditure). Since the 2018 REDs consensus, there have been >170 original research publications advancing the field of REDs science, including emerging data demonstrating the growing role of low carbohydrate availability, further evidence of the interplay between mental health and REDs and more data elucidating the impact of LEA in males. Our knowledge of REDs signs and symptoms has resulted in updated Health and Performance Conceptual Models and the development of a novel Physiological Model. This Physiological Model is designed to demonstrate the complexity of either problematic or adaptable LEA exposure, coupled with individual moderating factors, leading to changes in health and performance outcomes. Guidelines for safe and effective body composition assessment to help prevent REDs are also outlined. A new REDs Clinical Assessment Tool-Version 2 is introduced to facilitate the detection and clinical diagnosis of REDs based on accumulated severity and risk stratification, with associated training and competition recommendations. Prevention and treatment principles of REDs are presented to encourage best practices for sports organisations and clinicians. Finally, methodological best practices for REDs research are outlined to stimulate future high-quality research to address important knowledge gaps.
Collapse
Affiliation(s)
- Margo Mountjoy
- Family Medicine, McMaster University Michael G DeGroote School of Medicine, Waterloo, Ontario, Canada
- Games Group, International Olympic Committee, Lausanne, Switzerland
| | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Louise M Burke
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Naama Constantini
- Sports Medicine Center, Shaare Zedek Medical Center, The Hebrew University, Jerusalem, Israel
| | - Anthony C Hackney
- Exercise and Sport Science, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ida Aliisa Heikura
- Canada Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Anna Melin
- Department of Sport Science - Swedish Olympic Committee Research Fellow, Linnaeus University, Kalmar, Sweden
| | - Anne Marte Pensgaard
- Department of Sport and Social Sciences, Norwegian School of Sports Sciences, Oslo, Norway
| | - Trent Stellingwerff
- Canada Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | | | | | | | - Evert Verhagen
- Amsterdam Collaboration on Health & Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Richard Budgett
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
| | - Lars Engebretsen
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
| | - Uğur Erdener
- Department of Ophthalmology, Hacettepe University, Ankara, Turkey
- World Archery, Lausanne, Switzerland
| |
Collapse
|
2
|
Barrack MT, Domino S, Gray VB, Cotter JA, Rauh MJ, Nichols JF. Support for inadvertent undereating in female adolescent athletes with clinical indicators of low energy availability. J Sci Med Sport 2023:S1440-2440(23)00072-5. [PMID: 37248163 DOI: 10.1016/j.jsams.2023.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 05/31/2023]
Abstract
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 ± 1.38 vs. -0.07 ± 1.21, p < 0.001) and total body (-0.30 ± 0.98 vs. 0.53 ± 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.
Collapse
Affiliation(s)
- Michelle T Barrack
- Department of Family and Consumer Sciences, California State University Long Beach, United States of America.
| | - Sarah Domino
- Department of Family and Consumer Sciences, California State University Long Beach, United States of America
| | - Virginia B Gray
- Department of Family and Consumer Sciences, California State University Long Beach, United States of America
| | - Joshua A Cotter
- Department of Kinesiology, California State University Long Beach, United States of America
| | - Mitchell J Rauh
- Doctor of Physical Therapy Program, San Diego State University, United States of America
| | - Jeanne F Nichols
- Herbert Wertheim School of Public Health, University of California San Diego, United States of America; School of Exercise and Nutritional Sciences, San Diego State University, United States of America
| |
Collapse
|
3
|
De Souza MJ, Ricker EA, Mallinson RJ, Allaway HCM, Koltun KJ, Strock NCA, Gibbs JC, Kuruppumullage Don P, Williams NI. Bone mineral density in response to increased energy intake in exercising women with oligomenorrhea/amenorrhea: the REFUEL randomized controlled trial. Am J Clin Nutr 2022; 115:1457-1472. [PMID: 35170727 PMCID: PMC9170471 DOI: 10.1093/ajcn/nqac044] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 02/10/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Energy deficiency can result in menstrual disturbances and compromised bone health in women, a condition known as the Female Athlete Triad. OBJECTIVES The REFUEL randomized controlled trial assessed the impact of increased energy intake on bone health and menstrual function in exercising women with menstrual disturbances. METHODS Exercising women with oligomenorrhea/amenorrhea (Oligo/Amen) were randomly assigned to an intervention group (Oligo/Amen + Cal, n = 40, mean ± SEM age: 21.3 ± 0.5 y; weight: 55.0 ± 1.0 kg; BMI: 20.4 ± 0.3 kg/m2) who increased energy intake 20%-40% above baseline energy needs for 12 mo or a control group (Oligo/Amen Control, n = 36; mean ± SEM age: 20.7 ± 0.5 y; weight: 59.1 ± 1.3 kg; BMI: 21.3 ± 0.4 kg/m2). Energy intake and expenditure, metabolic and reproductive hormones, body composition, and areal bone mineral density (aBMD) were assessed. RESULTS Oligo/Amen + Cal improved energy status [increased body mass (2.6 ± 0.4 kg), BMI (0.9 ± 0.2 kg/m2), fat mass (2.0 ± 0.3 kg), body fat percentage (2.7% ± 0.4%), and insulin-like growth factor 1 (37.4 ± 14.6 ng/mL)] compared with Oligo/Amen Control and experienced a greater likelihood of menses (P < 0.05). Total body and spine aBMD remained unchanged (P > 0.05). Both groups demonstrated decreased femoral neck aBMD at month 6 (-0.006 g/cm2; 95% CI: -0.011, -0.0002 g/cm2 ; time main effect P = 0.043) and month 12 (-0.011 g/cm2; 95% CI: -0.021, -0.001 g/cm2; time main effect P = 0.023). Both groups demonstrated a decrease in total hip aBMD at month 6 (-0.006 g/cm2; 95% CI: -0.011, -0.002 g/cm2; time main effect P = 0.004). CONCLUSIONS Although higher dietary energy intake increased weight, body fat, and menstrual frequency, bone mineral density was not improved, compared with the control group. The 12-mo intervention may have been too short and the increase in energy intake (∼352 kcal/d), although sufficient to increase menstrual frequency, was insufficient to increase estrogen or improve aBMD. Future research should refine the optimal nutritional and/or pharmacological interventions for the recovery of bone health in athletes and exercising women with Oligo/Amen.This trial was registered at clinicaltrials.gov as NCT00392873.
Collapse
Affiliation(s)
- Mary Jane De Souza
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Emily A Ricker
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Rebecca J Mallinson
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Heather C M Allaway
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Kristen J Koltun
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Nicole C A Strock
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | - Jenna C Gibbs
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| | | | - Nancy I Williams
- Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
| |
Collapse
|
4
|
Pedreira CC, Maya J, Misra M. Functional hypothalamic amenorrhea: Impact on bone and neuropsychiatric outcomes. Front Endocrinol (Lausanne) 2022; 13:953180. [PMID: 35937789 PMCID: PMC9355702 DOI: 10.3389/fendo.2022.953180] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/29/2022] [Indexed: 12/01/2022] Open
Abstract
Functional hypothalamic amenorrhea is a state of reversible hypogonadism common in adolescents and young women that can be triggered by energy deficit or emotional stress or a combination of these factors. Energy deficit may be a consequence of (i) reduced caloric intake, as seen in patients with eating disorders, such as anorexia nervosa, or (ii) excessive exercise, when caloric intake is insufficient to meet the needs of energy expenditure. In these conditions of energy deficit, suppression of the hypothalamic secretion of gonadotrophin-releasing hormone (with resulting hypoestrogenism) as well as other changes in hypothalamic-pituitary function may occur as an adaptive response to limited energy availability. Many of these adaptive changes, however, are deleterious to reproductive, skeletal, and neuropsychiatric health. Particularly, normoestrogenemia is critical for normal bone accrual during adolescence, and hypoestrogenemia during this time may lead to deficits in peak bone mass acquisition with longstanding effects on skeletal health. The adolescent years are also a time of neurological changes that impact cognitive function, and anxiety and depression present more frequently during this time. Normal estrogen status is essential for optimal cognitive function (particularly verbal memory and executive function) and may impact emotion and mood. Early recognition of women at high risk of developing hypothalamic amenorrhea and its timely management with a multidisciplinary team are crucial to prevent the severe and long-term effects of this condition.
Collapse
Affiliation(s)
- Clarissa Carvalho Pedreira
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Neuroendocrine Unit, Center for Endocrinology and Diabetes of Bahia State, Salvador, Brazil
- *Correspondence: Clarissa Carvalho Pedreira,
| | - Jacqueline Maya
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Madhusmita Misra
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| |
Collapse
|
5
|
Disordered Eating, Development of Menstrual Irregularity, and Reduced Bone Mass Change After a 3-Year Follow-Up In Female Adolescent Endurance Runners. Int J Sport Nutr Exerc Metab 2021; 31:337-344. [PMID: 34098530 DOI: 10.1123/ijsnem.2021-0011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/08/2021] [Accepted: 04/08/2021] [Indexed: 11/18/2022]
Abstract
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.
Collapse
|
6
|
Singhal V, Karzar NH, Bose A, Buckless C, Ackerman KE, Bredella MA, Klibanski A, Misra M. Changes in marrow adipose tissue in relation to changes in bone parameters following estradiol replacement in adolescent and young adult females with functional hypothalamic amenorrhea. Bone 2021; 145:115841. [PMID: 33418100 PMCID: PMC8022869 DOI: 10.1016/j.bone.2021.115841] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/14/2020] [Accepted: 01/01/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Low energy availability causes disruption of hypothalamic gonadotropin-releasing hormone secretion leading to functional hypothalamic amenorrhea (FHA) and hypoestrogenism, which in turn contributes to decreased bone mineral density (BMD) and increased bone marrow adipose tissue (MAT). Transdermal estradiol administration in physiologic doses increases BMD in adolescents and adults with FHA. However, the impact of estrogen replacement on MAT in relation to changes in BMD has not been studied in adolescents and young adults. We hypothesized that physiologic estrogen replacement would lead to decreases in MAT, associated with increases in BMD. METHODS AND MATERIALS We studied 15 adolescent and young adult females with FHA (14-25 years). All participants received a17β- estradiol transdermal patch at a dose of 0.1 mg/day (applied twice weekly) for 12 months. Participants also received cyclic progestin for 10-12 days each month. We quantified MAT (lipid/water ratio) of the fourth lumbar (L4) vertebral body and femoral diaphysis by single proton (1H)-magnetic resonance spectroscopy, and compartmental volumetric BMD of the distal radius and tibia using high-resolution peripheral quantitative computed tomography. RESULTS Transdermal estradiol therapy over 12 months resulted in a decrease in MAT at the lumbar (L4) vertebra from 0.92 ± 0.55 at baseline to 0.63 ± 0.29 at 12-months (p = 0.008), and an increase in radial and tibial cortical vBMD (p = 0.006, p = 0.0003). Changes in L4 MAT trended to be inversely associated with changes in radial cortical vBMD (rho = -0.47, p = 0.08). CONCLUSION We show that in adolescent and young adult girls with FHA, MAT decreases following transdermal estrogen therapy and these changes are associated with increased cortical vBMD.
Collapse
Affiliation(s)
- Vibha Singhal
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Division of Pediatric Endocrinology, Mass General Hospital for Children and Harvard Medical School, Boston, MA, United States; MGH Weight Center, Massachusetts General Hospital, Boston, MA, United States.
| | - Nazanin Hazhir Karzar
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
| | - Amita Bose
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
| | - Colleen Buckless
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
| | - Kathryn E Ackerman
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
| | - Miriam A Bredella
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
| | - Anne Klibanski
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
| | - Madhusmita Misra
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Division of Pediatric Endocrinology, Mass General Hospital for Children and Harvard Medical School, Boston, MA, United States.
| |
Collapse
|
7
|
Wood KL, Barrack MT, Gray VB, Cotter JA, Van Loan MD, Rauh MJ, McGowan R, Nichols JF. Cognitive dietary restraint score is associated with lower energy, carbohydrate, fat, and grain intake among female adolescent endurance runners. Eat Behav 2021; 40:101460. [PMID: 33307469 DOI: 10.1016/j.eatbeh.2020.101460] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
This cross-sectional study investigated associations between cognitive dietary restraint (CDR), energy, macronutrient and food group intake, menstrual function, and bone density in female adolescent endurance runners. Participants were forty female adolescent endurance runners. The independent variable was CDR, as assessed by the Three Factor Eating Questionnaire (TFEQ). Runners with CDR subscale scores ≥11 were classified with elevated CDR. The main outcomes measured were dietary intake measured by 24-hour recall for 7 days, menstrual history, and bone mineral density (BMD). Twelve of 40 participants (30.0%) met criteria for elevated CDR. Compared to runners with normal CDR, runners with elevated CDR scores reported consuming lower energy (kcal/kg/day) (37.5 ± 8.6 vs. 44.0 ± 9.6, p = 0.052), lower carbohydrate (g/kg/day) (5.3 ± 1.3 vs. 6.3 ± 1.3, p = 0.042), more fiber (g/day) (24.9 ± 6.7 vs. 20.0 ± 5.3, p = 0.018), more servings of fruit (3.3 ± 1.4 vs. 1.9 ± 1.2, p = 0.003), more servings of vegetables (2.7 ± 1.4 vs. 1.7 ± 0.7, p = 0.004), and fewer servings of grain (7.6 ± 2.4 vs. 9.8 ± 2.4, p = 0.009) per day. Runners with elevated CDR exhibited significantly lower lumbar spine BMD Z-scores (adjusting for BMI) (-0.78 ± 0.19 vs. -0.22 ± 0.12, p = 0.016) than runners with normal CDR. Menstrual history did not significantly differ based on CDR status. Elevated CDR may increase risk of dietary patterns associated with consuming inadequate levels of energy, key nutrients, and developing low BMD in endurance runners. Trial Registration:ClinicalTrials.gov Identifier: NCT01059968.
Collapse
Affiliation(s)
- Kristen L Wood
- Department of Family and Consumer Sciences, California State University Long Beach, Long Beach, CA, United States of America
| | - Michelle T Barrack
- Department of Family and Consumer Sciences, California State University Long Beach, Long Beach, CA, United States of America.
| | - Virginia B Gray
- Department of Family and Consumer Sciences, California State University Long Beach, Long Beach, CA, United States of America
| | - Joshua A Cotter
- Department of Kinesiology, California State University Long Beach, Long Beach, CA, United States of America
| | - Marta D Van Loan
- U.S. Department of Agriculture, Agricultural Research Service, Western Human Nutrition Research Center, University of California Davis, Davis, CA, United States of America
| | - Mitchell J Rauh
- Doctor of Physical Therapy Program, San Diego State University, San Diego, CA, United States of America
| | - Rachel McGowan
- Department of Family and Consumer Sciences, California State University Long Beach, Long Beach, CA, United States of America
| | - Jeanne F Nichols
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, United States of America; School of Exercise and Nutritional Sciences, San Diego State University, San Diego, CA, United States of America
| |
Collapse
|
8
|
Characterizing the resting metabolic rate ratio in ovulatory exercising women over 12 months. Scand J Med Sci Sports 2020; 30:1337-1347. [DOI: 10.1111/sms.13688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/23/2020] [Accepted: 04/11/2020] [Indexed: 12/20/2022]
|
9
|
Geometric and "True" Densitometric Characteristics of Bones in Athletes with Stress Fracture and Menstrual Disturbances: A Systematic Review. Sports Med 2020; 49:1059-1078. [PMID: 31041601 DOI: 10.1007/s40279-019-01109-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Stress fractures can lead to short- and long-term consequences, impacting participation in sport and general health. Recognizing which skeletal characteristics render bones susceptible to stress fracture may aid stress-fracture prevention. Menstrual disturbances among exercising women are a known risk factor for stress fracture; therefore, assessing skeletal commonalities between women with stress fractures and women with menstrual disturbances may increase our understanding of why menstrual disturbances put athletes at greater risk for stress fracture. Three-dimensional (3D) bone imaging tools provide detailed information about volumetric bone mineral density (vBMD) and bone structure that cannot be obtained using traditional two-dimensional (2D) techniques. OBJECTIVES This systematic review serves to: (1) evaluate the current literature available on vBMD, bone geometry, and bone structure in exercising women with menstrual disturbances and exercising women with stress fractures, and (2) assess the common skeletal characteristics between both conditions. Our aim is to reveal bone properties beyond 2D areal BMD that may indicate increased susceptibility to stress fracture among exercising women with menstrual disturbances. SEARCH METHODS A search of the PubMed/Medline database was completed in May 2018. ELIGIBILITY CRITERIA Eligible articles included those that reported vBMD, bone geometry, or bone structure obtained from 3D imaging techniques or estimated from 2D imaging techniques. Only studies conducted in premenopausal exercising women and girls who had a stress fracture, a menstrual disturbance, or both were included. RESULTS Twenty-four articles met the inclusion criteria. Bone area and cortical thickness at the tibia were identified as altered both in women with menstrual disturbances and in women with stress fractures; however, there was inconsistency in the results observed for all bone parameters. The majority of skeletal parameters of the lower extremities were not significantly different between exercising women with and without stress fractures and between those with and without menstrual disturbances. DISCUSSION Most studies were moderate or low quality based on study design, and only one article combined both conditions to explore vBMD and bone geometry in athletes with menstrual disturbances and a history of stress fracture. These findings highlight the need for more skeletal research on the intersection of these health conditions in exercising women. The lack of observed differences in skeletal parameters suggests that risk factors other than bone geometry and structure may be the primary causes of stress fracture in these women.
Collapse
|
10
|
|
11
|
Eating Behavior Traits, Weight Loss Attempts, and Vertebral Dimensions Among the General Northern Finnish Population. Spine (Phila Pa 1976) 2019; 44:E1264-E1271. [PMID: 31205179 DOI: 10.1097/brs.0000000000003123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A population-based birth cohort study. OBJECTIVE To evaluate the associations of eating behavior traits and weight loss attempts with vertebral size among the general Northern Finnish population. SUMMARY OF BACKGROUND DATA Vertebral fragility fractures are a typical manifestation of osteoporosis, and small vertebral dimensions are a well-established risk factor for vertebral fracturing. Previous studies have associated cognitive eating restraint and diet-induced weight loss with deteriorated bone quality at various skeletal sites, but data on vertebral geometry are lacking. METHODS This study of 1338 middle-aged Northern Finns evaluated the associations of eating behavior traits (flexible and rigid cognitive restraint of eating, uncontrolled eating, emotional eating; assessed by the Three-Factor Eating Questionnaire-18) and weight loss attempts (assessed by a separate questionnaire item) with magnetic resonance imaging-derived vertebral cross-sectional area (CSA). Sex-stratified linear regression models were used to analyze the data, taking body mass index, leisure-time physical activity, general diet, smoking, and socioeconomic status as potential confounders. RESULTS Women with rigid or rigid-and-flexible cognitive eating restraints had 3.2% to 3.4% smaller vertebral CSA than those with no cognitive restraint (P ≤ 0.05). Similarly, the women who reported multiple weight loss attempts in adulthood and midlife had 3.5% smaller vertebral size than those who did not (P = 0.03). Other consistent findings were not obtained from either sex. CONCLUSION Rigid cognitive eating restraint and multiple weight loss attempts predict small vertebral size and thus decreased spinal health among middle-aged women, but not among men. Future longitudinal studies should confirm these findings. LEVEL OF EVIDENCE 3.
Collapse
|
12
|
Plessow F, Singhal V, Toth AT, Micali N, Eddy KT, Misra M. Estrogen administration improves the trajectory of eating disorder pathology in oligo-amenorrheic athletes: A randomized controlled trial. Psychoneuroendocrinology 2019; 102:273-280. [PMID: 30639922 PMCID: PMC6664444 DOI: 10.1016/j.psyneuen.2018.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/12/2018] [Accepted: 11/08/2018] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Estrogen replacement prevents worsening body dissatisfaction with weight gain in adolescents with anorexia nervosa. However, the impact of estrogen administration on eating disorder (ED) pathology in normal-weight young women with exercise-induced amenorrhea is unknown. We hypothesized that (1) normal-weight oligo-amenorrheic athletes (OA) would show greater ED pathology than eumenorrheic athletes (EA) and non-athletes (NA), and (2) 12 months of estrogen replacement would improve those symptoms. TRIAL DESIGN Randomized trial. METHODS One hundred seventeen OA, 50 EA, and 41 NA completed the Eating Disorder Inventory-2 (EDI-2) for measures of Drive for Thinness (DT) and Body Dissatisfaction (BD) and the Three-Factor Eating Questionnaire-R18 (TFEQ-R18). OA were then randomized to receive 100 mcg transdermal 17β-estradiol with cyclic progesterone (PATCH), an oral contraceptive pill (30 mcg ethinyl estradiol + 0.15 mg desogestrel) (PILL), or no estrogen (E-) for 12 months. Data are reported for the subset that completed questionnaires at 0 and 12 months between 11/2009 and 10/2016. RESULTS OA showed higher EDI-2 DT and TFEQ-R18 Cognitive Restraint scores than EA and NA and higher EDI-2 BD scores than EA. Over 12 months, the E+ group (PATCH+PILL), compared to E-, showed improved trajectories for EDI-2 DT and BD scores. In 3-group comparisons, PATCH outperformed E- for decreases in EDI-2 DT and BD, and the PILL for TFEQ-R18 Uncontrolled Eating. CONCLUSION In OA, 12 months of estrogen replacement improves ED pathology trajectories, emphasizing the broad importance of normalizing estrogen levels. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00946192.
Collapse
Affiliation(s)
- Franziska Plessow
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
| | - Vibha Singhal
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Division of Pediatric Endocrinology, Massachusetts General Hospital for Children and Harvard Medical School, Boston, MA, USA
| | - Alexander T. Toth
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Nadia Micali
- Child and Adolescent Psychiatry Division, Department of Psychiatry, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Kamryn T. Eddy
- Eating Disorders Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Madhusmita Misra
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Division of Pediatric Endocrinology, Massachusetts General Hospital for Children and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
13
|
Hohman EE, Balantekin KN, Birch LL, Savage JS. Dieting is associated with reduced bone mineral accrual in a longitudinal cohort of girls. BMC Public Health 2018; 18:1285. [PMID: 30466435 PMCID: PMC6251190 DOI: 10.1186/s12889-018-6206-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/08/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Peak bone mass accrual occurs during adolescence, a time when dieting and related eating behaviors are common. Impaired bone mineral accrual is a known consequence of eating disorders in adolescents, but the effects of subclinical dieting behaviors on bone mineral content (BMC) have not been described in this age group. The goal of this analysis was to determine whether dieting behavior in preadolescence and adolescence is associated with bone mineral accrual in adolescent girls. METHODS Non-Hispanic white girls (n = 139) were followed in a longitudinal cohort study. BMC was assessed at ages 9 and 15y. Dieting to lose weight was reported every 2 years, and dietary restraint and disinhibition, eating attitudes, weight concerns, and body esteem were assessed at age 11y. Girls were classified as "early dieters" if they first dieted by age 11y (31.7%), "adolescent dieters" if they first dieted after 11y (46.8%), or non-dieters if they did not report dieting by 15 y (21.6%). The effect of dieting related variables on BMC at 15y and change in BMC from 9 to 15y was assessed using linear regression, controlling for height, weight, BMI, physical activity, and pubertal status. RESULTS Girls who first reported dieting to lose weight by age 11y had a 4.2% lower bone mineral accrual across adolescence (p = 0.02) and 3.1% lower BMC at age 15y (p = 0.005) than girls who first reported dieting after 11y or not at all. Number of weight control behaviors used, dietary restraint, and weight concerns were also negatively associated with BMC (p < 0.05). CONCLUSIONS Dieting behavior in preadolescence is associated with reduced bone mineral accrual. Strategies to promote optimal bone development should include prevention of dieting. TRIAL REGISTRATION Clinicaltrials.gov NCT03342430, November 17, 2017. Retrospectively registered.
Collapse
Affiliation(s)
- Emily E Hohman
- Center for Childhood Obesity Research, The Pennsylvania State University, 129 Noll Laboratory, University Park, PA, 16802, USA.
| | - Katherine N Balantekin
- Department of Exercise and Nutrition Sciences, University at Buffalo, 12 Sherman Hall, Buffalo, NY, 14214, USA
| | - Leann L Birch
- Department of Foods and Nutrition, The University of Georgia, 172 Dawson Hall, Athens, GA, 30602, USA
| | - Jennifer S Savage
- Center for Childhood Obesity Research and Department of Nutritional Sciences, The Pennsylvania State University, 103 Noll Laboratory, University Park, PA, 16802, USA
| |
Collapse
|
14
|
Richard N, Palmer C, Adams HP. Female Athlete Triad. PHYSICIAN ASSISTANT CLINICS 2018. [DOI: 10.1016/j.cpha.2018.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
15
|
Okbay Güneş A, Alikaşifoğlu M, Şen Demirdöğen E, Erginöz E, Demir T, Kucur M, Ercan O. The Relationship of Disordered Eating Attitudes with Stress Level, Bone Turnover Markers, and Bone Mineral Density in Obese Adolescents. J Clin Res Pediatr Endocrinol 2017; 9:237-245. [PMID: 28196789 PMCID: PMC5596805 DOI: 10.4274/jcrpe.3794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To investigate the effect of stress caused by disordered eating attitudes on bone health in obese adolescents. METHODS A cross-sectional study comprising 80 obese adolescents was performed from November 2013 to September 2014. Twenty-four-hour urinary free cortisol levels were measured as a biological marker of stress. Bone turnover was evaluated using bone-specific alkaline phosphatase, serum osteocalcin, and urinary N-telopeptide concentrations. Bone mineral density was measured using dual-energy X-ray absorptiometry. The Eating Disorder Examination Questionnaire, Dutch Eating Behavior Questionnaire, Children's Depression Inventory, and the State-Trait Anxiety Inventory for Children were used to assess eating disorders, depression, and anxiety. Psychiatric examinations were performed for binge eating disorders. RESULTS In the Pearson's correlation test, a positive correlation was found between the 24-hour urinary cortisol level and Dutch Eating Behavior Questionnaire total and restrained eating subscale scores (p<0.05 for both). In linear regression analyses, the Dutch Eating Behavior Questionnaire total and restrained eating subscale scores were found to be significant contributors for urinary cortisol level (β=1.008, p=0.035; β=2.296, p=0.014, respectively). The femoral neck areal bone mineral density was found to be significantly higher in subjects who had binge eating disorder compared with those without binge eating disorder (p=0.049). CONCLUSION Despite the lack of apparent effects on bone turnover and bone mineral density in our obese adolescents at the time of the study, our results suggest that disordered eating attitudes, and especially restrained eating attitudes, might be a source of stress. Therefore, studies in this area should continue.
Collapse
Affiliation(s)
- Aslı Okbay Güneş
- İstanbul University Cerrahpaşa Faculty of Medicine, Department of Pediatrics, İstanbul, Turkey
| | - Müjgan Alikaşifoğlu
- İstanbul University Cerrahpaşa Faculty of Medicine, Department of Pediatrics, Division of Adolescent Medicine, İstanbul, Turkey
,* Address for Correspondence: İstanbul University Cerrahpaşa Faculty of Medicine, Department of Pediatrics, Division of Adolescent Medicine, İstanbul, Turkey E-mail:
| | - Ezgi Şen Demirdöğen
- İstanbul University Cerrahpaşa Faculty of Medicine, Department of Child and Adolescent Psychiatry, İstanbul, Turkey
| | - Ethem Erginöz
- İstanbul University Cerrahpaşa Faculty of Medicine, Department of Public Health, İstanbul, Turkey
| | - Türkay Demir
- İstanbul University Cerrahpaşa Faculty of Medicine, Department of Child and Adolescent Psychiatry, İstanbul, Turkey
| | - Mine Kucur
- İstanbul University Cerrahpaşa Faculty of Medicine, Department of Biochemistry, İstanbul, Turkey
| | - Oya Ercan
- İstanbul University Cerrahpaşa Faculty of Medicine, Department of Pediatrics, Division of Adolescent Medicine and Endocrinology, İstanbul, Turkey
| |
Collapse
|
16
|
Gordon CM, Ackerman KE, Berga SL, Kaplan JR, Mastorakos G, Misra M, Murad MH, Santoro NF, Warren MP. Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2017; 102:1413-1439. [PMID: 28368518 DOI: 10.1210/jc.2017-00131] [Citation(s) in RCA: 226] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/23/2017] [Indexed: 02/04/2023]
Abstract
COSPONSORING ASSOCIATIONS The American Society for Reproductive Medicine, the European Society of Endocrinology, and the Pediatric Endocrine Society. This guideline was funded by the Endocrine Society. OBJECTIVE To formulate clinical practice guidelines for the diagnosis and treatment of functional hypothalamic amenorrhea (FHA). PARTICIPANTS The participants include an Endocrine Society-appointed task force of eight experts, a methodologist, and a medical writer. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. CONSENSUS PROCESS One group meeting, several conference calls, and e-mail communications enabled consensus. Endocrine Society committees and members and cosponsoring organizations reviewed and commented on preliminary drafts of this guideline. CONCLUSIONS FHA is a form of chronic anovulation, not due to identifiable organic causes, but often associated with stress, weight loss, excessive exercise, or a combination thereof. Investigations should include assessment of systemic and endocrinologic etiologies, as FHA is a diagnosis of exclusion. A multidisciplinary treatment approach is necessary, including medical, dietary, and mental health support. Medical complications include, among others, bone loss and infertility, and appropriate therapies are under debate and investigation.
Collapse
Affiliation(s)
| | - Kathryn E Ackerman
- Boston Children's Hospital, Boston, Massachusetts 02115
- Massachusetts General Hospital, Boston, Massachusetts 02114
| | - Sarah L Berga
- Wake Forest School of Medicine, Winston-Salem, North Carolina 27157
| | - Jay R Kaplan
- Wake Forest School of Medicine, Winston-Salem, North Carolina 27157
| | - George Mastorakos
- Areteio Hospital, Medical School, National and Capodistrian University of Athens, Athens, Greece 10674
| | | | - M Hassan Murad
- Division of Preventive Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | | | - Michelle P Warren
- Center for Menopause, Hormonal Disorders, and Women's Health, Columbia University Medical Center, New York, New York 10021
| |
Collapse
|
17
|
Nieves JW, Ruffing JA, Zion M, Tendy S, Yavorek T, Lindsay R, Cosman F. Eating disorders, menstrual dysfunction, weight change and DMPA use predict bone density change in college-aged women. Bone 2016; 84:113-119. [PMID: 26746778 DOI: 10.1016/j.bone.2015.12.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 12/23/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION There are limited longitudinal studies that have evaluated bone mineral density (BMD) changes in college-aged women. Our objective was to simultaneously evaluate factors influencing 4-year BMD change. METHODS This was a longitudinal cohort study of healthy, physically active women in the US Military Academy (n=91; average age=18.4years). Assessments over four years included: height, weight, calcium intake, physical fitness, menstrual function (annual number cycles), oral contraceptives (OCs) or depot-medroxyprogesterone acetate (DMPA) use, and eating disorder behavior (Eating Disorder Inventory; (EDI)). BMD was measured annually at the lumbar spine and total hip by dual X-ray absorptiometry and calcaneal BMD by PIXI. Slope of 4year BMD change at each skeletal site (spine total hip and calcaneus) was calculated for each woman. RESULTS BMD gains occurred at the spine in 50% and the hip in 36% of women. In unadjusted analyses, spine bone gain was positively related to menstrual cycle frequency (p=0.04). Spine and hip BMD loss occurred in those using DMPA (p<0.01) and those with the highest EDI quartile scores (p<0.05). BMD change was unrelated to OC use. Hip and calcaneus BMD decreased with weight loss (average 4.8+2.2lb/year) as compared to those with stable weight/weight gain (p<0.05). In multivariable analysis, spine BMD increase was significantly related to African American (AA) race, normal EDI score and normal menses. Hip BMD increase was related to AA race, weight increase and normal menses. DMPA use was associated with spine, hip, and calcaneus bone loss. CONCLUSION On average, BMD may modestly increase in college-aged women, in the absence of risk factors. However, risk factors including subclinical eating disorders, weight loss, menstrual dysfunction and DMPA use can have significant detrimental effects on BMD in young healthy physically active women.
Collapse
Affiliation(s)
- Jeri W Nieves
- Clinical Research and Regional Bone Centers, Helen Hayes Hospital, West Haverstraw, NY, USA; Department of Epidemiology, Mailman School of Public Health Columbia University, NY, USA.
| | - Jamie A Ruffing
- Clinical Research and Regional Bone Centers, Helen Hayes Hospital, West Haverstraw, NY, USA; Department of Epidemiology, Mailman School of Public Health Columbia University, NY, USA
| | - Marsha Zion
- Clinical Research and Regional Bone Centers, Helen Hayes Hospital, West Haverstraw, NY, USA
| | - Susan Tendy
- United States Military Academy, West Point, NY, USA
| | | | - Robert Lindsay
- Clinical Research and Regional Bone Centers, Helen Hayes Hospital, West Haverstraw, NY, USA; Department of Medicine, College of Physicians and Surgeons of Columbia University, NY, USA
| | - Felicia Cosman
- Clinical Research and Regional Bone Centers, Helen Hayes Hospital, West Haverstraw, NY, USA; Department of Medicine, College of Physicians and Surgeons of Columbia University, NY, USA
| |
Collapse
|