Bone Issues in the Female Athlete amendedouccc.org.uk/wp-content/uploads/2012/10/UK-athletics-Dr.-M-Stone.pdfpresentation for UK Athletics Taunton Not everything is as it seems…

Dr. Millicent Stone

presentation for UK Athletics Taunton

Bone Issues in the Female Athlete;

from Energy deficiency to Fracture

Dr. Millicent A Stone

Consultant Rheumatologist Musgrove Park Hospital and Clinical

Reader University of Bath

Dr. Millicent Stone


Objectives

• Female athlete triad- description

and clinical features

• Skeletal structure and

minearalisation

• Consequences of not detecting

Triad - Osteoporosis

• Prevention of Triad

Dr. Millicent Stone


Female Athlete Triad

Dr. Millicent Stone


What is The Triad?

The Female Athlete Triad is a syndrome of

three interrelated conditions that exist on a

continuum of severity, including:

• Energy Deficit/Disordered Eating

• Menstrual Disturbances/Amenorrhea

• Bone Loss/Osteoporosis

Dr. Millicent Stone


What causes the Triad?

I Energy Deficit/Disordered Eating

II Menstrual Disturbances/Amenorrhea

III Bone Loss/Osteoporosis

Dr. Millicent Stone


What causes The Triad?

I Energy Deficit/Disordered Eating

• An energy deficit is an imbalance between the amount of energy consumed and the amount of energy expended during exercise.

• The primary cause of the Female Athlete Triad is energy deficiency. Often, this can involve a conscious restriction of food intake, problems with body image and a high drive for thinness.

• Sometimes, these conditions can lead to disordered eating, or more serious eating problems, like anorexia or bulimia.

Dr. Millicent Stone


II What causes the triad? Menstrual Disturbances/Amenorrhea

• The most serious menstrual problem associated with the Triad is amenorrhea, defined as no menstrual period for 3 months or more.

• However, athletes who have irregular menstrual cycles are also susceptible to the effects of the Triad.

Dr. Millicent Stone


III What causes the Triad? Bone Loss/Osteoporosis

• Women with the Triad are at higher risk for low bone mass leading to weakened bones, called osteoporosis in its severe form.

• This type of bone loss can cause an increased risk of fractures, including stress fractures

Dr. Millicent Stone


New Model of FAT

Dr. Millicent Stone


‘New Model’

• Continuum from Health to Disease

• Subclinical manifestations often with one or more elements

• May present with one element/progressing at different rates but likely to be suffering from all three elements

Dr. Millicent Stone


Prevention of the TRIADHealthy Athletic Culture

Eliminate

inappropriate

dietry practices

Triad Education

Public policy

Research

Dr. Millicent Stone


Chronic Energy expenditure

• Deficiency in energy expenditure

– negative imbalance between food intake and

energy expenditure through exercise — it

doesn’t matter if the imbalance is due to an

intentional caloric restriction or an increase

in exercise

1. Disordered eating behaviour

2. Unintentional caloric restriction********

Dr. Millicent Stone


Nutrition; A Trigger and Key to

prevention

• Research on appropriate threshold of

energy • Normal caloric intake up to 8 miles / day athletes

but other studies say menstrual irregularities in

women running up to 7.5 miles a week

Dr. Millicent Stone


Nutrition and educational preventative

efforts

• Clinically recognised eating disorders

• Subclinical – athletes with preoccupation

with body weight or body image

Dr. Millicent Stone


What should you as coach look out for

as a sign of the Triad

– Irregular or absent menstrual cycles

– Always feeling tired and fatigued

– Problems sleeping

– Stress fractures and frequent or recurrent injuries

– Often restricting food intake

– Constantly striving to be thin

– Eating less than needed in an effort to improve

performance or physical appearance

– Cold hands and feet

Dr. Millicent Stone


Key risk factors for Triad

• Playing sports that require weight checks

• Social isolation due to sporting activities

• Exercising more than necessary for a sport

• Pressure to “win at all costs”

• Punitive consequences for weight gain

• Controlling parents and/or coaches

• Being a gymnast, figure skater, ballet dancer, distance runner, swimmer or diver where undue emphasis is placed on having a low body weight and a lean physique

Dr. Millicent Stone


Warning signs!!!

• If the athlete suffers from ≥

– Irregular menstrual cycles

– Increased stress fractures

– Restrictive eating patterns

• Action

– Visit physician and inquire about testing and treatment

– If diagnosed improve energy balance

– Get help physician, nutritionist, counsellor

Dr. Millicent Stone


Consequences…..

FRACTURE

Dr. Millicent Stone


What is Osteoporosis?

Dr. Millicent Stone


Why is Osteoporosis so important?

KEY FACTS

• 3 million people in UK, costing

£6 million a day to the NHS

• I in 2 women and 1 in 5 men

over 50 years will suffer a

fracture

Dr. Millicent Stone


Osteoporosis + falls = fragility fractures

1. J Endocrinol Invest 1999;30:583-588 Kanis JA & Johnell O

2. Osteoporosis Review. 2009;17(1):14-16 Mitchell PJ

“Hip fracture is all too often the final destination of a 30 year journey

fuelled by decreasing bone strength and increasing falls risk”2

Morbidity

attributable to

ageing alone

Dr. Millicent Stone


It’s doesn’t just affect older women.....

Dr. Millicent Stone


Why do Bones Break?

Dr. Millicent Stone


Cortical bone

Adapted from Dempster DW. Anatomy and functions of the adult skeleton. In: Favus MJ, et al. (eds).Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 6th ed. ASBMR;2006;7-11.

Femur

Trabecularbone

Periosteum

Haversian system

Vertebrae

Skeletal form and function• The skeleton is a dynamic organ with

mechanical, protective, and metabolic functions

• Composed of two types of bone:

– Cortical bone

– Trabecular bone

Dr. Millicent Stone


Cortical bone

• Dense outer shell of compact

bone; defines bone shape

• 80% of skeletal mass

• Essential functions:

– Provides biomechanical

strength

– Attachment site for tendon

and muscle

– Protection against excess

trauma

• Turnover rate of 2 - 3%

per year

Adapted from Dempster DW. Anatomy and functions of the adult skeleton. In: Favus MJ, et al. (eds).Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 6th ed. ASBMR;2006;7-11.

Dr. Millicent Stone


Trabecular bone

• A sponge-like network of

delicate plates of bone

known as trabeculae

• 20% of skeletal mass

• Essential functions:

– Mineral metabolism

– Strength and elasticity

• Higher turnover rate

compared with cortical

bone

Dempster DW. Primer on the Metabolic Bone Diseases and Disorders oaf Mineral Metabolism. 6th ed. ASBMR;2006:7-11.

Dr. Millicent Stone


Bone cells

Osteoblasts• ‘Building’

Osteoclasts

- ‘Dismantling’ Osteocytes

- ‘Sensation’

1. Ross FP. Osteoclast biology and bone resorption; and Bonewald LF. Osteocytes In: Favus MJ, et al.(eds).Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 7th ed. Washington, DC:ASBMR;2008

Dr. Millicent Stone


When bone turnover is increased, bone loss dominates

Resorption

Reversal

Stromal and bone

lining cells

Osteoid

PreosteoblastsFormation

Mineralization

Activation

Resting

Stromal and

bone-lining

cells

Osteoclasts

Apoptotic osteoclasts

Osteoblasts

Adapted from Baron R. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 5th ed. 2003;1-8. Raisz LG. J Clin Invest. 2005;115:3318-3325.

Antiresorptives

Anabolics

Dr. Millicent Stone


BONE LOSSBONE LOSS

Calcium absorptionCalcium absorption Estrogen deficiencyEstrogen deficiency

Vitamin D intake and synthesisVitamin D intake and synthesisDietary calcium intakeDietary calcium intake

Plasma calcium Plasma calcium PTH secretionPTH secretion

Bone turnover and resorptionBone turnover and resorption

Age-related bone loss involves declines in estrogen and increases in bone

turnover

Adapted from Riggs BL and Melton LJ III. Raven Press. 1988:155-179

PTH = parathyroid hormone

Dr. Millicent Stone

presentation for UK Athletics TauntonImages courtesy of David W. Dempster, PhD. Reproduced with permission. NIH Consensus Devel;opmentProgram. Osteoporosis prevention, diagnosis, and therapy. NIH Consensus Development Conference 2000.

Osteoporosis

Over time this leads to significant bone loss

Increased osteoclast

activity leads to

bone loss with:» Impaired bone

architecture

» Compromised

bone strength

» Increased risk of

fracture

Dr. Millicent Stone


Summary: Excessive remodeling contributes to osteoporosis

Macroscopic Changes

• Trabecular Bone:

– Thinning

– Loss of connectivity

• Cortical Bone:

– Thinning

– Increased porosity

Increased bone remodeling

Increased skeletal fragility

Adapted from Heaney, RP. Bone. 2003;33:457-465.Borah et al. Anat Rec 2001; 365:101-110

Structural deterioration

Increased

fracture risk

Premenopausal

Woman at 52 Years Old

Osteoporotic

Woman at 68 Years Old

Dr. Millicent Stone


Distribution of calcium

• Total body calcium = 1kg

– 99% in bone

– 1% in blood and body fluids intracellular calcium

– Cytosol

– mitochondria other microsomes regulated by pumps

• Blood calcium = 10mg/100mls

– Non diffusible =3.5mgs

– Diffusible = 6.5mg

Dr. Millicent Stone


Dr. Millicent Stone


Dr. Millicent Stone


Roles of Vitamin D

• Regulation of blood pressure

• Regulation of insulin production

– (heart disease and diabetes prevention

• Regulation of immune function

– (Diabetes Type 1, MS , RA autoimmune

disease)

• Regulation of cell growth

– (cancer prevention)

Dr. Millicent Stone


Dr. Millicent Stone


Dr. Millicent Stone


Dr. Millicent Stone


Refer for Bone Health Consultation

Dr. Millicent Stone


DEXA Scan

Dr. Millicent Stone


Detection of Risk of Low bone density and

those at risk of fracture?

HEEL ULTRASOUND

+ FRAX (age . 40 only)

+ Clinical

decision

Dr. Millicent Stone


Investigation

• If Osteoporosis is diagnosed....

(Definition: BMD T score -2.5 SD below young

adult female T score)

• Full clinical evaluation

• FBC ESR CRP CA Albumin creatinine phosphate

LFTs, vitamin D (total)

• DEXA (unless already high fracture risk)

• Other (coeliac antibodies, urine electrophoresis/

depending on individual cases)

Dr. Millicent Stone


Dr. Millicent Stone


Prevention of Triad

• The best way to prevent The Female

Athlete Triad is through educating

athletes, parents, and coaches about what

it is, how to recognize it, and how to take

steps to prevent it.

Dr. Millicent Stone


Educational of Athletes and Coaches

1. Early detection of athletes with features of the

Triad

– Or those with one or more on a spectrum who may

be heading in wrong direction

– (Even modest caloric restrictions or minor menstrual

irregularities can be indicators)

2. Low threshold for intervention

3. IF ONE feature of Triad investigate others

– I.E. BMD for those with nutrition counselling for

those with minor menstrual irregularities

Dr. Millicent Stone


How can you proactively help your

athletes?

• Pre participating exam, pre season yearly

checkups or screening.

• Ask the right questions!

• Ask all female athletes

• Referral to a physician with an interest in

the area is critical

Dr. Millicent Stone


Not everything is as it seems…

Dr. Millicent Stone


Not everything is as it seems…

• Not all Triad-related symptoms are caused by an energy deficit or dietary problem.

• Amenorrhea might also be caused by an anatomic defect, premature ovarian failure, a prolactin-secreting tumor, polycystic ovarian syndrome (PCOS), or pregnancy.

• Low bone mass, too, can have other causes. A physician’s evaluation and testing can determine whether another health problem is present. If not, an examination of the balance of calories taken in versus those expended throughout the day could point to energy deficiency

Dr. Millicent Stone


Prevention- Coach

1. Remind your athletes that eating is an important part of successful training and performance.

2. Focus on health and a positive body image, do NOT focus on body weight.

3. Support athletes throughout their training and competition, as well as during their everyday life.

4. Mobilize available resources –nutritionists, athletic trainers, counselors, and physicians.

Dr. Millicent Stone


Prevention- as an athlete

1. Monitor your menstrual cycle by using a diary or calendar

2. Consult your physician if you have menstrual irregularities, have recurrent injuries or stress fractures

3. Seek counselling if you suspect you are overly concerned about your body image, for example, if you are constantly striving to be thin

4. Consult a sport nutritionist to help you design an appropriate diet that is specific to your sport and to your body’s energy needs.

5. Seek emotional support from parents, coaches and teammates.

Dr. Millicent Stone


Female Athlete Triad Coalition

• http://www.femaleathletetriad.org/

Documents

Bone Issues in the Female Athlete amendedouccc.org.uk/wp-content/uploads/2012/10/UK-athletics-Dr.-M-Stone.pdfpresentation for UK Athletics Taunton Not everything is as it seems…