Knowledge, Attitude, and Skill of High School Coaches with Regard to the Female Athlete Triad

Differences in Knowledge of Female Athlete Triad and Relative Energy Deficiency in Sport in Female Cross-Country Athletes

BACKGROUND

The female athlete triad (Triad) and relative energy deficiency in sport (REDs) describe potential health and performance consequences of low energy availability.

OBJECTIVE

We surveyed female cross-country athletes to assess differences in educational impact scores (EIS; knowledge score × confidence score factor) of Triad and REDs. Associations between EIS and participant characteristics (eg, mileage [current and peak], years of running experience, age, bone stress injury history, division level participation, academic area of study, Triad or REDs diagnoses, and Triad or REDs education) were explored.

MAIN OUTCOME MEASURE(S)

An evidence-based online survey was developed and administered via Qualtrics to female collegiate cross-country athletes (n = 275; age = 20 ± 1 years).

RESULTS

A weak correlation existed between peak career mileage and EIS (r = 0.195; P = .010). Educational impact scores significantly differed in athletes with a related academic area of study versus those without (21.91 ± 5.16 and 16.11 ± 5.54, respectively). Educational impact scores significantly differed in athletes with Triad and REDs diagnoses (21.69 ± 5.85 and 22.58 ± 6.82, respectively) versus those without (16.80 ± 6.54 and 17.20 ± 6.34, respectively). Educational impact scores were higher in those who had received Triad education versus those who had not (21.03 ± 6.86 and 18.12 ± 6.82, respectively). A significant interaction between peak career mileage and Triad diagnosis was found (P = .005).

CONCLUSIONS

Significant education-based and diagnosis differences suggest that Triad diagnoses correlate with peak career mileage. These findings support the facilitation of education to improve not only the treatment but also the prevention of Triad and REDs.

2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs)

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.

Best practice recommendations for body composition considerations in sport to reduce health and performance risks: a critical review, original survey and expert opinion by a subgroup of the IOC consensus on Relative Energy Deficiency in Sport (REDs)

BACKGROUND

The assessment of body composition (BC) in sport raises concern for athlete health, especially where an overfocus on being lighter or leaner increases the risk of Relative Energy Deficiency in Sport (REDs) and disordered eating.

METHODS

We undertook a critical review of the effect of BC on performance (29 longitudinal, prospective or intervention studies) and explored current practice related to BC considerations via a follow-up to a 2013 internationally distributed survey.

RESULTS

The review found that a higher level of body fat was negatively associated with endurance performance, while a gain in muscle mass resulted in performance benefits across sports. BC did not contribute to early talent identification, and no unique cut-off to signify a performance advantage for BC was identified. BC appears to be one of an array of variables impacting performance, and its influence should not be overstated. The survey (125 practitioners, 61 sports and 26 countries) showed subtle changes in BC considerations over time, such as an increased role for sport dietitian/nutrition practitioners as BC measurers (2013: 54%, 2022: 78%); less emphasis on reporting of body fat percentage (2013: 68%, 2022: 46%) and reduced frequency of BC assessment if ≥every fourth week (2013: 18%, 2022: 5%). Respondents remained concerned about a problematic focus on BC (2013: 69%, 2022: 78%). To address these findings, we provide detailed recommendations for BC considerations, including an overview of preferable BC methodology.

CONCLUSIONS

The 'best practice' guidelines stress the importance of a multidisciplinary athlete health and performance team, and the treatment of BC data as confidential medical information. The guidelines provide a health focus around BC, aiming to reduce the associated burden of disordered eating, problematic low energy availability and REDs.

Knowledge of the Female Athlete Triad and Relative Energy Deficiency in Sport Among Female Cross-Country Athletes and Support Staff

CONTEXT

Female endurance athletes exhibit an increased risk of the female athlete triad (Triad) and relative energy deficiency in sport (RED-S). The triad and RED-S are conditions that involve the health and performance consequences of low energy availability. Few authors of studies to date have assessed the knowledge that athletes, coaches, and athletic trainers (ATs) have regarding the Triad or RED-S. Proper education has been shown to be effective in increasing knowledge of sports medicine concerns for athletes, yet no known continuing education programs for the Triad or RED-S exist at collegiate institutions.

OBJECTIVE

To assess the knowledge, confidence, and educational impact of identifying, screening, treating, and preventing the Triad or RED-S.

DESIGN

Cross-sectional study.

SETTING

An evidence-based online survey was developed and administered via Qualtrics.

PATIENTS OR OTHER PARTICIPANTS

Female collegiate cross-country athletes (n = 275, age = 20 ± 1 years), collegiate cross-country coaches (n = 55, age = 34 ± 9 years), and ATs working with cross-country teams (n = 30, age = 36 ± 11 years).

MAIN OUTCOME MEASURE(S)

Knowledge, confidence, and educational impact scores were assessed among groups using analysis of variance. Independent t tests were calculated to determine differences in impact scores between people who had or had not received education on the topic.

RESULTS

Female cross-country athletes' total knowledge, confidence, and educational impact scores (mean scores = 25.00 ± 5.27, 95.42 ± 28.83, and 18.81 ± 7.05, respectively) were different from those of coaches (mean scores = 26.92 ± 5.02, 111.35 ± 24.14, and 22.41 ± 6.33, respectively) and ATs (mean scores = 28.66 ± 4.02, 117.67 ± 22.53, and 23.93 ± 5.69, respectively; P < .05).

CONCLUSIONS

Knowledge, confidence, and educational impact scores regarding Triad or RED-S were lowest in female cross-country athletes and highest in ATs. These findings support the call for education, which should be regarded as the primary tool for increasing knowledge, to improve the prevention and treatment of the Triad or RED-S.

Overtraining Syndrome (OTS) and Relative Energy Deficiency in Sport (RED-S): Shared Pathways, Symptoms and Complexities

The symptom similarities between training-overload (with or without an Overtraining Syndrome (OTS) diagnosis) and Relative Energy Deficiency in Sport (RED-S) are significant, with both initiating from a hypothalamic-pituitary origin, that can be influenced by low carbohydrate (CHO) and energy availability (EA). In this narrative review we wish to showcase that many of the negative outcomes of training-overload (with, or without an OTS diagnosis) may be primarily due to misdiagnosed under-fueling, or RED-S, via low EA and/or low CHO availability. Accordingly, we undertook an analysis of training-overload/OTS type studies that have also collected and analyzed for energy intake (EI), CHO, exercise energy expenditure (EEE) and/or EA. Eighteen of the 21 studies (86%) that met our criteria showed indications of an EA decrease or difference between two cohorts within a given study (n = 14 studies) or CHO availability decrease (n = 4 studies) during the training-overload/OTS period, resulting in both training-overload/OTS and RED-S symptom outcomes compared to control conditions. Furthermore, we demonstrate significantly similar symptom overlaps across much of the OTS (n = 57 studies) and RED-S/Female Athlete Triad (n = 88 studies) literature. It is important to note that the prevention of under-recovery is multi-factorial, but many aspects are based around EA and CHO availability. Herein we have demonstrated that OTS and RED-S have many shared pathways, symptoms, and diagnostic complexities. Substantial attention is required to increase the knowledge and awareness of RED-S, and to enhance the diagnostic accuracy of both OTS and RED-S, to allow clinicians to more accurately exclude LEA/RED-S from OTS diagnoses.

Reasons for and Consequences of Low Energy Availability in Female and Male Athletes: Social Environment, Adaptations, and Prevention

Low energy availability (LEA) represents a state in which the body does not have enough energy left to support all physiological functions needed to maintain optimal health. When compared to the normal population, athletes are particularly at risk to experience LEA and the reasons for this are manifold. LEA may result from altered dietary behaviours that are caused by body dissatisfaction, the belief that a lower body weight will result in greater performance, or social pressure to look a certain way. Pressure can also be experienced from the coach, teammates, and in this day and age through social media platforms. While LEA has been extensively described in females and female athletes have started fighting against the pressure to be thin using their social media platforms, evidence shows that male athletes are at risk as well. Besides those obvious reasons for LEA, athletes engaging in sports with high energy expenditure (e.g. rowing or cycling) can unintentionally experience LEA; particularly, when the athletes' caloric intake is not matched with exercise intensity. Whether unintentional or not, LEA may have detrimental consequences on health and performance, because both short-term and long-term LEA induces a variety of maladaptations such as endocrine alterations, suppression of the reproductive axis, mental disorders, thyroid suppression, and altered metabolic responses. Therefore, the aim of this review is to increase the understanding of LEA, including the role of an athlete's social environment and the performance effects related to LEA.

Menstrual Cycle Disorders in Professional Female Rhythmic Gymnasts

The aim of this research was to compare menstrual cycles, menstrual disorders, and the prevalence of premenstrual syndrome (PMS)and premenstrual dysphoric disorder (PMDD) in professional female gymnasts and their peers who donot practice any sport, and to identify factors causing a predisposition to premenstrual tension syndrome and premenstrual dysphoric disorders in both groups. The prospective study involved apopulation of 85 girls. The study group consisted of 45 professional female gymnasts (15-17 years of age) who lived inthe territory of Silesia, in the southern area of Poland. The control group consisted of 40 girls of the same age who lived in the same area but did not professionally practice any sport. The research tools included a questionnaire, a daily diary of PMS symptoms, a daily diary of PMDD symptoms, and a premenstrual symptom screening tool (PSST). The study showed that intensive physical activity undertaken by girls before their first menstruation is a menarche-delaying factor andthat competitive sport promotes premenstrual syndrome and premenstrual dysphoric disorder. The risk factors for PMS and PMDD were also identified, andincluded alcohol and coffee consumption.