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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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This section for MS Plan A Thesis or EdS Thesis/Field Project papers only Committee members (other than your advisor who is listed in the section above) 1. CMTE MEMBER’S NAME: DATE:

2. CMTE MEMBER’S NAME: DATE:

3. CMTE MEMBER’S NAME: DATE:

--------------------------------------------------------------------------------------------------------------------------------- This section to be completed by the Graduate School This final research report has been approved by the Graduate School.

Director, Office of Graduate Studies: DATE:

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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.

23

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

24

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

28

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 arvolda@uwstout.edu fahme@uwstout.edu 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, arvolda@uwstout.edu. Sue Foxwell, Director, Research Services 152 Vocational Rehabilitation Bldg.

Advisor: Dr. Esther Fahm, UW-Stout Menomonie, WI 54751 715-232-2550, fahme@uwstout.edu 715-232-2477 foxwells@uwstout.edu 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.”

46

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.

47

•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

48

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.

49

~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

50

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: _________________