Aurelia Nattiv

Lifestyles and health risks of collegiate athletes: a multi-center study.

ObjectiveTo determine whether college athletes are at greater risk for maladaptive lifestyle and health-risk behaviors than their nonathletic peers and to identify high risk taking groups by gender, sport, and other identifiers. DesignMulticenter, cross-sectional study. SettingSeven major geographically represented collegiate institutions in the United States. ParticipantsA total of 2,298 college athletes and 683 randomized nonathlete controls completed a confidential survey questionnaire between the summer of 1993 and winter of 1994, assessing lifestyle and health-risk behaviors over the previous 12 months. Main outcome measuresSelf-reports of lifestyle behaviors and health risks in the following areas: motor-vehicle safety, substance abuse, sexually transmitted diseases and contraception, mental health, cancer prevention, nutrition, exercise and general preventive health issues. ResultsAthletes demonstrated significantly higher risk-taking behaviors (p < 0.05) than their nonathlete peers in the following areas: less likely always to use seatbelts; less likely always to use helmets with motorcycles, mopeds, and bicycles; more often drive as a passenger with a driver under the influence of alcohol or drugs; greater quantity and frequency of alcoholic beverages; greater frequency of smokeless tobacco and anabolic steroid use; less-safe sex; greater number of sexual partners; less contraceptive use; and more involvement in physical fights. Female athletes reported a higher prevalence of irregular menses, amenorrhea, and stress fractures compared with female nonathletes. Male athletes had more risk-taking behaviors than did female athletes (p < 0.05), and athletes in contact sports demonstrated more risk-taking behaviors than did athletes in noncontact sports (p < 0.05). Athletes with one risk-taking behavior were likely to have multiple risk-taking behaviors (p < 0.05). ConclusionsCollege athletes appear to be at higher risk than their nonathletic peers for certain maladaptive lifestyle behaviors. Athlete subgroups at highest risk include male athletes and athletes participating in contact sports. Athletes at risk for one high-risk behavior demonstrated an increased risk for multiple risk-taking behaviors. Preventive health interventions deserve further study to determine strategies for risk reduction in high-risk groups.

2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction and (3) low bone mineral density. Female athletes often present with one or more of the three Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhoea and osteoporosis. This consensus statement represents a set of recommendations developed following the 1st (San Francisco, California, USA) and 2nd (Indianapolis, Indiana, USA) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers and other healthcare providers for the screening, diagnosis and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team and implementation of treatment contracts. This consensus paper has been endorsed by the Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians and other healthcare professionals, the American College of Sports Medicine and the American Medical Society for Sports Medicine.

Stress fractures and bone health in track and field athletes.

The effect of exercise on bone health has received much attention in recent years. The problems of the female athlete triad: disordered eating, amenorrhea and osteoporosis have helped us to better understand and appreciate the important interaction of mechanical, hormonal, nutritional as well as genetic factors on bone health in the young female athlete. The relatively high stress fracture incidence of young track and field athletes can be quite disabling for the athletes present and future running career. A number of risk factors including low bone mineral density (BMD), menstrual irregularities, dietary factors and prior history of stress fractures have been associated with an increased risk for stress fractures in the female athlete. Few studies have found risk factors for stress fractures in the male athlete. Female gender has been found to be a risk factor for stress fractures in the military population, but this finding is less apparent in athlete studies. Caucasians have been found to have a higher risk for stress fractures than African-American military recruits, but there is very limited data assessing stress fracture risk in athletes of varying ethnicity. Prevention of stress injury to bone involves maximizing peak bone mass in the pediatric and young adult age groups. Maintaining adequate calcium nutrition, caloric intake as well as hormonal and energy balance are important preventive measures, as are ensuring appropriate amounts of weight bearing exercise for optimizing bone health and preventing fractures. More research is needed to determine factors leading to improvements in bone density and fracture reduction in athletes at risk.

Correlation of MRI Grading of Bone Stress Injuries With Clinical Risk Factors and Return to Play A 5-Year Prospective Study in Collegiate Track and Field Athletes

Background: Bone stress injuries are common in track and field athletes. Knowledge of risk factors and correlation of these to magnetic resonance imaging (MRI) grading could be helpful in determining recovery time. Purpose: To examine the relationships between MRI grading of bone stress injuries with clinical risk factors and time to return to sport in collegiate track and field athletes. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: A total of 211 male and female collegiate track and field and cross-country athletes were followed prospectively through their competitive seasons. All athletes had preparticipation history, physical examination, and anthropometric measurements obtained annually. An additional questionnaire was completed regarding nutritional behaviors, menstrual patterns, and prior injuries, as well as a 3-day diet record. Dual-energy X-ray absorptiometry was performed at baseline and each year of participation in the study. Athletes with clinical evidence of bone stress injuries had plain radiographs. If radiograph findings were negative, MRI was performed. Bone stress injuries were evaluated by 2 independent radiologists utilizing an MRI grading system. The MRI grading and risk factors were evaluated to identify predictors of time to return to sport. Results: Thirty-four of the athletes (12 men, 22 women) sustained 61 bone stress injuries during the 5-year study period. The mean prospective assessment for participants was 2.7 years. In the multiple regression model, MRI grade and total-body bone mineral density (BMD) emerged as significant and independent predictors of time to return to sport. Specifically, the higher the MRI grade (P = .004) and lower the BMD (P = .030), the longer the recovery time. Location of the bone injury at predominantly trabecular sites of the femoral neck, pubic bone, and sacrum was also associated with a prolonged time to return to sport. Female athletes with oligomenorrhea and amenorrhea had bone stress injuries of higher MRI grades compared with eumenorrheic athletes (P = .009). Conclusion: Higher MRI grade, lower BMD, and skeletal sites of predominant trabecular bone structures were associated with a delayed recovery of bone stress injuries in track and field athletes. Knowledge of these risk factors, as well as nutritional and menstrual factors, can be clinically useful in determining injury severity and time to return to sport.

2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad.

The female athlete triad is a medical condition often observed in physically active girls and women and involves three components: 1) low energy availability with or without disordered eating, 2) menstrual dysfunction, and 3) low bone mineral density. Female athletes often present with one or more of the three triad components, and early intervention is essential to prevent its progression to serious end points that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement presents a set of recommendations developed following the first (San Francisco, CA) and second (Indianapolis, IN) International Symposia on the Female Athlete Triad. This consensus statement was intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the female athlete triad and to provide clear recommendations for return to play. The expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts.

Higher Incidence of Bone Stress Injuries With Increasing Female Athlete Triad–Related Risk Factors: A Prospective Multisite Study of Exercising Girls and Women

Background: Identifying the risk factors associated with a bone stress injury (BSI), including stress reactions and stress fractures, may aid in targeting those at increased risk and in formulating prevention guidelines for exercising girls and women. Purpose: To evaluate the effect of single or combined risk factors as defined by the female athlete triad—a syndrome involving 3 interrelated spectrums consisting of energy availability, menstrual function, and bone mass—with the incidence of BSIs in a multicenter prospective sample of 4 cohorts of physically active girls and women. Study Design: Cohort study; Level of evidence, 3. Methods: At baseline, participants’ (N = 259; mean age, 18.1 ± 0.3 years) anthropometric characteristics, eating attitudes and behaviors, menstrual function, sports participation or exercise activity, and pathological weight control behaviors were assessed. Dual-energy x-ray absorptiometry (DXA) measured the bone mass of the whole body, total hip, femoral neck, lumbar spine, and body composition. Participants were followed prospectively for the occurrence of injuries; those injuries confirmed by a physician were recorded. Results: Twenty-eight participants (10.8%) incurred a BSI. Forty-six percent of those who had ≥12 h/wk of purposeful exercise, a bone mineral density (BMD) Z score <–1.0, and who exhibited 3 to 4 of the following: BMI <21.0 kg/m2, oligo- or amenorrhea, elevated dietary restraint, and/or participation in a leanness sport exercise/activity at baseline, incurred a BSI during the prospective study period. Single factors significantly (P < .05) associated with the development of a BSI included ≥12 h/wk of purposeful exercise (14.7%), BMI <21.0 kg/m2 (15.3%), and low bone mass (BMD Z score <–1.0; 21.0%). The strongest 2- and 3-variable combined risk factors were low BMD (Z score <–1.0) + ≥12 h/wk of exercise, with 29.7% incurring a BSI (odds ratio [OR], 5.1; 95% CI, 2.2-12.1), and ≥12 h/wk of exercise + leanness sport/activity + dietary restraint, with 46.2% incurring a BSI (OR, 8.7; 95% CI, 2.7-28.3). Conclusion: In the sample, which included female adolescents and young adults participating in competitive or recreational exercise activities, the risk of BSIs increased from approximately 15% to 20% for significant single risk factors to 30% to 50% for significant combined female athlete triad–related risk factor variables. These data support the notion that the cumulative risk for BSIs increases as the number of Triad-related risk factors accumulates.

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

Abstract:The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves 3 components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with 1 or more of the 3 Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement represents a set of recommendations developed following the first (San Francisco, California) and second (Indianapolis, Indianna) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad Expert Panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts. This consensus paper has been endorsed by The Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians, and other health care professionals, the American College of Sports Medicine, the American Medical Society for Sports Medicine, and the American Bone Health Alliance.

Risk factors for fractures in older men and women: The Leisure World Cohort Study.

BACKGROUND Osteoporosis results in >1.5 million fractures in the United States each year, leading to substantial health care costs and loss of quality of life. One major gap in our knowledge is how to effectively identify individuals at risk of developing a fracture. OBJECTIVE We examined a population-based cohort for risk factors for fractures of the hip, wrist, and spine in men and women. METHODS The Leisure World Cohort Study was established between 1981 and 1985 when residents of a southern California retirement community completed a postal health survey. Multiple lifestyle, medical, attitudinal, and anthropomorphic factors were self-reported. Fractures were identified from 4 follow-up surveys, hospital discharge records, and death certificates. Fracture rates were determined separately for men and women. Cox proportional hazards regression was used to identify predictors of fracture. RESULTS Incident fractures of the hip (n = 1,227), wrist (n = 445), and spine (n = 729) incurred over the course of 2 decades were identified in the 13,978 residents surveyed. Mean (SD) age at entry was 74.9 (7.2) years for men and 73.7 (7.4) years for women. The most important risk factors for fracture were the same in men and women: age increased risk of hip and spine fractures (hazard ratio [HR] = 2.3-3.2 per 10 years) and history of fracture increased fracture risk at all 3 sites (HR = 1.4-3.2). In both men and women, glaucoma was a significant risk factor for hip fracture (HR = 1.9 and 1.3, respectively), and smoking was a risk factor for hip and spine fractures. Men and women with a positive mental attitude had fewer hip and spine fractures (HR = 0.7-0.9). High body mass index was protective at all 3 fracture sites in women (HR = 0.7-0.8), but those who used vitamin A supplements had increased rates of hip and wrist fracture (HR = 1.1 per 10,000 IU per day). CONCLUSIONS Attitude, lifestyle choices, and the presence of medical conditions may influence the rate of osteoporotic fracture in older women and men and may help identify individuals at high risk.

2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management.

Eating disorders, such as anorexia nervosa and bulimia nervosa, can have devastating effects on both the health and performance of athletes. Compared to non-athletes, both female and male athletes are at higher risk of developing an eating disorder. This is especially true for athletes participating in sports where low body weight or leanness confers a competitive advantage. Screening for disordered eating behaviours, eating disorders and for related health consequences should be a standard component of preparticipation examinations, and team physicians should be knowledgeable of the updated diagnostic criteria for eating disorders in the Diagnostic and Statistical Manual-V. Athletes with eating disorders should undergo thorough evaluation and treatment by an experienced multidisciplinary team. Team physicians play a critical role in decision-making on clearance for participation and return to play. Using evidence-based guidelines for clearance and return to play encourages transparency and accountability between the sports medicine care team and the athlete. Efforts to prevent eating disorders should be aimed at athletes, coaches, parents and athletic administrators, and focused on expanding knowledge of healthy nutrition in support of sport performance and health.

Low bone density risk is higher in exercising women with multiple triad risk factors.

UNLABELLED The cumulative effect of the female athlete triad (Triad) risk factors on the likelihood of low bone mineral density (BMD) in exercising women is unclear. PURPOSE This study aimed to determine the risk of low BMD in exercising women with multiple Triad risk factors. METHODS We retrospectively examined cross-sectional data from 437 exercising women (mean ± SD age of 18.0 ± 3.5 yr, weighed 57.5 ± 7.1 kg with 24.5% ± 6.1% body fat) obtained at baseline from 4 prospective cohort studies examining Triad risk factors. Questionnaires were completed to obtain information on demographic characteristics, self-reported eating attitudes/behaviors, menstrual function, sport/activity participation, and medication use. Height and body weight were measured. BMD was measured using dual energy x-ray absorptiometry. Low BMD was defined as z-scores of <-1 and ≤-2. Chi-square tests were performed to determine the percentage of women with low BMD who met the criteria for individual (current oligo/amenorrhea, late menarche, low body mass index (BMI), elevated dietary restraint, lean sport/activity participation) or multiple (2, 3, 4, or 5) Triad risk factors. RESULTS Late menarche and low BMI were associated with the highest percentage of low BMD (z-score < -1), 55% and 54%, respectively, and low BMD (z-score ≤-2), 14% and 16%, respectively. The percentage of participants with low BMD (z-score < -1 and ≤-2) increased from 10% to 62% and from 2% to 18%, respectively, as women met the criteria for an increasing number of Triad risk factors. CONCLUSIONS A cumulative number of Triad risk factors were associated with an increased risk of low BMD, suggesting a dose-response association between the number of Triad risk factors and BMD in exercising women. Further research should be conducted to develop a user-friendly algorithm integrating these indicators of risk for low BMD in exercising women (particularly factors associated with low BMI/body weight, menstrual dysfunction, lean sport/activity participation, and elevated dietary restraint).