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Low Bone Density Risk Is Higher in Exercising Women with Multiple Triad Risk Factors

Gibbs, Jenna C.1; Nattiv, Aurelia2; Barrack, Michelle T.2,3; Williams, Nancy I.1; Rauh, Mitchell J.4; Nichols, Jeanne F.5; De Souza, Mary Jane1

Medicine & Science in Sports & Exercise: January 2014 - Volume 46 - Issue 1 - p 167–176
doi: 10.1249/MSS.0b013e3182a03b8b
Applied Sciences

The cumulative effect of the female athlete triad (Triad) risk factors on the likelihood of low bone mineral density (BMD) in exercising women is unclear.

Purpose: This study aimed to determine the risk of low BMD in exercising women with multiple Triad risk factors.

Methods: We retrospectively examined cross-sectional data from 437 exercising women (mean ± SD age of 18.0 ± 3.5 yr, weighed 57.5 ± 7.1 kg with 24.5% ± 6.1% body fat) obtained at baseline from 4 prospective cohort studies examining Triad risk factors. Questionnaires were completed to obtain information on demographic characteristics, self-reported eating attitudes/behaviors, menstrual function, sport/activity participation, and medication use. Height and body weight were measured. BMD was measured using dual energy x-ray absorptiometry. Low BMD was defined as z-scores of <−1 and ≤−2. Chi-square tests were performed to determine the percentage of women with low BMD who met the criteria for individual (current oligo/amenorrhea, late menarche, low body mass index (BMI), elevated dietary restraint, lean sport/activity participation) or multiple (2, 3, 4, or 5) Triad risk factors.

Results: Late menarche and low BMI were associated with the highest percentage of low BMD (z-score < −1), 55% and 54%, respectively, and low BMD (z-score ≤−2), 14% and 16%, respectively. The percentage of participants with low BMD (z-score < −1 and ≤−2) increased from 10% to 62% and from 2% to 18%, respectively, as women met the criteria for an increasing number of Triad risk factors.

Conclusions: A cumulative number of Triad risk factors were associated with an increased risk of low BMD, suggesting a dose–response association between the number of Triad risk factors and BMD in exercising women. Further research should be conducted to develop a user-friendly algorithm integrating these indicators of risk for low BMD in exercising women (particularly factors associated with low BMI/body weight, menstrual dysfunction, lean sport/activity participation, and elevated dietary restraint).

1The Pennsylvania State University, University Park, PA; 2University of California, Los Angeles, CA; 3California State University, Northridge, CA; 4San Diego State University, San Diego, CA; and 5University of California, San Diego, CA

Address for correspondence: Mary Jane De Souza, Ph.D., Department of Kinesiology, The Pennsylvania State University, 104 Noll Laboratory, University Park, PA 16802; E-mail:

Submitted for publication February 2013.

Accepted for publication June 2013.

© 2014 American College of Sports Medicine