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

Relative Energy Deficiency in Sport (REDs) and knee injuries: current concepts for female athletes

In athletes, a mismatch between caloric intake and energy expended in exercise can eventually lead to Relative Energy Deficiency in Sport (REDs), where the athlete suffers from physiological derangements and decreased sport performance. The prevalence of REDs is higher in females than males. Females are already at a higher risk of knee injuries, which has been attributed to a multitude of factors such as hormonal influences, differences in musculoskeletal anatomy and neuromuscular control compared to males. The literature demonstrates an even higher risk of knee injuries in female athletes with symptoms of REDs. We propose the various factors that influence this risk. A reduction in anabolic hormones can affect muscle development and tendon repair. A relationship between poor neuromuscular control and knee injury has been established, and this can be further worsened in patients with menstrual dysfunction. Chronic deficiency in nutrients such as collagen and vitamin D can result in poorer recovery from microtrauma in tendons and ligaments. All these factors may contribute to increasing the risk of knee injuries, which may include anterior cruciate ligament tears, patella tendinopathy and patellofemoral pain syndrome. This review aims to educate sports clinicians to have a high index of suspicion when treating knee injuries in females; to screen and then manage for REDs if present, for holistic patient care.

Effect of increased protein intake and exogenous ketosis on body composition, energy expenditure and exercise capacity during a hypocaloric diet in recreational female athletes

Introduction: Since low body weight is an important determinant of success in many sports such as gymnastics, martial arts and figure skating, athletes can benefit from effective weight loss strategies that preserve muscle mass and athletic performance. The present study investigates the effects of increased protein intake and exogenous ketosis on body composition, energy expenditure, exercise capacity, and perceptions of appetite and well-being during a hypocaloric diet in females. Methods: Thirty-two female recreational athletes (age: 22.2 ± .5 years; body weight: 58.3 ± .8 kg; BMI: 20.8 ± .2 kg·m^-2) underwent 4 weeks of 30% caloric restriction and were randomized to receive either an increased daily amount of dietary protein (PROT, ∼2.0-2.2 g protein·kg^-1·day^-1), 3 × 20 g·day^-1 of a ketone ester (KE), or an isocaloric placebo (PLA). Body composition was measured by DXA, resting energy expenditure (REE) by indirect calorimetry, exercise capacity during a VO₂max test, appetite hormones were measured in serum, and perceptions of general well-being were evaluated via questionnaires. Results: The hypocaloric diet reduced body weight by 3.8 ± .3 kg in PLA, 3.2 ± .3 kg in KE and 2.4 ± .2 kg in PROT (P_time<.0001). The drop in fat mass was similar between treatments (average: 2.6 ± .1 kg, P_time<.0001), while muscle mass was only reduced in PLA and KE (average: .8 ± .2 kg, P_time<.05), and remained preserved in PROT (P_interaction<.01). REE [adjusted for lean mass] was reduced after caloric restriction in PLA (pre: 32.7 ± .5, post: 28.5 ± .6 kcal·day^-1·kg^-1) and PROT (pre: 32.9 ± 1.0, post: 28.4 ± 1.0 kcal·day^-1·kg^-1), but not in KE (pre: 31.8 ± .9, post: 30.4 ± .8 kcal·day^-1·kg^-1) (P_interaction<.005). Furthermore, time to exhaustion during the VO₂max test decreased in PLA (by 2.5 ± .7%, p < .05) but not in KE and PROT (P_interaction<.05). Lastly, the perception of overall stress increased in PLA and PROT (p < .05), but not in KE (P_interaction<.05). Conclusion: Increased protein intake effectively prevented muscle wasting and maintained exercise capacity during a period of caloric restriction in female recreational athletes. Furthermore, exogenous ketosis did not affect body composition, but showed its potential in weight management by preserving a drop in exercise capacity and REE and by improving overall stress parameters during a period of caloric restriction.

Factors Associated with the Prevalence and Severity of Menstrual-Related Symptoms: A Systematic Review and Meta-Analysis

This study aimed to identify factors associated with the prevalence and severity of menstrual-related symptoms. The protocol was registered in PROSPERO (CRD42021208432). We conducted literature searches of PubMed and Ichushi-Web and used the Jonna Briggs Institute critical appraisal checklist to assess the quality. Of the 77 studies included in the meta-analysis, significant odds ratios (ORs) were obtained for eight factors associated with primary dysmenorrhea (PD): age ≥ 20 years (OR: 1.18; 95% confidence interval [CI]: 1.04−1.34), body mass index (BMI) < 18.5 kg/m2 (OR: 1.51; 95% CI: 1.01−2.26), longer menstrual periods (OR: 0.16; 95% CI: 0.04−0.28), irregular menstrual cycle (OR: 1.28; 95% CI: 1.13−1.45), family history of PD (OR: 3.80; 95% CI: 2.18−6.61), stress (OR: 1.88; 95% CI: 1.30−2.72), sleeping hours < 7 h (OR: 1.19; 95% CI: 1.04−1.35), and bedtime after 23:01 (OR: 1.30; 95% CI: 1.16−1.45). Two factors were associated with severity of PD (moderate vs. severe): BMI < 18.5 kg/m2 (OR: 1.89; 95% CI: 1.01−3.54) and smoking (OR: 1.94; 95% CI: 1.08−3.47). PD severity (mild vs. severe) and prevalence of premenstrual syndrome were associated with BMI < 18.5 kg/m2 (OR: 1.91; 95% CI: 1.04−3.50) and smoking (OR: 1.86; 95% CI: 1.31−2.66), respectively. The identified risk factors could be utilized to construct an appropriate strategy to improve menstrual symptoms and support women’s health.

Runner's health choices questionnaire: female collegiate cross-country runners' perspectives on health and eating

OBJECTIVE

To assess female collegiate cross-country runners' perspectives regarding sport-related health and the factors impacting eating behaviors.

PARTICIPANTS/METHODS

The Runner's Health Choices Questionnaire, a previously validated survey, was electronically distributed to female collegiate cross-country runners. Quantitative descriptive analysis was performed on all questions.

RESULTS

A total of 353 female collegiate cross-country runners completed the survey. The most common intrinsic factors that impacted overall diet type were makes you feel healthy, enjoyment of food, and athletic performance enhancement. Extrinsic factors such as practice/race that day, creating a balanced diet, and choices in the cafeteria were the top factors influencing daily meal decisions. Seventy-seven percent of athletes reported that they would be likely to apply information from a healthcare professional if they had access.

CONCLUSION

Female cross-country runners appeared willing to apply nutritional information; therefore, it is important that generalized nutrition education with an emphasis on intrinsic and extrinsic factors for food choices be considered for female collegiate cross-country runners.

Clinical Measures of Adolescent Softball Players With and Without Upper-Extremity Pain: A Preliminary Study

CONTEXT

Upper-extremity (UE) pain is a concern among softball adolescent athletes. However, research on preseason screening of demographic characteristics and clinical measures among those with and without UE pain among adolescent softball athletes is underreported. This study sought to present functional outcomes and clinical measures of shoulder and hip complex flexibility, range of motion (ROM), and strength in adolescent softball athletes with and without UE pain.

DESIGN

Cross-sectional study.

METHODS

Sixty-seven athletes were assessed at the start of the spring season. The Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Questionnaire was administered to determine UE function. UE measurements included shoulder ROM, flexibility, and strength; lower-extremity measurements included hip ROM and strength. These variables were reported for players with and without UE pain as mean and SD. Independent samples t tests were performed to analyze differences between the groups.

RESULTS

Thirteen (19.4%) athletes reported UE pain during preseason screening. Mean Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Questionnaire score among athletes with UE pain was 58.0 (17.6) compared with 97.1 (6.9) for athletes reporting no UE pain (P < .001). Athletes with UE pain presented with significantly less dominant side external rotation ROM (UE pain: 106.5 [10.4], no UE pain: 114.6 [11.3]) and total ROM (UE pain: 163.7 [14.5], no UE Pain: 174.8 [14.3]).

CONCLUSION

These findings inform clinicians on function and preseason clinical measures in adolescent softball athletes who present with or without UE pain. Athletes with UE pain demonstrated lower outcome scores indicating likely impact on overall UE function. These athletes also appeared to demonstrate UE ROM differences compared with athletes without UE pain. Further research is needed to investigate larger sample sizes and positional differences at baseline and throughout the season to determine if clinical measures used in the current study are risk factors for pain and injury.

Prevalence of Risk Factors of the Female Athlete Triad among Young Elite Athletes of Pakistan

BACKGROUND

Female athletes who are not vigilant about their food choices and choose extraneous physical activities may head towards negative health effects.

PURPOSE

The purpose was to determine the prevalence of risk factors that may lead to the Female Athlete Triad among young elite athletes in Pakistan.

STUDY DESIGN & METHODS

A cross sectional questionnaire-based study was conducted in 2018 at Pakistan Sports Board to investigate the risk factors of The Female Athlete Triad among young elite athletes based in national training camps of major metropolitan cities. Trained and professional female elite athletes of age 18 - 25 years, able to comprehend questionnaire in English were included. Athletes completed the questionnaire including demographics, educational qualifications, Body Mass Index, sports participation, and playing hours. The Eating Aptitude Test-26 (EAT-26) and questionnaires on risks of amenorrhea and risks of low bone mineral density were completed. Individual prevalence of the risk factors of three components was assessed. The data were analyzed using SPSS-20 and descriptive statistics applied.

RESULTS

A sample of 60 elite athletes, (23.57 + 2.37 years, BMI 21.97 +1.90) who participated in various sports were included. EAT-26 results indicated that 50% of athletes were at risk of an eating disorder. Disordered Eating behaviors in need of referral were identified in 83.3%. Risks for amenorrhea were identified in 15%, and concerning low Bone Mineral Density, no risks were identified, except the intake of caffeinated beverages in 51.7%.

CONCLUSION

The prevalence of risk for disordered eating was found to be significant among female elite athletes of Pakistan, but risk of amenorrhea and low bone mineral density were not of major concern.

LEVEL OF EVIDENCE

3b.

Energy deficiency, menstrual disorders, and low bone mineral density in female athletes: a systematic review

PURPOSE

Low energy availability (LEA) may lead to menstrual disorders and low bone mineral density, predisposing to the female athlete triad. The primary aim of the present review was to systematically investigate the impact of chronic strenuous exercise on the energy status of professional female athletes compared to sedentary, recreationally active controls as concerns their menstrual status and bone mineral density (BMD). A secondary aim was evaluation of the combined prevalence of the components of the female athlete triad in athletes as compared to non-athletes.

METHODS

A systematic review was conducted from 2007 to February 2018. The inclusion and exclusion criteria of the studies were established in advance of the literature search according to the clinical inquiry and the study design.

RESULTS

Four studies were included in this systematic review. The female athlete triad was more prevalent in professional athletes compared to non-athletes. The same results were obtained for both LEA and menstrual disorders. However, BMD and Z-scores showed high heterogeneity among the studies.

CONCLUSION

Both female athletes and non-athletes are prone to LEA and subsequent menstrual disorders and low BMD or osteoporosis. Future studies are needed to examine energy availability in elite female athletes as well as in non-athletes.

Nutritional Risks among Adolescent Athletes with Disordered Eating

In their attempt to achieve the optimum weight or body shape for their activity, athletes frequently use harmful weight-control practices that may lead to the development of disordered eating or eating disorders. These practices are linked to several medical and mental consequences that may be more serious in adolescent athletes, as their bodies must meet both intensive growth demands and training requirements at the same time. Among other consequences, adolescent athletes may be at nutritional risk, due to their high nutrient needs and unhealthy eating behaviors. A literature review was conducted to examine the main nutritional risks and malnutrition issues faced by adolescent athletes that present disordered eating attitudes or eating disorders. Most studies refer to adult elite athletes, however research on adolescent athletes also indicates that the most common nutritional risks that may arise due to disordered eating include energy, macronutrient and micronutrient deficiencies, dehydration and electrolyte imbalances and changes in body composition that may lead to menstrual abnormalities, and decreased bone mass density. Educational programs and early detection of disordered eating and eating disorders are crucial to avoid the emergence and ensure timely management of nutrition-related problems in the vulnerable group of adolescent athletes.

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.

Habitual Dietary Status and Stress Fracture Risk Among Japanese Female Collegiate Athletes

OBJECTIVES

The aim of the present study was to identify the habitual dietary intake and stress fractures history among sport types and to determine the factors related to the risk of stress fractures among Japanese female collegiate athletes.

METHODS

This study involved 589 Japanese female collegiate athletes. We investigated habitual dietary intake (food frequency questionnaire), eating attitude (EAT-26), demographics, training status, participation in sports events, history of injury in their career, and menstrual status using a self-reported questionnaire. A multivariate logistic regression analysis was conducted to determine the risk factors associated with stress fractures.

RESULTS

Thirty percent of the total participants had a history of stress fractures, although most participants had no risk of eating disorders. Most Japanese female collegiate athletes consumed less than the dietary reference intake levels for the general Japanese female population aged 18-29 years and the athletes' dietary guideline for key bone-health nutrients such as calcium and vitamin D. The multivariate logistic regression analysis revealed body mass index (BMI; OR, 0.91; 95% CI, 0.82-0.99) and energy intake (EI; OR, 0.99; 95% CI, 0.99-0.99) as significant and independent factors in the history of stress fractures among Japanese female collegiate athletes (p = 0.047 and p = 0.039, respectively).

CONCLUSIONS

Japanese female collegiate athletes failed to meet energy and nutrient recommendations; BMI and EI were significantly associated with stress fractures, a diet that includes an appropriate amount of energy is essential.

Energy Intake Deficiency Promotes Bone Resorption and Energy Metabolism Suppression in Japanese Male Endurance Runners: A Pilot Study

It has been reported that male athletes face increased risk for low energy availability and resulting health consequences similar to female athletes. The present study aimed to reveal the energy status of Japanese male runners and to examine the association between energy deficiency and physiological characteristics such as energy metabolism, bone health, and hormonal status. Six male collegiate long-distance runners during a training season participated in this study. Energy intake (EI) was assessed using 3-day dietary records with food pictures. Exercise energy expenditure (EEE) was determined by the HR-VO₂ method. Body composition and bone status were measured by dual-energy X-ray absorptiometry. Energy availability (EA) was calculated by subtraction of EEE from EI and normalized by fat-free mass (FFM). Energy balance (EB) was calculated EI minus estimated total energy expenditure (TEE). Resting energy expenditure (REE) was measured by indirect calorimetry using the Douglas bag technique, and blood sampling was conducted to assess hormonal status. The mean EA of the subjects was 18.9 ± 6.8 kcal/kg FFM/day, and severe negative EB (range: -1444 ~ -722 kcal/d) was observed. REE of four runners was suppressed, and moreover, bone resorption was promoted in all subjects. The data in our study suggested that energy deficiency could promote bone resorption and energy metabolism suppression in Japanese male endurance runners. Additional short- and long-term studies are needed to clarify the health risks caused by energy deficiency in male athletes and explore strategies to prevent health problems related to energy deficiency in long-distance runners.

Female Athlete Body Project Intervention with Professional Dancers: A Pilot Trial

As aesthetic athletes, professional dancers have increased vulnerability for eating disorders (EDs), with three times higher risk than non-dancers. Among ballet dancers, generalized risk for EDs associated with internalization of western cultural female beauty ideals is compounded by idealization of a ballet-specific body ideal, a combination that confers unique vulnerability for eating pathology. Empirical support has been established for an athlete-specific intervention promoting body acceptance and reduced eating pathology among general populations of young-adult women and female collegiate athletes; the current study adapted this intervention for pilot implementation among professional ballet dancers. Participants from two elite ballet companies (N = 19) were randomized to a control and intervention condition. All participants self-reported eating pathology and related variables pre- and post-intervention, and at six-week follow-up. Post-intervention, participants receiving the intervention demonstrated reductions in body dissatisfaction, p = .005, r = -.63, dietary restraint, p = .008, r = -.59, and eating pathology, p = .007, r = -.60, as compared to control group counterparts; significant differences were retained at follow-up. Results provide preliminary evidence that this intervention has the potential to provide a feasible and acceptable means of ED prevention in female professional ballet dancers. Barriers to feasibility are identified and discussed.

Recovery of menses after functional hypothalamic amenorrhoea: if, when and why

BACKGROUND

Prolonged amenorrhoea occurs as a consequence of functional hypothalamic amenorrhoea (FHA) which is most often induced by weight loss, vigorous exercise or emotional stress. Unfortunately, removal of these triggers does not always result in the return of menses. The prevalence and conditions underlying the timing of return of menses vary strongly and some women report amenorrhoea several years after having achieved and maintained normal weight and/or energy balance. A better understanding of these factors would also allow improved counselling in the context of infertility. Although BMI, percentage body fat and hormonal parameters are known to be involved in the initiation of the menstrual cycle, their role in the physiology of return of menses is currently poorly understood. We summarise here the current knowledge on the epidemiology and physiology of return of menses.

OBJECTIVE AND RATIONALE

The aim of this review was to provide an overview of (i) factors determining the recovery of menses and its timing, (ii) how such factors may exert their physiological effects and (iii) whether there are useful therapeutic options to induce recovery.

SEARCH METHODS

We searched articles published in English, French or German language containing keywords related to return of menses after FHA published in PubMed between 1966 and February 2020. Manuscripts reporting data on either the epidemiology or the physiology of recovery of menses were included and bibliographies were reviewed for further relevant literature. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria served to assess quality of observational studies.

OUTCOMES

Few studies investigate return of menses and most of them have serious qualitative and methodological limitations. These include (i) the lack of precise definitions for FHA or resumption of menses, (ii) the use of short observation periods with unsatisfactory descriptions and (iii) the inclusion of poorly characterised small study groups. The comparison of studies is further hampered by very inhomogeneous study designs. Consequently, the exact prevalence of resumption of menses after FHA is unknown. Also, the timepoint of return of menses varies strongly and reliable prediction models are lacking. While weight, body fat and energy availability are associated with the return of menses, psychological factors also have a strong impact on the menstrual cycle and on behaviour known to increase the risk of FHA. Drug therapies with metreleptin or naltrexone might represent further opportunities to increase the chances of return of menses, but these require further evaluation.

WIDER IMPLICATIONS

Although knowledge on the physiology of return of menses is presently rudimentary, the available data indicate the importance of BMI/weight (gain), energy balance and mental health. The physiological processes and genetics underlying the impact of these factors on the return of menses require further research. Larger prospective studies are necessary to identify clinical parameters for accurate prediction of return of menses as well as reliable therapeutic options.

Sports and Metabolic Bone Disease

Physical activity (PA) increases bone mass and bone strength through different mechanisms and also reduces the risk of falls in the elderly, through proprioception and balance training. The benefits seen in adolescence continue into adulthood. Exercise delays and attenuates the effects of osteoporosis, and particular sports activities may be recommended to improve bone mineral density (BMD) of the spine or regional BMD, improve balance, and prevent falls. Stress injuries related to exercise are more common in osteopenic and osteoporotic individuals.Sports activity may in some cases be detrimental for bone health, with nutrition restriction a frequent cause for negative effects of the practice of PA on bone. The examples are the so-called female athlete triad of menstrual dysfunction resulting in reduced estrogen levels, low energy due to malnutrition, and decreased BMD. A similar triad is described in male athletes. This review analyzes the effects of sport on bone metabolism and in particular its relationship with metabolic bone disease.

A Narrative Review on Female Physique Athletes: The Physiological and Psychological Implications of Weight Management Practices

Physique competitions are events in which aesthetic appearance and posing ability are valued above physical performance. Female physique athletes are required to possess high lean body mass and extremely low fat mass in competition. As such, extended periods of reduced energy intake and intensive training regimens are used with acute weight loss practices at the end of the precompetition phase. This represents an increased risk for chronic low energy availability and associated symptoms of relative energy deficiency in sport, compromising both psychological and physiological health. Available literature suggests that a large proportion of female physique athletes report menstrual irregularities (e.g., amenorrhea and oligomenorrhea), which are unlikely to normalize immediately postcompetition. Furthermore, the tendency to reduce intakes of numerous essential micronutrients is prominent among those using restrictive eating patterns. Following competition, reduced resting metabolic rate, and hyperphagia, is also a concern for these female athletes, which can result in frequent weight cycling, distorted body image, and disordered eating/eating disorders. Overall, female physique athletes are an understudied population, and the need for more robust studies to detect low energy availability and associated health effects is warranted. This narrative review aims to define the natural female physique athlete, explore some of the physiological and psychological implications of weight management practices experienced by female physique athletes, and propose future research directions.

Impact of a Professional Nutrition Program on a Female Cross Country Collegiate Athlete: A Case Report

Low caloric intake or excessive energy expenditure can lead to a negative energy balance, which, in female athletes, may result in a condition called the female athlete triad. While several guidelines identified proper nutrition as a first line of treatment, little research has been reported to show the effect of a professional nutrition program (PNP) on the female athlete triad. The purpose of this case report was to measure the short- and long-term effects of a PNP on a female athlete presenting triad characteristics. A 20-year-old female track-and-field athlete at a Division I university who was in negative energy balance and amenorrheic underwent a one-month PNP. Short- and long-term effects measured by a dual X-ray absorptiometry scan prior to and after attending a PNP showed increased total energy intake from 2188 kcals to 3187 kcals, which resulted in an increase in body fat percent (BF%) from 4.7% to 6.7%. However, by the end of four months, energy intake and BF% (5.7% and 6.0%) values were reduced, respectively. After the twelve-month follow-up, BF% was increased (10.5%), suggesting that increasing energy intake to meet energy demands, without compromising athletic training, can be an effective treatment for the female athlete triad.

Energy Expenditure, Availability, and Dietary Intake Assessment in Competitive Female Dragon Boat Athletes

Dragon boat racing requires high physical activity levels during competition and training. The female athletic triad refers to a number of negative health consequences (e.g., amenorrhoea, low bone mineral density, and low energy availability) that may result from high physical activity in female athletes in parallel with inadequate dietary intake. This study aimed to estimate energy expenditure and dietary adequacy in female competitive dragon boat athletes. Following ethical approval, energy expenditure was assessed by use of Sensewear^TM armbands (which measure movement as well as galvanic heat loss) on nine dragon boat athletes preparing for the Southeast Asian Games 2013. The mean estimated energy expenditure for the athletes was 2226 ± 711 kJ/day. Mean total energy, recorded using three-day food diaries (6715 ± 2518 kJ/day) and energy availability (99 ± 56 kJ/kg/day), were low. Estimated micronutrient intake (calcium 699.3 ± 328.7 mg/day and iron 10.6 ± 4.7 mg/day) did not meet recommended daily allowances of 800 mg/day and 19 mg/day, respectively. The low intake of energy, calcium, and iron noted within this study could have negative effects on performance and short- and long-term health in female dragon boat athletes.

Comparison of body composition and nutrients' deficiencies between Portuguese rink-hockey players

We evaluated dietary intake and body composition of child and adolescent rink-hockey players and controls. Seventy-two male rink-hockey players (38 children and 34 adolescents) and 79 male controls (43 children and 36 adolescents) were evaluated in order to collect training data, detailed dietary intake and body composition. Rink-hockey players presented significantly lower body fat (BF) and higher fat-free mass (FFM) than controls. Mean intakes of carbohydrate and protein were considered to be adequate, but mean intakes of fat were above the recommended levels in athletes. Significant differences were found for energy intake (EI) and exercise energy expenditure (EEE) between athletes and controls (P < 0.05), resulting in some cases of low energy availability in rink-hockey players. Significant group differences (P < 0.05) were also observed for vitamins and mineral intakes in child and adolescent rink-hockey players due to higher mean intakes in control groups. Low intakes of vitamins D, E and K, calcium, iron, boron and magnesium were reported in athletes, with exception for thiamine (P = 0.449), riboflavin (P = 0.246), pantothenic acid (P = 0.065), magnesium (P = 0.061) and phosphorus (P = 0.051) in children and for niacin (P = 0.652), vitamin D (P = 0.406) and zinc (P = 0.783) in adolescents.

CONCLUSION

Nutritional deficiencies in macronutrients and micronutrients observed in very young rink-hockey players can impair their growth and development with negative consequences upon athletic performance. What is Known: • Adequate dietary intake is an important resource for athletes' short- and long-term health, performance and recovery. • There are no published studies in rink-hockey players' energy availability. What is New: • This study provides the first data on significant differences in energy intake between very young athletes and controls, resulting in low energy availability in rink-hockey players. • Mean intakes of fat were above the recommended levels, and micronutrients intakes were inappropriate in athletes with consequences for their health and performance.

Vegetarian, Gluten-Free, and Energy Restricted Diets in Female Athletes

Female athletes who follow a diet that fails to meet energy and nutrient needs are at risk for musculoskeletal injuries, menstrual disturbances, and poor sports performance. Common nutritional concerns for the female athlete include low energy availability (EA) (i.e., energy intake from food remaining for metabolic processes after accounting for energy expended during exercise) and inadequate dietary intakes (i.e., not meeting sports nutrition guidelines) of carbohydrates, protein, essential fatty acids (EFAs), B-vitamins, calcium, iron, and vitamin D. Low EA and the associated nutrient deficiencies are more common in athletes who compete in weight-sensitive sports (i.e., aesthetic, gravitational, and weight category sports) because low body fat and mass confer a competitive advantage. Other athletes at risk for energy and nutrient deficits include athletes following a vegetarian or gluten-free diet (GFD). Careful dietary planning can help an athlete meet energy and nutrient needs. This review covers the nutrition issues associated with low EA and special diets (i.e., vegetarian and GFD) and describes strategies to help female athletes meet their energy and nutrient needs.

Seasonal changes in serum progesterone levels in Thoroughbred racehorses in training

The objective of the present study was to verify the seasonal luteal activity of racehorses in training in Japan from March to August. We allocated 102 horses into a luteal activity group and non-luteal activity group. The luteal activity group included horses with serum progesterone levels that were consistently >1 ng/ml and changed by ± 1 ng/ml. In contrast, the progesterone levels of the non-luteal activity group were consistently <1 ng/ml. In late spring (from May 1 to June 30) and summer (from July 1 to August 31), the percentage of horses in the luteal activity group was significantly higher than in early spring (from March 1 to April 30, P<0.01). These findings demonstrate clear seasonal variations in ovarian activity. The present study also suggest that training for a race may not affect ovarian activity in female racehorses.

Assessing Intentions to Eat a Healthful Diet Among National Collegiate Athletic Association Division II Collegiate Athletes

CONTEXT

Many athletes fail to obtain the optimal levels of energy and nutrients to support health and performance. The constructs underlying the Theory of Planned Behavior (TPB) may help identify barriers to healthful eating that can be addressed in nutrition-education programs.

OBJECTIVE

To use the TPB to examine factors regarding collegiate male and female student-athletes' intentions of eating a healthful diet.

DESIGN

Cross-sectional study.

SETTING

Online survey tool.

PATIENTS OR OTHER PARTICIPANTS

The survey was taken by 244 male and female National Collegiate Athletic Association Division II athletes, and data from 201 were analyzed. Mean age of the athletes was 20 ± 1.31 years (range, 18-24 years); most were white (86.1%) and female (78.6%).

MAIN OUTCOME MEASURE(S)

We assessed predictive strength of attitude, subjective norms, and perceived behavioral control on behavioral intentions. Regression analysis evaluated how the variables of TPB were valued and how they predict behavioral intentions.

RESULTS

The combination of attitude, subjective norms, and perceived behavioral controls accounted for 73.4% (R 2) of the variance in behavioral intention (F = 180.82, P < .001). Attitude had the greatest influence on behavioral intentions (β = .534, P < .001).

CONCLUSIONS

Understanding both the intentions of collegiate athletes to eat healthfully and how highly they value nutrition is crucial for the development of effective nutrition education and counseling programs.

Ultra-Marathon Athletes at Risk for the Female Athlete Triad

BACKGROUND

Worldwide female participation in ultra-endurance events may place them at risk for the female athlete triad (FAT). The study objectives were to establish triad knowledge, occurrence of disordered eating and triad risk amongst participants of the 2014 89-km Comrades Marathon event.

METHODS

A survey utilising the Low Energy Availability in Females questionnaire (LEAF-Q) and Female Athlete Screening Tool (FAST) questionnaire was conducted on female participants in order to determine the risk. In addition, seven questions pertaining to the triad were asked in order to determine the athlete's knowledge of the triad. Athletes were requested to complete the anonymous questionnaire after written informed consent was obtained while waiting in the event registration queues. Statistical analyses included Pearson product-moment correlations, chi-square tests and cross-tabulations to evaluate associations of interest.

RESULTS

Knowledge of the triad was poor with 92.5 % of participants having not heard of the triad before and most of those who had, gained their knowledge from school or university. Only three athletes were able to name all 3 components of the triad. Amenorrhoea was the most commonly recalled component while five participants were able to name the component of low bone mineral density. Of the 306 athletes included in the study, 44.1 % were found to be at risk for the female athlete triad. One-third of participants demonstrated disordered eating behaviours with nearly half reporting restrictive eating behaviours. There is a significant association between athletes at risk for the triad according to the LEAF-Q and those with disordered eating (χ²(1) = 8.411, p = 0.014) but no association (or interaction) between triad knowledge and category (at risk/not at risk) of LEAF-Q score (χ²(1) = 0.004, p = 0.949). More athletes in the groups with clinical and sub-clinical eating disorders are at risk for the triad than expected under the null hypothesis for no association.

CONCLUSIONS

Only 7.5 % of the female Comrades Marathon runners knew about the triad despite 44.1 % being at a high risk for the triad. Therefore, education and regular screening programmes targeting these athletes are overdue. Postmenopausal athletes are at particularly high risk for large losses in bone mass if they experience chronic energy deficiency and hence require special focus.

Recommendations for Healthy Nutrition in Female Endurance Runners: An Update

The purpose of this review is to present the basic principles of a healthy nutrition in female endurance runner enriched by the latest scientific recommendations. Female endurance runners are a specific population of athletes who need to take specifically care of daily nutrition due to the high load of training and the necessity to keep a rather low body mass. This paradoxical situation can create some nutritional imbalances and deficiencies. Female endurance athletes should pay attention to their total energy intake, which is often lower than their energy requirement. The minimal energy requirement has been set to 45 kcal/kg fat free mass/day plus the amount of energy needed for physical activity. The usual recommended amount of 1.2–1.4 g protein/kg/day has recently been questioned by new findings suggesting that 1.6 g/kg/day would be more appropriate for female athletes. Although a bit less sensitive to carbohydrate loading than their male counterparts, female athletes can benefit from this nutritional strategy before a race if the amount of carbohydrates reaches 8 g/kg/day and if their daily total energy intake is sufficient. A poor iron status is a common issue in female endurance runners but iron-enriched food as well as iron supplementation may help to counterbalance this poor status. Finally, they should also be aware that they may be at risk for low calcium and vitamin D levels.

Exercise-trained men and women: role of exercise and diet on appetite and energy intake

The regulation of appetite and energy intake is influenced by numerous hormonal and neural signals, including feedback from changes in diet and exercise. Exercise can suppress subjective appetite ratings, subsequent energy intake, and alter appetite-regulating hormones, including ghrelin, peptide YY, and glucagon-like peptide 1(GLP-1) for a period of time post-exercise. Discrepancies in the degree of appetite suppression with exercise may be dependent on subject characteristics (e.g., body fatness, fitness level, age or sex) and exercise duration, intensity, type and mode. Following an acute bout of exercise, exercise-trained males experience appetite suppression, while data in exercise-trained women are limited and equivocal. Diet can also impact appetite, with low-energy dense diets eliciting a greater sense of fullness at a lower energy intake. To date, little research has examined the combined interaction of exercise and diet on appetite and energy intake. This review focuses on exercise-trained men and women and examines the impact of exercise on hormonal regulation of appetite, post-exercise energy intake, and subjective and objective measurements of appetite. The impact that low-energy dense diets have on appetite and energy intake are also addressed. Finally, the combined effects of high-intensity exercise and low-energy dense diets are examined. This research is in exercise-trained women who are often concerned with weight and body image issues and consume low-energy dense foods to keep energy intakes low. Unfortunately, these low-energy intakes can have negative health consequences when combined with high-levels of exercise. More research is needed examining the combined effect of diet and exercise on appetite regulation in fit, exercise-trained individuals.

Moderators and Predictors of Response to Eating Disorder Risk Factor Reduction Programs in Collegiate Female Athletes

OBJECTIVE

The primary aim of this paper was to investigate moderators and predictors of response to two programs designed to reduce eating disorder risk factors in collegiate female athletes. This study served as an ancillary study to a parent trial that investigated the feasibility of an athlete modified cognitive dissonance-based program (AM-DBP) and an athlete modified healthy weight intervention program (AM-HWI).

DESIGN

157 female collegiate athletes were randomized to either the AM-DBP or the AM-HWI program. Participants completed surveys at baseline, post-intervention, 6 weeks, and 1 year.

METHODS

After classifying sports as either lean or non-lean, we investigated if sport type acted as a moderator of program response to AM-DBP and AM-HWI using ANOVAs. Next, we examined whether baseline thin-ideal internalization, weight concern, shape concern, bulimic pathology, dietary restraint, and negative affect acted as predictors of changes in bulimic pathology using linear regression models.

RESULTS

Athletes in non-lean sports who received AM-DBP showed more improvement in negative affect versus non-lean sport athletes in AM-HWI. Higher baseline scores of bulimic pathology predicted greater response in bulimic pathology to both programs at 6-weeks. In contrast, athletes with higher dietary restraint and negative affect baseline scores showed decreased response to both interventions at 6-weeks. Finally, athletes with higher baseline shape concern showed a decreased response to the AM-HWI intervention at the post intervention time point.

CONCLUSION

Results from the present study indicate that lean/non-lean sport may not play a strong role in determining response to efficacious programs. Further, factors such as pre-existing bulimic pathology, dietary restraint, negative affect, and shape concern may affect general response to intervention versus specific responses to specific interventions.

Nine-month nutritional intervention improves restoration of menses in young female athletes and ballet dancers

Background

We hypothesized that an intervention designed to increase the energy and nutrient intake could serve as an efficacious method to restore normal menstrual functions in athletes and ballet dancers.

Methods

In this study, a 9-month nutritional intervention (NI) was conducted in 21 dancers and 31 athletes with menstrual disorders. Analyses of the body composition were performed, and the levels of LH, FSH, P, E2, TSH, T, PRL, SHBG, leptin, resting metabolic rate (RMR), energy and nutrient intake, total energy expenditure were estimated. The NI was based on an individual diet. The effects of the NI were controlled after 3, 6 and 9 months of use.

Results

The NI resulted in a significant change of the energy and nutrient intake. After 9 months, a significant increase in the LH level among dancers was observed, while in female athletes this effect was seen after 3 months of the NI use. The 9-month NI resulted in the restoration of regular menses in 3 dancers and 7 athletes, respectively. Women with regular cycles had a higher percentage of the fat mass (FM).

Conclusions

A non-pharmacological intervention in female athletes and ballet dancers with menstrual disorders can restore regular menstrual cycles, although restoration of menses may take more than 1 year. An increase in the body fat mass may be one of the most important predictors of restoration of menses.

Low energy availability and low body fat of female gymnasts before an international competition

The purpose of the present study was to evaluate dietary intake and body composition of elite rhythmic gymnastics (RG) athletes prior to a competition event. Sixty-seven rhythmic gymnasts (18.7 ± 2.9 years old) of high performance level, with 36.6 ± 7.6 h of training/week were evaluated in order to collect training and competition data, medical and gynaecological history, detailed dietary intake and body composition before an international competition. The majority of the participants (n = 40; 59.7%) had already menstruated, but age of menarche was delayed (15.3 ± 1.3 years) and all revealed menstrual irregularities. Gymnasts' body mass (48.4 ± 4.9 kg) and body mass index (BMI; 17.4 ± 1.1 kg/m(2)) were below the normal for age, and height (1.66 ± 0.05 m) was normal or even slightly above normal for age. Body fat was 9.0 ± 2.0% with no significant differences between age strata. Gymnasts exhibited low energy availability (EA; 31.5 ± 11.9 kcal/kg fat-free mass (FFM)/day). The average carbohydrate and protein intakes were 5.1 ± 2.3 g/kg/day and 1.6 ± 04 g/kg/day, which correspond to 51.4 ± 7.2% and 16.9 ± 3.4% of total energy intakes, respectively; average fat contribution was 33.0 ± 5.3%. Low intakes of pantothenic acid, folate and vitamins D, E and K and of minerals, including calcium, iron and magnesium were reported. Intakes of thiamine, riboflavin, niacin, vitamins A, B-6, B-12, C and manganese and zinc were above-adequate (P < 0.05). Low EA, low body fat and micronutrient deficiencies are common among RG.

Dietary intervention restored menses in female athletes with exercise-associated menstrual dysfunction with limited impact on bone and muscle health

Exercise-related menstrual dysfunction (ExMD) is associated with low energy availability (EA), decreased bone mineral density (BMD), and increased risk of musculoskeletal injury. We investigated whether a 6-month carbohydrate-protein (CHO-PRO) supplement (360 kcal/day, 54 g CHO/day, 20 g PRO/day) intervention would improve energy status and musculoskeletal health and restore menses in female athletes (n = 8) with ExMD. At pre/post-intervention, reproductive and thyroid hormones, bone health (BMD, bone mineral content, bone markers), muscle strength/power and protein metabolism markers, profile of mood state (POMS), and energy intake (EI)/energy expenditure (7 day food/activity records) were measured. Eumenorrheic athlete controls with normal menses (Eumen); n = 10) were measured at baseline. Multiple linear regressions were used to evaluate differences between groups and pre/post-intervention blocking on participants. Improvements in EI (+382 kcal/day; p = 0.12), EA (+417 kcal/day; p = 0.17) and energy balance (EB; +466 kcal/day; p = 0.14) were observed with the intervention but were not statistically significant. ExMD resumed menses (2.6 ± 2.2-months to first menses; 3.5 ± 1.9 cycles); one remaining anovulatory with menses. Female athletes with ExMD for >8 months took longer to resume menses/ovulation and had lower BMD (low spine (ExMD = 3; Eumen = 1); low hip (ExMD = 2)) than those with ExMD for <8 months; for 2 ExMD the intervention improved spinal BMD. POMS fatigue scores were 15% lower in ExMD vs. Eumen (p = 0.17); POMS depression scores improved by 8% in ExMD (p = 0.12). EI, EA, and EB were similar between groups, but the intervention (+360 kcal/day) improved energy status enough to reverse ExMD despite no statistically significant changes in EI. Similar baseline EA and EB between groups suggests that some ExMD athletes are more sensitive to EA and EB fluctuations.

Energy availability and the female athlete triad in elite endurance athletes

The female athlete triad (Triad), links low energy availability (EA), with menstrual dysfunction (MD), and impaired bone health. The aims of this study were to examine associations between EA/MD and energy metabolism and the prevalence of Triad-associated conditions in endurance athletes. Forty women [26.2 ± 5.5 years, body mass index (BMI) 20.6 ± 2.0 kg/m(2), body fat 20.0 ± 3.0%], exercising 11.4 ± 4.5 h/week, were recruited from national teams and competitive clubs. Protocol included gynecological examination; assessment of bone health; indirect respiratory calorimetry; diet and exercise measured 7 days to assess EA; eating disorder (ED) examination; blood analysis. Subjects with low/reduced EA (< 45 kcal/kg FFM/day), had lower resting metabolic rate (RMR) compared with those with optimal EA [28.4 ± 2.0 kcal/kg fat-free mass (FFM)/day vs 30.5 ± 2.2 kcal/kg FFM/day, P < 0.01], as did subjects with MD compared with eumenorrheic subjects (28.6 ± 2.4 kcal/kg FFM/day vs 30.2 ± 1.8 kcal/kg FFM/day, P < 0.05). 63% had low/reduced EA, 25% ED, 60% MD, 45% impaired bone health, and 23% had all three Triad conditions. 53% had low RMR, 25% hypercholesterolemia, and 38% hypoglycemia. Conclusively, athletes with low/reduced EA and/or MD had lowered RMR. Triad-associated conditions were common in this group of athletes, despite a normal BMI range. The high prevalence of ED, MD, and impaired bone health emphasizes the importance of prevention, early detection, and treatment of energy deficiency.

Effects of dietary intervention in young female athletes with menstrual disorders

Background

The aim of this study was to evaluate the influence of three months of dietary intervention on menstrual cycle in young female athletes with amenorrhea or oligomenorrhea.

Methods

From forty-five female professional athletes with menstrual irregularity that were recruited thirty-one, aged 18.1 ± 2.6 years, completed the study and were analyzed. Hyperprolactinemia, thyroid dysfunction, primary ovarian failure and hyperandrogenism were excluded in the study participants. The subjects started intense training at the age of 11.2 ± 3.5 years and continued during next 6.8 ± 3.3 years. Energy and nutrients intake, total energy expenditure, energy availability and body composition as well as serum concentrations of LH, FSH, 17 – beta estradiol and progesterone were measured at the beginning of the study and after three months of individualized dietary intervention.

Results

Following three months of dietary intervention significant increase in energy intake (2354 ± 539 vs. 258 8 ± 557 kcal, P = 0.004) and energy availability (28.3 ± 9.2 vs. 35.8 ± 12.3 kcal/kg FFM/d, P = 0.011) was observed as well as improved energy balance (−288 ± 477 vs. -51 ± 224 kcal/d, P = 0.002). Though no changes in BMI and body composition were noted but significant rise in LH concentrations (3.04 ± 1.63 vs. 4.59 ± 2.53 mIU/ml, P = 0.009) and LH to FSH ratio (0.84 ± 0.56 vs. 0.96 ± 0.52, P = 0.001) was achieved, but no restoration of menstrual cyclicity.

Conclusions

This report provides further support for the role of energy deficiency in menstrual disorders among young female athletes and the benefits of an adequate energy intake and energy availability on hormones concentration. Continuation controlled dietary intervention is needed to assess the extent to which long-term improvement in the nutritional status results in improvements in the hormonal status of female athletes, to an extent that would allow the regulation of the menstrual cyclity.

Influence of food restriction combined with voluntary running on bone morphology and strength in male rats

Athletes, in particular endurance athletes and dancers, are chronically exposed to a state of low energy availability due to insufficient dietary energy intake and massive exercise energy expenditure. Low energy availability sometimes causes bone fragility, thereby increasing the risk of bone disorders. Although the decrease in energy availability shows no sexual dimorphism, epidemiological studies have reported that bone disorders are less frequent in male athletes than in female athletes. We hypothesized that bone tissue was not affected by low energy availability in males. The purpose of this study was to examine the influence of food restriction combined with voluntary running training on bone morphology and strength in adult male rats. Fourteen-week-old male Sprague-Dawley rats were divided randomly into four groups: control (C) group, food restriction (R) group, exercise (Ex) group, and food restriction plus exercise (REx) group. For the R and REx groups, 30 % food restriction was carried out in comparison with the C group. Bone strength, bone mineral density (BMD), bone architecture, and bone turnover rate were measured after a 13-week experimental period. Bone strength was not significantly lower in the REx group compared with the C group. BMD and trabecular bone volume showed no difference among groups. These findings indicate that bone morphology and strength were little affected by food restriction combined with exercise training in adult male rats.

Comparison of self-reported energy availability and metabolic hormones to assess adequacy of dietary energy intake in young elite athletes

Previous intervention studies suggest that leptin, insulin, insulin-like growth factor 1 (IGF-1), and triiodthyronine (T3) are sensitive markers of inadequate energy intake in relation to exercise expenditures. Because of limitations in metabolic hormone measurements, self-reported energy availability (EA) based on food and activity records may present an alternative for characterizing energy status in young athletes. The purpose of the current study was to assess whether self-reported EA is related to leptin, insulin, IGF-1, and T3 in 352 young athletes. Sex, body composition, sport participation, and acute weight changes were considered as confounding variables. Multiple linear regression revealed that EA was negatively associated with leptin (p < 0.05) but not with insulin, IGF-1, or T3. Female athletes with low EA (<30 kcal·kg(-1) fat-free mass (FFM)) had higher leptin concentrations (5.0 ± 4.7 ng·mL(-1)) and more body fat (18.3% ± 5.1%) than did females with normal EA (leptin, 3.1 ± 2.4 ng·mL(-1); body fat, 15.8% ± 4.2%; both, p < 0.001). Athletes reporting acute weight loss (>1 kg·week(-1)) had a lower EA (18.9 ± 7.4 kcal·kg(-1) FFM) than did weight-stable athletes (30.0 ± 11.2 kcal·kg(-1) FFM) or athletes reporting weight gain (>1 kg; 49.7 ± 13.1 kcal·kg(-1) FFM). IGF-1 and T3 were also reduced in athletes who lost weight (p < 0.01). This cross-sectional study reveals a lack of association between self-reported EA and metabolic hormones indicative of energy status in young athletes. Further studies are needed to investigate whether self-reported EA and metabolic hormones are in better agreement when measured repeatedly.

The prevalence of disordered eating and possible health consequences in adolescent female tennis players from Rio de Janeiro, Brazil

The aim of this study was to estimate the prevalence of disordered eating and possible health consequences in adolescent female tennis players. This cross-sectional controlled study investigated the pubertal development (Tanner stages); body composition (dual energy X-ray absorptiometry-DXA); dietary intake (food record); presence of disordered eating (EAT-26, BITE and BSQ); menstrual status (questionnaire) and bone mineral density (DXA). The Female Athlete Triad (FAT) was divided into two severity stages. The study included 45 adolescents (24 athletes and 21 controls) at some pubertal developmental stage. The athletes exhibited better body composition profiles. We found that 91.7%, 33.3% and 25% of athletes and 71.4%, 9.5% and 33.3% of controls met criteria for disordered eating and/or low energy availability, menstrual irregularities and low bone mass, respectively. A greater percentage of athletes than controls presented with 1 and 2 FAT components (stage I), and 4.2% presented with the full syndrome. In conclusion, tennis players appear to present with more severe disorders than controls and should be monitored to avoid damage to their performance and health.

The female athlete triad

Context:

The female athlete triad (the triad) is an interrelationship of menstrual dysfunction, low energy availability (with or without an eating disorder), and decreased bone mineral density; it is relatively common among young women participating in sports. Diagnosis and treatment of this potentially serious condition is complicated and often requires an interdisciplinary team.

Evidence Acquisition:

Articles from 1981 to present found on PubMed were selected for review of major components of the female athlete triad as well as strategies for diagnosis and treatment of the conditions.

Results:

The main goal in treatment of young female athletes with the triad is a natural return of menses as well as enhancement of bone mineral density. While no specific drug intervention has been shown to consistently improve bone mineral density in this patient population, maximizing energy availability and optimizing vitamin D and calcium intake are recommended.

Conclusions:

Treatment requires a multidisciplinary approach involving health care professionals as well as coaches and family members. Prevention of this condition is important to minimize complications of the female athlete triad.

Analysis of stress fractures in athletes based on our clinical experience

AIM

To analyze stress fractures in athletes based on experience from our sports medicine clinic.

METHODS

We investigated the association between stress fractures and age, sex, sports level, sports activity, and skeletal site in athletes seen at our sports medicine clinic between September 1991 and April 2009. Stress fractures of the pars interarticularis were excluded from this analysis.

RESULTS

During this period (18 years and 8 mo), 14276 patients (9215 males and 5061 females) consulted our clinic because of sports-related injuries, and 263 patients (1.8%) [171 males (1.9%) and 92 females (1.8%)] sustained stress fractures. The average age of the patients with stress fractures was 20.2 years (range 10-46 years); 112 patients (42.6%) were 15-19 years of age and 90 (34.2%) were 20-24 years of age. Altogether, 90 patients (34.2%) were active at a high recreational level and 173 (65.8%) at a competitive level. The highest proportion of stress fractures was seen in basketball athletes (21.3%), followed by baseball (13.7%), track and field (11.4%), rowing (9.5%), soccer (8.4%), aerobics (5.3%), and classical ballet (4.9%). The most common sites of stress fractures in these patients were the tibia (44.1%), followed by the rib (14.1%), metatarsal bone (12.9%), ulnar olecranon (8.7%) and pelvis (8.4%). The sites of the stress fractures varied from sport to sport. The ulnar olecranon was the most common stress fracture site in baseball players, and the rib was the most common in rowers. Basketball and classical ballet athletes predominantly sustained stress fractures of the tibia and metatarsal bone. Track and field and soccer athletes predominantly sustained stress fractures of the tibia and pubic bone. Aerobics athletes predominantly sustained stress fractures of the tibia. Middle and long distance female runners who sustained multiple stress fractures had the female athlete triad.

CONCLUSION

The results of this analysis showed that stress fractures were seen in high-level young athletes, with similar proportions for males and females, and that particular sports were associated with specific sites for stress fractures. Middle and long distance female runners who suffered from multiple stress fractures had the female athlete triad.

Role of the hypothalamus in the neuroendocrine regulation of body weight and composition during energy deficit

Energy deficit in lean or obese animals or humans stimulates appetite, reduces energy expenditure and possibly also decreases physical activity, thereby contributing to weight regain. Often overlooked in weight loss trials for obesity, however, is the effect of energy restriction on neuroendocrine status. Negative energy balance in lean animals and humans consistently inhibits activity of the hypothalamo-pituitary-thyroid, -gonadotropic and -somatotropic axes (or reduces circulating insulin-like growth factor-1 levels), while concomitantly activating the hypothalamo-pituitary-adrenal axis, with emerging evidence of similar changes in overweight and obese people during lifestyle interventions for weight loss. These neuroendocrine changes, which animal studies show may result in part from hypothalamic actions of orexigenic (e.g. neuropeptide Y, agouti-related peptide) and anorexigenic peptides (e.g. alpha-melanocyte-stimulating hormone, and cocaine and amphetamine-related transcript), can adversely affect body composition by promoting the accumulation of adipose tissue (particularly central adiposity) and stimulating the loss of lean body mass and bone. As such, current efforts to maximize loss of excess body fat in obese people may inadvertently be promoting long-term complications such as central obesity and associated health risks, as well as sarcopenia and osteoporosis. Future weight loss trials would benefit from assessment of the effects on body composition and key hormonal regulators of body composition using sensitive techniques.

Can we reduce eating disorder risk factors in female college athletes? A randomized exploratory investigation of two peer-led interventions

Female athletes are at least as at risk as other women for eating disorders (EDs) and at risk for the female athlete triad (i.e., inadequate energy availability, menstrual disorders, and osteoporosis). This study investigated whether two evidence-based programs appear promising for future study if modified to address the unique needs of female athletes. Athletes were randomly assigned to athlete-modified dissonance prevention or healthy weight intervention (AM-HWI). ED risk factors were assessed pre/post-treatment, and 6-week and 1-year follow-up. Results (analyzed sample, N=157) indicated that both interventions reduced thin-ideal internalization, dietary restraint, bulimic pathology, shape and weight concern, and negative affect at 6 weeks, and bulimic pathology, shape concern, and negative affect at 1 year. Unexpectedly we observed an increase in students spontaneously seeking medical consultation for the triad. Qualitative results suggested that AM-HWI may be more preferred by athletes.

Obstacles in the optimization of bone health outcomes in the female athlete triad

Maintaining low body weight for the sake of performance and aesthetic purposes is a common feature among young girls and women who exercise on a regular basis, including elite, college and high-school athletes, members of fitness centres, and recreational exercisers. High energy expenditure without adequate compensation in energy intake leads to an energy deficiency, which may ultimately affect reproductive function and bone health. The combination of low energy availability, menstrual disturbances and low bone mineral density is referred to as the 'female athlete triad'. Not all athletes seek medical assistance in response to the absence of menstruation for 3 or more months as some believe that long-term amenorrhoea is not harmful. Indeed, many women may not seek medical attention until they sustain a stress fracture. This review investigates current issues, controversies and strategies in the clinical management of bone health concerns related to the female athlete triad. Current recommendations focus on either increasing energy intake or decreasing energy expenditure, as this approach remains the most efficient strategy to prevent further bone health complications. However, convincing the athlete to increase energy availability can be extremely challenging. Oral contraceptive therapy seems to be a common strategy chosen by many physicians to address bone health issues in young women with amenorrhoea, although there is little evidence that this strategy improves bone mineral density in this population. Assessment of bone health itself is difficult due to the limitations of dual-energy X-ray absorptiometry (DXA) to estimate bone strength. Understanding how bone strength is affected by low energy availability, weight gain and resumption of menses requires further investigations using 3-dimensional bone imaging techniques in order to improve the clinical management of the female athlete triad.

Urinary levels of cross-linked N-terminal telopeptide of type I collagen and nutritional status in Japanese professional baseball players

The objective of the present study was to investigate the nutritional status from the aspect of bone metabolism in Japanese elite male athletes with increased bone resorption. Urinary levels of a bone resorption marker, cross-linked N-terminal telopeptide of type 1 collagen (NTX), were measured in 71 professional baseball players (age, 18-39 years); the mean urinary NTX level was 65.6 (range, 17.5-269.0) nM BCE/mM Cr. Of 71 athletes, 9 with high levels of urinary NTX (greater than mean + 1 SD) were examined by measuring serum biochemical markers and nutritional assessment (simple food frequency questionnaire). Serum biochemical marker analysis showed that 7 of these 9 athletes had vitamin D insufficiency, as indicated by low serum levels of 25-hydroxyvitamin D, and that all 9 athletes showed vitamin K insufficiency as indicated by low levels of vitamins K(1) and K(2). Nutritional assessment revealed high intakes of protein and low intakes of calcium and vitamin D based on adequate intake (AI). However, daily vitamin K intake achieved the AI. These results suggest that there exist elite male athletes who show increased bone resorption and calcium and vitamin D insufficiency. However, there was a discrepancy between vitamin K intake and serum levels of vitamins K(1) and K(2). The present study raised an issue regarding the nutritional status from the point of view of bone metabolism in elite male athletes such as professional baseball players.