Bone Issues in the Female Athlete...
Transcript of Bone Issues in the Female Athlete...
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
presentation for UK Athletics Taunton
Objectives
• Female athlete triad- description
and clinical features
• Skeletal structure and
minearalisation
• Consequences of not detecting
Triad - Osteoporosis
• Prevention of Triad
Dr. Millicent Stone
presentation for UK Athletics Taunton
Female Athlete Triad
Dr. Millicent Stone
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
What causes the Triad?
I Energy Deficit/Disordered Eating
II Menstrual Disturbances/Amenorrhea
III Bone Loss/Osteoporosis
Dr. Millicent Stone
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
New Model of FAT
Dr. Millicent Stone
presentation for UK Athletics Taunton
‘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
presentation for UK Athletics Taunton
Prevention of the TRIADHealthy Athletic Culture
Eliminate
inappropriate
dietry practices
Triad Education
Public policy
Research
Dr. Millicent Stone
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
Nutrition and educational preventative
efforts
• Clinically recognised eating disorders
• Subclinical – athletes with preoccupation
with body weight or body image
Dr. Millicent Stone
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
Consequences…..
FRACTURE
Dr. Millicent Stone
presentation for UK Athletics Taunton
What is Osteoporosis?
Dr. Millicent Stone
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
It’s doesn’t just affect older women.....
Dr. Millicent Stone
presentation for UK Athletics Taunton
Why do Bones Break?
Dr. Millicent Stone
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
Dr. Millicent Stone
presentation for UK Athletics Taunton
Dr. Millicent Stone
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
Dr. Millicent Stone
presentation for UK Athletics Taunton
Dr. Millicent Stone
presentation for UK Athletics Taunton
Dr. Millicent Stone
presentation for UK Athletics Taunton
Refer for Bone Health Consultation
Dr. Millicent Stone
presentation for UK Athletics Taunton
DEXA Scan
Dr. Millicent Stone
presentation for UK Athletics Taunton
Detection of Risk of Low bone density and
those at risk of fracture?
HEEL ULTRASOUND
+ FRAX (age . 40 only)
+ Clinical
decision
Dr. Millicent Stone
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
Dr. Millicent Stone
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
Not everything is as it seems…
Dr. Millicent Stone
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
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
presentation for UK Athletics Taunton
Female Athlete Triad Coalition
• http://www.femaleathletetriad.org/