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Eating Disorder and Menstrual Dysfunction Screening, Education, and Treatment Programs

Survey Results From NCAA Division 1 Schools

Katherine A. Beals, PhD, RD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 31 - NO. 7 - JULY 2003

ABSTRACT

OBJECTIVE: To describe the nature, scope, and perceived effectiveness of selected National Collegiate Athletic Association (NCAA) Division 1 programs for the screening, education, and treatment of eating disorders (ED) and menstrual dysfunction (MD).

METHODS: Surveys were mailed to the team physician or the head athletic trainer of all NCAA Division 1 schools currently supporting at least two of the following women's sports: cross-country/track, swimming, and gymnastics. The survey contained closed- and open-ended questions to ascertain the types of ED and MD screening, education, and treatment programs and their perceived effectiveness.

RESULTS: A total of 170 surveys were sent, and 81% were returned. Although 79% of schools reported screening for MD, only 24% used a comprehensive menstrual history questionnaire. An MD treatment protocol was used by 33% of schools, and 7% reported withholding those with MD from athletic participation. Screening for ED was reported by 60% of schools, but less than 6% used a structured interview or a validated ED questionnaire. Athletes with confirmed ED were withheld from athletic participation by 21% of the schools; athletes with suspected ED were withheld by 9%. Education about ED and MD was made available to athletes by 73% of the schools, and 61% of the schools made this education available to coaches. However, less than 41% of schools made such education a requirement. Thirty-five percent of respondents perceived their MD screening programs to be successful or very successful, compared with 26% for ED screening programs.

CONCLUSIONS: These results indicate a pressing need for more standardized ED and MD screening, prevention, and treatment programs among NCAA Division 1 schools. At the very least, all NCAA-member institutions should implement mandatory ED and MD education for all athletes and athletic personnel.

The female athlete triad refers to three distinct but interrelated disorders: disordered eating, menstrual dysfunction, and osteoporosis.1 Although any of these disorders can, and do, occur in isolation, they often follow a typical developmental pattern. An athlete may initially develop disordered eating that leads to menstrual dysfunction and subsequent loss of bone mineral density.1,2 While each disorder of the triad is a significant medical concern, when all three disorders occur together, the potential health consequences worsen substantially.2-8 For this reason, both legislative and educational efforts have attempted to stem the growing prevalence of the triad among young women.

The Eating Disorders Information and Education Act was incorporated into the Women's Health Equity Act of 1993 to provide information and education about the prevention and treatment of eating disorders and the associated medical problems.2 One of the most important movements to arise from this legislation is the National Eating Disorder Screening Program, which has been implemented on college campuses nationwide to aid in eating disorder (ED) education and prevention.9

The scientific community and various medical and athletic organizations have also become involved in triad prevention and treatment efforts. In 1990, the National Collegiate Athletic Association (NCAA) published a list of warning signs and symptoms for ED in athletes and developed a set of educational materials and resources (recently revised and expanded) for coaches, athletic trainers, and athletic administrators.10 In 1997, the American College of Sports Medicine (ACSM) issued a position stand that advised development of programs to prevent, recognize, and treat the triad and outlined the steps necessary to achieve these program objectives.1

Despite the global attention that the triad has received, ED and menstrual dysfunction (MD) remain serious problems among female athletes.11-14 Leading experts agree that the key to stemming the growing prevalence of the triad is identification and early intervention.1,15,16 Currently, the NCAA does not provide specific guidelines for programs to identify, prevent, or treat these disorders nor does it monitor the effectiveness of existing programs. Thus, this study sought to examine the nature, scope, and perceived effectiveness of NCAA Division 1 programs for the screening, education, and prevention of ED and MD.

Methods

Subjects and procedures. NCAA Division 1 schools supporting at least two of the following three women's sports were chosen as the study population: cross-country/track, gymnastics, or swimming. Research suggests that these sports have the highest prevalence rates for MD and ED, and schools with these sports should have a particular interest in triad identification, education, and treatment programs.1

The primary investigator made the initial telephone contact with the head athletic trainer or team physician of each school that met the inclusion criteria (a total of 170 schools) to explain the aims of the study and enlist participation. These personnel were chosen because they generally have the primary responsibility for organizing and conducting the preparticipation examinations and are therefore most familiar with their schools' ED and MD screening, prevention, and treatment protocols. A total of 170 surveys were mailed, and reminder calls were made if surveys were not returned within a month. All procedures were approved by the Ball State University Institutional Review Board.

Instrumentation. A survey was developed for this study. It consisted of open- and closed-ended questions (18 major questions with some that had additional subquestions) designed to determine the nature, scope, and perceived effectiveness of ED and MD screening, education, and treatment programs (table 1). A panel of five experts in triad disorders reviewed and evaluated the survey for content validity. Respondents were also asked to provide a description of their preparticipation exam (components, process, etc) and any other questionnaires that they used (eg, health history, ED or MD screening tools, food logs).

TABLE 1. Selected Sample Questions From the Female Athlete Triad Survey*
The survey included 18 primary questions (and several subquestions) designed to elicit information about screening, prevention, and treatment protocols for the female athlete triad. Some included were:

1. Do you currently screen for menstrual dysfunction in female athletes? ___Yes ___ No
If yes, please indicate how menstrual dysfunction is screened:
      ___ 1-2 questions on the preparticipation exam (eg, Is your period regular? Have you ever skipped a period?)
___ Comprehensive menstrual history (eg, questions about age of menarche, frequency of menstrual periods [ie, no./yr and no./6 mo], regularity of periods, incidence of amenorrhea or oligomenorrhea, oral contraceptive use and reason for use)
___ Gynecological exam
___ Other (Please describe) __________________________________________________________________

2. Do you currently have a standard treatment protocol for menstrual dysfunction?
___ Yes (Please describe)___________________________________________________        ___ No

3. If you do not have a standard treatment protocol for menstrual dysfunction, how is it typically treated? (Check all that apply)
___ Oral contraceptives/hormone replacement therapy
___ Nutritional consultation/intervention (Please describe)
___ Alterations in the athlete's training regimen (Please describe)
___ Other (Please describe)

4. Do you currently screen for eating disorders in female athletes? ___ Yes___ No
If yes, how are eating disorders screened? (Check all that apply)
___ Self-report eating disorder questionnaire
___ Eating Disorder Inventory (EDI)
___ Eating Attitudes Test (EAT)
___ Bulemia test (BULIT)
___ Setting Conditions for Anorexia Nervosa Scale (SCANS)
___ Restrained Eating Questionnaire
___ Self-developed questionnaire
___ Other (Please describe) __________________________________________________________________
___ DSM-IV (Diagnostic criteria for anorexia nervosa and bulimia nervosa)
___ Weight-for-height guidelines
___ Weight-loss history
___ Dieting history
___ Excessive/frequent musculoskeletal injuries
___ Self-reported dissatisfaction with body weight
___ Other (Please describe) __________________________________________________________________

5. Do you currently have a standard treatment protocol for confirmed cases of eating disorders?
___ Yes (Please describe)___________________________________________________        ___ No

6. If you do not have a standard treatment protocol for confirmed cases of eating disorders, how (or by whom) are they typically treated? (Check all that apply)
___ Treated by the team physician
___ Referred to a psychiatrist/psychologist
___ Referred to an eating disorder specialist
___ Referred to a dietitian
___ Other (Please describe) __________________________________________________________________


*The complete survey is available from the author

Results

The survey response rate was 81% (138 of 170). The respondent was most often the head athletic trainer (75%), followed in order by an assistant trainer (17%) and team physician (8%). Seventy-nine percent of the schools reported screening for MD; however, the screening most often consisted of one or two questions included on the preparticipation exam (eg, Do you have regular periods? Have you ever skipped a period?). Only 24% of schools reported using a comprehensive menstrual history survey. Thirty-three percent of schools reported having a treatment protocol for MD, with the rest (67%) citing treatment as case-by-case, which included one or more of the following: referral to a gynecologist (38%), hormone replacement therapy (23%), nutrition intervention (21%), and/or a reduction in training volume (14%). (Multiple responses were allowed.) Seven percent of the schools reported withholding those with MD from athletic participation.

Sixty percent of the schools reported screening for ED during the preparticipation exam, although only 4% used a structured interview, and 5% used a comprehensive and/or validated self-report ED questionnaire (eg, Eating Disorder Inventory, Eating Attitudes Test, Restrained Eating Questionnaire). The rest of the schools indicated that they used self-developed questionnaires (27%) or more indirect measures of assessing ED (eg, weight-for-height standards, weight-loss history, excessive injuries). Forty percent had a treatment protocol for ED, while the other 60% stated that treatment was case by case and involved one or more of the following healthcare providers: team physician (53%), psychologist or psychiatrist (62%), registered dietitian (46%), and/or eating-disorder specialist (45%).

Twenty-one percent of the schools reported completely restricting (ie, withholding) athletes with diagnosed ED from athletic participation, while 46% indicated "degrees of restriction" from training and/or competition based on the presence and severity of medical complications. Nine percent of schools reported withholding athletes with suspected ED from athletic participation.

Education about ED and MD (eg, group seminars, individual counseling, videos, written materials) was made available to female athletes by 73% of the schools, yet only 41% made the education a requirement (figure 1). Similarly, while 61% of schools indicated that ED and MD education was available to the coaches, less than 28% made participation mandatory (figure 2). Thirty-five percent of schools perceived their screening programs for MD to be successful or very successful (>51% of MD cases identified), while 26% perceived their ED screening programs to be successful or very successful (>51% ED of cases identified; figure 3).

Discussion

In 1997, the ACSM issued a position stand outlining the components of the female athlete triad and advising that "...strategies specific to prevention, surveillance, research, health consequences, medical care, and public and professional education need to be developed, implemented, and monitored."1

The results of this study suggest that much work remains to be done in all of the areas described in the position stand if we are to stem the growing prevalence of MD and ED among female athletes. Even though 79% of the schools surveyed reported screening for MD, the reported "screening" would not be considered sufficiently comprehensive by most experts.15,17-20 Similarly, less than 6% of schools reported using a comprehensive or validated self-report ED questionnaire, or an in-depth interview, as has been recommended by experts.15,17,19,21

To screen effectively for MD, the preparticipation exam should include a comprehensive menstrual history that includes questions ascertaining age of menarche, frequency (number of cycles per year) and regularity of periods since menarche, frequency and duration of amenorrhea, oral contraceptive use, and the reasons for contraceptive use.17,18,20,22 Similarly, ED screening should include a comprehensive or validated questionnaire or structured interview to assess disordered eating behaviors, weight or shape satisfaction or dissatisfaction, weight-control behaviors, and typical eating patterns.16,17,21 A food frequency questionnaire, dietary recall, or food log can be used to assess energy intake, avoidance of foods or food groups, or risk for nutritional deficiencies.16

This study found that few schools had a formal treatment protocol for either disorder. Thirty-three percent employed a treatment protocol for MD, while 40% had one for managing ED. Failure to maintain a protocol for treating ED and MD can be problematic for both the athlete and the academic institution. For the athlete, a treatment protocol is important to ensure prompt and effective management of ED and MD. Practitioners contend that the severity and chronicity of ED are positively associated with the duration of treatment required and negatively associated with treatment outcomes.23 Thus, the sooner the athlete is identified and treated, the greater the likelihood for a quick and successful recovery. Similarly, the health risks associated with MD (eg, reproductive dysfunction, decreased immune function, cardiovascular problems, decreased bone mineral density) become increasingly severe the longer MD remains untreated.3

From an administrative standpoint, a treatment protocol is imperative for protecting the institution against liability. In addressing the legal responsibilities of college athletic departments to athletes, Bickford24 asserted that institutions that ignore eating and menstrual disorders may be found negligent and subject to all of the accompanying legal ramifications. A treatment protocol should outline the specific steps to be taken when an athlete is identified with ED and/or MD. The University of Texas at Austin's Performance Team has successfully developed and implemented comprehensive ED and MD identification and treatment protocols.25 Originally developed in 1985, the Performance Team of the University of Texas at Austin comprises experts in the fields of orthopedics, endocrinology, exercise physiology, body composition, cardiology, pharmacology, psychology, sociology, allergy and immunology, physical therapy, and athletic training. The Performance Team protocols have been published in many texts, spotlighted in several journal articles, and copied by many academic institutions for the simple reason that they have been so successful in their mission of protecting the health and well-being and enhancing the performance of elite female athletes.

According to the 1997 ACSM position stand, successful treatment of the triad lies in its prevention, and prevention ultimately depends on widespread educational efforts.1 This study indicated that education is not receiving the priority necessary to effectively prevent ED and MD in female collegiate athletes. Nearly 75% of the schools surveyed reported that ED and MD education were available to coaches and athletes, but less than 41% of the schools made participation mandatory. Educational programs for MD and ED should focus on dispelling the myths and misconceptions regarding nutrition, dieting, and body weight and composition—and their impact on athletic performance—while stressing the importance of sound nutrition practices for health and optimal performance.1,16 These programs should be mandatory for all athletes, coaches, team physicians, athletic trainers, and support staff.

Taking the Next Step

Because the pressures on female athletes to be thin are unlikely to abate any time soon, neither will the risk of developing one or more of the triad disorders. For this reason, sports medicine professionals have a responsibility to become skilled in recognizing, preventing, and treating disorders constituting the triad. Only through the development and implementation of comprehensive ED and MD screening, prevention, and treatment programs can we hope to reduce the potentially serious physiologic and psychological problems arising from the triad.

I would like to thank the following individuals who provided invaluable insight into triad screening and prevention and aided in the evaluation of the survey used in this investigation: Renata Frankovich, MD (team physician, University of Ottawa), Mimi Johnson, MD (physician, Washington Sports Medicine Clinic), Elizabeth Joy, MD (team physician, University of Utah), Aurelia Nattiv, MD (team physician, University of California at Los Angeles), and Randa Ryan, PhD (associate athletic director, University of Texas at Austin).

References

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  2. Nattiv A, Agostini R, Drinkwater B, et al: The female athlete triad: the inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med 1994;13(2):405-418
  3. Constantini NW: Clinical consequences of athletic amenorrhea. Sports Med 1994;17(4):213-223
  4. Beckvid-Henriksson G, Schnell C, Linden-Hirschberg A: Women endurance runners with menstrual dysfunction have prolonged interruption of training due to injury. Gynecol Obstet Invest 2000;49(1):41-46
  5. Keen AD, Drinkwater BL: Irreversible bone loss in former amenorrheic athletes. Osteoporos Int 1997;7(4):311-315
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  10. National Collegiate Athletic Association Available at: The female athlete triad: a review of disordered eating, amenorrhea, and osteoporosis. Available at http://www.ncaa.org/news/1998/19980420/active/3516n18.htm. Accessed April 24, 2003
  11. Dick RW: Eating disorders in NCAA athletic programs. J Athl Train 1991;26(3):137-140
  12. Dick RW: Eating disorders in NCAA athletic programs: replication of a study. NCAA Newsletter. Spring 1993:3-4
  13. Johnson C, Powers PS, Dick R: Athletes and eating disorders: the National Collegiate Athletic Association study. Int J Eat Disord 1999;26(2):179-188
  14. Beals KA, Manore MM: Disorders of the female athlete triad among collegiate athletes. Int J Sport Nutr Exerc Metab 2002;12(3):281-293
  15. Nattiv A, Lynch L: The female athlete triad: managing an acute risk to long-term health. Phys Sportsmed 1994;22(1):60-68
  16. Sanborn CF, Horea M, Siemers BJ, et al: Disordered eating and the female athlete triad. Clin Sports Med 2000;19(2):199-213
  17. Johnson MD: Tailoring the preparticipation exam to female athletes. Phys Sportsmed 1992;20(7):61-72
  18. Tanner SM: Preparticipation examination targeted for the female athlete. Clin Sports Med 1994;13(2):337-353
  19. Smith AD: The female athlete triad: causes, diagnosis, and treatment. Phys Sportsmed 1996;24(7):67-75
  20. American Academy of Pediatrics: Committee on Sports Medicine and Fitness: medical concerns in the female athlete. Pediatrics 2000;106(3):610-613
  21. Walsh JM, Wheat ME, Freund K: Detection, evaluation, and treatment of eating disorders: the role of the primary care physician. J Gen Intern Med 2000;15(8):577-590
  22. Shangold M, Rebar RW, Wentz AC, et al: Evaluation and management of menstrual dysfunction in athletes. JAMA 1990;263(12):1665-1669
  23. Thompson RA, Sherman RT: Helping Athletes With Eating Disorders. Champaign, IL, Human Kinetics, 1993
  24. Bickford B: The legal duty of a college athletics department to athletes with eating disorders: a risk management perspective. Marquette Sports Law J 1999;10(1):87-116
  25. Ryan R: Management of eating problems in athletic settings, in Brownell K, Rodin J, Wilmore JH (eds): Eating, Body Weight, and Performance in Athletes: Disorders of Modern Society. Philadelphia, Lea & Febiger, 1992, pp 344-362

Dr Beals is associate professor of nutrition in the department of family and consumer sciences at Ball State University in Muncie, Indiana. Address correspondence to Katherine A. Beals, PhD, RD, Dept of Family and Consumer Sciences, Ball State University, Muncie, IN 47306; e-mail to kbeals@bsu.edu.

Disclosure information: Dr Beals discloses no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.

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