Female Athlete Triad Coalition cumulative risk assessment tool: proposed alternative scoring strategies

We (i) identified alternative scoring strategies for the Female Athlete Triad Coalition cumulative risk assessment (CRA) tool to be utilized when particular risk factors (bone mineral density (BMD), oligomenorrhea/amenorrhea) cannot be determined; (ii) objectively defined dietary restriction for use in the CRA tool; and (iii) explored proxy measures of energy deficiency. This cross-sectional investigation of exercising women (n = 166) utilized an existing database derived from multiple studies designed to assess health, exercise, and menstrual function. Data from the screening/baseline period of each study included: anthropometrics, dual-energy X-ray absorptiometry, disordered eating questionnaires, descriptive data, and proxy measures of energy deficiency (total triiodothyronine (TT3) and ratio of measured-to-predicted resting metabolic rate (mRMR/pRMR)). Substituting delayed menarche for BMD was the best-fit replacement resulting in 15 (9%) participants being categorized in different clearance categories. When menstrual status cannot be assessed, such as during hormonal contraceptive use, low energy availability (EA) determined using self-report and disordered eating questionnaires was the best substitution, resulting in 34 (20%) participants being categorized in different clearance categories. Based on original clearance categorizations, the provisional group had lower TT3 (78.3 ± 2.2 ng/dL; 92.7 ± 2.7 ng/dL) and Harris–Benedict mRMR/pRMR (0.85 ± 0.01; 0.90 ± 0.01) than the full group. Until an updated risk assessment tool is developed, delayed menarche can substitute for low BMD and low EA for oligomenorrhea/amenorrhea. Novelty This investigation addresses previous limitations of the Triad CRA tool. Disordered eating questionnaires can be used to objectively identify dietary restriction for the low EA risk factor. When a risk factor cannot be assessed, delayed menarche can substitute for low BMD and low EA for oligomenorrhea/amenorrhea.

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Characterization of Risk Quantification Differences Using Female Athlete Triad Cumulative Risk Assessment and Relative Energy Deficiency in Sport Clinical Assessment Tool

International Journal of Sport Nutrition and Exercise Metabolism ◽

10.1123/ijsnem.2019-0002 ◽

2019 ◽

Vol 29 (6) ◽

pp. 569-575 ◽

Cited By ~ 5

Author(s):

Bryan Holtzman ◽

Adam S. Tenforde ◽

Allyson L. Parziale ◽

Kathryn E. Ackerman

Keyword(s):

Female Athlete ◽

Assessment Tool ◽

Cumulative Risk ◽

Relative Energy ◽

Risk Level ◽

Energy Availability ◽

Female Athlete Triad ◽

Mineral Density ◽

Energy Deficiency ◽

Low Energy Availability

This study’s objective was to identify differences in risk for low energy availability and athletic clearance level by comparing scores on Female Athlete Triad Cumulative Risk Assessment (Triad CRA) and Relative Energy Deficiency in Sport Clinical Assessment Tool (RED-S CAT). A total of 1,000 female athletes aged 15–30 years participating in ≥4 hr of physical activity/week for the previous ≥6 months completed an extensive survey assessing health, athletic history, family disease history, and specific Triad/RED-S risk factors. Retrospective chart review ascertained laboratory and bone mineral density measures. Triad CRA and RED-S CAT were used to assign each athlete’s risk level (low, moderate, and high), and case-by-case comparison measured the level of agreement between the tools. We hypothesized that the tools would generally agree on low-risk athletes and that the tools would be less aligned in the specific elevated risk level (moderate or high). Most of the sample was assigned moderate or high risk for Triad CRA and RED-S CAT (Triad: 54.7% moderate and 7.9% high; RED-S: 63.2% moderate and 33.0% high). The tools agreed on risk for 55.5% of athletes. Agreement increased to 64.3% when only athletes with bone mineral density measurements were considered. In conclusion, Triad CRA and RED-S CAT provide consensus on the majority of athletes at elevated (moderate or high) risk for low energy availability, but have less agreement on the specific risk level assigned.

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Association of the Female Athlete Triad Risk Assessment Stratification to the Development of Bone Stress Injuries in Collegiate Athletes

The American Journal of Sports Medicine ◽

10.1177/0363546516676262 ◽

2016 ◽

Vol 45 (2) ◽

pp. 302-310 ◽

Cited By ~ 75

Author(s):

Adam S. Tenforde ◽

Jennifer L. Carlson ◽

Audrey Chang ◽

Kristin L. Sainani ◽

Rebecca Shultz ◽

...

Keyword(s):

Risk Assessment ◽

High Risk ◽

Female Athlete ◽

Cumulative Risk ◽

Collegiate Athletes ◽

Female Athlete Triad ◽

Assessment Score ◽

Bone Stress ◽

Cross Country ◽

Risk Categories

Background: The female athlete triad (referred to as the triad) contributes to adverse health outcomes, including bone stress injuries (BSIs), in female athletes. Guidelines were published in 2014 for clinical management of athletes affected by the triad. Purpose: This study aimed to (1) classify athletes from a collegiate population of 16 sports into low-, moderate-, and high-risk categories using the Female Athlete Triad Cumulative Risk Assessment score and (2) evaluate the predictive value of the risk categories for subsequent BSIs. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 323 athletes completed both electronic preparticipation physical examination and dual-energy x-ray absorptiometry scans. Of these, 239 athletes with known oligomenorrhea/amenorrhea status were assigned to a low-, moderate-, or high-risk category. Chart review was used to identify athletes who sustained a subsequent BSI during collegiate sports participation; the injury required a physician diagnosis and imaging confirmation. Results: Of 239 athletes, 61 (25.5%) were classified into moderate-risk and 9 (3.8%) into high-risk categories. Sports with the highest proportion of athletes assigned to the moderate- and high-risk categories included gymnastics (56.3%), lacrosse (50%), cross-country (48.9%), swimming/diving (42.9%), sailing (33%), and volleyball (33%). Twenty-five athletes (10.5%) assigned to risk categories sustained ≥1 BSI. Cross-country runners contributed the majority of BSIs (16; 64%). After adjusting for age and participation in cross-country, we found that moderate-risk athletes were twice as likely as low-risk athletes to sustain a BSI (risk ratio [RR], 2.6; 95% confidence interval [95% CI], 1.3-5.5) and high-risk athletes were nearly 4 times as likely (RR, 3.8; 95% CI, 1.8-8.0). When examining the 6 individual components of the triad risk assessment score, both the oligomenorrhea/amenorrhea score ( P = .0069) and the prior stress fracture/reaction score ( P = .0315) were identified as independent predictors for subsequent BSIs (after adjusting for cross-country participation and age). Conclusion: Using published guidelines, 29% of female collegiate athletes in this study were classified into moderate- or high-risk categories using the Female Athlete Triad Cumulative Risk Assessment Score. Moderate- and high-risk athletes were more likely to subsequently sustain a BSI; most BSIs were sustained by cross-country runners.

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Female Athlete Triad Coalition risk assessment tool is an evidenced-based tool that is reliable and well-described

Journal of Sports Sciences ◽

10.1080/02640414.2020.1738120 ◽

2020 ◽

Vol 38 (9) ◽

pp. 996-999

Author(s):

Mary Jane De Souza ◽

Nancy I. Williams ◽

Kristen J. Koltun ◽

Nicole C. A. Strock

Keyword(s):

Risk Assessment ◽

Female Athlete ◽

Assessment Tool ◽

Risk Assessment Tool ◽

Female Athlete Triad ◽

Evidenced Based

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Preliminary Results from a Prospective Study Using the Female Athlete Triad Cumulative Risk Assessment

Medicine & Science in Sports & Exercise ◽

10.1249/01.mss.0000520026.24336.5f ◽

2017 ◽

Vol 49 (5S) ◽

pp. 1098

Author(s):

Emily Kraus ◽

Aurelia Nattiv ◽

Adam Tenforde ◽

Andrea Kussman ◽

Michelle Barrack ◽

...

Keyword(s):

Risk Assessment ◽

Prospective Study ◽

Female Athlete ◽

Cumulative Risk ◽

Female Athlete Triad ◽

Preliminary Results ◽

A Prospective Study

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Components of a risk assessment tool for prevention and control of bovine respiratory disease in preweaned dairy calves

Animal Health Research Reviews ◽

10.1017/s1466252320000201 ◽

2020 ◽

pp. 1-7

Author(s):

Sharif S. Aly ◽

Betsy M. Karle ◽

Deniece R. Williams ◽

Gabriele U. Maier ◽

Sasha Dubrovsky

Keyword(s):

Risk Factors ◽

Risk Assessment ◽

Risk Factor ◽

Respiratory Disease ◽

Scoring System ◽

Prevention And Control ◽

Assessment Tool ◽

Bovine Respiratory Disease ◽

And Control ◽

Management Changes

Abstract Bovine respiratory disease (BRD) is the leading natural cause of death in US beef and dairy cattle, causing the annual loss of more than 1 million animals and financial losses in excess of $700 million. The multiple etiologies of BRD and its complex web of risk factors necessitate a herd-specific intervention plan for its prevention and control on dairies. Hence, a risk assessment is an important tool that producers and veterinarians can utilize for a comprehensive assessment of the management and host factors that predispose calves to BRD. The current study identifies the steps taken to develop the first BRD risk assessment tool and its components, namely the BRD risk factor questionnaire, the BRD scoring system, and a herd-specific BRD control and prevention plan. The risk factor questionnaire was designed to inquire on aspects of calf-rearing including management practices that affect calf health generally, and BRD specifically. The risk scores associated with each risk factor investigated in the questionnaire were estimated based on data from two observational studies. Producers can also estimate the prevalence of BRD in their calf herds using a smart phone or tablet application that facilitates selection of a true random sample of calves for scoring using the California BRD scoring system. Based on the risk factors identified, producers and herd veterinarians can then decide the management changes needed to mitigate the calf herd's risk for BRD. A follow-up risk assessment after a duration of time sufficient for exposure of a new cohort of calves to the management changes introduced in response to the risk assessment is recommended to monitor the prevalence of BRD.

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Stress Fractures And The Reproductive System In The Female Athlete

10.2310/fm.1513 ◽

2018 ◽

Author(s):

Irfan M Asif ◽

Kimberly Harmon ◽

Mallory Shasteen

Keyword(s):

Femoral Neck ◽

Disordered Eating ◽

Reproductive System ◽

Female Athlete ◽

Female Athletes ◽

Stress Fractures ◽

Female Athlete Triad ◽

Low Back ◽

Mineral Density ◽

Pubic Ramus

Stress fractures are more common in the female athlete. Stress fractures of the pubic ramus and femoral neck are particularly more common in females than in males. Rib stress fractures are an important injury to consider in the female rower, whereas spondylolysis is a common cause of low back pain in female athletes who hyperextend their spines. The higher incidence of stress fractures in females is mainly due to the higher prevalence of disordered eating and subsequent energy imbalance, which leads to detrimental effects on bone. This review discusses stress fractures and unique issues related to exercise and the female reproductive system. This review contains 6 figures, 5 tables and 49 references Key words: amenorrhea, bone mineral density, disordered eating, female athlete triad, femoral neck, pregnancy, pubic ramus, rib, spondylolysis, stress fracture

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Female Athlete Triad (TRIAD), Relative Energy Deficiency of the Sport (RED-S), and Burnout Syndrome of the Athlete (BSA): Concepts, Similarities, and Differences from Overtraining Syndrome (OTS)

Overtraining Syndrome in Athletes ◽

10.1007/978-3-030-52628-3_9 ◽

2020 ◽

pp. 167-176

Author(s):

Flavio Cadegiani

Keyword(s):

Female Athlete ◽

Relative Energy ◽

Burnout Syndrome ◽

Female Athlete Triad ◽

Energy Deficiency ◽

Overtraining Syndrome ◽

Similarities And Differences

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The LEAF questionnaire is a good screening tool for the identification of the Female Athlete Triad/Relative Energy Deficiency in Sport among young football players

PeerJ ◽

10.7717/peerj.12118 ◽

2021 ◽

Vol 9 ◽

pp. e12118

Author(s):

Edyta Łuszczki ◽

Pawel Jagielski ◽

Anna Bartosiewicz ◽

Maciej Kuchciak ◽

Katarzyna Dereń ◽

...

Keyword(s):

At Risk ◽

Body Composition ◽

Energy Intake ◽

Female Athlete ◽

Relative Energy ◽

Screening Tools ◽

Football Players ◽

Female Athlete Triad ◽

Energy Deficiency ◽

Not At Risk

Background It has been noticed that Female Athlete Triad (Fat) and Relative Energy Deficiency (Red-S) in Sport are characterized by the symptoms of impaired endocrine-metabolic function and bone health in female athletes. In addition, it may be evaluated with a qualitative tool, such as Low Energy Availability in Females questionnaire (LEAF-Q) and quantitative measurements: bone mineral density (BMD), resting energy expenditure (REE), body composition, 24-hour dietary recall. Methods The aim of this study was to assess the prevalence of Triad and Red-S using the LEAF-Q in youth female football players. Additionally, the difference in the BMD, body composition, REE and energy intake (EI) were assessed between the Triad/Red-S risk and not at-risk groups. Results Almost two thirds (64.7%) of participants are classified as being at-risk for the triad according to their LEAF-Q scores. There were no statistically significant differences (p > 0.05) between most of the values among children from the analyzed groups. There was a statistically significant difference (p < 0.001) between the EI values among girls from the two analyzed groups: at-risk (1,773.18 kcal ± 232.57) and not at-risk (2,054.00 kcal ± 191.39). Girls who did not meet the energy intake recommendations were 10.00 as likely to be in the Triad/Red-S risk group. Conclusion Early identification of Fat/Red-S symptoms by screening tools such as the LEAF questionnaire is important in protecting young athletes from long-term damage due to the progression of the risk factors associated with the Fat/Red-S.

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2 The prevalence of musculoskeletal injuries, menstrual irregularity and disordered eating in junior elite athletics in the UK

British Journal of Sports Medicine ◽

10.1136/bjsm-2021-basemabs.2 ◽

2021 ◽

Vol 55 (16) ◽

pp. 940.2-941

Author(s):

J Wilkinson ◽

L Mayhew

Keyword(s):

Disordered Eating ◽

Sports Medicine ◽

Injury Risk ◽

Relative Energy ◽

Track And Field ◽

Energy Availability ◽

Female Athlete Triad ◽

Menstrual Dysfunction ◽

Energy Deficiency ◽

The Uk

The prevalence of injury in adolescent elite track and field competitors is high,1 however only one study has been conducted with UK athletes.2 Relative Energy Deficiency in Sport (RED-S), encapsulating the Female Athlete Triad, is a syndrome whereby decreased energy availability affects health and performance, potentially leading to an increased injury risk; particularly to bone (3). Calculating decreased energy availability is difficult, however identifying contributing factors, such as disordered eating and menstrual dysfunction, is more viable.3AimThis study was conducted to identify the prevalence of musculoskeletal injury, disordered eating and menstrual dysfunction in elite junior UK track and field athletes.MethodData was collected from track and field athletes ranked within the top 10 of the UK U17 rankings in 2017 or 2018, with 138 athletes participating. Participants completed a self-reported musculoskeletal injury, disordered eating and menstrual dysfunction questionnaire relating to a 12-month time period.ResultsThis study found a 12-month retrospective injury prevalence of 43.5%. 13% of participants presented with disordered eating, whilst 37.7% of female participants presented with menstrual dysfunction. There was a statistically significant difference in injury prevalence according to gender, with more male athletes sustaining an injury compared with female athletes. No differences in injury prevalence were noted according to event group, menstrual dysfunction or disordered eating. The anatomical location displaying the highest prevalence of injury was the ankle and foot (22.5%). The anatomical structure displaying the highest 12-month injury prevalence was muscle (43.6%), followed by bone (30.9%). Additionally, 21.7% of respondents reported having previously sustained a stress fracture prior to taking part in this study.ConclusionThere is a high prevalence of injuries in junior UK track and field athletes, with most injuries affecting the lower limb. Although there was no difference noted in injury risk for athletes with menstrual dysfunction or disordered eating, the prevalence of bone injuries was alarmingly high. This study indicates the requirement for future research investigating RED-S within this population.ReferenceZemper, E. Track andField Injuries. In: Caine DJ, Maffulli N. (eds). Epidemiology of Pediatric Sports Injuries. Individual Sports. Med Sport Science: Volume 48. Basel, Karger; 2005. p. 138–151D’Souza D. Track and field athletics injuries - a one-year survey. British Journal of Sports Medicine 1994; 28 (3): 197–202.Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine 2014; 48: 491–497.

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