Nutritional intakes and status of highly trained amenorrheic and eumenorrheic women runners*†*Supported by grant CO76AD from the Uniformed Services University of the Health Sciences.†The opinions or assertions contained herein are the private ones of the authors and are not to be construed as official or reflecting the views of the Department of Defense or the Uniformed Services University Health Sciences

Current Status of the Female Athlete Triad: Update and Future Directions

PURPOSE OF REVIEW

This review provides an update on the primary clinical sequelae of the Female Athlete Triad.

RECENT FINDINGS

Scientific advancements have contributed to improve understanding of Triad-related conditions, including leptin's role as a potential neuroendocrine link between energy status and reproductive function. Use of finite element analysis of HRpQCT imaging has provided a more accurate assessment of bone geometry and bone strength and may be clinically relevant. New perspectives aimed at developing and implementing a multi-disciplinary, personalized approach in the prevention and early treatment of triad-related symptoms are provided. The Female Athlete Triad is a multi-dimensional condition that affects active women across the lifespan. Energy availability impacts reproductive function and bone with implications for health and performance. Understanding the contributions of each individual component as well as their interconnected effects is necessary for progression and expansion of the Triad literature.

Prevalence of Dietary Supplement Use by Athletes: Systematic Review and Meta-Analysis

BACKGROUND

Dietary supplements (DSs) are commercially available products consumed as an addition to the usual diet and are frequently ingested by athletes.

OBJECTIVE

Our objective was to examine the prevalence of DS use by athletes.

DATA SOURCES

PubMed, Ovid MEDLINE, OVID Healthstar, and Cumulative Index to Nursing and Allied Health were searched for original research articles published up to August 2014. Search terms included specific sports, specific DSs, and other terms.

STUDY SELECTION

Studies were selected if they were written in English, involved athletes, and provided a quantitative assessment of the proportion of athletes using specific DSs. Percent of athletes using specific DSs.

SYNTHESIS OF DATA

Methodological quality of studies was assessed by three reviewers using an 8-point scale that included evaluations for sampling methods, sampling frame, sample size, measurement tools, bias, response rate, statistical presentation, and description of the participant sample. Where there were at least two investigations, meta-analysis was performed to obtain summary (pooled) prevalence estimates (SPEs) on (1) DS use prevalence by sport and sex, (2) DS use prevalence by elite versus non-elite athletic status, and (3) specific DS prevalence for all athletic groups combined. Meta-analyses included evaluations of homogeneity and publication bias.

RESULTS

A total of 159 unique studies met the review criteria. Methodological quality was generally low with an average ± standard deviation of 43 ± 16% of available rating points. There was low homogeneity for SPEs when compiled by sport, athletic status, and/or specific DSs. Contributing to the lack of homogeneity were differences in studies' objectives and types of assessments used (e.g., dietary surveys, interviews, questionnaires). Despite these limitations, the data generally indicated that elite athletes used DSs much more than their non-elite counterparts. For most DSs, use prevalence was similar for men and women except that a larger proportion of women used iron while a larger proportion of men used vitamin E, protein, and creatine. No consistent change in use over time was observed because even the earliest investigations showed relatively high use prevalence.

CONCLUSION

It was difficult to generalize regarding DS use by athletes because of the lack of homogeneity among studies. Nonetheless, the data suggested that elite athletes used dietary supplements far more than their non-elite counterparts; use was similar for men and women with a few exceptions; use appeared to change little over time; and a larger proportion of athletes used DSs compared with the general US population. Improvements in study methodology should be considered in future studies especially (1) defining DSs for participants; (2) querying for very specific DSs; (3) using a variety of reporting timeframes (e.g., daily, 2-6 times/week, 1 time/week and <1 time/week); (4) reporting the sampling frame, number of individuals solicited, and number responding; (5) reporting characteristics of volunteers (and non-volunteers, if available); and (6) using similar methods on several occasions to examine possible temporal trends among athletes.

2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, CA, May 2012, and 2nd International Conference held in Indianapolis, IN, May 2013

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves 3 components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with 1 or more of the 3 Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement represents a set of recommendations developed following the first (San Francisco, California) and second (Indianapolis, Indianna) International Symposia on the Female Athlete Triad. It is 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 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad 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. This consensus paper has been endorsed by The Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians, and other health care professionals, the American College of Sports Medicine, and the American Medical Society for Sports Medicine.

The relation between athletic sports and prevalence of amenorrhea and oligomenorrhea in Iranian female athletes

BACKGROUND

In 1992, the concept of female athlete triad was introduced to describe the interrelated problems of amenorrhea, eating disorders and osteoporosis seen in female athletes. To gain a clearer picture of amenorrhea/oligomenorrhea in Iran, one of the main components of the female athlete triad, we therefore established this study on the prevalence of amenorrhea/oligomenorrhea in elite Iranian female athletes, also evaluating the risk factors of these disorders in the same population.

METHODS

This study performed as a cross-sectional study. All elite Iranian female athletes of 34 sports federation, including female athletes in national teams and medalists of Tehran were invited to participate. A total of 788 (95% response rate) returned the questionnaires and were examined. Younger athletes under the age of menarche were excluded. Each athlete completed a self-administered questionnaire, which covered the following questions about participant's demographic information, athletic history, history of injuries and menstrual pattern. In order to diagnose the causes of amenorrhea/Oligomenorrhea including polycystic ovary syndrome(PCOS), participants with amenorrhea/Oligomenorrhea underwent further investigation. They were evaluated by following Para clinic investigation, and an ultrasonographic study of ovary.

RESULTS

The age ranged from 13-37 (mean = 21.1, SD = 4.5). Seventy one (9.0%) individuals had amenorrhea/oligomenorrhea, among those, 11 (15.5%) had PCOS.There was also a positive association between amenorrhea/oligomenorrhea and the following: age under 20 OR; 2.67, 95%CI(1.47 - 4.85), weight class sports OR; 2.09, 95%CI(1.15 - 3.82), endurance sports OR; 2.89, 95%CI(1.22 - 6.84), late onset of menarche OR; 3.32 95%CI(1.04-10.51), and use of oral contraceptive pills OR; 6.17, 95%CI(3.00 - 12.69). Intensity of training sport or BMI were not risk factors.

CONCLUSION

These findings support the previous findings in the literature that the prevalence of amenorrhea/oligomenorrhea is high in athletes. Furthermore, we provided the first report on the prevalence of PCOS in female athletes with amenorrhea/oligomenorrhea. Athletes would be greatly benefited by greater general awareness about the complications of amenorrhea/oligomenorrhea.To increase awareness of exercise-associated menstrual cycle irregularities, it is necessary to design complete and comprehensive education programs for female athletes, their parents, their coaches, and the relevant authorities.

The female athlete triad: components, nutrition issues, and health consequences

This paper, which was part of the International Association of Athletics Federations (IAAF) 2007 Nutritional Consensus Conference, briefly reviews the components of the female athlete triad (Triad): energy availability, menstrual status, and bone health. Each component of the Triad spans a continuum from health to disease, and female athletes can have symptoms related to each component of the Triad to different degrees. Low energy availability is the primary factor that impairs menstrual dysfunction and bone health in the Triad. We discuss nutritional issues associated with the Triad, focusing on intakes of macronutrients needed for good health, and stress fractures, the most common injury associated with the Triad. Finally, we briefly discuss screening and treatment for the Triad and the occurrence of the Triad in men.

Energy availability and infertility

PURPOSE OF REVIEW

To relate recent research on the dependence of reproductive function on energy availability in women to recent clinical experience in the treatment of anorexia nervosa.

RECENT FINDINGS

The dependence of luteinizing hormone pulsatility on energy availability declines during adolescence, but the responses of leptin and other peripheral signals of energy deficiency do not. This finding suggests that central sensitivity to these signals may decline during adolescence. Energy availability may be inadequate in anorexia nervosa patients whose menstrual cycles are not restored after weight recovery.

SUMMARY

Energy availability is a theoretically satisfying and operationally controllable concept for understanding, investigating, and managing the energy dependence of reproductive function. Nutritional intervention to restore menstrual cycles in anorexia nervosa patients might be more successful if it was guided by energy availability and ovarian volume rather than energy intake and body weight.

The Female Athlete Triad

The female athlete triad (Triad) refers to the interrelationships among energy availability, menstrual function, and bone mineral density, which may have clinical manifestations including eating disorders, functional hypothalamic amenorrhea, and osteoporosis. With proper nutrition, these same relationships promote robust health. Athletes are distributed along a spectrum between health and disease, and those at the pathological end may not exhibit all these clinical conditions simultaneously. Energy availability is defined as dietary energy intake minus exercise energy expenditure. Low energy availability appears to be the factor that impairs reproductive and skeletal health in the Triad, and it may be inadvertent, intentional, or psychopathological. Most effects appear to occur below an energy availability of 30 kcal.kg(-1) of fat-free mass per day. Restrictive eating behaviors practiced by girls and women in sports or physical activities that emphasize leanness are of special concern. For prevention and early intervention, education of athletes, parents, coaches, trainers, judges, and administrators is a priority. Athletes should be assessed for the Triad at the preparticipation physical and/or annual health screening exam, and whenever an athlete presents with any of the Triad's clinical conditions. Sport administrators should also consider rule changes to discourage unhealthy weight loss practices. A multidisciplinary treatment team should include a physician or other health-care professional, a registered dietitian, and, for athletes with eating disorders, a mental health practitioner. Additional valuable team members may include a certified athletic trainer, an exercise physiologist, and the athlete's coach, parents and other family members. The first aim of treatment for any Triad component is to increase energy availability by increasing energy intake and/or reducing exercise energy expenditure. Nutrition counseling and monitoring are sufficient interventions for many athletes, but eating disorders warrant psychotherapy. Athletes with eating disorders should be required to meet established criteria to continue exercising, and their training and competition may need to be modified. No pharmacological agent adequately restores bone loss or corrects metabolic abnormalities that impair health and performance in athletes with functional hypothalamic amenorrhea.

A prospective study of dietary carbohydrate quantity and quality in relation to risk of ovulatory infertility

OBJECTIVE

To evaluate whether the amount or quality of carbohydrate in diet is associated with ovulatory infertility.

SUBJECTS AND METHODS

In total, 18,555 married, premenopausal women without a history of infertility were followed as they attempted a pregnancy or became pregnant during an 8-year period. Diet was assessed two times during follow-up using a validated food-frequency questionnaire and prospectively related to the incidence of infertility due ovulatory disorder.

RESULTS

During follow-up, 438 women reported ovulatory infertility. Total carbohydrate intake and dietary glycemic load were positively related to ovulatory infertility in analyses adjusted for age, body mass index, smoking, parity, physical activity, recency of contraception, total energy intake, protein intake and other dietary variables. The multivariable-adjusted risk ratio (RR) (95% confidence interval (CI)) of ovulatory infertility comparing the highest-to-lowest quintile of total carbohydrate intake was 1.91 (1.27-3.02). The corresponding RR (95% CI) for dietary glycemic load was 1.92 (1.26-2.92). Dietary glycemic index was positively related to ovulatory infertility only among nulliparous women. Intakes of fiber from different sources were unrelated to ovulatory infertility risk.

CONCLUSIONS

The amount and quality of carbohydrate in diet may be important determinants of ovulation and fertility in healthy women.

Dietary fatty acid intakes and the risk of ovulatory infertility

BACKGROUND

Pharmacologic activation of the peroxisome proliferator-activated receptor gamma (PPAR-gamma) improves ovulatory function in women with polycystic ovary syndrome, and specific dietary fatty acids can affect PPAR-gamma activity.

OBJECTIVE

The objective of the study was to assess whether the intakes of total fat, cholesterol, and major types of fatty acids affect the risk of ovulatory infertility.

DESIGN

We conducted a prospective cohort study of 18 555 married, premenopausal women without a history of infertility who attempted a pregnancy or became pregnant between 1991 and 1999. Diet was assessed twice during follow-up by using a food-frequency questionnaire.

RESULTS

During follow-up, 438 incidents of ovulatory infertility were reported. In logistic regression analyses, intakes of total fat, cholesterol, and most types of fatty acids were not related to ovulatory infertility. Each 2% increase in the intake of energy from trans unsaturated fats, as opposed to that from carbohydrates, was associated with a 73% greater risk of ovulatory infertility after adjustment for known and suspected risk factors for this condition [relative risk (RR) = 1.73; 95% CI: 1.09, 2.73]. Obtaining 2% of energy intake from trans fats rather than from n-6 polyunsaturated fats was associated with a similar increase in the risk of ovulatory infertility (RR = 1.79; 95% CI: 1.11, 2.89). In addition, obtaining 2% of energy from trans fats rather than from monounsaturated fats was associated with a more than doubled risk of ovulatory infertility (RR = 2.31; 95% CI: 1.09, 4.87).

CONCLUSION

trans Unsaturated fats may increase the risk of ovulatory infertility when consumed instead of carbohydrates or unsaturated fats commonly found in nonhydrogenated vegetable oils.

Menstrual disorders in athletes

The various menstrual disorders in athletes may reflect different degrees of exposure to a disrupting factor or differences in the susceptibility of various women to disruption. The incidences of these disorders are not well documented, but they appear to be highest in aesthetic, endurance and weight-class sports, and at younger ages, higher training volumes and lower bodyweights. The morbid effects of these disorders include infertility, low bone mass, impaired endothelium-dependent vasodilation, and impaired skeletal muscle oxidative metabolism. The high incidences of menstrual disorders in athletes may derive in part from the self-selection of extraneously affected women into athletics, but many women acquire their menstrual disorders in athletics by failing to adequately increase dietary energy intake in compensation for exercise energy expenditure. Applied research is needed to develop effective dietary interventions that are acceptable to athletes.

The consequences of negative energy balance in anorexia syndrome

STUDY OBJECTIVE

Using four cases, this study describes common etiological factors and clinical sequelae in anorexia nervosa and athletic anorexia to present a biological explanation for interactions.

DESIGN

Four anorectic girls were interviewed regarding their training programs and dietary intake. Bone mineral content, hormonal status, and energy intake were assessed during follow-ups.

RESULTS

All the girls began training before puberty and had a low energy intake for age and height. Amenorrhea, low bone mineral content with stress fractures in three cases, and growth retardation in one case, were present at the follow-up after 6 years. Low amount of body fat and high serum cortisol is indicated and included in the discussion. The etiology is presented in an integrated model in addition to a biological explanation based on a negative energy balance, an acidic condition.

CONCLUSION

Energy deficits during puberty can result in the clinical sequela of the anorexia syndrome.

Protein requirements for endurance athletes

Acute endurance exercise results in the oxidation of several amino acids. The total amount of amino acid oxidation during endurance exercise amounts to only 1-6% of the total energy cost of exercise. The branched chain amino acid, leucine, has been most often studied in relation to endurance exercise. Leucine is oxidized by the enzyme, branched-chain oxo-acid dehydrogenase (BCOAD). BCOAD is relatively inactive at rest ( approximately 4-7%) and is activated at the onset of exercise by dephosphorylation (to about 25%). After a period of endurance exercise training, the activation of BCOAD and amino acid oxidation are attenuated, however the total amount of BCOAD enzyme is up-regulated. A low energy and/or carbohydrate intake will increase amino acid oxidation and total protein requirements. With adequate energy and carbohydrate intake, low to moderate intensity endurance activity has little impact on dietary protein requirements and 1.0 gPRO/kg/d is sufficient. The only situation where dietary protein requirements exceed those for relatively sedentary individuals is in top sport athletes where the maximal requirement is approximately 1.6 gPRO/kg/d. Although most endurance athletes get enough protein to support any increased requirements, those with low energy or carbohydrate intakes may require nutritional advice to optimize dietary protein intake.

Lessons from experimental disruptions of the menstrual cycle in humans and monkeys

Prospective studies in humans and monkeys have informed our understanding of the mechanism of exercise-associated menstrual disorders (EAMD). These studies have provided convincing evidence that a key causal factor in the development of EAMD is an imbalance between energy intake and energy expenditure. This imbalance is created by the increased energy cost of exercise in the face of inadequate supplementation of caloric intake. Although one prospective study in humans documents the impact of weight loss, studies in nonhuman primates (Macaca fasicularis) reveal that EAMD can occur with unobtrusive compensatory mechanisms indicative of energy conservation. The onset of EAMD is variable between individuals, but is abrupt, and with little forewarning with respect to recognizable symptoms. Future studies aimed at mechanisms should build upon the finding that key metabolic signals such as T3 are correlated with both the onset and reversal of EAMD, perhaps by focusing on concomitant metabolic changes that directly influence GnRH neurons. Translational studies examining the energetics of the reversal of EAMD by manipulating food intake and or exercise should build on the findings in the monkey model. Lastly, because EAMD is often associated with disordered eating, future prospective studies in humans should incorporate the potential interaction of disordered eating and psychosocial stress on EAMD.

Relationship between self-reported food and fluid intake and menstrual disturbance in female recreational runners

A 1 year prospective study was conducted in France in 1993-1994 to examine the extent of menstrual cycle impairment in a sample of recreational French runners, and to relate the extent of impairment to dietary characteristics. The runners provided 7-day weighed food and fluid intake at intervals of 3 months during the year, as well as full details of their menstrual cycles and training schedules. The food survey commenced with 34 runners and 21 provided information on all four occasions. About 6% of the women, at any session, unrealistically report their dietary intakes. However, there was no evidence of any relationship between extent of under-reporting and menstrual status. The sample was divided into three menstrual cycle groups of eumenorrhoeic, irregular and amenorrhoeic (including oligomenorrhoeic). No significant differences in mean energy intake, carbohydrate, fat and protein intakes were found between groups. However, there were very marked differences in fluid and fibre intake, with amenorrhoeic and oligomenorrhoeic runners consuming about twice the mean daily fluid intake of eumenorrhoeic or irregularly menstruating groups.

Disordered eating and the female athlete triad

Female athletes are under intense pressure to have a low percentage of body fat for performance, which may result in a vulnerable athlete resorting to disordered eating, developing amenorrhea, and suffering the consequences of osteoporosis. Prevention of disordered eating practices among female athletes requires a de-emphasis of a low percentage of body fat and a good nutrition education program. The female athlete triad is a serious syndrome that requires a multidisciplinary approach to diagnosis and treatment.

Weight and diet concerns in Finnish female and male athletes

PURPOSES AND METHODS: Factors related to eating disorders were studied in five groups of female (N = 173) and male (N = 190) athletes, and in female (N = 79) and male (N = 61) controls. Factors associated with menstrual status were also examined.

RESULTS

The sum of drive for thinness and body dissatisfaction subscales in the Eating Disorders Inventory was higher (P < 0.05) in female controls (median: 5; 25th and 75th percentiles: 1 and 14) than in endurance athletes (0; 0 and 2). The male groups did not differ from each other (P = 0.08) or from female subjects (P = 0.62). The preferred weight loss in the female controls (-4.0 kg; -6.2 and -2.0) was larger (P < 0.05) than in most athletic groups. Males, on average, did not want to lose weight (different from females, P < 0.001). The prevalence of weight reduction attempts (85%) in female weight-class athletes was higher (P < 0.05) compared with endurance and ballgame athletes and the controls (29-58%). In males, the frequency (93%) of weight reduction attempts was also highest in the weight-class athletes (P < 0.05). The prevalence of menstrual disturbances was 27-37% in aesthetic, endurance, and weight-class athletes, and 5% in controls (P = 0.06).

CONCLUSIONS

The results confirmed that the risk for eating disorders is dependent on the type of sport. The claim that some female athlete groups are at greater risk than controls did not receive evidence.

Exercise and reproductive dysfunction

OBJECTIVE

To provide an overview of our current understanding of exercise-induced reproductive dysfunction and an approach to its evaluation and management.

DESIGN

A MEDLINE search was performed to review all articles with title words related to menstrual dysfunction, amenorrhea, oligomenorrhea, exercise, and athletic activities from 1966 to 1998. The pathophysiology, proposed mechanisms, clinical manifestations, evaluation, and management of exercise-associated reproductive dysfunction were compiled.

CONCLUSION(S)

Exercise-induced menstrual irregularity appears to be multifactorial in origin and remains a diagnosis of exclusion. The underlying mechanisms are mainly speculative. Clinical manifestations range from luteal phase deficiency to anovulation, amenorrhea, and even delayed menarche. Evaluation should include a thorough history and a complete physical plus pelvic examination. Most cases are reversible with dietary and exercise modifications. Hormonal replacement in cases of a prolonged hypoestrogenic state with evidence of increased bone loss is recommended, although the long-term consequences of prolonged hormonal deficiency are ill-defined.

Bone density and cyclic ovarian function in trained runners and active controls

This study was conducted to determine whether rigorous exercise training adversely affects ovarian hormone levels and bone health in cyclically menstruating trained runners. Ovarian hormones, bone mineral density (BMD), body composition, 3-d diet records, 3-d estimated energy expenditure, and menstrual histories were evaluated in 10 trained collegiate runners and 10 moderately active controls. The trained runners had lower total body calcium per kg of soft lean tissue measured by DEXA (P = 0.045). Half of the trained runners had experienced stress fractures compared with only one of the moderately active controls. The trained runners' lumbar (L2-L4) BMD (1.178 g.cm-2) was not significantly different from that of the active controls (1.283 g.cm-2) (P = 0.074) but, for all subjects combined, there wasa significant inverse relation between L2-L4 BMD and distance run per week (P = 0.036). Further, adding age, body weight, percent body fat, daily energy intake, and daily calcium intake to a stepwise multiple regression analysis did not significantly improve predictive precision. The trained runners consumed nearly twice the amount of calcium (1089 mg.d-1 vs 641 mg.d-1, respectively; P = 0.036), while intake of other nutrients did not differ significantly between groups. Urinary estrone conjugates (E1C) were lower in the trained runners during the early follicular phase (P = 0.028), while pregnanediol-3-glucuronide (PdG) was not significantly different between groups during the luteal phase (P = 0.213). Thus, it appears that lower estrogen production, especially during the early follicular phase, and not progesterone, is associated with lower whole body calcium per kg of soft lean tissue and, probably, L2-L4 BMD. Results of this study also suggest that regular menstrual cycles do not imply normal ovarian hormone function in young women who are engaged in either recreational or competitive running.

Nutritional aspects of amenorrhea in the female athlete triad

Female athletes experience a high incidence of menstrual abnormalities. This has critical health consequences because amenorrheic athletes are at greater risk of developing osteopenia and bone injury compared to normally menstruating athletes or nonathletic normally cycling females. Female performers and athletes are also at risk for developing disordered eating behaviors. There appears to be a connection between menstrual dysfunction, athletic training, and disordered eating, but how they relate is not fully understood. In this paper we explore how low calorie intakes, nutritional inadequacies, vegetarianism, low body fat stores, and specific training behaviors may contribute to the abnormal menstrual patterns seen in this population. Recommendations for the detection and prevention of eating and training problems and consequent menstrual abnormalities are included.

Role of energy balance in athletic menstrual dysfunction

The cessation of menstrual function in the female athlete may reflect her inability to adapt to the environmental and lifestyle stressors associated with training and competition. As society's emphasis on thinness, dieting, and exercise continues to increase, so will the incidence of menstrual dysfunction in active females. Unfortunately, some individuals view athletic menstrual dysfunction as a benign consequence of strenuous exercise. Conversely, it is most likely a strong indicator of overtraining and a marker for future decrements in performance, and it can have long-term health consequences. Thus, it is imperative that the active female be appropriately educated regarding the adverse consequences of menstrual dysfunction and the interventions available. This paper focuses on the most current information regarding athletic menstrual dysfunction and its multifactorial etiology, especially the role of energy drain. In addition, common misconceptions, adverse health and performance effects, and available treatment options are discussed.

Nutrient intake and psychological and physiological assessment in eumenorrheic and amenorrheic female athletes: a preliminary study

The present study showed that amenorrheic athletes (AAs) scored higher on the Eating Attitudes Test (EAT) (p < .05) than eumenorrheic athletes (EAs), indicating more aberrant eating patterns in the first group. Scores on the EAT were inversely correlated with fat intake (p < .05), simple carbohydrate intake (p < .01), and percentage saturation of iron (p < .05) and were positively correlated with total iron binding capacity (p < .01) for the total sample. Physiological assessment of athletes revealed that there were no significant differences between groups in serum lipoproteins, with both EAs and AAs having serum lipid profiles indicative of low cardiovascular risk. Furthermore, low-density lipoprotein cholesterol was the only lipoprotein significantly and positively correlated with serum estradiol levels for the entire sample (p = .01). The present study was in agreement with previous work showing that scores of the EAT represent a primary difference between EAs and AAs; the present study was somewhat different than previous work in that serum lipoproteins were not significantly related to menstrual status.

Gender-specific issues

Gender-specific differences in body composition and body size are well documented and mainly due to hormonal differences. Women benefit from physical training in the same way as men do. Regarding substrate utilization during exercise, females seem to exhibit a greater ability to utilize fat as a substrate resulting in a glycogen sparing effect. This may indicate a greater ability for endurance exercise. High levels of aerobic activity coupled with an insufficient energy intake, will result in a rapid loss of body mass and amenorrhea, a loss of calcium from bone tissue and the development of early osteoporosis. Nutritional advice for athletes of both sexes is very much the same, except that females require more iron and calcium.

Helping Active Women Avoid Anemia

In brief Many active women, especially those in sports that place a premium on a lean physique, don't consume enough iron, which puts them at risk for anemia. When evaluating an active woman's iron status, it's important to determine her hemoglobin baseline and identify various sources of iron loss from the medical history. Hemoglobin, hematocrit, and serum ferritin levels are most often the only laboratory values needed for evaluation. Treatment of anemia and iron deficiency focuses on improving iron intake through food and supplements and monitoring the patient's progress. Prevention tactics include diet counseling for those with known risk factors for anemia.

Vitamin/mineral supplement use among athletes: a review of the literature

Vitamin/mineral supplements are often used by athletes as ergogenic aids to improve performance. This paper reviews studies of the prevalence, patterns, and explanations for vitamin/mineral supplement use among athletes. Fifty-one studies provided quantitative prevalence data on 10,274 male and female athletes at several levels of athletic participation in over 15 sports. The overall mean prevalence of athletes' supplement use was 46%. Most studies reported that over half of the athletes used supplements (range 6% to 100%), and the larger investigations found lower prevalence levels. Elite athletes used supplements more than college or high school athletes. Women used supplements more often than men. Varying patterns existed by sport. Athletes appear to use supplements more than the general population, and some take high doses that may lead to nutritional problems. Sport nutritionists should include a vitamin/mineral supplement history as part of their dietary assessment so they can educate athletes about vitamin/mineral supplements and athletic performance.

Nutrient intake of women runners and nonrunners

The nutrient intakes of women who ran at different levels of intensity and the relationship between nutrient intake and ovulatory disturbances were studied. Ninety-five women, including sedentary non-runners (n = 16), low-level runners (n = 27), medium-level runners (n = 29), and high-level runners (n = 23), completed data for a 3-day nutritional assessment. The high-level runners met the Food and Nutrition Board's Recommended Daily Allowances (RDAs) for all 17 nutrients examined, with the exception of calcium. The other groups of women failed to meet RDAs for iron, carbohydrate, and fiber. In general, the women in the study reported healthier diets than did women in a general national survey of nutrient intake conducted in 1985. Eighty-two of the women reported luteinizing hormone level data that were accurate enough to indicate ovulatory functioning; of these women, 30 had ovulatory disturbances. There was no relationship between ovulatory disturbance and nutrient intake; however, 5 amenorrheic women reported a significantly lower nutrient density intake of fat and higher intake of carbohydrate, fiber, and vitamin A than did the nonamenorrheic women.

Dietary iron deficiency and sports anaemia

In order to determine whether dietary inadequacies can explain the sub-optimal iron status widely documented in endurance-trained athletes, the food intake records of Fe-deficient and Fe-replete distance runners and non-exercising controls of both sexes were analysed. In all the male study groups the mean dietary Fe intake met the recommended dietary allowances (RDA; > 10 mg/d (US) Food and Nutrition Board, 1989). However, both female athletes and controls failed to meet the RDA with regard to Fe (< 15 mg/d) and folate (< 200 micrograms/d). There was no difference in the total Fe intakes of Fe-deficient and Fe-replete athletes and the controls of each sex. However, Fe-deficient male runners, but not female runners, consumed significantly less haem-Fe (P = 0.048) than their comparative groups. This suggests that the habitual consumption of Fe-poor diets is a factor in the aetiology of athletes' Fe deficiency.

Everyday eating behavior and menstrual function in young women

OBJECTIVE

To examine the association of different types of everyday eating behavior with disturbances of menstrual function.

DESIGN

Prospective cohort study with two groups, low dietary restraint (n = 13) and high dietary restraint (n = 9), identified with the Three-Factor Eating Questionnaire by Stunkard and Messick.

SETTING

Research clinic.

PARTICIPANTS

Normal volunteers (students and young professionals).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Frequent serum and urine samples for determination of estradiol (E2), progesterone (P), and metabolites. Food and behavioral diaries.

RESULTS

Eleven of the 13 women with low dietary restraint had menstrual cycles that fulfilled the following standard criteria: Serum E2 maximum of 440 pmol/L or more, P maximum of 19 nmol/L or more, and luteal phase length of 9 days or more. Only 2 of the 9 women with high dietary restraint had cycles that satisfied these criteria. Of the remaining 7, 1 had an anovulatory cycle and 6 had decreased P concentrations (P less than 0.05) and/or a shortened luteal phase (P less than 0.02).

CONCLUSIONS

High cognitive restraint in everyday eating behavior may be a risk factor for the development of menstrual disturbance in young women.

Adolescent smoking, weight changes, and binge-purge behavior: associations with secondary amenorrhea

BACKGROUND

The association of secondary amenorrhea with extreme forms of substance use, weight control, and exercise in nonrepresentative samples raises questions as to whether adolescents in the general population who engage in these behaviors are at increased risk for secondary amenorrhea. We examined the prevalence and behavioral correlates of secondary amenorrhea in a county-wide high school population of 2544 girls aged 13 to 18.

METHODS

A survey questionnaire, which elicited menstrual history as well as weight history, weight control practices, level of exercise, and use of cigarettes, wine, and beer, was administered during school hours; absentees were also surveyed. The completion rate was 91%.

RESULTS

The 1-year prevalence of secondary amenorrhea was 8.5%. Secondary amenorrhea was associated with smoking one or more packs of cigarettes per day (adjusted relative risk [RRa] = 1.96, 1.21-3.10), with multiple binge-eating behaviors in combination with laxative use or self-induced vomiting (RRa = 4.17, 2.54-6.32), and with weight fluctuation due to weight control (RRa = 2.59, 1.33-4.79). There was no association between amenorrhea and alcohol consumption or exercise level.

CONCLUSIONS

Estimates of attributable risk are provided and indicate that bulimic behaviors and cigarette smoking may result in a considerable excess of cases of secondary amenorrhea in an adolescent population.

Limits of energy turnover in relation to physical performance, achievement of energy balance on a daily basis

Limits of energy turnover in relation to physical performance were addressed in terms of upper and lower limit, changes during a training programme and how to regulate energy balance at a changing energy turnover. At the lower limit we stress the risk of energy restriction to reach a desired body size or body composition for reduced performance, early osteoporosis and weight cycling. The upper limit of energy turnover can be increased by the consumption of energy dense carbohydrate-rich foods. Training induces an increase in energy turnover which can initially be more then twice the calculated energy costs from laboratory measurements of physical activity. In the long term, training can induce a reduction in resting energy expenditure even while the active cell mass (muscle mass) of the body has increased. The regulation of energy balance on a day to day basis seems to be better at high levels of energy turnover either as a consequence of the physiological need or as a consequence of the fact that athletes performing at a high level of energy expenditure have learned to ingest as much food as possible.

Impact of menstrual periodicity on serum lipid levels and estimates of dietary intakes

Nine eumenorrheic women were studied at five separate times each month for a minimum of 2 months. Fasting bloods and 1-day food records were obtained from all women at these times to describe the pattern and magnitude of within-person variation in selected nutrient and lipid indicators attributable to menstrual cyclicity. Serum cholesterol, beta-carotene, 17 beta-estradiol (E2), and dietary selenium intakes exhibited significant periodic regressions against time. For the group as a whole, however, only serum cholesterol and E2 measures exhibited significantly strong consistent periodicities. Future studies with a larger sample of women are warranted to confirm these findings. Unless strict blood sampling protocols are followed, variation attributable to menstrual cyclicity may mitigate the reliability of the serum cholesterol screenings advocated in the past few years.

Breast feeding and post-partum amenorrhea in Serere women in Senegal

The duration of post-partum amenorrhea and of breast-feeding was studied in a population of Serere people in Senegal, using an actuarial method. The use of the Cox method enabled us to show a positive correlation between these two factors and a negative correlation between the duration of amenorrhea, the survival of the breast-fed child, and the weaned status of the child. The characteristics of the diet of these sedentary women were similar to those found for amenorrheic American marathon runners. Given the results of other studies of African populations, these observations are discussed in the light of recent models of gonadotrophic involvement in the possible regulatory mechanisms in women who breast-feed for long periods whilst having an energy balance which is close to zero or even negative.