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Joan E. Benson, Kathryn A. Engelbert-Fenton and Patricia A. Eisenman

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

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Aurelia Nattiv, Rosemary Agostini, Kimberly K. Yeager and Barbara Drinkwater

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Kirsty J. Elliott-Sale, Adam S. Tenforde, Allyson L. Parziale, Bryan Holtzman and Kathryn E. Ackerman

: 25397605 doi:10.1249/MSS.0000000000000574 10.1249/MSS.0000000000000574 Ackerman , K.E. , & Misra , M. ( 2011 ). Bone health and the female athlete triad in adolescent athletes . Physician and Sportsmedicine, 39 ( 1 ), 131 – 141 . PubMed ID: 21378496 doi:10.3810/psm.2011.02.1871 10.3810/psm.2011

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Karen S. Hostetter and Jan L. Drummond

Edited by Joe J. Piccininni

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W. Craig Stevens, Rebecca A. Brey, Jeffrey E. Harris and Sandra Fowkes-Godek

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Jason D. Vescovi and Jaci L. VanHeest

This observational case study examined the association of inter- and intraday energy intake and exercise energy expenditure with bone health, menstrual status and hematological factors in a female triathlete. The study spanned 7 months whereby energy intake and exercise energy expenditure were monitored three times (13 d); 16 blood samples were taken, urinary hormones were assessed for 3 months, and bone mineral density was measured twice. Energy availability tended to be sustained below 30 kcal/kg FFM/d and intraday energy intake patterns were often “back-loaded” with approximately 46% of energy consumed after 6 p.m. Most triiodothyronine values were low (1.1–1.2nmol/L) and supportive of reduced energy availability. The athlete had suppressed estradiol (105.1 ± 71.7pmol/L) and progesterone (1.79 ±1.19nmol/L) concentrations as well as urinary sex-steroid metabolites during the entire monitoring period. Lumbar spine (L1-L4) bone mineral density was low (age-matched Z-score −1.4 to −1.5). Despite these health related maladies the athlete was able to perform typical weekly training loads (swim: 30–40 km, bike: 120–300 km, run 45–70 km) and was competitive as indicated by her continued improvement in ITU World Ranking during and beyond the assessment period. There is a delicate balance between health and performance that can become blurred especially for endurance athletes. Education (athletes, coaches, parents) and continued monitoring of specific indicators will enable evidence-based recommendations to be provided and help reduced the risk of health related issues while maximizing performance gains. Future research needs to longitudinally examine how performance on standardized tests in each discipline (e.g., 800-m swim, 20-km time trial, 5-km run) is impacted when aspects of the female athlete triad are present.

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Petter Fagerberg

, M.J. , Williams , N.I. , Nattiv , A. , Joy , E. , Misra , M. , Loucks , A.B. , … McComb , J. ( 2014 ). Misunderstanding the female athlete triad: Refuting the IOC consensus statement on relative energy deficiency in sport (RED-S) . British Journal of Sports Medicine, 48 ( 20

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Margo Mountjoy, Jorunn Sundgot-Borgen, Louise Burke, Kathryn E. Ackerman, Cheri Blauwet, Naama Constantini, Constance Lebrun, Bronwen Lundy, Anna Melin, Nanna Meyer, Roberta Sherman, Adam S. Tenforde, Monica Klungland Torstveit and Richard Budgett

In 2014, the International Olympic Committee (IOC) published a consensus statement entitled “Beyond the Female Athlete Triad: Relative Energy Deficiency in Sport (RED-S)”. The syndrome of RED-S refers to: “impaired physiological functioning caused by relative energy deficiency, and includes but is