Disordered eating, menstrual irregularity, and bone mineral density in female runners

Return to Running for Postpartum Elite and Subelite Athletes

CONTEXT

There is little evidence to guide elite athletes who desire returning to competition after giving birth to a child. Ultimately, this can result in decreased performance and increased risk of injury. This paper addresses aspects that must be considered when building and monitoring a return to running program for a postpartum elite or subelite athlete, including pelvic floor and core stability, progressive reloading of the musculoskeletal system, monitoring of nutritional parameters, and considerations for lactation.

EVIDENCE ACQUISITION

PubMed and CINAHL (Cumulative Index for Nursing and Allied Health Literature) were searched with the following search strategy: (extreme sports OR elite athletes OR running OR exercise) AND (breastfeeding OR lactation OR bone density OR fetal weight OR gestational weight gain OR postpartum or post-partum OR postnatal OR post-natal OR pregnancy OR childbirth). The following information is based on best available evidence and clinical experience.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Due to the interplay between cardiovascular fitness, postpartum nutrition, lactation, and progressive reloading of the muscular and skeletal system, we propose a multimodal, multidisciplinary approach to safely and successfully allow an athlete to return to an elite level of competition.

CONCLUSION

Return to running in the postpartum period is a highly individualized process that benefits from multidisciplinary, individualized care. This includes monitoring of nutrition, core and pelvic floor function, bone reloading, muscle and tendon reloading, and breastfeeding care when applicable.

STRENGH OF RECOMMENDATION TAXONOMY (SORT)

C.

A systematic review, meta-analysis, and meta-regression of the prevalence of self-reported disordered eating and associated factors among athletes worldwide

BACKGROUND

The purpose of this meta-analysis was to provide a pooled prevalence estimate of self-reported disordered eating (SRDE) in athletes based on the available literature, and to identify risk factors for their occurrence.

METHODS

Across ten academic databases, an electronic search was conducted from inception to 7th January 2024. The proportion of athletes scoring at or above predetermined cutoffs on validated self-reporting screening measures was used to identify disordered eating (DE). Subgroup analysis per country, per culture, and per research measure were also conducted. Age, body mass index (BMI), and sex were considered as associated/correlated factors.

RESULTS

The mean prevalence of SRDE among 70,957 athletes in 177 studies (132 publications) was 19.23% (17.04%; 21.62%), I2 = 97.4%, τ2 = 0.8990, Cochran's Q p value = 0. Australia had the highest percentage of SRDE athletes with a mean of 57.1% (36.0%-75.8%), while Iceland had the lowest, with a mean of 4.9% (1.2%-17.7%). The SRDE prevalence in Eastern countries was higher than in Western countries with 29.1% versus 18.5%. Anaerobic sports had almost double the prevalence of SRDE 37.9% (27.0%-50.2%) compared to aerobic sports 19.6% (15.2%-25%). Gymnastics sports had the highest SRDE prevalence rate, with 41.5% (30.4%-53.6%) while outdoor sports showed the lowest at 15.4% (11.6%-20.2%). Among various tools used to assess SRDE, the three-factor eating questionnaire yielded the highest SRDE rate 73.0% (60.1%-82.8%). Meta-regression analyses showed that female sex, older age, and higher BMI (all p < 0.01) are associated with higher prevalence rates of SRDE.

CONCLUSION

The outcome of this review suggests that factors specific to the sport affect eating behaviors throughout an athlete's life. As a result, one in five athletes run the risk of developing an eating disorder. Culture-specific and sport-specific diagnostic tools need to be developed and increased attention paid to nutritional deficiencies in athletes.

Menstrual Function, Eating Disorders, Low Energy Availability, and Musculoskeletal Injuries in British Servicewomen

PURPOSE

This study aimed to investigate associations between menstrual function, eating disorders, and risk of low energy availability with musculoskeletal injuries in British servicewomen.

METHODS

All women younger than 45 yr in the UK Armed Forces were invited to complete a survey about menstrual function, eating behaviors, exercise behaviors, and injury history.

RESULTS

A total of 3022 women participated; 2% had a bone stress injury in the last 12 months, 20% had ever had a bone stress injury, 40% had a time-loss musculoskeletal injury in the last 12 months, and 11% were medically downgraded for a musculoskeletal injury. Menstrual disturbances (oligomenorrhea/amenorrhea, history of amenorrhea, and delayed menarche) were not associated with injury. Women at high risk of disordered eating (Female Athlete Screening Tool score >94) were at higher risk of history of a bone stress injury (odds ratio (OR; 95% confidence interval (CI)), 2.29 (1.67-3.14); P < 0.001) and time-loss injury in the last 12 months (OR (95% CI), 1.56 (1.21-2.03); P < 0.001) than women at low risk of disordered eating. Women at high risk of low energy availability (Low Energy Availability in Females Questionnaire score ≥8) were at higher risk of bone stress injury in the last 12 months (OR (95% CI), 3.62 (2.07-6.49); P < 0.001), history of a bone stress injury (OR (95% CI), 2.08 (1.66-2.59); P < 0.001), a time-loss injury in the last 12 months (OR (95% CI), 9.69 (7.90-11.9); P < 0.001), and being medically downgraded with an injury (OR (95% CI), 3.78 (2.84-5.04); P < 0.001) than women at low risk of low energy availability.

CONCLUSIONS

Eating disorders and risk of low energy availability provide targets for protecting against musculoskeletal injuries in servicewomen.

Exploring the Relationship between Micronutrients and Athletic Performance: A Comprehensive Scientific Systematic Review of the Literature in Sports Medicine

The aim of this systematic review is twofold: (i) to examine the effects of micronutrient intake on athletic performance and (ii) to determine the specific micronutrients, such as vitamins, minerals, and antioxidants, that offer the most significant enhancements in terms of athletic performance, with the goal of providing guidance to athletes and coaches in optimizing their nutritional strategies. The study conducted a systematic search of electronic databases (i.e., PubMed, Web of Science, Scopus) using keywords pertaining to micronutrients, athletic performance, and exercise. The search involved particular criteria of studies published in English between 1950 and 2023. The findings suggest that vitamins and minerals are crucial for an athlete's health and physical performance, and no single micronutrient is more important than others. Micronutrients are necessary for optimal metabolic body's functions such as energy production, muscle growth, and recovery, which are all important for sport performance. Meeting the daily intake requirement of micronutrients is essential for athletes, and while a balanced diet that includes healthy lean protein sources, whole grains, fruits, and vegetables is generally sufficient, athletes who are unable to meet their micronutrient needs due to malabsorption or specific deficiencies may benefit from taking multivitamin supplements. However, athletes should only take micronutrient supplements with the consultation of a specialized physician or nutritionist and avoid taking them without confirming a deficiency.

Healthy Runner Project: a 7-year, multisite nutrition education intervention to reduce bone stress injury incidence in collegiate distance runners

Objectives

We evaluated the effect of a nutrition education intervention on bone stress injury (BSI) incidence among female distance runners at two NCAA Division I institutions.

Methods

Historical BSI rates were measured retrospectively (2010-2013); runners were then followed prospectively in pilot (2013-2016) and intervention (2016-2020) phases. The primary aim was to compare BSI rates in the historical and intervention phases. Pilot phase data are included only for descriptive purposes. The intervention comprised team nutrition presentations focused on optimising energy availability plus individualised nutrition sessions for runners with elevated Female Athlete Triad risk. Annual BSI rates were calculated using a generalised estimating equation Poisson regression model adjusted for age and institution. Post hoc analyses were stratified by institution and BSI type (trabecular-rich or cortical-rich).

Results

The historical phase included 56 runners and 90.2 person-years; the intervention phase included 78 runners and 137.3 person-years. Overall BSI rates were not reduced from the historical (0.52 events per person-year) to the intervention (0.43 events per person-year) phase. Post hoc analyses demonstrated trabecular-rich BSI rates dropped significantly from 0.18 to 0.10 events per person-year from the historical to intervention phase (p=0.047). There was a significant interaction between phase and institution (p=0.009). At Institution 1, the overall BSI rate dropped from 0.63 to 0.27 events per person-year from the historical to intervention phase (p=0.041), whereas no decline was observed at Institution 2.

Conclusion

Our findings suggest that a nutrition intervention emphasising energy availability may preferentially impact trabecular-rich BSI and depend on team environment, culture and resources.

12-months of increased dietary intake does not exacerbate disordered eating-related attitudes, stress, or depressive symptoms in women with exercise-associated menstrual disturbances: The REFUEL randomized controlled trial

Disordered eating-related attitudes are a leading cause of energy deficiency and menstrual disturbances in exercising women. Although treatment recommendations include psychological counseling with increases in dietary intake, a key concern is whether increased dietary intake may exacerbate negative eating behaviors.

OBJECTIVE

To determine the effects of a 12-month nutritional intervention on eating-related attitudes and psychological characteristics in exercising women with oligomenorrhea/amenorrhea (Oligo/Amen).

METHODS

Intent-to-treat analysis of the REFUEL randomized controlled trial (#NCT00392873) in 113 exercising women (age [mean±SEM]:] 21.9 ± 0.4 yrs; BMI: 20.9 ± 0.2 kg/m²). Women were randomized to increase energy intake 20-40% above baseline energy needs (Oligo/Amen+Cal, n = 40) or maintain energy intake (Oligo/Amen Control, n = 36) while maintaining their exercise behaviors. A reference group of ovulatory women (OVref, n = 37) maintained diet and exercise behaviors. Body composition, eating attitudes, stress, and depressive symptoms were assessed at baseline and every 3 months.

RESULTS

At baseline, the Oligo/Amen groups had higher drive for thinness, cognitive restraint, and eating disorder risk than OVref group (p < 0.001). Increased energy intake led to increases in percent body fat and fat mass (p < 0.010), but not psychobehavioral outcomes, in the Oligo/Amen+Cal compared to Oligo/Amen Control group. Independent of group, cognitive restraint decreased (p < 0.001) and resilient coping increased (p < 0.007) over 12-months, while perceived stress (p = 0.143) and depressive symptoms (p = 0.344) were unchanged.

DISCUSSION

Long-term nutritional intervention consisting of modest increases in dietary intake with guidance from a registered dietician and a psychologist increases body and fat mass without increasing disordered eating-related attitudes, stress, or depressive symptoms in exercising women with Oligo/Amen.

Identifying latent classes of Relative Energy Deficiency in Sport (RED-S) consequences in a sample of collegiate female cross country runners

OBJECTIVE

The purpose of this study was to identify patterns of clustering of the 10 health consequences identified in the Relative Energy Deficiency in Sport (RED-S) framework among collegiate female Cross-Country runners. We also assessed risk characteristics associated with each cluster.

METHODS

This randomly sampled population included 211 current National Collegiate Athletics Association (NCAA) Division I (DI) female cross country runners who completed a quantitative survey. We used latent class analysis (LCA) to group athletes into mutually exclusive classes based on shared response patterns of RED-S consequences. We computed descriptive statistics to identify demographics, personal characteristics, disordered eating and emotional health characteristics associated with each class.

RESULTS

The average age of the sample was 21 years with mean body mass index 20.4 kg/m². The LCA identified three unique classes of potential RED-S presentations: (1) low probability of RED-S consequences; (2) complex physical and psychological concerns with a higher burden of cardiovascular concern and (3) very high probability of anxiety with high burden of menstrual disturbance, bone injury and gastrointestinal concern. All classes were characterised by high levels of menstrual disturbance and distinguished by the number and burden of other potential RED-S consequences and in reported abuse history, emotional regulation and perfectionism.

CONCLUSION

This study identified a high burden of menstrual disturbance in NCAA D1 cross country runners, and three unique presentations of RED-S consequences. Future research is warranted to better understand how early prevention and intervention strategies may mitigate RED-S consequences in distance runners.

Participation in varsity sports, dance, and Greek life associated with menstrual disturbance in a national sample of female college students

Objective: The objective of this study was to identify university-sponsored activities associated with increased odds of menstrual disturbance among female college students. Participants: The sample included 3,277 female-identifying students at 12 colleges and universities participating in the Healthy Bodies Study during the 2013-2014 and 2014-2015 academic years. Methods: Crude and adjusted logistic regression models were run to report odds of any menstrual disturbance and amenorrhea (AMN) for participants in sports, dance, and Greek Life. Survey weights were used to account for response bias. Results: In the adjusted models, participation in varsity sport (OR = 1.82, CI 1.37, 2.37), dance (OR = 1.68, CI 1.37, 2.05) and Greek life (OR= 2.12, CI 0.13,0.18) was significantly associated with increased odds of menstrual disturbance, compared to non-participants. Conclusions: Findings suggest additional need for prevention and intervention programming against menstrual disturbance in varsity sports, dance, and Greek life activities.

The Prevalence of Menstrual Cycle Disorders in Female Athletes from Different Sports Disciplines: A Rapid Review

The aim of this study was to rapidly review the literature on the prevalence of menstrual disorders in female athletes from different sports modalities. Articles were searched in the Web of Science and PubMed database in May 2022. A total of 1309 records were identified, and 48 studies were included in the final stage. The menstrual disorders described in the included studies were primary (in 33% of included studies) and secondary amenorrhea (in 73% of included studies) and oligomenorrhea (in 69% of included studies). The prevalence of menstrual disorders among the studies ranged from 0 to 61%. When data were pooled according to discipline (mean calculation), the highest prevalence of primary amenorrhea was found in rhythmic gymnastics (25%), soccer (20%) and swimming (19%); for secondary amenorrhea in cycling (56%), triathlon (40%) and rhythmic gymnastics (31%); and oligomenorrhea in boxing (55%), rhythmic gymnastics (44%) and artistic gymnastics (32%). Based on the results of this review, the study supports the literature of the higher prevalence of menstrual disorders in gymnastics and endurance disciplines. However, team sports modalities such as volleyball and soccer also presented a considerable percentage of menstrual disorders compared to the general population. It reinforces the importance of coaches and physicians paying attention to athletes' menstrual cycle as the occurrence of menstrual disorders can be associated with impairment on some health components.

Menstrual disturbances in British Servicewomen: A cross-sectional observational study of prevalence and risk factors

Female athletes are at increased risk of menstrual disturbances. The prevalence of menstrual disturbances in British Servicewomen and the associated risk factors is unknown. All women under 45 years in the UK Armed Forces were invited to complete a survey about demographics, menstrual function, eating and exercise behaviors, and psychological well-being. 3,022 women participated; 18% had oligomenorrhoea or amenorrhoea in the last 12 months, 25% had a history of amenorrhoea, and 14% had delayed menarche. Women who sleep ≥ 8 h were at a lower risk of a history of amenorrhoea than women who sleep ≤ 5 h [odds ratio (95% confidence intervals) = 0.65 (0.48, 0.89), p = 0.006]. Women who completed > 10 days of field exercise in the last 12 months were at higher risk of a history of amenorrhoea than women completing no field exercise [1.45 (1.13, 1.85), p = 0.004]. Women at high risk of an eating disorder (FAST score >94) were at higher risk of oligomenorrhoea or amenorrhoea [1.97 (1.26, 3.04), p = 0.002] and history of amenorrhoea [2.14 (1.63, 2.79), p < 0.001]. Women with symptoms of anxiety or depression were at higher risk of a history of amenorrhoea [1.46 (1.20, 1.77) and 1.48 (1.22, 1.79), p < 0.001]. British Servicewomen had a similar prevalence of menstrual disturbances to some endurance athletes. Eating disorders, sleep behaviors, and management of mental health, provide targets for protecting health of the reproductive axis.

Association of Short-Term Changes in Menstrual Frequency, Medication Use, Weight and Exercise on Bone Mineral Density in College-Aged Women

To evaluate if experiencing a short-term exposure (18-months) to factors such as menstrual irregularities, dieting, changes in exercise or body weight, and medication usage is associated with bone mineral density (BMD) in college-aged females. A retrospective survey assessing health behaviors during a recent 18-month time period and a DXA scan were completed in 641 females. A total of 45.5% of participants reported amenorrhea during the 18-month time period. Those who experienced amenorrhea had lower femoral neck BMD (p = 0.018), trochanter (p = 0.018) and spine BMD (p = 0.022) compared to eumenorrheic women. Lifetime oral contraceptive usage longer than six months was negatively associated with BMD at femoral neck (p = 0.018) and total hip (p = 0.021). Women who lost weight trended towards having the lowest BMD at all sites compared to women who gained weight. Following a very-low calorie diet during the time period was negatively correlated with spine BMD (p = 0.001). Time spent in vigorous and very vigorous activity was weakly correlated with some hip BMD sites but time spent in extremely vigorous activity was not. In conclusion, females who experienced weight loss, amenorrhea, or a very low-calorie diet within an 18-month period of time in young adulthood had lower BMD. Additionally, oral contraceptive usage for longer than six months during their lifetime was associated with lower BMD.

Prevalence of amenorrhea in elite female competitive climbers

Elite competitive sport climbers exhibit a high strength-to-weight ratio and are reported in the literature to be lighter and leaner than their athletic counterparts. Current research regarding nutrition among climbers is sparse but suggests that they may be at high risk for low energy availability and Relative Energy Deficiency in Sport (RED-S). The prevalence of amenorrhea, one of the primary indicators of RED-S, is unknown in this athletic population. The purpose of this study was to determine the prevalence of current (previous 12 months) amenorrhea among elite level competitive sport climbers.

Methods

An anonymous online survey was distributed via email to 1,500 female climbers registered as competitors within the International Federation of Sport Climbing to assess the prevalence of amenorrhea over the past 12 months.

Results

A total of 114 female sport climbers answered all survey questions regarding menstrual function and 18 athletes (15.8%) presented with current amenorrhea. The majority of the athletes (72%; n = 82) were categorized with eumenorrhea. An additional 14 athletes (12.3%) provided information that indicated irregular cycles, but answers to all menstrual cycle questions were not congruent to elicit a classification of amenorrhea and these athletes were categorized with a menstrual status of unsure. The average BMI for climbers with eumenorrhea was 20.8 ± 1.8 kg/m2 and 19.9 ± 2.4 kg/m2 for those with amenorrhea. A higher percentage of climbers with amenorrhea revealed they currently struggle with an eating disorder compared to those without amenorrhea (13.5 vs. 22.2%, respectively).

Conclusion

This study indicates that some female climbers competing at the World Cup level do have menstrual disturbances with relatively normal BMIs and some currently struggle with one or more eating disorders. Even though World Cup competitions use BMI critical margins to screen competitors, this research highlights the need for more medical supervision of competitive elite female sport climbers in order to protect their overall health, including menstrual function. Further research is required to clarify how many climbers suffer from endocrine abnormalities related to RED-S. With more scientific evidence in this area practitioners will be better equipped to educate the athlete and coach with evidence-based nutrition recommendations.

Prevalence of Female and Male Athlete Triad Risk Factors in Ultramarathon Runners

OBJECTIVE

To identify the prevalence of male and female athlete triad risk factors in ultramarathon runners and explore associations between sex hormones and bone mineral density (BMD).

DESIGN

Multiyear cross-sectional study.

SETTING

One hundred-mile ultramarathon.

PARTICIPANTS

Competing runners were recruited in 2018 and 2019.

ASSESSMENT OF RISK FACTORS

Participants completed a survey assessing eating behaviors, menstrual history, and injury history; dual-energy x-ray absorptiometry for BMD; and laboratory evaluation of sex hormones, vitamin D, and ferritin (2019 cohort only).

MAIN OUTCOME MEASURE

A Triad Cumulative Risk Assessment Score was calculated for each participant.

RESULTS

One hundred twenty-three runners participated (83 males and 40 females, mean age 46.2 and 41.8 years, respectively). 44.5% of men and 62.5% of women had elevated risk for disordered eating. 37.5% of women reported a history of bone stress injury (BSI) and 16.7% had BMD Z scores <-1.0. 20.5% of men had a history of BSI and 30.1% had Z-scores <-1.0. Low body mass index (BMI) (<18.5 kg/m 2 ) was seen in 15% of women and no men. The Triad Cumulative Risk Assessment classified 61.1% of women and 29.2% of men as moderate risk and 5.6% of both men and women as high risk.

CONCLUSIONS

Our study is the first to measure BMD in both male and female ultramarathon runners. Our male population had a higher prevalence of low BMD than the general population; females were more likely to report history of BSI. Risk of disordered eating was elevated among our participants but was not associated with either low BMD or low BMI.

Bone mineral density in response to increased energy intake in exercising women with oligomenorrhea/amenorrhea: the REFUEL randomized controlled trial

BACKGROUND

Energy deficiency can result in menstrual disturbances and compromised bone health in women, a condition known as the Female Athlete Triad.

OBJECTIVES

The REFUEL randomized controlled trial assessed the impact of increased energy intake on bone health and menstrual function in exercising women with menstrual disturbances.

METHODS

Exercising women with oligomenorrhea/amenorrhea (Oligo/Amen) were randomly assigned to an intervention group (Oligo/Amen + Cal, n = 40, mean ± SEM age: 21.3 ± 0.5 y; weight: 55.0 ± 1.0 kg; BMI: 20.4 ± 0.3 kg/m2) who increased energy intake 20%-40% above baseline energy needs for 12 mo or a control group (Oligo/Amen Control, n = 36; mean ± SEM age: 20.7 ± 0.5 y; weight: 59.1 ± 1.3 kg; BMI: 21.3 ± 0.4 kg/m2). Energy intake and expenditure, metabolic and reproductive hormones, body composition, and areal bone mineral density (aBMD) were assessed.

RESULTS

Oligo/Amen + Cal improved energy status [increased body mass (2.6 ± 0.4 kg), BMI (0.9 ± 0.2 kg/m2), fat mass (2.0 ± 0.3 kg), body fat percentage (2.7% ± 0.4%), and insulin-like growth factor 1 (37.4 ± 14.6 ng/mL)] compared with Oligo/Amen Control and experienced a greater likelihood of menses (P < 0.05). Total body and spine aBMD remained unchanged (P > 0.05). Both groups demonstrated decreased femoral neck aBMD at month 6 (-0.006 g/cm2; 95% CI: -0.011, -0.0002 g/cm2 ; time main effect P = 0.043) and month 12 (-0.011 g/cm2; 95% CI: -0.021, -0.001 g/cm2; time main effect P = 0.023). Both groups demonstrated a decrease in total hip aBMD at month 6 (-0.006 g/cm2; 95% CI: -0.011, -0.002 g/cm2; time main effect P = 0.004).

CONCLUSIONS

Although higher dietary energy intake increased weight, body fat, and menstrual frequency, bone mineral density was not improved, compared with the control group. The 12-mo intervention may have been too short and the increase in energy intake (∼352 kcal/d), although sufficient to increase menstrual frequency, was insufficient to increase estrogen or improve aBMD. Future research should refine the optimal nutritional and/or pharmacological interventions for the recovery of bone health in athletes and exercising women with Oligo/Amen.This trial was registered at clinicaltrials.gov as NCT00392873.

Restrictive Eating and Prior Low-Energy Fractures Are Associated With History of Multiple Bone Stress Injuries

Bone stress injuries (BSIs) are common among athletes and have high rates of recurrence. However, risk factors for multiple or recurrent BSIs remain understudied. Thus, we aimed to explore whether energy availability, menstrual function, measures of bone health, and a modified Female Athlete Triad Cumulative Risk Assessment (CRA) tool are associated with a history of multiple BSIs. We enrolled 51 female runners (ages 18-36 years) with history of ≤1 BSI (controls; n = 31) or ≥3 BSIs (multiBSI; n = 20) in this cross-sectional study. We measured lumbar spine, total hip, and femoral neck areal bone mineral density by dual-energy X-ray absorptiometry, bone material strength index using impact microindentation, and volumetric bone mineral density, microarchitecture, and estimated strength by high-resolution peripheral quantitative computed tomography. Participants completed questionnaires regarding medical history, low-energy fracture history, and disordered eating attitudes. Compared with controls, multiBSI had greater incidence of prior low-energy fractures (55% vs. 16%, p = .005) and higher modified Triad CRA scores (2.90 ± 2.05 vs. 1.84 ± 1.59, p = .04). Those with multiBSI had higher Eating Disorder Examination Questionnaire (0.92 ± 1.03 vs. 0.46 ± 0.49, p = .04) scores and a greater percentage difference between lowest and highest body mass at their current height (15.5% ± 6.5% vs. 11.5% ± 4.9% p = .02). These preliminary findings indicate that women with a history of multiple BSIs suffered more prior low-energy fractures and have greater historical and current estimates of energy deficit compared with controls. Our results provide strong rationale for future studies to examine whether subclinical indicators of energy deficit contribute to risk for multiple BSIs in female runners.

Differences in Dietary Quality by Sexual Orientation and Sex in the United States: NHANES 2011-2016

BACKGROUND

There are persistent disparities in weight- and diet-related diseases by sexual orientation. Lesbian and bisexual females have a higher risk of obesity and cardiovascular disease compared with heterosexual females. Gay and bisexual males have a higher risk of diabetes and cardiovascular disease compared with heterosexual males. However, it remains unknown how sexual orientation groups differ in their dietary quality.

OBJECTIVE

This study aimed to determine whether dietary quality differs by sexual orientation and sex among US adults.

DESIGN

This was a cross-sectional study of 24-hour dietary recall data from a nationally representative sample of adults aged 20 through 65 years participating in the 2011-2016 National Health and Nutrition Examination Survey.

PARTICIPANTS/SETTING

Study participants were adults (n = 8,851) with complete information on dietary intake, sexual orientation, and sex.

MAIN OUTCOME MEASURES

The main outcome measures were daily energy intake from 20 specific food and beverage groups and Healthy Eating Index-2015 (HEI-2015) scores for sexual orientation groups (heterosexual vs gay/lesbian/bisexual).

STATISTICAL ANALYSES PERFORMED

Ordinary least squares regressions were used to calculate adjusted means for each food and beverage group and HEI-2015, stratified by sex and controlling for covariates (eg, age and race/ethnicity) and survey cycles (2011-2012, 2013-2014, and 2015-2016).

RESULTS

Among males, red and processed meat/poultry/seafood (P = .01) and sandwiches (P = .02) were smaller contributors to energy intake for gay/bisexual males compared with heterosexual males. Among females, cereals (P =.04) and mixed dishes (P = .02) were smaller contributors to energy intake for lesbian/bisexual females compared with heterosexual females. Gay/bisexual males had significantly higher total HEI-2015 scores than heterosexual males (mean ± standard deviation 53.40 ± 1.36 vs 49.29 ± 0.32, difference = 4.14; P = .004). Lesbian/bisexual females did not differ in total or component HEI-2015 scores from heterosexual females.

CONCLUSIONS

Although gay/lesbian/bisexual groups were similar for a variety of dietary outcomes compared with heterosexual groups, gay and bisexual men displayed healthier dietary quality for processed meat (by consuming smaller amounts) and overall dietary quality (according to HEI-2015) compared with heterosexual males.

Impact of Low Energy Availability on Skeletal Health in Physically Active Adults

For decades researchers reported that pre-menopausal women who engage in extensive endurance exercise and have menstrual dysfunction can develop low bone mineral density (BMD) or osteoporosis. More recently, low energy availability has been recognized as the initiating factor for low BMD in these women. Furthermore, the relationship between low energy availability and poor skeletal health is not exclusive to women engaging in endurance exercise. Rather, both males and females commonly experience endocrine dysfunction resulting from low energy availability and high exercise levels that degrades skeletal health. Consequences to skeletal health can range from short-term changes in bone metabolism and increased risk of bone stress injuries to long-term consequences of low BMD, such as osteoporosis and related fragility fractures. The degree to which low energy availability degrades skeletal health may be dependent on the length and extent of the energy deficit. However, the complex relationships between under-fueling, short- and long-term skeletal consequences and the factors that mediate these relationships are not well described. In this review, we discuss the consequences of low energy availability on sex hormones and skeletal health in two highly-active populations-athletes and military trainees-and provide a summary of existing knowledge gaps for future study.

Estrogen depletion alters osteogenic differentiation and matrix production by osteoblasts in vitro

Recent studies have revealed that the effects of estrogen deficiency are not restricted to osteoclasts and bone resorption, but that bone matrix composition is altered and osteoblasts exhibit an impaired response to mechanical stimulation. In this study, we test the hypothesis that estrogen depletion alters osteogenic differentiation and matrix production by mechanically stimulated osteoblasts in vitro. MC3T3-E1 cells were pre-treated with estrogen for 14 days, after which estrogen was withdrawn or inhibited with Fulvestrant up to 14 days. Fluid shear stress (FSS) was applied using an orbital shaker. Under estrogen depletion in static culture, osteogenic marker (ALP) and gene expression (Runx2) were decreased at 2 and after 7 days of estrogen depletion, respectively. In addition, up to 7 day the inhibition of the estrogen receptor significantly decreased fibronectin expression (FN1) under static conditions. Under estrogen depletion and daily mechanical stimulation, changes in expression of Runx2 occurred earlier (4 days) and by 14 days, changes in matrix production (Col1a1) were reported. We propose that changes in osteoblast differentiation and impaired matrix production during estrogen depletion may contribute to the altered quality of the bone and act as a contributing factor to increased bone fragility in postmenopausal osteoporosis.

Self-Reported Restrictive Eating, Eating Disorders, Menstrual Dysfunction, and Injuries in Athletes Competing at Different Levels and Sports

The purpose of this study was to investigate the prevalence of self-reported restrictive eating, current or past eating disorder, and menstrual dysfunction and their relationships with injuries. Furthermore, we aimed to compare these prevalences and associations between younger (aged 15–24) and older (aged 25–45) athletes, between elite and non-elite athletes, and between athletes competing in lean and non-lean sports. Data were collected using a web-based questionnaire. Participants were 846 female athletes representing 67 different sports. Results showed that 25%, 18%, and 32% of the athletes reported restrictive eating, eating disorders, and menstrual dysfunction, respectively. Higher rates of lean sport athletes compared with non-lean sport athletes reported these symptoms, while no differences were found between elite and non-elite athletes. Younger athletes reported higher rates of menstrual dysfunction and lower lifetime prevalence of eating disorders. Both restrictive eating (OR 1.41, 95% CI 1.02–1.94) and eating disorders (OR 1.89, 95% CI 1.31–2.73) were associated with injuries, while menstrual dysfunction was associated with more missed participation days compared with a regular menstrual cycle (OR 1.79, 95% CI 1.05–3.07). Our findings indicate that eating disorder symptoms and menstrual dysfunction are common problems in athletes that should be managed properly as they are linked to injuries and missed training/competition days.

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.

Tibial Macrostructure and Microarchitecture Adaptations in Women During 44 Weeks of Arduous Military Training

Bone adapts to unaccustomed, high-impact loading but loses mechanosensitivity quickly. Short periods of military training (≤12 weeks) increase the density and size of the tibia in women. The effect of longer periods of military training, where the incidence of stress fracture is high, on tibial macrostructure and microarchitecture in women is unknown. This observational study recruited 51 women (age 19 to 30 years) at the start of 44 weeks of British Army Officer training. Tibial volumetric bone mineral density (vBMD), geometry, and microarchitecture were measured by high-resolution peripheral quantitative computed tomography (HRpQCT). Scans of the right tibial metaphysis (4% site) and diaphysis (30% site) were performed at weeks 1, 14, 28, and 44. Measures of whole-body areal bone mineral density (aBMD) were obtained using dual-energy X-ray absorptiometry (DXA). Blood samples were taken at weeks 1, 28, and 44, and were analyzed for markers of bone formation and resorption. Trabecular vBMD increased from week 1 to 44 at the 4% site (3.0%, p < .001). Cortical vBMD decreased from week 1 to 14 at the 30% site (-0.3%, p < .001). Trabecular area decreased at the 4% site (-0.4%); trabecular bone volume fraction (3.5%), cortical area (4.8%), and cortical thickness (4.0%) increased at the 4% site; and, cortical perimeter increased at the 30% site (0.5%) from week 1 to 44 (p ≤ .005). Trabecular number (3.5%) and thickness (2.1%) increased, and trabecular separation decreased (-3.1%), at the 4% site from week 1 to 44 (p < .001). Training increased failure load at the 30% site from week 1 to 44 (2.5%, p < .001). Training had no effect on aBMD or markers of bone formation or resorption. Tibial macrostructure and microarchitecture continued to adapt across 44 weeks of military training in young women. Temporal decreases in cortical density support a role of intracortical remodeling in the pathogenesis of stress fracture. © 2021 Crown copyright. Journal of Bone and Mineral Research © 2021 American Society for Bone and Mineral Research (ASBMR). This article is published with the permission of the Controller of HMSO and the Queen's Printer for Scotland.

An investigation into the association of bone characteristics and body composition with stress fracture in athletes

BACKGROUND

The aim of the study was to establish the bone and body composition characteristics of high-level athletes with and without a history of stress fracture injury.

METHODS

Overall, 279 high-level athletes (212 men, 67 women) (age 28.0±9.2 years; body mass 75.0±17.4 kg; height 1.78±0.10 m) and 112 non-athletic controls (60 women, 52 men) 36.2±15.0 years; 70.9±12.9 kg; 1.71±0.10 m) were assessed by DXA to establish their bone mineral density and content, body fat and lean mass. Athletes completed a questionnaire detailing their stress fracture history.

RESULTS

There were no differences in whole-body bone mineral density (men 1.41±0.12 g/cm², women 1.19±0.09 g/cm²), bone mineral content (men 3709±626 g, women 2263±290 g), body fat (men 16.3±5.0%,women 23.0±4.6%) and lean mass (men 65.4±9.9 kg, women 38.7±3.6 kg) between athletes with a history of stress fracture (34 men, 16 women) and those without (176 men, 40 women).

CONCLUSIONS

DXA derived bone and body composition characteristics were not independent risk factors for stress fracture injury in high-level athletes. This study in a large cohort of high-level athletes provides normative bone and body composition values that can be used as a benchmark for researchers and applied practitioners.

Performance and Health Decrements Associated With Relative Energy Deficiency in Sport for Division I Women Athletes During a Collegiate Cross-Country Season: A Case Series

The purpose of this case series was to evaluate the presence of low Energy Availability (EA) and its impact on components of Relative Energy Deficiency in Sport (RED-S) in a population of female collegiate runners. Seven female NCAA Division I athletes (age: 22.3 ± 1.5 yrs; height: 169.7 ± 5.7 cm; weight: 58.3 ± 4.1 kg) were tracked from August until February, covering the beginning (Pre XC), end (Post XC) of their competitive cross country season, and beginning of the following track season (Pre Track). The athletes were assessed for female athlete triad (Triad) risk, energy availability, body composition, resting metabolic rate (RMR), nutritional intake, and blood markers (including vitamin D, ferritin, and triiodothyronine (T3)). From Pre XC to Post XC there were no significant differences in body mass, fat free mass or body fat percentage. At Pre XC, mean EA was 31.6 ± 13.3 kcal/kg FFM∙d^-1. From Post XC to Pre Track, there was a significant increase in body mass (59.1 ± 5.1 to 60.6 ± 5.7 kg, p<0.001,d=0.27). From Post XC to Pre Track, there was a significant increase in RMR (1466 ± 123.6 to 1614.6 ± 89.1 kcal·d^-1, p<0.001,d=2.6). For 25(OH) vitamin D, there was a significant reduction from Pre XC to Post XC (44.1 ± 10.6 vs 39.5 ± 12.2 ng·mL^-1, p=0.047,d=-0.4), and a significant increase from Post XC to Pre Track (39.5 ± 12.2 vs. 48.1 ± 10.4 ng·mL^-1, p=0.014,d=0.75). For ferritin, there was a trend towards a decrease from Pre XC to Post XC (24.2 ± 13.2 vs. 15.7 ± 8.8 ng·mL^-1, p=0.07, d=-0.75), as well as a trend toward an increase from Post XC to Pre Track (15.7 ± 8.8 vs. 34.1 ± 18.0 ng·mL^-1, p=0.08, d=1.3). No differences in T3 were observed across time points. Average Triad risk score was 2.3 ± 1.4. Notably, 5 of 7 athletes met criteria for moderate risk. Despite many athletes meeting criteria for low EA and having elevated Triad risk assessment scores, most were able to maintain body mass and RMR. One athlete suffered severe performance decline and a reduced RMR. Surprisingly, she was the only athlete above the recommended value for ferritin. Following increased nutritional intake and reduced training volume, her performance and RMR recovered. Changes in body mass and body composition were not indicative of the presence of other concerns associated with RED-S. This exploratory work serves as a guide for future, larger studies for tracking athletes, using RMR and nutritional biomarkers to assess RED-S.

Predisposing Risk Factors for Stress Fractures in Collegiate Cross-Country Runners

ABSTRACT

Giffin, KL, Knight, KB, Bass, MA, and Valliant, MW. Predisposing risk factors and stress fractures in collegiate cross-country runners. J Strength Cond Res 35(1): 227-232, 2021-The purpose of this study was to explore factors associated with increased stress fractures in collegiate cross-country runners. Subjects in this study were 42 male and female cross-country runners at a Division I university. Each athlete completed a questionnaire regarding smoking status, vitamin/mineral intake, previous stress fracture history, birth control usage, menstrual status, and demographic information. Nutritional assessment using a 3-day food record and measurements of whole body, lumbar spine, and hip bone mineral densities (BMDs) were also conducted on each athlete. Results indicated that 40% of the female and 35% of the male runners reported a history of stress fracture, and that all of them did not meet the recommended daily energy intake or adequate intakes for calcium or vitamin D required for their amount of training. Two-tailed t-test found statistically higher incidences of lumbar spine BMD in male and female runners whose daily calcium and vitamin D intakes were below minimum requirements as well as for women whose caloric intake was below the required level. When data on the lumbar spine was evaluated, 31% of subjects (31.8% of the male and 30% of the female runners) were identified as having osteopenia and 4.8% with osteoporosis. Results warrant a need for future longitudinal studies.

Cultural and environmental associations with body image, diet and well-being in NCAA DI female distance runners: a qualitative analysis

OBJECTIVE

We aimed to describe current and former National Collegiate Athletic Association (NCAA) Division One (DI) female distance runners' experiences of perceived norms of body image and disordered eating in their sport, as well as the emergence and influence of coach-athlete power dynamics.This manuscript reports a qualitative research study (consisting of interviews and thematic analysis) of women athletes' experiences of perceived norms of body image and disordered eating in their sport. We also report athletes' experiences of coach-athlete power dynamics.

METHODS

The study sample included 29 current and former female NCAA DI female distance runners, defined as competing in 800-metre distance or greater. Interviews were conducted, audio-recorded and hand transcribed. A thematic analysis was performed and presented.

RESULTS

Two major themes emerged: (1) sport body ideals and body image norms and myths that exist in the sport, and (2) the power dynamic between athletes and coaches. It is not clear whether sport body ideals and culture of running influences coaching culture, or whether the coaches-who maintain positions of power in the sport-perpetuate the culture. These themes likely feed into each other and reinforce the existing and dominant mentalities of the sport.

CONCLUSION

Sport body image ideals and the power dynamic between coach and athlete may contribute to female athlete's risk of disordered eating and body image disturbance. We call for the NCAA and athletic departments to develop and implement prevention and intervention programmes to prevent eating and body image disorders in this high-risk population.

Assessing the effectiveness of a pharmaceutical care service on the quality of life of women with polycystic ovarian syndrome living in war and non-war countries

RATIONALE, AIMS, AND OBJECTIVES

Polycystic ovarian syndrome (PCOS) is a serious health problem that affects women of all ages worldwide, including their quality of life (QOL). Interventions on lifestyle modification can be a suitable therapy. This study aimed to evaluate the effect of a PCOS pharmaceutical care service on QOL for women diagnosed with PCOS living in Syria (a country affected by war) and Jordan (non-war-zone country).

METHODS

PCOS women from both Syria and Jordan with age above 16 years were recruited in the study. Women randomly allocated into active group received an educational intervention by the pharmacist (via oral and written educational module) with special focus on diet and exercise. Women allocated to the control group did not receive the educational intervention. Both groups were followed for 4 months. Women in both groups completed the QOL questionnaire at both baseline and end of study. Multiple-regression analysis was performed to identify factors associated with change in QOL scores across the study.

RESULTS

PCOS women (n = 118) from both Syria (n = 60) and Jordan (n = 58) were recruited. Unlike control group patients, QOL was significantly improved in the active group at the end of the study for Syrian (102.75 vs 118.50, P < 0.001) and Jordanian women (95.31 vs 112.67, P < 0.001). Study group (active versus control) and difference in anxiety scores across the study were the only independent variables that showed association with the dependent variable, difference in QOL mean scores across the study period.

CONCLUSION

A pharmacist led intervention on lifestyle modification delivered to PCOS women led to positive effects on QOL scores. The intervention was successful in Syria and Jordan. This highlights the significant role that pharmacists can play in improving the life of women with PCOS whether living in war or non-war-zone countries.

Prevalence of disordered eating in athletes categorized by emphasis on leanness and activity type - a systematic review

BACKGROUND

Disordered Eating (DE) shows a strong association with athletics and can lead to several negative mental and physical health effects. Traditionally, sports have been grouped based upon whether or not the sport emphasizes leanness as a competing factor. Due to sociocultural factors, risk for DE may also be associated with the sport type. The aim of this review is to critically analyze the available research and data in this field to consider the relationship between DE and sport type to see which factors influence prevalence among athletes.

METHOD

A systematic review was completed using keywords specific to DE and sport types. Articles were either excluded due to lack of specification of athlete type or failure to use a standardized screening tool or interview for data collection.

RESULTS

6 out of 7 studies found a significant increase in DE rates among lean sport types. When classifying by sport type reports were less consistent, but show non-lean sports also have increased rates of DE.

CONCLUSION

There are variations in prevalence of DE behaviors depending on athlete type. It is important to identify the risk for DE early in athletes so emphasis can be placed on treatment options to nullify progression to an eating disorder, lower negative impacts on an athlete's performance, and prevent other negative health effects. Using sport groups is important to clinical practice as well as research, as certain sports may have a higher risk for development of DE.

Energy Deficiency in Soldiers: The Risk of the Athlete Triad and Relative Energy Deficiency in Sport Syndromes in the Military

Military personnel experience energy deficit (total energy expenditure higher than energy intake), particularly during combat training and field exercises where exercising energy expenditures are high and energy intake is reduced. Low energy availability (energy intake minus exercising energy expenditure expressed relative to fat free mass) impairs endocrine function and bone health, as recognized in female athletes as the Female Athlete Triad syndrome. More recently, the Relative Energy Deficiency in Sport (RED-S) syndrome encompasses broader health outcomes, physical and cognitive performance, non-athletes, and men. This review summarizes the evidence for the effect of low energy availability and energy deficiency in military training and operations on health and performance outcomes. Energy availability is difficult to measure in free-living individuals but doubly labeled water studies demonstrate high total energy expenditures during military training; studies that have concurrently measured energy intake, or measured body composition changes with DXA, suggest severe and/or prolonged energy deficits. Military training in energy deficit disturbs endocrine and metabolic function, menstrual function, bone health, immune function, gastrointestinal health, iron status, mood, and physical and cognitive performance. There are more data for men than women, and little evidence on the chronic effects of repeated exposures to energy deficit. Military training impairs indices of health and performance, indicative of the Triad and RED-S, but the multi-stressor environment makes it difficult to isolate the independent effects of energy deficiency. Studies supplementing with energy to attenuate the energy deficit suggest an independent effect of energy deficiency in the disturbances to metabolic, endocrine and immune function, and physical performance, but randomized controlled trials are lacking.

Prevalence of anxiety and depression among women with Polycystic Ovary Syndrome living in war versus non-war zone countries: A randomized controlled trial assessing a pharmacist intervention

BACKGROUND

Polycystic ovary syndrome (PCOS) is a serious health problem. In women experiencing PCOS, there are myriad physical and mental health consequences; anxiety/depression are commonly associated with this condition. Community pharmacists are in a pivotal position to identify and help women diagnosed with PCOS.

OBJECTIVES

To investigate the prevalence/severity of anxiety/depression among females diagnosed with PCOS living in Syria (a war-zone country) and Jordan (a non-war zone country). Secondly, to evaluate the impact of a pharmaceutical care service delivered by a clinical pharmacist on participants' anxiety/depression severity.

METHODS

Females, diagnosed with PCOS above the age of 16, were recruited into the study and randomly allocated into either the active or the control group. The active group participants received a PCOS pharmaceutical care service. This service involved the provision of verbal and written educational materials, with a special focus on diet and exercise. The control group participants received only standard counseling. Both groups were followed up for four months. All participants completed the Beck Anxiety Inventory and the Beck Depression Inventory at baseline and follow-up.

RESULTS

Data from study participants (n = 118) from both Syria (n = 60) and Jordan (n = 58) highlighted a high prevalence of anxiety (Syria = 95% vs. Jordan = 98%) and depression (Syria = 83% vs. Jordan = 65%). At follow-up, active group participants, from both countries, showed significant improvements in anxiety and depression mean scores (anxiety: Syria = 34.97 ± 14.8 vs. 30.47 ± 14.3, p < 0.001; Jordan = 26.93 ± 13.7 vs. 23.37 ± 15.2, p < 0.001; depression: Syria = 26.53 ± 12.6 vs. 22.93 ± 12.2, p < 0.001; Jordan = 17.70 ± 11.0 vs. 15.76 ± 11.1, p = 0.049). No significant improvements were evident for control group participants from either countries.

CONCLUSION

Prevalence of anxiety/depression for females with PCOS living in Syria and in Jordan is high and calls for special attention by healthcare specialists and policymakers in both countries. Females, who received the PCOS pharmaceutical care service, showed significant improvements in anxiety/depression scores. Improvements were similar in both countries.

Evaluation of the Association between Menstrual Cycle Irregularity and Dental Pain or Chewing Discomfort in Women before Menopause

This study was performed to assess the relationship between menstrual irregularity and dental pain or chewing discomfort in women before menopause, using nationally representative data. This study analyzed 4595 participants who were ≥19 years or older, and did not have missing values for outcome variables from the Korean National Health and Nutrition Examination Survey. Tooth pain was considered present if the participant felt throbbing discomfort, pain, or sensitivity when eating hot or cold food or drinking hot or cold beverages. Self-reported oral chewing discomfort was obtained. Adjusted odds ratios and their 95% confidence intervals for tooth pain in the individuals with menstrual cycle irregularity were 1.30 (1.05, 1.62) after adjustment for age, body mass index, drinking, smoking, income, exercise, stress, metabolic syndrome, and the frequency of tooth brushing. Adjusted odds ratios and their 95% confidence intervals for chewing discomfort in the individuals with menstrual cycle irregularity were 1.33 (1.03, 1.72) after adjustment. The association between menstrual irregularity and dental pain or chewing discomfort in women before menopause was proven—after adjusting for confounding factors—by multiple logistic regression analyses. Menstrual cycle irregularity may be considered a potential risk indicator for dental pain or chewing discomfort in Korean women before menopause.

Skeletal responses to an all-female unassisted Antarctic traverse

PURPOSE

To investigate the skeletal effects of the first all-female trans-Antarctic traverse.

METHODS

Six women (mean ± SD, age 32 ± 3 years, height 1.72 ± 0.07 m, body mass 72.8 ± 4.0 kg) hauled 80 kg sledges over 1700 km in 61 days from coast-to-coast across the Antarctic. Whole-body areal bone mineral density (aBMD) (dual-energy X-ray absorptiometry) and tibial volumetric BMD (vBMD), geometry, microarchitecture and estimated mechanical properties (high-resolution peripheral quantitative computed tomography) were assessed 39 days before (pre-expedition) and 15 days after the expedition (post-expedition). Serum and plasma markers of bone turnover were assessed pre-expedition, and 4 and 15 days after the expedition.

RESULTS

There were reductions in trunk (-2.6%), ribs (-5.0%) and spine (-3.4%) aBMD from pre- to post-expedition (all P ≤ 0.046); arms, legs, pelvis and total body aBMD were not different (all P ≥ 0.075). Tibial vBMD, geometry, microarchitecture and estimated mechanical properties at the metaphysis (4% site) and diaphysis (30% site) were not different between pre- and post-expedition (all P ≥ 0.082). Bone-specific alkaline phosphatase was higher 15 days post- than 4 days post-expedition (1.7 μg∙l^-1, P = 0.028). Total 25(OH)D decreased from pre- to 4 days post-expedition (-36 nmol∙l^-1, P = 0.008). Sclerostin, procollagen 1 N-terminal propeptide, C-telopeptide cross-links of type 1 collagen and adjusted calcium were unchanged (all P ≥ 0.154).

CONCLUSION

A decline in aBMD of the axial skeleton may be due to indirect and direct effects of prolonged energy deficit. We propose that weight-bearing exercise was protective against the effects of energy deficit on tibial vBMD, geometry, microarchitecture and strength.

Bone accrual in oligo-amenorrheic athletes, eumenorrheic athletes and non-athletes

BACKGROUND

Mechanical loading improves bone mineral density (BMD) and strength while decreasing fracture risk. Cross-sectional studies show that exercise advantage is lost in oligo-amenorrheic athletes (OA). Longitudinal studies examining the opposing effects of exercise and hypogonadism on bone are lacking in adolescents/young adults.

OBJECTIVE

Evaluate differences in bone accrual over 12 months in OA, eumenorrheic athletes (EA) and non-athletes (NA). We hypothesized that bone accrual would be lower in OA than EA and NA, with differences most pronounced at non-weight bearing trabecular sites.

METHODS

27 OA, 29 EA, and 22 NA, 14-25 years old, completed 12-months of the prospective study. Athletes were weight-bearing endurance athletes. Subjects were assessed for areal BMD and bone mineral content (BMC) using DXA at the femoral neck, total hip, lumbar spine and whole body (WB). Failure load (a strength estimate) at the distal radius and tibia was assessed using microfinite element analysis of data obtained via high resolution peripheral quantitative computed tomography (HRpQCT). The primary analysis was a comparison of changes in areal BMD, BMC, and failure load across groups over 12-months at the respective sites.

RESULTS

Groups did not differ for baseline age, height or BMI. Percent body fat was lower in both OA and EA compared to NA. OA attained menarche later than EA and NA. Over the follow-up period, OA gained 1.9 ± 2.7 kg of weight compared to 0.5 ± 2.4 kg and 0.8 ± 2.3 kg in EA and NA respectively (p = 0.09); 39% of OA resumed menses. Changes in BMD, BMD Z-scores, and tibial failure load over 12-months did not differ among groups. At follow up, EA had higher femoral neck, hip and WB BMD Z-scores than NA, and higher hip BMD Z-scores than OA (p < 0.05) after adjusting for covariates. At follow-up, radial failure load was lower in OA vs. NA, and tibial failure load lower in OA and NA vs. EA (p ≤ 0.04 for all). Change in weight and fat mass were associated with changes in BMD measures at multiple sites.

CONCLUSION

Despite weight gain and menses recovery in many OA during follow-up, residual deficits persist without catch-up raising concerns for suboptimal peak bone mass acquisition.

Risk and Protective Factors for Middle- and Long-Distance Running-Related Injury

BACKGROUND

Despite a rapidly growing body of research, a systematic evidence compilation of the risk and protective factors for middle- and long-distance running-related injury (RRI) was lacking.

OBJECTIVES

Our objective was to compile the evidence about modifiable and non-modifiable training-related and behavioral risk and protective factors for middle- and long-distance RRI.

METHODS

We searched five databases (PubMed, CINAHL, MEDLINE, SPORTDiscus, and PsycINFO) for the dates 1 January 1970 to 31 December 2015, inclusive, for original peer-reviewed articles. The eligible designs were cross-sectional, case-control, longitudinal observational studies, and randomized controlled trials involving runners competing at distances from ≥800 m to ≤42.2 km. Outcomes were any specific and/or general RRI, and exposures included training-related and behavioral factors. We extracted authors and date, study design, injury type(s), descriptors and comparators for each exposure, and results and measures of association from the selected studies. Methodological quality was independently appraised using two separate checklists: a modified checklist for observational study designs and the Physiotherapy Evidence Database (PEDro) scale for randomized controlled trials.

RESULTS

Among 73 articles eligible for inclusion, 19 (26.0%) and 30 (41.0%) were of high or satisfactory methodological quality, respectively. As a non-modifiable exposure, a history of previous injury was found to be associated with an increased risk of both general and specific RRI. In terms of modifiable exposures, irregular and/or absent menstruation was found to be associated with an increased risk of stress fracture development, whereas the use of oral contraceptives was found to be associated with a decreased risk. High clinical, methodological, and statistical heterogeneity meant it was not feasible to estimate a pooled effect size across similar studies.

CONCLUSIONS

A history of previous injury was associated with an increased risk of both general and specific RRI. The use of oral contraceptives was found to be associated with a decreased risk of skeletal stress fracture. Conversely, irregular and/or absent menstruation was associated with an increased risk. The varied effect directions and/or a number of statistically insignificant results associated with the majority of factors hindered our ability to draw any definitive conclusions about their relationship to RRI risk.

Bone mineral density in vocational and professional ballet dancers

According to existing literature, bone health in ballet dancers is controversial. We have verified that, compared to controls, young female and male vocational ballet dancers have lower bone mineral density (BMD) at both impact and non-impact sites, whereas female professional ballet dancers have lower BMD only at non-impact sites.

INTRODUCTION

The aims of this study were to (a) assess bone mineral density (BMD) in vocational (VBD) and professional (PBD) ballet dancers and (b) investigate its association with body mass (BM), fat mass (FM), lean mass (LM), maturation and menarche.

METHODS

The total of 152 VBD (13 ± 2.3 years; 112 girls, 40 boys) and 96 controls (14 ± 2.1 years; 56 girls, 40 boys) and 184 PBD (28 ± 8.5 years; 129 females, 55 males) and 160 controls (27 ± 9.5 years; 110 female, 50 males) were assessed at the lumbar spine (LS), femoral neck (FN), forearm and total body by dual-energy X-ray absorptiometry. Maturation and menarche were assessed via questionnaires.

RESULTS

VBD revealed lower unadjusted BMD at all anatomical sites compared to controls (p < 0.001); following adjustments for Tanner stage and gynaecological age, female VBD showed similar BMD values at impact sites. However, no factors were found to explain the lower adjusted BMD values in VBD (female and male) at the forearm (non-impact site), nor for the lower adjusted BMD values in male VBD at the FN. Compared to controls, female PBD showed higher unadjusted and adjusted BMD for potential associated factors at the FN (impact site) (p < 0.001) and lower adjusted at the forearm (p < 0.001). Male PBD did not reveal lower BMD than controls at any site.

CONCLUSIONS

Both females and males VBD have lower BMD at impact and non-impact sites compared to control, whereas this is only the case at non-impact site in female PBD. Maturation seems to explain the lower BMD at impact sites in female VBD.

Food Versus Pharmacy: Assessment of Nutritional and Pharmacological Strategies to Improve Bone Health in Energy-Deficient Exercising Women

PURPOSE OF REVIEW

The review aims to summarize our current knowledge surrounding treatment strategies aimed at recovery of bone mass in energy-deficient women suffering from the Female Athlete Triad.

RECENT FINDINGS

The independent and interactive contributions of energy status versus estrogen status on bone density, geometry, and strength have recently been reported, highlighting the importance of addressing both energy and estrogen in treatment strategies for bone health. This is supported by reports that have identified energy-related features (low body weight and BMI) and estrogen-related features (late age of menarche, oligo/amenorrhea) to be significant risk factors for low bone mineral density and bone stress injury in female athletes and exercising women. Nutritional therapy is the recommended first line of treatment to recover bone mass in energy-deficient female athletes and exercising women. If nutritional therapy fails after 12 months or if fractures or significant worsening in BMD occurs, pharmacological therapy may be considered in the form of transdermal estradiol with cyclic oral progestin (not COC).

Reduced energy availability: implications for bone health in physically active populations

Purpose

The present review critically evaluates existing literature on the effects of short- and long-term low energy availability (EA) on bone metabolism and health in physically active individuals.

Methods

We reviewed the literature on the short-term effects of low EA on markers of bone metabolism and the long-term effects of low EA on outcomes relating to bone health (bone mass, microarchitecture and strength, bone metabolic markers and stress fracture injury risk) in physically active individuals.

Results

Available evidence indicates that short-term low EA may increase markers of bone resorption and decrease markers of bone formation in physically active women. Bone metabolic marker responses to low EA are less well known in physically active men. Cross-sectional studies investigating the effects of long-term low EA suggest that physically active individuals who have low EA present with lower bone mass, altered bone metabolism (favouring bone resorption), reduced bone strength and increased risk for stress fracture injuries.

Conclusions

Reduced EA has a negative influence on bone in both the short- and long-term, and every effort should be made to reduce its occurrence in physically active individuals. Future interventions are needed to explore the effects of long-term reduced EA on bone health outcomes, while short-term low EA studies are also required to give insight into the pathophysiology of bone alterations.

Secular Trend in Thinness Prevalence for 26 Years (1989 - 2014) among High School Runners in Japan

Background

Female distance runners are predisposed to thinness for performance reasons and at greater risk for health-related consequences than the general population.

Objectives

The aim of the study was to evaluate the secular trends in thinness among competitive distance runners in Japanese high schools with sex-specific comparison.

Methods

Body mass index (BMI) were analysed in 9,881 female and 12,786 male runners participating in the annual national road relay races between 1989 and 2014 using the directory of a track and field magazine. The age-specific trends of these variables and the prevalence of thinness were tested by linear and logistic regression, respectively.

Results

Although BMI declined significantly among both male and female runners (coefficients: boys, -0.033, -0.030, and -0.032; girls, -0.033, -0.034, and -0.034 [all P < 0.001] in 15.5-, 16.5-, and 17.5-year-olds, respectively), the prevalence of severely thin runners significantly increased only among girls (odds ratios for the yearly change = 1.05 and 1.06 [both P < 0.01] for 16.5- and 17.5-year-olds, respectively). Only 0.13% of male runners were regarded as severely thin throughout the study period.

Conclusions

The results suggested that severely thin girl runners has steadily increased. Surveys on the health consequences of extreme thinness are necessary for the female adolescent runners.

The Female Athlete Triad

The number of girls participating in sports has increased significantly since the introduction of Title XI in 1972. As a result, more girls have been able to experience the social, educational, and health-related benefits of sports participation. However, there are risks associated with sports participation, including the female athlete triad. The triad was originally recognized as the interrelationship of amenorrhea, osteoporosis, and disordered eating, but our understanding has evolved to recognize that each of the components of the triad exists on a spectrum from optimal health to disease. The triad occurs when energy intake does not adequately compensate for exercise-related energy expenditure, leading to adverse effects on reproductive, bone, and cardiovascular health. Athletes can present with a single component or any combination of the components. The triad can have a more significant effect on the health of adolescent athletes than on adults because adolescence is a critical time for bone mass accumulation. This report outlines the current state of knowledge on the epidemiology, diagnosis, and treatment of the triad conditions.

Anticipatory Guidance for Long-Distance Running in Young Athletes

More young children are participating in endurance running events such as full and half marathons, and the safety of these events for children has been heavily debated. There is a paucity of evidence on either side of the debate. However, overuse injuries, stress fractures, as well as the potential for psychologic burnout are legitimate concerns. Parents who are seeking advice from pediatricians about child participation in these endurance events should be made aware of these risks. Young children may participate in endurance running events under close supervision from health professionals, coaches, and parents, with full medical evaluation before initiation of training, throughout training, as well as 6 to 12 months post-race. Special attention should be made to the psychologic well-being of the child, with the participation in running being child-driven, not parent- or coach-driven, and emphasis on enjoyment and fitness, not competition.

Eating disorders, menstrual dysfunction, weight change and DMPA use predict bone density change in college-aged women

INTRODUCTION

There are limited longitudinal studies that have evaluated bone mineral density (BMD) changes in college-aged women. Our objective was to simultaneously evaluate factors influencing 4-year BMD change.

METHODS

This was a longitudinal cohort study of healthy, physically active women in the US Military Academy (n=91; average age=18.4years). Assessments over four years included: height, weight, calcium intake, physical fitness, menstrual function (annual number cycles), oral contraceptives (OCs) or depot-medroxyprogesterone acetate (DMPA) use, and eating disorder behavior (Eating Disorder Inventory; (EDI)). BMD was measured annually at the lumbar spine and total hip by dual X-ray absorptiometry and calcaneal BMD by PIXI. Slope of 4year BMD change at each skeletal site (spine total hip and calcaneus) was calculated for each woman.

RESULTS

BMD gains occurred at the spine in 50% and the hip in 36% of women. In unadjusted analyses, spine bone gain was positively related to menstrual cycle frequency (p=0.04). Spine and hip BMD loss occurred in those using DMPA (p<0.01) and those with the highest EDI quartile scores (p<0.05). BMD change was unrelated to OC use. Hip and calcaneus BMD decreased with weight loss (average 4.8+2.2lb/year) as compared to those with stable weight/weight gain (p<0.05). In multivariable analysis, spine BMD increase was significantly related to African American (AA) race, normal EDI score and normal menses. Hip BMD increase was related to AA race, weight increase and normal menses. DMPA use was associated with spine, hip, and calcaneus bone loss.

CONCLUSION

On average, BMD may modestly increase in college-aged women, in the absence of risk factors. However, risk factors including subclinical eating disorders, weight loss, menstrual dysfunction and DMPA use can have significant detrimental effects on BMD in young healthy physically active women.

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.

Are Elite Female Soccer Athletes at Risk for Disordered Eating Attitudes, Menstrual Dysfunction, and Stress Fractures?

OBJECTIVE

To determine the prevalence of stress fractures, menstrual dysfunction and disordered eating attitudes in elite female soccer athletes.

DESIGN

Cross-sectional descriptive study.

SETTING

Female soccer athletes were recruited from a national level youth soccer club, an NCAA Division I university team, and a women's professional team.

PARTICIPANTS

Two hundred twenty female soccer athletes with a mean age of 16.4 ± 4 years and BMI of 20.8 ± 2 kg/m(2) completed the study, representing all athletes from the included teams.

METHODS

One-time surveys completed by the athletes.

MAIN OUTCOME MEASUREMENTS

Height and weight were recorded, and body mass index (BMI) was calculated for each athlete. Athletes reported age of menarche, history of missing 3 or more menses within a 12-month period and stress fracture. The Eating Attitudes Test (EAT-26) was used to assess the athlete's body perception and attitudes toward eating.

RESULTS

Of the 220 soccer athletes, 3 athletes (1.6%) had a low BMI for their age, and 19 (8.6%) reported stress fractures of the lower extremity. Among athletes who had reached menarche, the average onset was 13 + 1 year; menstrual dysfunction were present in 21 (19.3%). On the EAT-26, 1 player scored in the high risk range (>20) and 17 (7.7%) scored in the intermediate risk range (10-19) for eating disorders. Athletes with an EAT-26 score ≥ 10 points had a significantly higher prevalence of menstrual dysfunction in the past year compared to athletes with an EAT-26 score of less than 10 (P = .02).

CONCLUSIONS

Elite female soccer athletes are susceptible to stress fractures and menstrual dysfunction and have delayed onset of menarche despite normal BMI and appropriate body perception and attitudes towards eating. Further studies are needed to better understand stress fracture risk in female soccer athletes and in other team sports to determine how these findings relate to long-term bone health in this population.

Body fat in children and adolescents participating in organized sports: Descriptive epidemiological study of 6048 Latvian athletes

BACKGROUND

Pressure among young athletes to meet body composition goals may lead to poor nutrition and affect growth.

AIMS

To examine the proportion of body fat (%BF), measured by bioimpedance analysis, among Latvian children and adolescents participating in organized sports.

METHODS

Our study had a nationally representative sample of 6048 young athletes, aged 10-17 years. Their %BF was measured using a multifrequency, 8-pole, bioelectrical impedance leg-to-hand analyzer.

RESULTS

About 19.2% (CI 14.4-20.0) of boys and 15.1% (CI 14.0-16.3) of girls had a %BF value below the recommended levels. The %BF in young female athletes participating in aesthetic sports was lower than among their peers participating in other sports. Young male athletes participating in aesthetic sports had lower %BF levels at 10 and 12 years of age, compared with participants in weight-class sports; and lower levels of %BF from age 10-14 years, compared with participants in non-weight-sensitive sports.

CONCLUSIONS

Almost every fifth child and adolescent participating in organized sports displayed critically low body fat levels. Body fat needs to be assessed regularly in young athletes, to prevent negative consequences on health.

Risk Factors for Eating Disorders among Male Adolescent Athletes

OBJECTIVE

Eating disorders (ED) are an important and increasing problem in adolescents. The objective of this study was to examine the risk factors and the prevalence of risk for ED among male adolescent elite athletes and nonathletic controls. Differences between male athletes competing in aerobic, anaerobic and aerobic-anaerobic sports were examined as well.

METHODS

This was a cross-sectional epidemiological study. A cross-sectional questionnaire survey and anthropometric measurements were conducted on 351 adolescents (athletes n = 228; controls n = 123). All participants were aged 15-17 at the time of measuring. Risk for ED was determined using a SCOFF questionnaire.

RESULTS

The overall prevalence of the risk for ED in male adolescents was 24.8%, with no significant differences among athletes and controls or different subgroups of athletes (p>0.05), although the highest prevalence (37.2%) was registered in aerobic subgroup of athletes. Higher number of attempts to lose weight was associated with increased risk of ED in each group (athletes and controls). Other predictors referred to lack of breakfast and body composition in aerobic subgroup of athletes and number of meals and training frequency in anaerobic subgroup. The most common reasons for dieting were improvement of sport results (19.6-44.2%) and better self-esteem (41.5%) in athletes and controls respectively.

CONCLUSIONS

Participation in the competitive sport itself is not associated with the increased risk for ED. It seems that risk factors for ED for adolescent athletes competing in aerobic and anaerobic sports represent a subject that deserves consideration and further investigation in the future.