Athlete bone health education -
Let's talk about bone health. We know that we can build bone density until about age After that we can only work to maintain what we've got. If young female athletes are losing bone density, it can never be replaced. We also know that female athletes suffer from two to three times the number of stress fractures compared to male athletes.
And women athletes with missed menstrual cycles which can happen when activity outpaces calories consumed have two to four times the risk of stress fractures compared to women with normal monthly menstrual cycles. A stress fracture occurs when the bone is subject to more stress or impact than it can handle.
This may simply be due to overtraining, or increasing training too quickly without giving the bones adequate time to adapt. Stress fractures can also be due to a lower bone mineral density, which means it takes less force to cause damage.
This often is the result of the female athlete triad — a direct result of not eating enough, or not eating enough of the right foods. If we can educate our youth on the importance of maintaining a healthy diet and supplying their active bodies with the energy they need, then we can prevent many of these injuries and maybe even reduce the chances that a woman develops osteoporosis later in life.
We know exercise is important. We know that a healthy weight is important. But what may not get enough attention is the fact that eating healthy calories to replenish and fuel the body is vital to athletes' health, in particular for strong and resilient bones. Remember, bones are also a girl's best friends.
And they should be like diamonds — strong and dense. We need to work to make sure they are. As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of last review or update on all articles.
No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.
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Sign up to get tips for living a healthy lifestyle, with ways to fight inflammation and improve cognitive health , plus the latest advances in preventative medicine, diet and exercise , pain relief, blood pressure and cholesterol management, and more. However, there is no definitive consensus on how they should be used in athletes and as a result their use is often restricted to either research studies or in specialist bone centres 5.
It is generally accepted that vitamin D plays a key role for the athlete in order to prevent stress fractures and muscle injury 6. The role of vitamin D supplementation and athletic performance has been debated extensively in the medical literature, however there is a lack of robust evidence to support widespread routine use 7.
Vitamin D measurement in asymptomatic patients is not routinely advised by NICE but may be considered in patients with significant risk factors for low BMD. Calcium supplementation is also not routinely recommended in the athlete and generally should only be considered if dietary intake is less than mg daily or less than mg a day in those with diagnoses osteoporosis 8.
Dual energy x-ray absorptiometry DEXA measures the amount of bone mineral per unit area of volume of bone tissue and is the main imaging modality used in the UK to assess BMD 9. Standard protocols measure the lumbar spine BMD to monitor treatment and hip BMD to predict fracture risk.
The BMD is widely measured using the T-score which is the amount of standard deviations the BMD is of a patient compared to a year old healthy adult of the same sex. However, it is important to remember that in young athletes the Z-score should also be considered in order to compare scores against a healthy person of the same age and sex where we would expect the BMD to be higher These scores are not validated for use in younger patients.
The decision on when and how to return to training is a key part of the rehabilitation process after a bone stress response. The following factors should be considered 12 :. The bones response to loading is thought to saturate quickly so shorter sessions — spaced out with an interval of hours, are thought to be more effective than single longer sessions It is also recommended that the direction of loading and exercises should be varied and include rest periods, to help load the bone in multiple directions 14 and maximise the response.
Since that time, several more iterations on the female athlete triad have been published up to the most recent consensus statement in [ 5 ]. The components of the triad have evolved to be defined as 1 low energy availability with or without disordered eating, 2 menstrual dysfunction, and 3 low BMD [ 5 ].
The most clinically significant outcomes of the triad include clinical eating disorders, amenorrhea, and osteoporosis; however, many athletes suffer from less severe but still harmful conditions such as reduced energy availability without disordered eating, subclinical menstrual disturbances i.
A review of the recent literature by Logue et al. The primary etiology of the triad is low energy availability, or lack of adequate energy to support physiologic functioning after removing the energy expenditure from exercise, leading to various hormonal alterations [ 60 ].
However, energy availability thresholds are subject to individual variability and have not been clearly delineated in the pediatric population [ 61 ].
The hormonal disturbances that occur in the setting of low energy availability, particularly hypoestrogenism, lead to not only declines in areal BMD aBMD , but also impairments in bone microarchitecture and strength [ 60 ].
In the period of adolescence during peak bone mass accrual, low energy availability and its downstream effects on bone may result in lack of attainment of optimal bone mass [ 62 ]. In a recent study by Singhal et al. Eumenorrheic athletes had higher failure loads, suggesting greater estimated bone strength, at the weight-bearing tibia compared to non-athletes at baseline and 12 months and oligo-amenorrhoeic athletes at 12 months , although this became non-statistically significant after adjusting for changes in weight in addition to other covariates.
Across the month period, there were no significant differences in change in aBMD between the three groups.
The key takeaways of this study are that despite the weight-bearing exercise of oligo-amenorrhoeic athletes, their aBMD and bone strength estimates did not significantly differ from non-athletes, suggesting that hypoestrogenism negates the benefit of weight-bearing exercise on bone and may account for the increased risk of lower extremity BSIs.
This is in line with prior studies revealing both reduced aBMD [ 63 ] and impaired bone microarchitecture [ 64 ] in amenorrhoeic adolescent athletes compared to eumenorrheic athletes and controls, as well as the long-term negative effect of amenorrhea on bone health and ability to achieve peak bone mass in young athletes [ 65 ].
Further research is needed to better understand the combined and independent effects of both amenorrhea and low energy availability on bone density, microarchitecture, and strength. There have been several important studies published in the last few years regarding treatment of the female athlete triad.
The first line of treatment continues to be non-pharmacologic management to address the underlying energy deficiency and restore adequate energy status.
This is typically achieved in a multidisciplinary manner with a team including but not limited to a clinician experienced in treating the triad, a sports dietitian, and a mental health practitioner if there is any concern for disordered eating, body dysmorphia, or other psychological issues contributing to the low energy availability [ 5 ].
The following include the recommended dietary intake of macronutrients for adolescent athletes: protein: 0.
The dietitian can also assess for micronutrient deficiencies, mostly commonly iron, vitamin D, and calcium, and make recommendations for supplementation if medically warranted, preferably guided by laboratory testing [ 67 ].
In the event that an athlete may be unsuccessful with lifestyle changes to address energy availability, has a decline in BMD, or has a new fracture over the course of 1 year of non-pharmacologic management, then the pharmacological treatment should be considered [ 5 ]. Combined oral contraceptives COCs are often prescribed to treat functional hypothalamic amenorrhea, despite there being limited data to support this practice [ 68 ].
A recent randomized clinical trial led by Ackerman et al. compared changes in BMD [ 69 ] and bone geometry and microarchitecture [ 70 ] in 14—year-old oligo-amenorrhoeic, normal weight, female athletes treated with transdermal 17β-estradiol versus a common COC versus no estrogen.
In the same study population, high-resolution peripheral computed tomography HR-pQCT was performed at baseline and 12 months, with findings demonstrating significantly greater percent increases in total and trabecular volumetric BMD, cortical area, cortical thickness, and trabecular number in the PATCH vs PILL group at the weight-bearing distal tibia [ 70 ].
These studies were the first to compare the effects of transdermal 17β-estradiol versus COC on bone outcomes in young female athletes with oligo-amenorrhea, and the first to demonstrate the greater efficacy of transdermal 17β-estradiol in improving BMD, bone geometry, and microarchitecture compared to COCs.
One proposed explanation for these findings is that 17β-estradiol, the physiological form of estradiol, does not undergo first-pass metabolism in the liver, therefore bypassing the downregulation of insulin-like growth factor-1 IGF-1 as occurs with ethinyl estradiol in COCs [ 69 ].
With assessment of bone markers in the same study population, Singhal et al. reported a significant decline in IGF-1 in the PILL group compared to the PATCH and NONE groups, which supports this explanation [ 71 ].
Additionally, ethinyl estradiol in COCs stimulates sex hormone-binding globulin, which may lower bioavailable estradiol, leading to negative impacts on bone accrual [ 69 , 70 ]. The conclusion of these studies was that transdermal 17β-estradiol with cyclic progesterone should be considered an adjunct treatment for young female athletes with oligo-amenorrhea to improve skeletal health, while also focusing on non-pharmacologic measures to restore energy availability.
However, future research is necessary to understand how different estradiol formulations and doses in COCs may impact bone health, the role of progesterone supplementation, and how these findings translate to fracture and bone stress injury risk.
Research over the last decade has led to the recognition of the athlete triad in male athletes [ 72 ], culminating in a two-part consensus statement on the male athlete triad published in [ 6 , 73 ].
Like the female athlete triad, the male athlete triad includes low energy availability with and without disordered eating and low BMD, but with hypogonadotropic hypogonadism in place of menstrual dysfunction [ 6 ].
It appears that low energy availability and hypogonadism impair bone health with declines in BMD in male athletes, particularly in sports that emphasize leanness [ 6 ]. The Male Athlete Triad Coalition consensus statement recommends screening young male athletes for the triad starting in middle or high school and through college for early identification of those at risk to optimize bone health during the critical years of adolescence [ 73 ].
This should be done at the time of the preparticipation physical examination, and when an athlete presents with any one component of the triad [ 73 ]. These recommendations mirror those outlined for young female athletes, and the suggested screening questions for both male and female athletes can be found in Fig.
Using baseline responses from the triad screening questions, in addition to individual BMI, BMD Z -scores, and number of prior BSIs, to calculate a cumulative risk score, Kraus et al. Recommended screening questions for the Female and Male Athlete Triad, adapted from the Female and Male Athlete Triad Coalition consensus statements [ 5 , 73 ].
Assessment of energy availability, disordered eating, and bone health with dual X-ray absorptiometry DXA is also indicated [ 73 ].
For pediatric patients under the age of 19, total body less head and lumbar spine sites should be assessed by DXA [ 79 ]. Like the management of the female athlete triad, the first line of treatment is addressing the underlying energy deficiency and restoring adequate energy status.
Data is lacking regarding the safety and efficacy of pharmacologic therapies including testosterone replacement [ 73 ]. The and consensus statements on RED-S [ 61 , 80 ] outline the physiological, psychological, and performance impairments that occur in the setting of low energy availability [ 61 ].
The RED-S expands the female athlete triad to highlight the multiple other body systems affected by energy deficiency [ 61 ]. While the focus of this review is on bone health in the young athlete, it is important to acknowledge the other implications of low energy availability in athletes, and the need for more research to better understand these relationships and lifelong consequences in the young athlete population.
When approaching the pediatric athlete, clinicians and researchers should consider the unique attributes of the growing skeleton and how this relates to musculoskeletal injury incidence and risk.
BSIs are an inherent risk due to the repetitive nature of sport and can occur in the setting of low BMD related to the athlete triad. The female athlete triad can lead to suboptimal bone accrual despite regular weight-bearing activity in female adolescent athletes.
Recent evidence demonstrates that in addition to addressing the underlying low energy availability, transdermal estradiol should be considered an adjunct treatment for young female athletes with oligo-amenorrhea to improve skeletal health. It is essential to recognize that young male athletes can suffer from the male athlete triad, a condition that parallels the female athlete triad and can lead to reduced BMD in the setting of low energy availability and reproductive hormonal suppression.
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The Blackberry picking tips Enhances digestive function will be re-opening on Hezlth 1st, We Enhances digestive function cutting-edge treatment and Caffeine and work performance in new and innovative Ath,ete to reduce edufation risk and improve quality of life. It commonly affects women over the age of 50 but this condition can affect anyone. Today, we are leading experts in the management and treatment of this condition. We take a multidisciplinary approach to bone health and our team includes: physicians, nurses, pharmacist, physiotherapist, occupational therapist, registered dietitian and bone densitometry technologists. Visit the Our Team tab learn more about our allied health members. Educatipn research shows little risk of infection Tips for a happy digestive system Caffeine and work performance biopsies. Kettlebell workouts at work is linked Athlete bone health education blne blood pressure. Icy fingers and toes: Athletf circulation educatioj Raynaud's phenomenon? As the educaion Olympics Athlete bone health education underway, we will see elite women athletes compete at the highest level of their sports. And as we cruise toward September, many more young women will return to the field, court, and pool on college and high school teams. We know that many women who don't consider themselves athletes exercise more and restrict calories to lose or maintain their weight. This can be a formula for disaster.
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