Posts Tagged ‘stress fractures’
Let me start by saying, of course this is a complicated issue with no black and white solution. I honestly think it will take me a number of posts to say what I would like to.
Both the pro and anti oral contraception crowds have some data to backup their claims. It’s easy to find female athletes across the spectrum: from those who are able to perform fine on the pill; to those who recognized that they couldn’t achieve their athletic potential while taking the hormones; to women who simply couldn’t function on any form of oral contraception.
The truth is that the studies are extremely limited, and the ones using actual athletes are even more so. Like many issues in women’s health, the lack of data is extremely frustrating.
Though some distance runners begin taking the pill for other reasons – such as acne, birth control, ovarian cysts, etc. – many are urged to start taking it because they are amenorrheic, meaning their menstrual cycles have stopped. There is documented evidence that women who are amenorrheic in young adulthood fail to build the optimal amount of bone and may suffer from low bone density later in life. There is even some data to suggest that a certain extent of this loss may be irreversible.
While the link between estrogen and bone density seems to be established, the logic that birth control pills will protect bone density has not been thoroughly tested. This approach to amenorrhea in young women is actually based on the treatment of post-menopausal women with low bone density using hormone replacement therapy.
There are many reasons that a woman can experience amenorrhea, and by extension thought to be low estrogen. My theory is that our bodies can only handle so much stress and that they need a certain level of homeostasis to function properly. Our stress levels are affected by our diet, activity level, emotional health, and environmental pollutants. Any combination of these assaults can contribute to a stress load that is too much for our system to function normally. When this happens the body goes into crisis mode and decides to stop menstruating.
The reality is that there are a number of highly trained, extremely lean competitive athletes who have normal menstrual cycles. There are also many non-athletic, average weight young women who are amenhorreic. Body-fat and training-level don’t necessarily tell the whole story.
One of the side effects of oral contraceptives that I find very troubling is the increased incidence of depression and mood disorders. The altered brain activity is largely contributed to interference of serotonin uptake and absorption of B-vitamins. This can be extremely detrimental for athletes and anyone suffering from disordered eating. In addition to helping the body handle and process stress, B-vitamins also play an important role in carbohydrate metabolism.
Another consideration is that the hormones in birth control pills, estrogen and progesterone, help feed the overgrowth of yeasts in the female body. Systemic yeast imbalance can result in a variety of very serious conditions including many digestive problems, food sensitivities, allergies, yeast infections, UTIs, skin conditions like acne and eczema, infertility problems, weight gain, and various other ailments.
The latest study about birth control pills reducing a women’s chance of gaining lean muscle mass is really disturbing for athletes. Running, especially, is all about strength to weight ratio.
Again, there isn’t an easy answer to the question of whether birth control pills are good for female distance runners (or athletes in general). There are a number of reasons why I think they aren’t a good idea for everyone. I don’t agree with the blanket prescription policy that is currently in place in most health institutions. Obviously birth control pills can be appropriate for some individuals, but that doesn’t mean that they should be prescribed out so quickly as the solution to every female problem.
I am not a medical doctor, but in my experience, health and athletic performance are best fostered when we look at the whole person. I also feel that a discussion of oral contraceptives in female distance runners or other athletes is incomplete without a further discussion of eating disorders, but I’ll reserve that for another post.
If you are wondering whether you should be taking the birth control pill, I urge you to weigh the positives and negatives and research the subject for yourself. Most doctors see a variety of patients, don’t specialize in treating athletes, and don’t necessarily keep up on the latest research. You have to be your own advocate. If you are you only taking the pill for birth control and are a serious athlete, it might really be worth taking the time to evaluate the trade-offs.
*A side note about Ortho Tricyclen…. My theory is that this company gives a lot free samples and kickbacks to Doctor’s offices because they always prescribe patients on this pill first. According to doctors, they start women on a tri-phasal pill (meaning three different levels of hormones) because it mimics the normal phases of the female’s cycle. The flaw in this logic, as far as I’m concerned, is that when you’re talking about girls who are amenorehic, they don’t have a cycle… so this artificial phasing is very difficult on their systems.
I feel that my situation was pretty typical of what a number of female athletes go through. I was prescribed Ortho Tri Cyclen* when I was 17 because I hadn’t had a period for more than two years. Not wanting to put anything artificial in my body and being scared about the hormones, I didn’t actually start taking the pills until I sustained a stress fracture in my foot during my freshman cross-country season at college.
After the fracture, a doctor convinced me that it occurred because my bone density was low. He said my bones were suffering because I didn’t have periods. This was the case because the absence of menses meant that my body didn’t have enough estrogen… and estrogen was the key to calcium being absorbed by my bones. He told me that my estrogen was low because I ran so much. And he said all this could be corrected by taking the birth control pill because it would supply my body with artificial estrogen that would keep my bones strong.
The Female Athlete Triad- of disordered eating, amenorrhea, and osteoporosis- was a relatively new buzzword ten years ago and doctors, trainers, and coaches were quick to jump to the conclusion that the birth control pill was the easiest, quickest-fix band-aid solution to the most bothersome part of it. I wish that I could say that as a community, sports medicine has made tremendous progress – that doctors, coaches, and trainers know a great deal more about how to address these situations with their athletes, but I don’t really believe it’s much better. Birth control pills are more than ever being prescribed to young athletes (and non-athletes alike) as a quick-fix solution to problems that require a much deeper and more comprehensive look at the whole system.
When I look back at my own situation, I realize that the Doctor made a lot of assumptions in his hypothesis. First, he assumed that my stress fracture was due to having low bone density, though he never measured the density of my bones. In reality it was my training that changed significantly – I had gone from running maybe 40 miles per week on dirt roads in high school in Colorado to running 70+ miles per week in college mostly on pavement.
The other reality about my situation was that running or body fat percentage wasn’t the cause of my amenorrhea. I was always a very active teenager and a “late bloomer.” I played 3-4 varsity level sports during high school. I only had a couple “regular periods” when I was 15 years old and they ceased when I left to be an exchange student in southern Brazil. In Brazil I wasn’t allowed outside of the house alone. It was, by far, the most sedentary I have ever been at any time in my life. And like all exchange students, I gained a few pounds. And yet this is the time in my life when my periods stopped. When I returned from Brazil, I embarked on a 30-day wilderness education course backpacking across Colorado’s San Juan Range. But still my cycle didn’t return.
Over the years I stopped taking birth control twice for several months at time to see if my period would return on its own. Each time I noticed a marked improvement in my mood and digestion, but each time a friend or doctor encouraged me to go back on the pill because I needed it for my bones. I remained on a mono-phasal birth control pill until the age of 25. At that point, my digestive problems and allergies were so bad that I wanted to try anything to alleviate the situation. I read as much as I could find on the subject, scheduled a bone density scan that came back on the low side of normal, and quit the pill for good. It was a liberating feeling!
Eventually, about 7 months later, my cycle returned naturally for the first time in over 10 years. For the first year or two it was not consistent- some months it wouldn’t come, some months it would only last a day. However, the overall trend was one of progress.
Acupuncture has been the single most helpful tool for me in finding hormonal balance and regulating my periods. I highly recommend it!
To go long distances, especially those longer than 10,000m, runners place a premium on relying primarily on aerobic metabolic pathways during the majority of the run. Runners who are capable of doing this rely mainly on fat for the majority of fuel, enabling them to limit the usage of carbohydrate. Carbohydrate storage is finite, but fat storage is, from a practical standpoint, limitless. The higher reliance on fat enables long-distance runners to run very long distances. It also enables them to preserve carbohydrate for moments during the race when they require fast acceleration (e.g., at the end of the race or while passing another runner). According to one study, only 2 to 7 percent of the total energy burned in aerobic activity is derived anaerobically.24 A small amount of carbohydrate is used even when maintaining aerobic activity, so distance runners must develop strategies for delivering carbohydrate during the run. A failure to do so will result in either low blood sugar or low muscle glycogen, both of which impair endurance by leading to premature muscle fatigue.
Keeping this in mind, distance runners must consider the following nutritionally relevant factors for their sport.
Long-distance runners are at risk of amenorrhea, low bone density, and stress fractures. The distances that these athletes run weekly to train may predispose them to stress fractures, despite the potential stimulating impact of running on skeletal mass.25 Although stress fractures occur more frequently in women runners than in men, all runners should ensure that their calcium intake is adequate to reduce the risk of fracture. Female runners are at higher risk of stress fractures because hard endurance training is often associated with cessation of the menstrual cycle. The reduced estrogen associated with amenorrhea is linked to lower bone density. Therefore, runners who experience either primary or secondary amenorrhea should seek appropriate medical advice to determine if rea son able steps can be taken to return to normal menstrual status.26
Female runners should take the following steps to reduce the risk of osteoporosis:
Consume calcium (1,500 milligrams per day) from food or a combination of food and supplements.
Avoid overconsumption of protein because excess protein is associated with higher urinary calcium losses.
Control the production of stress hormones (particularly cortisol) by maintaining hydration and blood sugar during exercise.
Avoid overtraining, which is associated with amenorrhea.
Inadequate energy intake is a red flag that the intake of vitamins and minerals may also be low. A study comparing the nutrient intakes of trained female runners who were amenorrheic, oligomenorrheic, or menstruating normally found clear nutrition differences between these groups, despite being matched on height, weight, training distance, and body fat percentage.27 The runners who were not menstruating had zinc intakes well below the recommended level of intake and lower than those found in the runners who had normal menses. In addition, the runners who had normal menses had higher intakes of fat and a more adequate total energy consumption. This suggests that high-carbohydrate diets, which are preferred for optimal performance, make it more difficult to consume the needed level of energy because carbohydrates have a lower caloric density than high-fat foods. Therefore, athletes should concentrate on consuming more food when carbohydrates constitute the main energy source. A failure to menstruate normally is a strong risk factor in the development of weaker bones and resulting stress fractures. Female runners have good cause to be fully aware of the adequacy of their energy and nutrient intakes because almost no injury is more frustrating or potentially career ending than the development of frequent stress fractures. Endurance runs require enormous amounts of energy (a marathon requires about 2,900 calories); they cannot be adequately trained for or run without an adequate total energy consumption. Food intake strategies, including eating snacks between meals and consuming snacks or sports beverages before, during, and after exercise, are important for ensuring that fuel consumption matches need.
Elite runners depend heavily on both fat and carbohydrate for fuel to accelerate and vary speed over the course of a long-distance race.
Surveys of distance runners confirm that total energy and carbohydrate intakes are below the recommended levels, suggesting that runners must make a concerted effort to consume the recommended amounts before, during, and after exercise.28,29 In a case study assessing the nutrient intake of an ultraendurance runner during a race, it was found that if the pre-event and during-event guidelines for food and beverage are followed, then athletes will have sufficient energy and fluids to successfully complete the event.30
Tapering activity before a competition improves competition performance.31 It does so by increasing glycogen stores, but it also makes the runner calmer, which gives the athlete an improved economy of running motion that enhances endurance. The importance of tapering exercise and of carbohydrate loading before an important event cannot be overemphasized.
Fluids are crucial. Fluid consumption should be on a fixed time schedule (every 10 to 15 minutes) to avoid underhydration and thirst. Perhaps no single factor is more important for ensuring a long-distance runner’s success than maintaining an optimal hydration state. Athletes should drink now, drink again in 10 to 15 minutes, and when they believe they’ve had enough, they should drink
more. Of course, the type of beverage consumed is also important.
A great deal of body heat is generated over the course of an endurance run, and this heat is liberated through sweat evaporation. Studies strongly suggest that a 6 to 7 percent carbohydrate solution with electrolytes is most effective in maintaining exercise endurance.31 It has been firmly concluded that acute heat exposure is detrimental to muscular endurance.32 Therefore, long-distance runners should develop the habit of frequent fluid consumption to maintain body water status, whether they are thirsty or not. A fluid intake of .5 to 1 liter per hour is sufficient to prevent significant dehydration in most athletes in mild environmental conditions, but a greater intake of fluids is needed for athletes running at higher intensities or in more severe environmental conditions in order to avoid heat stress.33
Distance runners typically have relatively low body fat levels. Successful long-distance runners are commonly thin, and this body profile may be advantageous to them in dissipating heat during long runs.34 However, since very low body fat levels are associated with amenorrhea, female athletes should seek a balance between low body fat levels and normal hormone function.
A critical factor in the performance of all endurance athletes is iron status, and evidence exists that endurance runners have reduced hemoglobin, hematocrit, and red blood cell counts when compared with strength and mixed-trained athletes.35 Iron status is sufficiently important that one of the more common illegal ergogenic aids used by endurance runners is erythropoietin (EPO),36 which stimulates the production of red blood cells, thereby enhancing oxygen-carrying capacity.37 Iron is an essential oxygen-carrying component of hemoglobin (red blood cell iron), myoglobin (muscle cell iron), and ferrochromes (oxygen-carrying enzymes essential for making ATP) in the mitochondria. It appears that hemoglobin status is of highest priority, so iron from other cells is cannibalized to support a normal hemoglobin production when iron stores (ferritin) and intake are inadequate. Therefore, a standard blood test measuring hemoglobin may appear normal while other iron-containing cells are depleted. For this reason, it is important that blood tests in endurance athletes always include a measure of ferritin, which should be at the level of a minimum of 20 nanograms per deciliter. Besides having an inadequate dietary intake, which is most common in runners who do not eat red meat or who are vegetarian, there are several other common causes of low iron status in runners:38-40
Excess iron loss in sweat
Excess loss of blood through the GI tract
Excess loss of blood in the urine (hematuria)
Excess menstrual blood loss in female runners
Poor absorption of iron
Daily supplements of calcium and vitamin D, long linked to improving bone health, may also reduce the risk of stress fractures during exercise, scientists have reported.
The results, presented yesterday at the 53rd annual Orthopaedic Research Society meeting in San Diego, were obtained from a randomized, double-blind study with 5,201 female U.S. Navy recruits during eight weeks of basic training.
“What really surprised us is that calcium/vitamin D supplements made a significant difference in such a short period of time. Frankly, we were not sure we would see any statistically significant results in only eight weeks,” said lead researcher Joan Lappe from Creighton University in Omaha.
The combination of vitamin D and calcium has long been recommended to reduce the risk of bone fracture for older people, particularly those at risk of or suffering from osteoporosis, which is estimated to affect about 75m people in Europe, USA and Japan.
The action of the nutrients is complimentary, with calcium supporting bone formation and repair, while vitamin D helps the body absorb calcium.
The new study, funded by the U.S. Department of Defense, appears to suggest that daily supplements of the vitamin and mineral may also provide benefits for those engaged in athletic training.
Stress factures are said to be one of the most common and debilitating overuse injuries seen in U.S. military recruits with 21 per cent of female recruits reported to suffer from this form of injury. Male recruits suffer less.The research of Professor Lappe, presented to attendees in San Diego, divided the recruits into two groups – one group received a daily supplement of 2,000 Mg of calcium and 800 IU of vitamin D, and the other group received a placebo.
At the end of the eight weeks of basic training, 170 women in the placebo group experienced stress fractures; 25 per cent more women than in the calcium/vitamin D supplemented group. NutraIngredients.com has not seen the full data.
“It appears that supplementation with calcium and vitamin D provides a health-promoting, easy and inexpensive intervention that does not interfere with training goals,” said Lappe.
Further studies are needed to confirm these findings, but the results appear to fit with numerous other studies linking the nutrients to improved bone health.
The current EU recommended daily intake of calcium is 800mg, with an upper safe limit of 2500mg. Vitamin D has a RDI of 400 IU, although campaigners are calling for an increase to 1000 IU, half the upper safe limit recommended by the EU and US.
In the US, the DRI (dietary reference intake) for calcium is 1000mg for adults aged 19 to 50, and 1200mg from 51 to 70. For vitamin D it is five micrograms per day, rising to 10 after the age of 50.