Kinesiology, physiology professor presents study on female athletes

Marjorie S. Miller
November 05, 2014

UNIVERSITY PARK, Pa. - In Noll Laboratory, Mary Jane De Souza, professor of kinesiology and physiology, presented “Understanding the Clinical Sequelae of the Female Athlete Triad,” which addressed health problems among female athletes as well as a treatment and “return-to-play” protocol.

Her paper on the same topic, “2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad,” was published in the British Journal of Sports Medicine in March.

The lecture was part of a Chinese delegation, in which about 25 sport physicians, physical therapists and sport scientists visited University Park last month to learn the latest in sport medicine clinical practices, scientific research, and training and conditioning.

The group, which represents the General Administration of Sports of China, traveled to the United States to better understand sport science in other parts of the world. During their trip, the delegates also visit other universities and cities. The group, hosted by Penn State’s Department of Kinesiology, the Penn State Center for Sports Medicine, and Penn State Intercollegiate Athletics, visited University Park from Oct. 20 to 24.

De Souza is a member of the Intercollege Graduate Degree Program in Physiology and past president of the Female Athlete Triad Coalition: An International Consortium. Her research has focused on the physiological basis of how exercise modulates reproductive function and bone health through alterations in energy balance. She has served as co-director of an ongoing randomized clinical trial in its eighth year of funding from the U.S. Department of Defense, aimed at reversing menstrual disturbances and related bone loss by using nutritional strategies.

The female athlete triad is a medical condition often observed in physically active girls and women, and involves three components: low energy availability with or without disordered eating, menstrual dysfunction and low bone mineral density. According to De Souza’s paper, which involves a variety of collaborators, female athletes often present with one or more of the three Triad components, and early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, loss of menstrual cycle and osteoporosis.

“In the healthy athlete, the assumption is that they have enough food intake to support all of their energy expenditure,” De Souza said to the group on Oct. 23 in the Noll kinesiology research laboratory.

The triad begins with inadequate food intake, causing mild to severe energy deficiency, De Souza said. This can occur in a woman with or without disordered eating behaviors. Disordered eating, De Souza said, differs from an eating disorder such as anorexia or bulimia.

“Disordered eating is the chronic restriction of food intake,” she said. “These women consciously restrict how much food they eat.”

“We see this often in sports where there are judges, like gymnastics or figure skating,” De Souza continued, or sports where thinness is desired among the athletes.

“These athletes go from healthy energy to unhealthy energy,” she said. “Some of them have a disordered eating problem and some do not.”

Energy deficiency can result in osteoporosis, or amenorrhea, or loss of menstrual cycle.

“Energy deficiency comes first, and then these other problems follow,” De Souza said.

A Dexa scan can measure how much bone is present, but not how strong the bone is, she said. Another imaging tool, a pQCT, can measure bone strength.

Risk factors for the triad include disordered eating; energy deficiency; menstrual dysfunction; sports that involve leanness; late onset of first period, usually age 14; low weight or body mass index; genetics; bone geometry abnormalities; and nutritional inadequacies, such as poor calcium or Vitamin D levels.

“The more risk factors you have, the higher your risk for low bone mass,” De Souza said.

Bone mass, she said, is a big deal.

“These girls are young and these problems are occurring at a time when they should be at their peak bone mass,” De Souza said. “If they don’t reach their peak bone mass, how can we fix it later?”

A decrease in bone strength, she said, is the “most critical factor that we have to worry about.”

Next, De Souza outlined the protocol for treatment and “return-to-play,” as referenced by her paper, which includes complete guidelines on Triad diagnosis for physicians as well as risk assessments.

The main question to ask, De Souza said, is: “Are (these athletes) able to return to sport after injury or illness?”

Many athletes with the triad are cleared to play sports without being adequately assessed, managed or treated, she said. The goal is to return these athletes back to competition and practice without putting them at any risk for additional illness or injury.

“This is the idea we’d like to share with the Chinese sport organizations,” she said.

First, a variety of evaluations must take place. Referred to as a medical or health evaluation, the patient’s age, ethnicity, family history, psychological state and a number of other factors are examined, De Souza said.

The next step involves an evaluation of participation risk: the type of sport played, the position played and competitive levels. Following, a decision is assessed based on the timing and season of the sport, pressure from the athlete and any conflict of interests, she said.

Each evaluation receives a numerical score.

The final score will grant an athlete one of the following: full clearance, provisional/limited clearance or complete restriction from training and competition.

Provisional clearance means an athlete can compete but must have follow up and necessary testing. Limited clearance means the athlete must follow up, as determined by the physician and undergo necessary tests within a defined period of time.

Athletes who are not cleared to return to play are deemed unable to safely train or compete, and must be treated for medical problems, De Souza said.

Athletes who fall under the provisional/limited or “not cleared” category are recommended to develop a multidisciplinary team of physicians, mental health professionals, nutritionists and other professionals to provide complete care, she said.

“It’s better to have these people who work with you regularly,” she said, adding a contract between the athlete and physician is also a good idea.

“We’re doing this to have a healthy athlete who’s not going to have an injury that’s going to prevent them from sports … or God forbid a life-threatening injury that’s going to affect their whole life,” De Souza said.

If a patient is 18 with low bone mass, she said, that patient is at greater risk for bone fracture later in life and especially after menopause.

“We take low bone mass seriously because it has life-altering outcomes,” she said.

For more information about the female athlete triad, or to view the paper online, visit

  • De Souza female athlete triad

    Mary Jane De Souza, professor of kinesiology and physiology, presented “Understanding the Clinical Sequelae of the Female Athlete Triad,” which addressed health problems among female athletes as well as a treatment and “return-to-play” protocol, Oct. 23 in Noll Laboratory.

    IMAGE: Marjorie S. Miller

(Media Contacts)

Last Updated November 05, 2014