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Sherry Robertson and Margo Mountjoy

physiological function, including metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular function, and psychological health ( Mountjoy et al., 2014 ). The “Female Athlete Triad” is defined as a medical condition observed in athletic girls and women, comprising three

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Ida A. Heikura, Arja L.T. Uusitalo, Trent Stellingwerff, Dan Bergland, Antti A. Mero and Louise M. Burke

 al., 2015 ) endurance athletes and is emerging as one of the most significant factors associated with athlete illness/injury ( Tenforde et al., 2017 ). Original recognition of this syndrome in females, the Female Athlete Triad (Triad), identified the interrelatedness of low EA, menstrual dysfunction, and

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Louise M. Burke, Graeme L. Close, Bronwen Lundy, Martin Mooses, James P. Morton and Adam S. Tenforde

criticism of the elevation of these scenarios to the same level of concern or management as afforded the Female Athlete Triad ( De Souza et al., 2014 ). This was based on considerations of both the relative recentness of the investigations among male athletes and suggestions that physiological

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Jeanne F. Nichols, Mitchell J. Rauh, Michelle T. Barrack, Hava-Shoshana Barkai and Yael Pernick

The authors’ purpose was to determine the prevalence and compare associations of disordered eating (DE) and menstrual irregularity (MI) among high school athletes. The Eating Disorder Examination Questionnaire (EDE-Q) and a menstrual-history questionnaire were administered to 423 athletes (15.7 ± 1.2 y, 61.2 ± 10.2 kg) categorized as lean build (LB; n = 146) or nonlean build (NLB; n = 277). Among all athletes, 20.0% met the criteria for DE and 20.1% for MI. Although the prevalence of MI was higher in LB (26.7%) than NLB (16.6%) athletes (P = 0.01), no differences were found for DE. For both sport types, oligo/amenorrheic athletes consistently reported higher EDE-Q scores than eumenorrheic athletes (P < 0.05). Athletes with DE were over 2 times as likely (OR = 2.3, 95%CI: 1.3, 4.2) to report oligo/amenorrhea than athletes without DE. These data establish an association between DE and MI among high school athletes and indicate that LB athletes have more MI but not DE than NLB athletes.

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Nanci S. Guest and Susan I. Barr

High levels of cognitive dietary restraint (CDR) have been associated with subclinical menstrual cycle irregularities and increased cortisol levels, both of which can affect bone mineral density (BMD). Low BMD has been implicated in stress fracture risk. We assessed CDR in female runners (≥ 20 km/wk) with a recent stress fracture (SF) and with no stress fracture history (NSF). A sample of 79 runners (n = 38 SF, 29 ± 5 y; n = 41 NSF, 29 ± 6 y) completed a 3-d food record and questionnaire assessing physical activity, menstrual cycle history, and perceived stress. SF and NSF runners had similar body mass index (21.2 ± 1.8 vs. 22.0 ± 2.5 kg/m2), physical activity (35.7 ± 13.5 vs. 33.4 ± 1.34 km/wk), perceived stress, and dietary intakes. CDR, however, was higher in SF runners (11.0 ± 5.4 vs. 8.4 ± 4.3, P < 0.05). Subclinical menstrual cycle disturbances and increased cortisol levels that are associated with high CDR, might in turn contribute to lowered BMD and increased stress fracture risk.

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Julie C. Arends, Min-Yuen C. Cheung, Michelle T. Barrack and Aurelia Nattiv

Background:

Functional hypothalamic amenorrhea is common among female athletes and may be difficult to treat. Restoration of menses (ROM) is crucial to prevent deleterious effects to skeletal and reproductive health.

Objectives:

To determine the natural history of menstrual disturbances in female college athletes managed with nonpharmacologic therapies including increased dietary intake and/or decreased exercise expenditure and to identify factors associated with ROM.

Study Design:

A 5-yr retrospective study of college athletes at a major Division I university.

Methods:

373 female athletes’ charts were reviewed. For athletes with menstrual disturbances, morphometric variables were noted. Months to ROM were recorded for each athlete.

Results:

Fifty-one female athletes (19.7%) had menstrual disturbances (14.7% oligomenorrheic, 5.0% amenorrheic). In all, 17.6% of oligo-/amenorrheic athletes experienced ROM with nonpharmacologic therapy. Mean time to ROM among all athletes with menstrual disturbances was 15.6 ± 2.6 mo. Total absolute (5.3 ± 1.1 kg vs. 1.3 ± 1.1 kg, p < .05) and percentage (9.3% ± 1.9% vs. 2.3% ± 1.9%, p < .05) weight gain and increase in body-mass index (BMI; 1.9 ± 0.4 kg/m2 vs. 0.5 ± 0.4 kg/m2, p < .05) emerged as the primary differentiating characteristics between athletes with ROM and those without ROM. Percent weight gain was identified as a significant positive predictor of ROM, OR (95% CI) = 1.25 (1.01, 1.56), p < .05.

Conclusions:

Nonpharmacologic intervention in college athletes with menstrual disturbances can restore regular menstrual cycles, although ROM may take more than 1 yr. Weight gain or an increase in BMI may be important predictors of ROM.

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Dan Benardot

Athletes are influenced by coaches, other athletes, media, parents, the national sport governing body, members of the sports medicine team, and the athlete's own desire for success. It is impossible, therefore, for one member of the sports medicine team to unilaterally determine workable solutions that enhance performance and diminish health problems in an athlete. A focus on ensuring that the athlete can perform to the best of her ability is a key to encouraging discussion between the nutritionist, athlete, and coach. Using the assumption that health and top athletic performance are compatible, this focus on performance provides a discussion point that all parties can agree to and, if approached properly, also fulfills the nutritionist's goal of achieving optimal nutritional status. Membership on the sports medicine team mandates that the nutritionist know the paradigms and health risks associated with the sport and develop assessment and feedback procedures specific to the athlete's needs.

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Jenna C. Gibbs, Nancy I. Williams, Jennifer L. Scheid, Rebecca J. Toombs and Mary Jane De Souza

A high drive-for-thinness (DT) score obtained from the Eating Disorder Inventory-2 is associated with surrogate markers of energy deficiency in exercising women. The purposes of this study were to confirm the association between DT and energy deficiency in a larger population of exercising women that was previously published and to compare the distribution of menstrual status in exercising women when categorized as high vs. normal DT. A high DT was defined as a score ≥7, corresponding to the 75th percentile for college-age women. Exercising women age 22.9 ± 4.3 yr with a BMI of 21.2±2.2 kg/m2 were retrospectively grouped as high DT (n = 27) or normal DT (n = 90) to compare psychometric, energetic, and reproductive characteristics. Chi-square analyses were performed to compare the distribution of menstrual disturbances between groups. Measures of resting energy expenditure (REE) (4,949 ± 494 kJ/day vs. 5,406 ± 560 kJ/day, p < .001) and adjusted REE (123 ± 16 kJ/LBM vs. 130 ± 9 kJ/LBM, p = .027) were suppressed in exercising women with high DT vs. normal DT, respectively. Ratio of measured REE to predicted REE (pREE) in the high-DT group was 0.85 ± 0.10, meeting the authors’ operational definition for an energy deficiency (REE:pREE <0.90). A greater prevalence of severe menstrual disturbances such as amenorrhea and oligomenorrhea was observed in the high-DT group (χ2 = 9.3, p = .003) than in the normal-DT group. The current study confirms the association between a high DT score and energy deficiency in exercising women and demonstrates a greater prevalence of severe menstrual disturbances in exercising women with high DT.

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Laurie Stickler, Trisha Armstrong, Alyssa Polso and Melissa Smith

Context:

Low energy availability has been identified through research as the cornerstone of the female athlete triad, yet reasons for nutritional choices among female collegiate athletes are poorly understood.

Objective:

To explore the perspectives of female collegiate cross country runners on eating behaviors and attitudes toward health.

Design:

Phenomenologic qualitative study with individual, semistructured interviews.

Methods:

Ten collegiate female cross country runners, ages 18–22, participated in the study. All interviews were audiotaped then transcribed. Three researchers independently coded data and developed themes and subthemes before meeting and negotiating findings.

Results:

The following four themes were identified: health behaviors, nutritional knowledge, internal and external factors, and health attitudes.

Conclusions:

This study contributes to understanding “the why” behind health behaviors of female collegiate cross country runners. This developmental understanding may assist in interpreting the behavioral causes of low energy availability; thus, both management and prevention of the triad may be aided by this information.

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Anna Melin, Monica Klungland Torstveit, Louise Burke, Saul Marks and Jorunn Sundgot-Borgen

Disordered eating behavior (DE) and eating disorders (EDs) are of great concern because of their associations with physical and mental health risks and, in the case of athletes, impaired performance. The syndrome originally known as the Female Athlete Triad, which focused on the interaction of energy availability, reproductive function, and bone health in female athletes, has recently been expanded to recognize that Relative Energy Deficiency in Sport (RED-S) has a broader range of negative effects on body systems with functional impairments in both male and female athletes. Athletes in leanness-demanding sports have an increased risk for RED-S and for developing EDs/DE. Special risk factors in aquatic sports related to weight and body composition management include the wearing of skimpy and tight-fitting bathing suits, and in the case of diving and synchronized swimming, the involvement of subjective judgments of performance. The reported prevalence of DE and EDs in athletic populations, including athletes from aquatic sports, ranges from 18 to 45% in female athletes and from 0 to 28% in male athletes. To prevent EDs, aquatic athletes should practice healthy eating behavior at all periods of development pathway, and coaches and members of the athletes’ health care team should be able to recognize early symptoms indicating risk for energy deficiency, DE, and EDs. Coaches and leaders must accept that DE/EDs can be a problem in aquatic disciplines and that openness regarding this challenge is important.