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Author: Cook, Andrea, R Title: The Female Athlete Triad in Collegiate Athletes and Non-athlete
Undergraduate Students at a Division III University The accompanying research report is submitted to the University of Wisconsin-Stout, Graduate School in partial
completion of the requirements for the
Graduate Degree/ Major: MS Human Nutritional Science
Research Advisor: Esther Fahm, Ph.D.
Submission Term/Year: Spring, 2013
Number of Pages: 50
Style Manual Used: American Psychological Association, 6th edition
I understand that this research report must be officially approved by the Graduate School and that an electronic copy of the approved version will be made available through the University Library website
I attest that the research report is my original work (that any copyrightable materials have been used with the permission of the original authors), and as such, it is automatically protected by the laws, rules, and regulations of the U.S. Copyright Office.
My research advisor has approved the content and quality of this paper. STUDENT:
NAME Andrea Cook DATE: 5/13/13
ADVISOR: (Committee Chair if MS Plan A or EdS Thesis or Field Project/Problem):
NAME Dr. Esther Fahm DATE: 5/14/13
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Cook, Andrea R. The Female Athlete Triad in Collegiate Athletes and Non-athlete
Undergraduate Students at a Division III University
Abstract
The purpose of this study was to evaluate the prevalence of the female athlete triad
(disordered eating, amenorrhea, and low bone mineral density) in athletes and non-
athletes and to determine if there was a difference between the two groups at the
University of Wisconsin-Stout. The study consisted of 24 student athletes and 26 non-
athlete students who completed a survey on disordered eating (Eating Disorder
Inventory-3) and menstrual history. Also their height, weight and bone density (heel
bone test) were recorded at the Nutrition Assessment Lab at UW-Stout.
The study determined that 16.7% (n=4) of athletes and 11.5% (n=3) of non-
athletes had both disordered eating and amenorrhea with no statistical significance
between the groups. There were no participants in either group who had low bone
mineral density when a t-score of -2.0 was used. In conclusion, the findings show that
there were no cases of the complete female athlete triad among the athletes and non-
athletes studied; however there are signs of the female athlete triad starting to form in
both athletes and non-athletes.
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Acknowledgments
I would first like to thank my research advisor and mentor, Dr. Esther Fahm, for always
supporting me throughout my undergraduate and graduate years at UW-Stout. If it was not for
her positive attitude and words of encouragement I may not have reached this point and I
genuinely appreciate all of the support she has provided me. I would also like to thank Dr. Carol
Seaborn for working with me when things got rough and supporting my choices in order to finish
my graduate work.
Finally I would like to thank my family. To my parents, thank you for supporting me
throughout this process when I felt it may be too difficult. To my husband, I appreciate your
words of encouragement when I felt frustrated and did not know what to write next or how I was
going to get something done. Without your support this whole process would have proved to be
even more difficult.
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Table of Contents
............................................................................................................................................. Page
Abstract ...................................................................................................................................... 2
List of Figures ............................................................................................................................. 6
Chapter I: Introduction ............................................................................................................... 7
Statement of the Problem ................................................................................................. 9
Purpose of the Study ...................................................................................................... 10
Assumptions of the Study .............................................................................................. 10
Definition of Terms ....................................................................................................... 11
Limitations of the Study ................................................................................................ 12
Methodology ................................................................................................................. 13
Chapter II: Literature Review .................................................................................................... 14
Components of the Female Athlete Triad ....................................................................... 14
Disordered Eating ................................................................................................ 15
Amenorrhea ......................................................................................................... 17
Osteoporosis ........................................................................................................ 19
Contributing Factors ...................................................................................................... 20
Prevention and Referral ................................................................................................. 21
Chapter III: Methodology .......................................................................................................... 25
Subject Selection and Description .................................................................................. 25
Instrumentation.............................................................................................................. 26
Data Collection Procedures ............................................................................................ 26
Data Analysis ................................................................................................................ 28
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Limitations .................................................................................................................... 29
Chapter IV: Results ................................................................................................................... 30
Description of Sample ................................................................................................... 30
Disordered Eating .......................................................................................................... 30
Amenorrhea ................................................................................................................... 32
Body Mass Index ........................................................................................................... 33
Bone Density ................................................................................................................. 34
Prevalence of the Female Athlete Triad ......................................................................... 34
Table 1: Prevalence of Disordered Eating along with Amenorrhea among Non-Athletes
and Athletes ................................................................................................................... 35
Chapter V: Discussion ............................................................................................................... 36
Limitations ................................................................................................................... 36
Conclusions ................................................................................................................... 36
Recommendations ......................................................................................................... 37
References ................................................................................................................................ 39
Appendix A: Clinical Eating Disorder Diagnostic Criteria ......................................................... 42
Appendix B: International Review Board Approval................................................................... 43
Appendix C: Informed Consent ................................................................................................. 44
Appendix D: Eating Disorder Inventory – 3 Survey................................................................... 46
Appendix C: Anthropometric Data Handout .............................................................................. 50
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List of Figures
Figure 1: Frequency of eating disorder traits in non-athletes…………………………………...31
Figure 2: Frequency of eating disorder traits in athletes………………….……………………..32
Figure 3: Non-athletes and athletes with three months or longer without menstruation.……….33
Figure 4: Body Mass Index (BMI) of non-athletes and athletes..………....…………………….34
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Chapter I: Introduction
In society today, female athletes are competing in a variety of sports at the national,
state, and local level. According to Reinking and Alexander (2005), the number of female
athletes participating at the college level has increased from 32,000 to 150,000 which is more
than a 500% increase. Due to this increase in female athletes, there has also been an increase in
the awareness of the unique physiological and psychological responses of women to the athletic
activity (Reinking & Alexander, 2005). There has been evidence that the increase in female
activity has great health benefits, which include having better overall fitness levels and overall
well being (Derus, 2003). Hobart and Smucker (2000) warn, however that “potential adverse
health consequences are associated specifically with the overzealous female athlete” (p. 3357).
Research has shown that there are three main issues that affect the health of female
athletes. These issues are: eating disorders, osteoporosis, and amenorrhea. When female
athletes have all three of these components, they are said to have the female athlete triad (the
triad). The triad was not recognized although quietly observed until 1992 when the American
College of Sports Medicine (ACSM) brought it up at their annual conference (Wein & Micheli,
2002). The female athlete triad is of growing concern, especially due to the increasing pressure
on adolescent girls to maintain an "ideal" body weight. Many sports easily lend themselves to
further increasing the pressure that girls feel to be thin. Sports such as gymnastics and dance as
well as endurance sports such as soccer are sports that girls frequently are concerned about their
weight and appearance, which can lead to eating disorders, ranging from poor nutritional habits
to anorexia and bulimia (Estronaut, 1999).
Eating disorders can result in serious endocrine, skeletal, and psychiatric disorders.
Research has shown that 62% of female college athletes have disordered eating, which includes
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symptoms of bulimia and/or anorexia (McKeown, 2003). With the possible risk of poor
nutritional habits associated with disordered eating, a female athlete’s diet may result in a lower
caloric intake than her energy output. According to the American College of Sports Medicine
(2003), low caloric intake can contribute to energy drain and the resulting possibility of
compromise to reproductive and bone health.
Torstveit and Sundgot-Borgen (2005) reported that there has been recent research
suggesting that the female athlete triad develops on a continuum. On one end of the continuum,
for example, eating disorders have abnormal eating behaviors and the other end clinical eating
disorders exist such as anorexia nervosa and bulimia nervosa. Athletes may be trying to cut
calories and cause a negative energy balance in an attempt to lose body weight or body fat and if
left untreated, they may proceed to try more extremes and eliminate full food groups or purge
themselves of any food that they have consumed. If the early stages on the continuum are not
treated promptly and properly in females, extremes of the eating disorder continuum may later
develop.
Beals and Hill (2006) conducted a study on the prevalence of disordered eating,
menstrual dysfunction, and low bone mineral density among US collegiate athletes. They
conducted their study at a Division II university and they looked at female athletes who were
participating in collegiate sports. The total number of subjects for this study was 117
representing seven different sports. Beals and Hill did not find significant evidence that the
female athlete triad is present when all three components are being examined; however this
research team decided to analyze the triad components individually to see if there was evidence
that at least two present. These results showed that there was significant evidence that both
clinical eating disorders and menstruation dysfunction were present in nine of the 117 athletes
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(Beals & Hill, 2006). Another study conducted by Torstveit and Sundgot-Borgen (2005) was
performed on female elite athletes in Norway to examine the prevalence of the female athlete
triad in Norwegian athletes and controls. When evaluating the data from the athletes, the authors
found that out of 300 participants, only eight athletes met the criteria for all of the components of
the triad; however the study found significant evidence that the components of the triad were
present when individually analyzed. The prevalence ranged from 5.4% to 26.9% depending on
how each component was matched (Torstveit & Sundgot-Borgen, 2005). When the components
were individually evaluated, 14.2% (or 45 out of 300) athletes had both clinical eating disorders
and menstrual dysfunction. These studies show strong evidence that there is a need for more
research on the female athlete triad.
Statement of the Problem
In an ideal situation, female athletes would use nutrition and training to help improve
their overall fitness and performance without putting their physical and mental health at risk.
Unfortunately this outcome is not always the case, as athletes want to be the best, perform at the
highest level and win no matter how they do it. Female athletes will lower their weight through
calorie restriction in order to be faster (less weight to carry) and may train excessively (over their
recommended training) in the gym through aerobic activity to improve their stamina and strength
not realizing this practice may harm them. When a female athlete’s calorie intake does not meet
her calorie needs she is at risk of menstrual dysfunctions, bone fractures and mental fatigue.
If female athletes continue to restrict their calorie intake to less than their needs and over-
exercise they put their health and life at risk. By studying the body mass index (BMI), bone
density and disordered eating at University of Wisconsin-Stout (UW-Stout), we could gain a
better understanding of the prevalence of the female athlete triad among student athletes and how
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to help these athletes. Education could be provided to coaches, trainers and athletes on proper
fueling for their sports and signs that an athlete may be struggling with the female athlete triad.
Purpose of the Study
The purpose of this study is to determine if the female athlete triad is more prevalent in
collegiate female athletes at a NCAA Division III University versus general the female college
student at that same university. If there is evidence of the female athlete triad, education on
preventive measures and treatment for this disorder may benefit the training staff and coaches.
The specific research questions of this study are as follows:
1. How prevalent is the female athlete triad in collegiate female athletes?
2. Is the female triad present in non-collegiate undergraduate students?
3. How prevalent are the individual components of the female athlete triad in female
athletes?
4. How prevalent are the individual components of the female athlete triad in non-athletes?
5. Are there differences between the prevalence rates of athletes and non-athletes?
The research was carried out during the spring 2007 semester and University of
Wisconsin-Stout. Participants were 18-24 year-old female student athletes and female non-
athletes enrolled in the Nutrition for Healthy Living class.
Assumptions of the Study
There are a few assumptions regarding the study. First, it is assumed that the students
responded accurately and honestly to the questions on questionnaire used for data collection.
Since there was no way to verify the accuracy of responses, this aspect of the study is one of the
most difficult areas because there is very little way to control it. The second assumption is that
equipment used to determine body weight and bone density was calibrated and accurate.
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Definition of Terms
The following are terms used throughout the study and their appropriate definitions are
stated in order to help further understand the literature.
Amenorrhea. Absence of the female’s menstrual cycle (Beals 2004).
Anorexia. A clinical eating disorder characterized by a person restricting his/her food
consumption due to the intense fear of gaining weight despite being currently
underweight (American Psychological Association DSM IV, 1994).
Anthropometric measurement. The determination of the dimensions of the human body
such as height, and weight (Dooly & Beals, 2006).
Body Mass Index. Weight to height ratio which helps determine if a person is
considered underweight, normal weight, above weight or obese. Body mass index (BMI)
is calculated by taking a persons weight in kilograms and dividing it by their height in
meters squared (Beals 2004).
Bulimia. A clinical eating disorder whereby a person binges on an excessive amount of
food in a short period of time and then purges the food through unusual ways such as
vomiting, excessive exercise, or even laxatives in attempt to get rid of the calories
consumed (American Psychological Association DSM IV, 1994).
Disordered eating. Refers to the range of abnormal eating behaviors that may not meet
the clinical diagnosis for eating disorders established by the American Psychiatric
Association (Nattiv, Callahan & Kelman-Sherstinsky, 2002).
Eating disorder. A serious condition whereby a person has a preoccupation with weight
and food, which can interfere with everyday life (Beals, 2006).
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Female athlete triad. The combination of disordered eating behaviors, amenorrhea, and
osteoporosis found in females (Beals, 2006).
Ideal body weight. Weight that is considered ideal for a person based on their height
and adjusted for frame size (small frame, medium frame or large frame) (Dooly & Beals,
2006).
Menarche. The onset of menstruation for a female (Nattiv, Loucks, Manroe, Sanborn,
Sundgot-Borgen, & Warren, 2007).
Oligomenorrhea. Infrequent or very light menstrual flow in a female, who had periods
that were regularly established, resulting in 4 to 9 periods per year (Nattiv et al., 2007).
Osteopenia. Is a condition characterized by is a decrease in bone density. It is less
severe than osteoporosis with a t-score of -1.0 to -2.5 according to the World Health
Organization (World Health Organization Study Group, 1994).
Osteoporosis. A disease whereby there is decrease in bone mass and the increase in the
susceptibility to fractures with a t-score of < -2.5 according to the World Health
Organization (World Health Organization Study Group, 1994).
T-Scores: The number of standard deviations above or below the average bone density
score (-1.0 and above is average) (World Health Organization Study Group, 1994).
Limitations of the Study
The following are limitations of the study:
1. The Eating Disorders Survey, EDI-3 SC, was a self-report questionnaire, based previous the
knowledge and views of eating disorders by respondents.
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2. Heel bone mineral density test performed is not the most accurate for determining the overall
bone mineral density. The dual-energy x-ray absorption (DEXA) scan is considered the gold
standard for bone density; however this procedure is costly and only available in select locations.
3. A high dropout rate was observed in both athletes and non-athletes participating in this study,
resulting in a small sample size. Also, the sample selection procedure was a convenience
sampling technique, and consequently findings may not be generalized to the student female
population at UW-Stout or that of other colleges/universities.
4. The athletes at UW-Stout had access to a Registered Dietitian who educates on proper
nutrition for their sport prior to their seasons, which may have influenced their responses.
Methodology
Once the Institutional Review Board (IRB) approved this study, the researcher discussed
the study with the pre-approved Nutrition for Healthy Living class and various sports teams at
UW-Stout during the spring 2007 semester. The Eating Disorders Inventory-3 Survey was
handed out and participants were asked to complete and return them to the Nutritional
Assessment Lab in the Home Economics Building (now Heritage Hall) at UW-Stout. Height,
weight and bone density measurements were obtained on each participant at the same time the
surveys were returned. Appropriate statistical analyses were preformed to access at the
prevalence of the triad within the each group and between groups studied.
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Chapter II: Literature Review
This chapter will review the literature on the female athlete triad. The first part will
provide an overall description of the components of the female athlete triad; then each
component of the triad then be discussed individually. Next, factors contributing to the triad will
be reviewed. The chapter will conclude with a discussion of prevention and treatment options
for the female athlete triad.
Components of the Female Athlete Triad
The female athlete triad consists of three components: disordered eating, amenorrhea, and
osteoporosis. The primary component of the triad is disordered eating and amenorrhea and
osteoporosis are secondary to it. An athlete who has the three components of the female athlete
triad may be in extreme danger; however even if there are signs of just one of the disorders
individually it can cause morbidity and mortality (Wein & Micheli, 2002). All three of the
components of the triad are very interrelated and considered as being a continuum. Disordered
eating is thought to start the triad, which in turn causes amenorrhea and low bone density.
Reinking and Alexander (2005) reported that two different studies have shown that disordered
eating, specifically caloric restriction, caused menstrual dysfunction (amenorrhea). Due to
amenorrhea, there is a lack of circulating plasma estrogen, which can reduce the amount of
calcium retained by the bone and lead to premature osteoporosis. The absence of menstruation
for more than six months may decrease bone mineral density that potentially can be irreversible
(Thrash & Anderson, 2000). A lack of research exists on the prevalence of the female athlete
triad as a whole; however its individual components have been thoroughly researched (Nattiv et
al., 2002).
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Disordered eating. Beals and Houtkooper (2008) stated, “disordered eating is a general
term used to describe the spectrum of abnormal and harmful eating behaviors that are used in a
misguided attempt to lose weight and/or maintain a body weight that is lower than a person’s
ideal weight” (p. 202). It is important to distinguish disordered eating from clinical eating
disorders. Disordered eating is a term used to describe a category of pathological eating
behaviors that do not meet the criteria for a clinical eating disorder.
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV) (1994) identifies three clinical eating disorders: anorexia nervosa, bulimia
nervosa and eating disorder not otherwise specified. They are characterized by severe
disturbances in eating behavior and body image. They are psychiatric conditions with a
multifactoral etiology, and go beyond body image dissatisfaction. The diagnostic criteria are
outlined in Appendix A. Like disordered eating, clinical eating disorder may also occur in
athletes. According to Beals (2006), “athletes with clinical eating disorders resemble their
nonathletic counterparts in many ways; however there are some subtle differences” (p. 337).
Athletes who have anorexia have a similar strive for thinness that a non-athlete would
have; however athletes would also strive to improve their performance to the level they believe
they will achieve. Beals (2006) states “although starving in the name of improved performance
may seem counterproductive to the objective eye, the athlete with anorexia is not logical when it
comes to body weight and often has come to embrace the notion that thinner is better (they are
faster, stronger, etc…)” (p. 337). It is important to remember that athletes who have anorexia are
more resistant to treatment because it may entail taking a break from their sport. Athletes who
have anorexia may believe that they do not actually have an eating disorder but that by
maintaining their low body weight they are improving themselves for their sport (Beals, 2004).
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If athletes with anorexia are unable to maintain a low body weight along with a strict diet and
exercise regime, they feel it is a failure or weakness.
Athletes who suffer from bulimia nervosa engage in the same binge-purge cycles
associated with the disease, however in athletes, binging and purging are less clearly defined
(Beals, 2004). According to the DSM-IV (1994) definition, a binge is the intake of a large
amount of food in a short period of time. A large amount of food is described as being larger
than the quantity most individuals would normally eat in similar circumstances. A binge is
difficult to interpret with athletes because they tend to expend larger amounts of energy than
average and may require larger amounts of food in one setting, for example carbohydrate loading
the night before an event. This meal may be a larger amount of food than most individuals
would eat, however it is a common practice within the sports world. Thompson and Sherman
(1993) indicated that athletes would be more likely to use excessive exercise as a form of
purging while their non-athlete counterparts would typically choose to purge through vomiting or
laxatives. This difference may be because most athletes are with teammates or on the road,
making it difficult to use vomiting or laxatives to purge and the increase in exercise may be
disguised as training to improve their performance. Beals (2006) reported that athletes who
suffer from bulimia nervosa and anorexia both share the connection of self-esteem and self-
worth to athletic performance. “Anything that threatens these athletes’ fragile sense of self-
esteem (poor performance, negative comment from a coach or teammates) can serve to elicit a
binge-purge cycle” (p. 338).
Nattiv, Callahan and Kelman-Sherstinsky (2002) found that a majority of athletes do not
meet the criteria for anorexia nervosa or bulimia nervosa; however they do have a significant
abnormal eating behaviors and dissatisfaction with their body size, shape or weight. They
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partake in various methods of weight loss, including calorie restriction and purging through
vomiting or excessive exercise. The criteria for anorexia nervosa and bulimia nervosa are strict
and are listed in the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV).
A person does not need to have an exact clinical diagnosis to have eating behaviors that are
damaging the body and to be experiencing both amenorrhea and osteoporosis (the triad).
According to the American College of Sports Medicine, low energy availability is also a
factor in the triad. An athlete may not be intentionally trying to diet or restrict her intake, yet her
energy intake is less than her energy expenditure. This state of energy imbalance may be due to
an athlete’s increased activity level while her intake remains the same. It is important that
athletes know how to increase their energy intake to meet their increased needs throughout
training. This needs to be considered when treating a patient who has eating disorder symptoms;
the patient they may not present psychological signs but may be experiencing the female athlete
triad.
An athlete who currently presents symptoms of disordered eating can eventually
manifest into a clinical eating disorder if left untreated. Loucks and Nattiv (2005) reported that
“the prevalence of disordered eating, involving dietary restriction and purgative behaviors such
as vomiting and misuse of laxatives, ranges from 1% to 62% dependent on the sport, and it is
highest in sports in which low body weight conveys a competitive advantage” (p. 49).
Amenorrhea. Amenorrhea is described as the absence of the menstrual cycle and
according to Wein & Micheli (2002), and may possibly be a warning sign of an eating disorder
and a potential consequence of that disorder. Athletes do not recognize the risks associated with
the lack of menstruation. Instead, athletes often welcome the cessation of menstruation as one
less stressor to cope with and consider it to be a desirable consequence of intense training (Wein
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& Micheli, 2002). Two different forms of amenorrhea have been indentified, primary and
secondary. Primary amenorrhea consists of having no menstrual periods before the age of 16
when otherwise normally developed (Hobart & Smucker 2000). Secondary amenorrhea occurs
when there is a six-month absence of menstruation in a woman with primary amenorrhea or a
twelve-month absence when there has been prior oligomenorrhea.
Amenorrhea and oligomenorrhea are more prevalent in athletes than in non-athletes
especially endurance athletes. Thrash and Anderson (2000) reported a prevalence rate of nearly
70% for altered menstrual cycles in women who were strenuously exercising. With secondary
amenorrhea, other authors reported a 15%-66% prevalence rate depending on the sport and other
factors. Beals and Hill (2006) conducted a study where they discovered 26% of the athletes had
reported menstrual dysfunction; however 44% of the athletes also reported the use of oral
contraceptives to regulate their menstrual cycle.
Multiple factors contribute to amenorrhea. Poor nutrition, low body weight, low caloric
intake, hormonal status, and intense physical exercise are a few of the known factors that play a
role in the menstrual dysfunction. Overall the etiology of amenorrhea associated with the female
athlete triad has been found to be the disruption of hormones in the hypothalamus (Nattiv et al.,
2002). The hypothalamus secretes a hormone called the gonadotrophic releasing hormone
(GnRH) and when an athlete has amenorrhea, a decrease in production of the GnRH occurs
(Nattiv et al., 2002). According to Thrash and Anderson (2000), exercise has been shown to
directly affect the hypothalamic-pituitary-adrenal access and in athletes, cortisol levels remain
elevated throughout the day whereas in a non-athlete, cortisol levels are elevated only in the
early morning. If amenorrhea goes untreated, major damage to the skeletal system can result
because there is a decrease in bone mineral density.
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Osteoporosis. There are varying degrees of osteoporosis starting with osteopenia and
worsening to osteoporosis. The World Health Organization (WHO) defines osteopenia as
condition characterized by a decrease in bone density with a t-score of -1.0 to -2.5 or 10-25%
below the optimal bone mineral density in adults (WHO Study Group, 1994). The National
Institute of Health (2012) defines osteoporosis as a disease characterized by a decrease in bone
mass to the skeletal system and an increase in the susceptibility to fractures. Osteoporosis is
diagnosed with a t-score of less than -2.5 or at least 25% below the peak bone mass for adults.
To test for the degree of bone mineral loss various tests can be run on the spine, neck, heel or
wrist. Three of the most common tests are a dual-energy X-ray absorptiometry (DEXA),
computed tomography (CT) scan, or ultrasound of the heel. Results are interpreted with a t-score
that the World Health Organization established as a diagnostic tool for osteoporosis in 1994
(WHO Study Group, 1994).
Most athletes do not have bone density levels so low they are considered to have
osteoporosis; however they may develop levels that are in the osteopenic range (Nattiv et al.,
2002). Beals and Hill (2006) conducted a study taking the bone density of athletes using a
DEXA scan and found 2 athletes had t-scores that fell into the osteoporosis category; however
when they evaluated the osteopenia range, 11 athletes were at risk. Athletes who has low bone
mineral density are more susceptible to stress fractures in the short term; however even more
severe, they are at high risk of developing osteoporosis later in life. “Stress fractures occur in a
small percentage of athletes especially runners, but they may account for as much as 10% of all
sports related injuries” (Thrash & Anderson, 2000, p 171). Stress fractures are said to be caused
by a cumulative overload onto the bone, which may result in either a partial or full fracture to the
bone. Fractures can cause severe pain, which can affect athletes to such an extent that they will
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have to stop training in order to heal the fracture. If an athlete develops a stress fracture, it can
be career ending if not treated properly. The effects of the bone loss in athletes who have the
female athlete triad are irreversible; therefore intervention needs to take place in order to prevent
further loss of bone (Thrash & Anderson, 2000).
Contributing Factors
There are various factors that can put female athletes at increased risk for the female
athlete triad. Beals (2006) stated that the etiology of disordered eating is multifactoral and
complex. Disordered eating may develop because of social, demographic, environmental,
biological and psychological factors present in an athlete’s life. Many of these factors are due to
the pressure that is placed on a female athlete to excel in her sport. In college, many times the
administration may put pressure on the female athlete because the college relies on athletic
success for notoriety and even financial support (Derus 2003). Also there is pressure from an
individual sport to maintain a desired body shape and size. Athletes at the greatest risk of
pressure are those who participate in sports where revealing clothing is the uniform because a
greater emphasis is placed on physique (Wein & Micheli, 2002). According to Hobart and
Smucker (2000), “Societal perpetuation of the ideal body image may intensify the endeavor for a
thin physique. Athletic endeavors such as gymnastics, figure skating, ballet, distance running,
diving, and swimming that emphasize low body weight and a lean physique can also increase the
risk of developing the female athlete triad” (p 3359).
Brownell and Foryet (1986) stated that individuals with eating disorders might come
from families where there is dysfunction, whether it is controlling, abusive or history of alcohol
and drug abuse. “Such family environments can cause severe psychological and emotional
distress, undermine the development of self-esteem, and lead to inadequate coping skills, all of
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which may increase the risk an eating disorder may develop,” reported Beals (2006, p. 341).
When athletes feel out of control or overwhelmed, possibly due to injury or coaching decisions,
and come from a dysfunctional family, they may lack the coping skills needed to handle the
situation. This situation may lead athletes to focus on personal aspects they can control, possibly
body weight.
A female athlete who has achieved success in competition tends to be a perfectionist,
high achiever, and sometimes shows obsessive/compulsive traits that are all behaviors similar to
those described in eating disorder patients (Nattiv et al., 2002). “Just as athletes push their
bodies to physical limits to achieve a high level of performance, so too can athletes push
themselves to achieve or maintain a low body weight, despite potential negative consequences to
performance or health” (Beals, 2004, p. 45).
Prevention and Referral
When focusing on prevention of the female athlete triad in athletes, it is thought to first
focus on the disordered eating, which in turn can cause amenorrhea and osteoporosis. According
to Beals and Houtkooper (2006), the prevention of disordered eating targets the risk factors for
disordered eating and lower or eliminate them. However, this approach to prevention can be
difficult because many risk factors associated with disordered eating are out of the control of a
coach, trainer or health professional. Consequently, it becomes important to focus on the
predisposing factors that can be controlled, including the sociocultural emphasis that is placed on
thinness, unrealistic body weight ideals, and unhealthful eating and weight control methods.
Prevention is two-fold, including education and the preventative measures set up in an
athletic environment. When it comes to education, the proper health care professional should
provide sound education targeting coaches, athletic training staff, administration and athletes.
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Education should be provided on dispelling the myths and misconceptions of weight loss, body
composition and nutrition. Accurate and appropriate nutrition education is essential to help
promote healthful eating, but should not be too rigid, keeping variety and moderation in mind.
Nutrition education needs to foster optimal health and athletic performance, follow
recommended dietary guidelines for healthy eating, and emphasize that everyone will have
different needs and dietary recommendations (Beals, 2006).
Preventative measures need to be put in place to change athletes and staffs’ behaviors,
building upon the education that has been provided. Beals (2006) reported that preventative
strategies should de-emphasize body weight and composition, promote and practice healthful
eating, de-stigmatize eating disorders and foster an athlete’s individuality within a team
environment.
In a perfect world, elimination of anthropometric measurements would take place;
however in many sports there is a need to have the data. If that is the case, anthropometric data
should be taken by a professional other then the coach or trainer and education on limitations of
the data should be explained (such as an athlete may have a higher BMI due to larger amounts of
muscle mass). The stress an athlete feels during the measurement process may possibly send a
vulnerable athlete into a tailspin of disordered eating (Beals, 2004).
Nutrition education must be practiced by the coaches and training staff. Coaches can
help reinforce the nutrition education by providing athletes with healthful snacks and selecting
restaurants with healthful options for meals before and after competition. If a coach is
consistently going to fast food restaurants after games, this practice can undermine the nutrition
education previously provided. On the other hand, if a coach never allows fast foods, it can cause
a false sense that those foods may be harmful for an athlete to consume.
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It is extremely important that a safe environment is created by coaches, training staff and
administration, where body image, weight and eating may be discussed. There needs to be a
trust between athletes and their team so athletes feel they can confide in someone without
punishment if they are struggling with disordered eating. Athletes struggle to tell others about
how they feel or what they are doing for weight control because they typically feel it is a
weakness and do not want to disappoint the team, coach or trainer. “In short, coaches, trainers
and athletic administration must make it clear that they place the athletes’ health and well-being
ahead of athletic performance” (Beals, 2004, p. 112).
Finally, athletes need to be viewed individually and not compared to the “optimal body
shape”. Trainers, coaches and athletes understand the importance of needing personal training
regimens; however there seems to be a lack of connection to also needing their own personal
body shape, size and composition goals. According to Beals (2006), individualization of each
athlete’s body weight or composition goals and dietary practices is necessary to achieve optimal
performance and prevent disordered eating behavior. A coach, trainer, athlete and health care
professional need to routinely take into account weight history, diet history, training regimen and
how to help the athlete maintain a nutritionally sound diet.
If an athlete has been identified as having some disordered eating, it is important to refer
that athlete to a treatment program. This step can be difficult because many athletes do not want
to admit they are having a problem due to the consequences they feel will occur such as anger
from teammates, disappointment from coaches and fear of being pulled from their sport. A
person confronting an athlete with disordered eating should be sensitive yet firm and describe the
observed behaviors that are causing concern. The quicker the intervention for athletes, the
higher the rate of success they have in treatment. Once athletes have agreed to seek help, it is
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important to refer them to a treatment facility that specializes in eating disorders so athletes can
receive medical treatment, psychological treatment and nutritional treatment. During this time,
coaches, trainers and teammates are encouraged to continue to provide support so athletes do not
feel punished for receiving help (Beals & Houtkooper, 2006).
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Chapter III: Methodology
The purpose of this study is to determine if the female athlete triad is more prevalent in
collegiate female athletes at a NCAA Division III University versus general female student at
that same university. If there is evidence of the female athlete triad, educational points may need
to be discussed with the training staff and coaches on prevention and treatment of this disorder.
This chapter will describe the subject selection process and the instrumentation used to
collect data along with its reliability and validity. Methods for data collection and analysis will
be presented. The chapter will conclude with limitations that were found in the study,
specifically as related to methodology.
Subject Selection and Description
Prior to initiation of this study, the Institutional Review Board (IRB) at UW-Stout
evaluated and approved the research plan (Appendix B). The subjects in this study were selected
from the undergraduate female student population enrolled in the 2007 spring semester at the
UW-Stout. Students were required to be 18 years of age or older to be eligible to participate in
the study.
The lead investigator discussed the study with 100 athletes on the female soccer, softball,
track and field teams at the University. They were provided with an oral explanation of the study
and invited to volunteer to participate in the study. Interested athletes were provided a copy of
the informed consent statement (Appendix C) and asked to read it prior to volunteering. To select
non-athletes for comparison, the lead investigator discussed the study with FN-102 Nutrition for
Healthy Living class. Similarly, interested students were given the informed consent statement to
read. Female students were able to decide for themselves to volunteer for the study if they were
18 years of age or older. There were 24 athletes and 26 non-athletes who volunteered to
26
participate in this study. All students who volunteered and completed the data collection
requirements for the study were selected as participants.
Instrumentation
The disordered eating and menstrual dysfunction portion of the triad was assessed using
the Eating Disorders Inventory-3 symptoms checklist created by David M. Garner, PhD (EDI-3,
Psychological Assessment Resources, UN, Odessa, FL) (Appendix D). This survey contains
questions that asked participants if they have ever dieted, exercised, engaged in binge eating,
purging, laxative use, and diet pill use. Also the survey asked questions regarding their
menstrual history in order to later determine if there was any evidence of menstrual dysfunction
in the participant.
Anthropometric data were collected, using an instrument designed by the investigator to
record height, weight, body mass index, and bone density (Appendix E). The heel bone density
was obtained using the Sahara Clinical Bone Sonometer to evaluate the participant’s bone
density and relation to osteoporosis risk.
Data Collection Procedures During the Spring 2007 semester, the lead investigator handed out the Eating Disorders
Inventory-3 survey to collegiate athletes during team meetings set up by the coaches. Volunteers
completed the survey and returned it to the investigator on the day anthropometric measurements
were collected.
Anthropometric measurements were made in the Nutrition Assessment Laboratory at
UW-Stout by the lead investigator and a trained nutrition assessment laboratory graduate
assistant. In order to ensure privacy, names were not collected but numbers were placed on the
survey and coordinated with anthropometric measurement worksheet in order properly analyze
27
the data. Two (2) sealed boxes with a small opening at the top were placed on the counter inside
the assessment lab with one clearly marked” athlete” and the second marked “non-athlete”.
Participants were asked to place their Eating Disorder Inventory SC-3 survey in the appropriate
box prior to entering the next room where the anthropometric measurements were made,
including height, weight and heel bone density. Only the researcher or lab assistant was allowed
in the room while height, weight and bone density were measured and recorded.
To obtain participants’ height, they were asked to remove their shoes and stand up
straight against the stadiometer and the researcher or assistant moved the headpiece to lay just on
top of the participant’s head. Height in centimeters was read and recorded by the researcher/lab
assistant. After that, the participant was asked to stand on the balance scale while the researcher
or assistant read body weight and recorded it kilograms. These two pieces of data were used to
calculate body mass index (BMI), using the participant’s weight in kilograms and dividing by
her height in meters squared. BMI values were used to classify the body weight status of
participants according to the following standards: underweight = <18.5m2, normal weight = 18.6-
24.9m2, and overweight = >25m2.
Bone density was taken using the Sahara Clinical Bone Sonometer. The participants
were asked to remove their shoe and sock from the right foot. Their foot was then cleaned with
an alcohol swab and thoroughly dried using the dry wipes. The right foot was placed into the
foot well of the bone sonometer and aligned for proper measurement. The positioning aid was
then placed snug around the foot and there was a strap placed on the participant’s leg to assure
proper alignment for the most accurate reading. Once the participant was set up and
comfortable, the researcher/lab assistant took the heel bone density measurement and recorded as
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a t-score ranging from less than -2.0 to greater than 2.0 Finally the participant’s foot was
removed from the machine and wiped clean to ensure her comfort.
Once the participant was finished, she placed the anthropometric data sheet in the same
box she had previously placed her survey. Only the researcher and research advisor had access
to the survey boxes.
Data analysis
A number of statistical analyses were used in this study. The Statistical Program for
Social Sciences, version 19, was used to analyze the data. A standard of p < 0. 05 was used as
the significance level.
First, the individual components (disordered eating, amenorrhea and low bone density) of
the triad were analyzed to determine the prevalence in non-athletes and athletes. Frequencies
were run for disordered eating questions of the survey to determine how many participants either
had (a yes answer) or did not have (a no answer) a history of dieting, exercise, binging, purging,
laxative use, diet pill use or diuretic use. Differences between groups were tested using a
crosstabulation and chi-square analysis. To determine if any participants had a history of
amenorrhea, a frequency was run to determine how many participants answered “Yes” or ” No”
to the question regarding absence of menstruation. Differences between groups were evaluated
by running a crosstabulation and chi square analysis. Finally to evaluate bone density,
frequencies were run on each group of t-scores and then the bone density t-scores in both groups
were compared using independent samples t-test
After disordered eating, amenorrhea and low bone density were evaluated separately,
they were analyzed together to determine the prevalence of the whole triad in participants.
29
Frequencies were run for each group and then differences were compared using a crosstabulation
and chi-square analysis.
Limitations
There were a few limitations that presented themselves with this study. First, the sample
size was small. Of the 100 surveys distributed to each group, the return rate was 24% (n = 24) for
athletes and 26% (n = 26) for non-athletes. The researcher was only able to distribute surveys to
3 of the 9 women’s athletic teams at UW-Stout. Because of this limitation, the following sports
were omitted: basketball, cross-country, golf, gymnastics, tennis and volleyball.
Several questions on the survey may have involved sensitive information regarding
dieting and exercise history, which may have been difficult for participants to answer. Such
questions could also have affected the response rate for particular questions, and participants’
actual responses; there may be false negatives because of honesty on the survey.
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Chapter IV: Results
The purpose of this study was to determine the prevalence of the female athlete triad in
non-athletes versus athletes at a Division III University. The participants were given a survey
regarding disordered eating symptoms and menstrual history, and anthropometric data including
height, weight and bone density were collected. This chapter will present the demographic
characteristics of the participants, and findings for the five research questions of the study:
6. How prevalent is the female athlete triad in collegiate female athletes?
7. Is the female triad present in non-collegiate undergraduate students?
8. How prevalent are the individual components of the female athlete triad in female
athletes?
9. How prevalent are the individual components of the female athlete triad in non-athletes?
10. Are there differences between the prevalence rates of athletes and non-athletes?
Description of the Sample
The sample consisted of 24 female student athletes and 26 female non-athletes who
volunteered to participate in the study. All participants were18 years of age or older, and were
enrolled at UW-Stout in the spring semester 2007. Student athletes were participating in soccer,
track and field and softball, and non-athletes were enrolled in the FN 102 Nutrition for Healthy
Living class. No further demographic information was collected for purposes of this study.
Disordered Eating
On the EDI-3 SC survey, questions A-G regarded eating disorder behaviors. These
questions pertained to dieting, amount of exercise, binge eating, purging, laxative use and
diuretic use. Figure 1 shows the results for non-athletes. The two most common traits or
symptoms of an eating disorder noted in non-athletes were exercise and dieting. At some point,
31
92.3% (n = 24) of students reported exercising to help control weight or body shape, and 53.8%
(n =14) reported dieting to control overweight or body size. Diet pills were used 15.4% (n = 4)
of the time and diuretics 11.5% (n = 3) of the time. A history of binging, purging or laxative use
as a weight control method was reported 7.7% (n = 2) of the time in non-athletes.
Figure 1. Frequency of eating disorder traits in non-athletes.
Figure 2 shows the results from the athletes surveyed regarding eating disorder traits.
Approximately 62.5% (n = 15) of athletes dieted at one point to help control body shape or
weight and 100% used exercise. Binging episodes in athletes was reported 16.7% (n = 4) of the
time. Purging and diet pills were used as weight control methods in 8.3% (n = 2) of athletes who
responded. Notably, 33% (n = 8) of the athletes did not respond to questions regarding the use of
purging, diet pills and laxatives.
32
Figure 2. Frequency of eating disorder traits among athletes.
A crosstabs and chi-square test was conducted to evaluate the difference between
individual traits of eating disorders for non-athletes and athletes. No statistical significant
difference was found.
Amenorrhea
Question H on the EDI-3SC survey helped establish a menstrual history; which helped
evaluate risk for amenorrhea. All participants had already gone through puberty and started their
menstrual cycle. The question also asked if the participant had ever experienced three months
without a menstrual cycle. Results are shown in Figure 3. Of the non-athletes, 19.2% (n =5) had
experienced three months or longer without having a period, whereas 33.3% (n = 6) of athletes
had a three-month time lapse between periods at some point since the start of menstruation.
After conducting a chi-square test on both groups, no significant difference was found between
33
non-athletes and athletes in their menstrual history.
Figure 3. Non-athletes and athletes with three months or longer without menstruation.
Body Mass Index
Body mass index (BMI) was calculated after taking the participant’s height and weight.
Figure 4 shows the frequency distribution of BMI categories for both groups of participants.
Most of the participants in both groups fell in the healthy weight category based on their BMI.
Among the non-athletes, the BMI of 7.7% (n = 2) fell into the underweight category, while 4.2%
(n = 1) of athletes had a BMI that put her in the underweight category. There was no statistically
significant difference between the groups.
34
Figure 4. Body Mass Index (BMI) of non-athletes and athletes.
Bone Density
Bone mineral density scores for non-athletes ranged from -1.0 to 1.6, which all fall within
the World Health Organization’s normal standards for bone health. Athletes bone mineral
density scores ranged from -0.7 to 2.3 which also fall within normal limits for bone health. After
independent t-tests were performed, there was no statistical significance between the scores.
Prevelance of all Components of the Triad
The sample of both athletes and non-athletes had no participants with low bone mineral
density scores; therefore all three components of the triad were not present. A frequency was run
for each group to assess for the number of both non-athletes and athletes who had disordered
eating traits in combination with and history of ammenorrhea which would put them at future
risk for low bone density. The results are noted in Table 1. When evaluating the prevalence of
disordered eating and amenorrhea between non-athletes and athlete no statistical significance
difference was oberved in prevalence between the two groups.
35
Table 1.
Prevalence of Disordered Eating along with Amenorrhea among Non-Athletes and Athletes
Response __ Non-Athletes______ Frequency (N = 26)
Percentage %
_________Athletes_________ Frequency (N = 24)
Percentage %
Present 3 11.5%
4 16.7%
Not present 23 88.5%
20 83.3%
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Chapter V: Discussion
This study was conducted to evaluate the prevalence of the female athlete triad in
collegiate athletes and non-athlete undergraduate students at a Division III University. This
chapter will discuss the results to the research questions in comparison to previous studies. The
chapter will conclude with recommendations for further research.
Limitations
Limitations were discussed in chapter 3; however after data were collected and analyzed
further limitations were observed which could affect the outcome of the study. First, the
response rate was low with 24% (n=24) of athletes and 26% (n=26) of non-athletes participating
out of 200 possible participants. The limited number of participants may be due to the time it
would take to complete the survey and then the need to go to the assessment lab to have height,
weight and bone density recorded. The small sample size may make it difficult to compare
results to larger scale studies that have been previously conducted. Another limitation was that
eight athletes did not answer questions regarding purging, laxative use, diuretic use or diet pill
use, which can alter the results for athletes and in turn the comparisons between the groups.
Conclusion
The first two research questions the study determined the prevalence of the female athlete
triad in both athletes and non-athletes. The results showed that no participant had all three
components of the triad: disordered eating, amenorrhea and low bone density. This finding is
not an unusual one when compared to other research. In a study by Beals and Hill (2006), only
one participant out of 112 US collegiate athletes had all three components of the female athlete
triad. Torstveit and Sundgot-Borgen (2005) studied the Norwegian elite athlete population and
37
out of 186 athletes and 145 controls that participated, only three athletes and three non-athletes
had the full-blown triad.
To further evaluate the female athlete triad, the study determined the prevalence of each
individual component of the female athlete triad in both athletes and non-athletes. It was
discovered that 16.7% (n=4) of athletes showed signs of both disordered eating and amenorrhea
and 11.5% (n=3) of non-athletes demonstrated signs of both disordered eating and amenorrhea.
These results are similar to other studies that were reviewed. In the study by Torstveit and
Sundgot-Borgen (2005), 24.2% of the athletes tested showed signs of disordered eating and
amenorrhea and 11.7% of the control population in the study had signs of disordered eating and
amenorrhea. Beals and Hill (2006) found that nine athletes (8%) met the criteria for disordered
eating and amenorrhea out of 112 athletes studied. Unlike the methods used in the present study,
Beals and Hill used a survey that involved combining two established surveys into one to assess
disordered eating, and Torstveit and Sundgot-Borgen added in a clinical interview to assess for
disordered eating.
In the current study there were no participants in either group that could be considered to
have low bone mineral density when the t-score of -2.0 was used as the standard. These results
were similar to the study by Beals and Hill (2006). In their study only two athletes had a low
bone mineral density, which was tested with the DEXA scan and with the t-score of -2.0;
however when the t-score was raised to -1.0, 11 athletes could be classified as having low bone
mineral density.
Recommendations
After conducting this study and reviewing the results, there are a few recommendations to
make for UW-Stout and future research. First, this study was not a large-scale study and did not
38
expand to all athletes at the UW-Stout. To obtain more representative numbers, it is
recommended to start the study in the fall semester and continue with the winter and spring
semesters. This duration period for the study will help to include the sports that were not
meeting in the spring when the current survey was conducted. Another recommendation would
be to consider other survey instruments that are less likely to be falsified. It is difficult to get
accurate disordered eating results when the survey is direct in asking questions regarding dieting,
diuretic use, laxative use, purging and diet pills. A combination of assessments, like Beals and
Hill (2006) used in their study, may provide more accurate results. Finally, despite not having a
DEXA scan available for use and needing to use the heel bone density test, it would be
interesting to evaluate bone density results with t-scores of -1.0 since athletes are considered a
special interest group and potentially have a 5-10% higher bone mineral density than non-
athletes (Torsveit and Sundgot-Borgen 2005).
Currently at the UW-Stout, a dietitian is available should athletes need to seek advice on
proper fueling and nutrition. This dietitian also does provide some education to teams if coaches
request. After reviewing the study results it may be beneficial for all teams to be provided
nutrition education at the beginning of their season to help athletes fully understand their
nutrition and energy needs for competition and training. Also, it would also be beneficial for all
coaches and trainers to be educated on the female athlete triad, how to detect symptoms of each
component and how to handle the situation should interventions need to be done. The female
athlete triad may not be significant at the University at this time; however evidence in the study
does show that signs are present for some of the components, which may manifest over time into
the full female athlete triad if untreated.
39
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Appendix A: Clinical Eating Disorder Diagnostic Criteria
Clinical diagnostic criteria from the American Psychological Association: Diagnostic and statistical manual of mental disorders 4th Ed (1994) Anorexia Nervosa
1. Refusal to maintain body weight at or above a minimally normal weight range for age and height. (Weight loss leading to maintenance of body weight <85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected.)
2. Intense fear of weight gain or becoming fat despite being underweight 3. Disturbance in the way one’s body weight or shape are experienced, undo influence of
body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight
4. Amenorrhea (for at least 3 consecutive cycles).
Bulimia 1. Recurrent episodes of binge eating characterized by:
a. Eating in a discrete period of time (2 hours) and amount of food that is larger than most people would eat during a similar period or time in a similar period.
b. Sense of lack of control over eating during that period. 2. Inappropriate compensatory behavior recurrently occurring on average at least twice a
week for three months. 3. Self-evaluation is unduly influenced by body shape or weight 4. The disturbance does not occur exclusively during Anorexia Nervosa episodes.
Eating Disorder Not Otherwise Specified 1. In female patients, all criteria for anorexia are met except the patient has regular menses. 2. All criteria for anorexia are met except weight is within normal range despite significant
weight loss 3. All criteria for bulimia are met except that binge eating and compensatory mechanisms
occur less than twice per week or less then three months. 4. Patient has normal body weight and uses inappropriate compensatory behavior after
eating small amounts of food.
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Appendix B: International Review Board Approval
Date: April 30, 2007 To: Andrea Arvold Cc: Esther Fahm From: Sue Foxwell, Research Administrator and Human Protections Administrator, UW-Stout Institutional Review Board for the Protection of Human Subjects in Research (IRB) Subject: Protection of Human Subjects in Research Your project, "The Female Athlete Triad in Collegiate Athletes and Non-athlete Undergraduate Students at a Division III University," is Exempt from review by the Institutional Review Board for the Protection of Human Subjects. The project is exempt under Category 2/3 of the Federal Exempt Guidelines and holds for 5 years.
Please copy and paste the following message to the top of your survey form before dissemination:
Please contact the IRB if the plan of your research changes. Thank you for your cooperation with the IRB and best wishes with your project. *NOTE: This is the only notice you will receive – no paper copy will be sent.
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Appendix C: Informed Consent
Consent to Participate in UW-Stout Approved research Title: The Female Athlete Triad in Collegiate Athletes and Non-athlete Undergraduate Students at a Division III University. Investigator Research Sponsor Andrea Arvold Dr. Esther Fahm 507-421-0161 232-2550 [email protected] [email protected] If you are under 18 years old, do not participate in this study Description The objective of this study is to determine if the Female Athlete Triad (The Triad) and its individual components may be more prevalent in collegiate female athletes compared to college women who are non-athletes. You will be asked to fill out an Eating Disorders Inventory-3 survey, which will assess participants disordered eating behaviors and menstrual dysfunction. Your name will not be recorded on the survey ensuring confidentiality. Height, weight, body mass index and bone density will be taken in the Nutrition Assessment Lab in the Home Economics building at a later time. Risks and Benefits The risks associated with your participating in this research are minimal, and you may actually benefit from participating. There are no physical risks of participating in this study. For height and bone density measurements, your feet may feel cold from contact with the instrument; however any discomfort is barely detectable and short lasting. The balance scale and bone sonameter are sanitized with alcohol swabs between each measurement. For body weight measurement, you may feel shyness but risks are minimal, similar to what occurs during regular physical exams at your doctor’s office. Due to the nature of some of the questions on the Eating Disorder -3 survey, there may be psychological risks involved but these are minimal. By participating in this study you will receive beneficial health information about yourself, including height, weight, bone density, and body mass index for personal knowledge. Participants will also be informed of the overall outcome of the study. Overall outcomes will be shared with the athletic training staff at University of Wisconsin-Stout, which will allow them to adjust their nutrition information sessions that are conducted before each athletic season. Time Commitment and Payment Participants will be asked to complete two surveys, which will take approximately 20 to 30 minutes to complete. This can be done at a time that is convenient to the participant. Participants will also be asked to come into the Nutrition Assessment Lab located in Home
45
Economics Building 427 to have their height, weight, and bone mineral density recorded. This should take approximately 5 to 10 minutes depending on the time available. The non-athlete participants will receive 10 points extra credit in their Nutrition for Healthy Living class for participating in this study. Confidentiality Your name will not be included on any research questionnaires or documents. We do not believe that you can be identified from any of this information. This informed consent will not be kept in a separate file, not with any of the other documents completed with this project. After completion of this project, all documents will be shredded. Right to withdraw Your participation in this study is entirely voluntary. You may choose not to participate without any reprisal or avers consequences to you. If you choose to participate and later withdraw from this study, you can do so at any time without coercion or adverse consequences to you. However there is no way to identify your anonymous document after it has been turned in to the investigator. IRB Approval: This study has been reviewed and approved by The University of Wisconsin-Stout’s Institutional Review Board (IRB). The IRB has determined that this study meets the ethical obligations required by federal law and University policies. If you have questions or concerns regarding this study please contact the Investigator or Advisor. If you have any questions, concerns, or reports regarding your rights as a research subject, please contact the IRB Administrator. Investigator: Andrea Arvold IRB Administrator
507-421-0161, [email protected]. Sue Foxwell, Director, Research Services 152 Vocational Rehabilitation Bldg.
Advisor: Dr. Esther Fahm, UW-Stout Menomonie, WI 54751 715-232-2550, [email protected] 715-232-2477 [email protected] Statement of Consent: “By completing the following surveys you agree to participate in the project entitled, The Female
Athlete Triad in Collegiate Athletes and Non-athlete Undergraduate Students at a Division III
University.”
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Appendix D: Eating Disorder Inventory – 3 Survey
-ED:l-3 SC David 1~. Garner, PhD
DIRECTIONS Enter your name, the date, your age, gender, marital status. and occupation. Complete the questions in this booklet as accwately a.!JOU c-an. _ --Name ___________________________ ~--~----------Dare ______ L_ ____ ~------
• Age _____ Gender ______ 11arita\ Status-------- Occupation---------
A. DIETING "'Have you ever -restricted yow food intake due to concerns about your body size or weight?
Yes No
How old were you the very first time that you began to seriously restrict your food intake due to concerns about your body size or weight? ____ years old
B. EXEROSE On average, over the la.st 3 months, how often have you exercised (including going on walks, riding a bicycle, etc.)? ___ If you exercise more than once a day. please count the total number of times that you exercise in a typical week. ___ times .a week
On average, how tong do you exercise each time? ___ minutes
'*What percentage of yow exercise is aimed at controlling your weight?
____ 0% ___ tess than 25% ____ 25%-50% more than 75% ____ 100%
C. BINGE EATING Please remember in answering the following questions that an eating binge only refers to eating an amount of food that others of your age and gender regard as unusually large. 1t does not include times when you may have eaten a normal quantity of food tltat you would have prefeued not t(l have eaten.
• Have you ever had an episode of eating an amount of food that others would regard as unusually large? ___ Yes ___ No
[J nof please skip to Question D.
How old were you when you first had an eating blnge? ____ years old
How old were you when you began binge eating on a regular basis? ____ years old
W8 Ps)'(lhologlcal ASS<!SSRHlnl Resour<:es, Inc. ·1620.1 N. Anrida A•tnue ·Lutz. A. 33549 • 1.800.331.8378 ·"ww.oarlnc.wm Copyright -4' 1984. 1991. 200ii by Psychological Assessment Resources, Inc. AU rlgllt$ re$erved. M1y not bet •ePmduc~d in whole or in part it1 ~ny form or by •ny fl'lti\nS without written pefl'Tlission of P~yct-10logical Assessment Reiource!., lnc. Contains the original EOJ Item$ dt-vtloped by Gamer, Olmsted, and PoUvy 0984). This for"m i$lltint~ in purple ink on white paper. An~· other ve:rsion is unauthorized. 9 8 7 6 54 3 Reorder lll\O·S390 Printed in tfle U.S.A.
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•During the last 3 mont/Is, how often have you typically had an eating bing~?
___ I have not binged in the last 3 months.
___ Monthly I usualty binge __ times(s) a month.
__ Weekly I usualty binge __ time(s) a week. __ Daily I usualty binge __ tirnes(s) a day.
• At the worst of times, what was your average number of binges per w:eek? ___ binges per week
How long ago was that? ___ months ago ___ at its worst right now
U you have not binged In the last 3 months, please skip to Question D.
·Do you feel out of control when you binge?
___ Never ___ Rarely ___ Sometimes Often ___ Usually ___ Always
Do you feel that you can stop once a binge has .started? ___ Never ___ Rarely __ Sometimes __ Often ___ Usually __ Always
Do you feel that you can prevent a binge from starting in the first place? ___ Never ___ Rarely ___ Sometimes _ __ Often ___ Usually ___ Always
Do you feel that you can control your urges to eat large quantities of food?
___ Never ___ Rarely ___ Sometimes ___ Often ___ Usually __ Always
Do you feel distressed by your bingeing? __ Never ___ Rarely __ Sometimes ___ Often ___ Usual\y ___ Always
Do you find bingeing pleasurable?
___ Never ___ Rarely __ Sometimes ___ Often ___ Usualty ___ Always
D. PURGING 'Have you ever tried to vomit after eating in or<ler to get rid of the food eaten? ___ Yes ___ No
If no. please skip to Question E.
How old were you 1~hen you induced vomiting for the first time? ___ yeaJS old
"During the last 3 months, how often have you typically induced vomiting?
___ I have not vomited in the last'3 months.
___ Monthly I usually vomit ___ time(s) a month.
__ weekly
__ Daily
l usuatly vomit ___ tirne(s) a week.
I usuatly vomit ___ time(s) a day.
• At the worst of times, what was your average number of vomiting episodes per week?
___ vomiting episodes per week
How tong ago was that? ___ months
2
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E .• LAXATIVES "Have you ever used la.utives to control your weight or •get rid of food?' ___ Yes ___ No
If no, please skip to Question F.
How old were you when you first took laxatives for weight control? ___ years old
How old were you when you began taking laxatives for weight control on a regulor basi$? ___ years old
• During the last J montlu. how often nave you tal<tn laxatives for weight control?
I hive not Ql<en laxatives in the last 3 months.
__ Monthly I usually lake laxatives _ _ tlme(s) a month.
___ Weekly I usually take laxatives __ tim•(s) a week.
__ Dally 1 usually take laxatives __ tirne(s) a day.
Row many laxatives do you usually take each time? ___ laxatives
What kind of laxatives do you take?----------------------• At the worst of times. what was the average number of laxatives that you were taking per week?
_ __ laxatives per week
Haw lDng ogo wa. that? ___ months
F. DUT PILLS 'Have you'"'' token diet pills? ___ Yes ___ No
If no, please skip to Question G.
'During the lost J months, how often have you typically taken diet pil ls'
___ I have not taken diet pills in the last 3 rnonths.
___ Monthly I usually take diet pills _ __ tlme(s) a month.
__ Weekly I usually lake diet pills time(s) a week.
_ _ Dally I usually taU diet pills __ time(s) a day.
• At the ""TSI of times, what was the average number of diet pills that you were laldng pet "oeek?
__ diet pills per w~k
How long ago was that? _ __ months
G. DIURETICS ·Have you eVI!r taken diuretics (water pills) to control your weight? _ __ Yes ___ No
U no, plea~ skip to Question H.
'During the last J montiu, how often have you typica\ly taken diuretics?
I hive not tal<tn diwetics in the last l months.
_ __ Monthly I usually take diuretics ___ time(s) a month.
__ Weekly
__ Daily
I usually take diuretics _ _ time(s) a week.
I usually take diuretics __ time(s) a day.
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~At the woJst of times. what was the average numbel of diuretics that you were taking per week?
___ diuretics per week
How tong ago was that? ___ months
H. MENSTRUAL HISTORY (For jemoies only) •Have you ever had a menstrual period? ___ Yes ___ t<o
If no, please skip to Question I.
How old were you when you first starting menstruating? ___ years old
• Do you have menstrual periods now? (Check one)
___ Yes, regularly every month.
___ Yes. but 1 skip a month once in a while.
___ Yes. but not VeJY often (for example .. once in 6 months).
___ No. l have not had a period' in at least 6 month!s.
___ No. I am postmenopausal, have had a hysterectomy, or am pregnant.
___ 'How long has it been since your last period? ___ months
•Have you ever had a period of time when you did not menstruate for 3 months or more (excluding pregnancy)? ___ Yes ___ No
If yes, ho.v old were you when you first missed your period for 3 months or more? ___ years old
For how many months did you miss your period? ___ months
How much did you weigh when you stopped mens.truating? ___ pounds
Are you currently ta.ldng birth control pills? ___ Yes ___ No
If yes. how old were you when you first started using the pill? ___ years old
I. CURRENT MEDICATION Are you currently taking any medication prescribed by a physician? ___ Yes ._.No
[f yes, please list the medications you are taking.
Addtb 1ill (;(~lies ~~l<~ble from: DAD Psychological Assessment Resourcles, lnc. a,g&& 16204 N. - AI moo • IAJIJ. Fl ll!>t9 • t.iOO.aJ1.837lJ-www.pwilc.cxm
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Appendix E: Anthropometric Data Handout
The Female Athlete Triad in Collegiate Athletes and Non-athlete Undergraduate Students at a Division III University. Your participation in this study is entirely voluntary. You may choose not to participate without
any reprisal or adverse consequence to you. If you choose to participate and later wish to
withdraw from this study, you can do so at any time without coercion or adverse consequences to
you. However, there is no way to identify your anonymous document after it has been turned in
to the investigator.
Anthropometric Questionnaire
Subject Number______________ Anthropometric Administration Survey
The investigator or a trained assistant will complete this survey.
Height (cm): _______________ Weight (kg): _______________ BMI (calculate as follows) kg/m2: _________________ Bone Density (g/cm2) t-score: _________________