The Female Athlete Triad – PediaCast 285

Dr Stacy Fischer and Jessica Buschmann join Dr Mike in the PediaCast Studio to discuss The Female Athlete Triad. What is it? Who’s at risk? How is it treated? And how can doctors, parents, coaches, and teammates recognize the disorder and intervene before it’s too late?  Also discussed: distracted teenage drivers.


  • The Female Athlete Triad
  • Distracted Teenage Drivers




Announcer 1: This is PediaCast.


Announcer 2: Welcome to PediaCast a pediatric podcast for parents. And now direct from the campus of Nationwide Children’s here is your host Dr. Mike.

Dr. Mike Patrick: Hello everyone and welcome once again to PediaCast. It’s a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children’s Hospital. We’re in Columbus, Ohio it is April 30, 2014 episode 285 and we’re calling this one The Female Athlete Triad. I want to welcome everyone to the program. So we have a teenage focused show lined up for you this week and although the title would suggest that we’re only talking about girls, there’s actually good information here for young men who are student athletes as well.


So stay tune for discussion on the female athlete triad and then our usual fashion we’ll take a nuts and bolts approach with the who, what, when, where, why and how of this disorder. We’re going to talk signs and symptoms, diagnosis and treatment, prognosis or long term outlook and prevention as well as the latest research topics. And also on our usual fashion I have a couple of great studio guests lined up to help me talk about it. Dr. Stacy Fisher is a sports medicine physician, and Jessica Bushman is a clinical dietician and sports nutritionist both from Nationwide Children’s Hospital, so that’s coming up. Then stay with us at the end of the program for a final word on distracted teenage drivers. They’re not only a danger to themselves but to others as well including you and me. So we’ll take a closer look at the danger and talk about the role of parents in keeping your teenage drivers safe.


And not only teenage drivers, really all drivers should take distraction while driving seriously. So we’ll touch base on that as well again at the end of the program. Blog topics, the 700 Children’s Blog here at Nationwide Children’s Hospital is alive and kicking and you’ll find it at Some recent topics, “Raising a Child with Ambiguous Genitalia…, promises to be an interesting read. Also “Autism Awareness…, “Surviving the Stomach Bug… parent edition, “Tips for Making the Next Shot Visit Less Stressful…, “Talking to Your Medical Provider About HIV…, “Know Your Baby’s Developmental Timeline… and “Gillian’s Journey: One Micro-Preemie’s Story of Hope…. So lots of interesting content, really written by the doctors and other healthcare providers here at Nationwide Children’s Hospital. So check out those stories and more on our 700 Children’s Blog. You can find it over at


Spring is here or at least around the corner depending on where you live which means that kids will be back outside hopefully, running around, climbing, jumping, riding bikes, swimming and getting hurt which is why we recently teamed up with Working Mother magazine to dispel some common myths surrounding first aid treatment. You can check that out at and I’ll put a link to the article and the video that goes along with the story in the show notes for this episode 285 over at I do want to remind you that PediaCast is your show, so if you have a topic that you’d like us to talk about, if you have a question for me or want to point me in the direction of a news article, or journal article. It’s really easy to get in touch, just head over to and click on the contact link. I do read each and every one of those that come through so if you got something to say just head over there and let me know what it is. I also want to remind you, the information presented in every episode of our program is for general educational purposes only, we do not diagnose medical conditions or formulate treatment plans for specific individuals.


So if you do have a concern about your child’s health, make sure you call your doctor and arrange a face to face interview and hands on physical examination. Also your use of this audio program is subject to the PediaCast terms of use agreement which you’ll find over at Let’s take a quick break. We’ll get Dr. Stacy Fisher and Jessica Bushman settled in to the studio for an interesting talk on the female athlete triad, that’s coming up right after this.



Dr. Mike Patrick: We are back. Dr. Stacy Fisher is a sports medicine physician at Nationwide Children’s Hospital and an assistant professor of pediatrics at the Ohio State University College of Medicine. Dr. Fisher also recently served on the board of directors for the mid-west chapter of the American College of Sports Medicine. She’s a volunteer physician with the Greater Ohio Bicycle Adventure and team physician for Groveport Madison High School in Central Ohio. Dr. Fisher has a special interest in research and advocacy regarding the adolescent female athlete and is a member of the Female Athlete Triad Coalition. That’s what we’re talking about today and it’s with a warm PediaCast welcome that we say hello to Dr. Stacy Fisher. Thank you for joining us today.

Dr. Fisher: Good morning, thank you for having me.

Dr. Mike Patrick: We really appreciate you stopping by. Jessica Bushman is also with us, she is a registered dietician and an important member of the Sports Medicine Team at Nationwide Children’s Hospital. She completed her master’s degree in sports nutrition and exercise science at Marywood University in Scranton, PA.


She helps a wide range of student athletes with dietary and nutritional concerns including those involved in sports where a lean body is beneficial, things like tract, rowing, gymnastics and dance. These student athletes are at a higher risk for developing the female athlete triad. Jessica’s also a member of the Female Athlete Triad Coalition, so we really appreciate Jessica stopping in to share her expertise with us today. Welcome to PediaCast.

Jessica: Thank you very much.

Dr. Mike Patrick: We really appreciate you stopping by as well.

Jessica: My pleasure.

Dr. Mike Patrick: Let’s start with Dr. Fisher, what exactly is the definition of the female athlete triad, what exactly is it?

Dr. Fisher: The female athlete triad is a medical syndrome that consists of three conditions that are all inter-related by what we call decreased energy availability. That’s when an athlete in particular isn’t getting enough fuel to fuel not just their sport but their work day, or their school day as well. You only need one of the three conditions to qualify for the female athlete triad but what they are is the first one is some aspect of disordered eating.


Whether it’s a girl who might have an eating disorder diagnosed by a physician or a picky eater over someone who’s just not getting enough nutrition accidentally because they’re under estimating what they need. The other two conditions are result of that decreased energy availability and those are some type of menstrual dysfunction and ultimately decreased bone mineral density.

Dr. Mike Patrick: Great. And that’s the disordered eating, you can kind of see where this could be a cycle that just sort of perpetuates itself so when an athlete sees, hey I’m able to stay lean by not eating as much but then they’re not making that connection with the fact that in terms of their sport they’re actually using more energy and they need that food.

Dr. Fisher: Correct. Sometimes we’ll see girls who actually meet their energy requirements when they’re off season and then they don’t realize it when they start exercising more, they need more fuel for that and they’re not meeting those needs.

Dr. Mike Patrick: Now Jessica just how common is this condition? Is this something that you deal with frequently in the clinic or is this something that’s rarely seen?


Jessica: I deal with it pretty frequently. Dr. Fisher first meets quite a number of patients with the female athlete triad. The data kind of shows it’s anywhere between 15-62%, our own data here at Children’s chose about 14% of those based on the injury that we’ve been able to collect. But as far as my numbers, I’m not exactly sure but it is something that I’m treating at least weekly.

Dr. Mike Patrick: Now I would imagine this isn’t necessarily something that people come to the clinic primarily for. You may see a sports injury. Do you do some kind of screening to try to pick up these girls?

Dr. Fisher: One of the things we started doing here at Nationwide Children’s back in about October was we were so impressed by the prevalence data that we had seen last far that we started tracking it. We actually created a way in our medical chart to ask girls about their periods. So every athlete who comes in to see us whether it’s for ankle sprain, or a sore knee, or a concussion is being asked about their menstrual cycle.


If they are late getting their period, meaning they are older than the age of 15, if they’re going more than 35 days between periods, if they’re getting less than nine periods in a year, things like that is triggering us to kind of start looking deeper. We’re also collecting BMI data. So we’re doing a weight for height ratio on these girls and if we’re finding anyone who’s less than the 85th percentile of what are expected for their age, that’s also triggering us to look for other aspects of the triad.

Dr. Mike Patrick: Now I’d mention some specific sports during the introduction material but Jessica you really can see this with any sport right?

Jessica: Correct, yes.

Dr. Mike Patrick: Are there some in your experience that you’ve seen more with a particular sports?

Jessica: I’d definitely say gymnastics, dancing, rowing is a new one for me, I’m learning a lot from the athletes about rowing. Track and field, cross country, dancing in general and cross ballet, tap, whatever it is. So those are the most common sports that I see.


Dr. Mike Patrick: Do you see disordered eating among boy athletes?

Dr. Fisher: We do. Unfortunately there’s not as easy a way for us to track it in our offices, we can certainly be on the lookout for BMI and again less than the 85th percentile can clue us in for that, or if we start seeing guys who are having kind of recurrent injuries that we think maybe related to energy availability.

Dr. Mike Patrick: Would you see the osteoporosis factor in boys or not so much, is that more estrogen related?

Dr. Fisher: Certainly it is estrogen related and it has been shown to be directly related to estrogen levels. Now boys have estrogen as well. I don’t know of data that suggests similar courses for decreased bone marrow density on boy athletes I should say. That’s eating disorder data but not athlete data.

Dr. Mike Patrick: But there are things like wrestling for instance where boys are really trying to keep to a certain weight class that you could see some disordered eating and then that could decrease energy and could have other effects as well.


Dr. Fisher: Absolutely. Now fortunately here in Ohio there’s more regulation about weight loss in wrestling. I probably see it more often in the runners in the cross country track runners who are trying to maintain a low body profile.

Dr. Mike Patrick: So something that parents with boys should as were going through this at least keep that in the back of their mind that boy athletes also need enough fuel in order to do their sport.

Dr. Fisher: Absolutely.

Dr. Mike Patrick: So let’s talk a little bit about causes. What would cause this to happen?

Dr. Fisher: Well not having enough fuel in your tank frankly. So if you don’t have enough calories to support your activities of daily living in addition to your sport, what your body starts doing is shutting down various non-necessary systems to meet their energy needs throughout the day. And those are the things, once they start shutting down, that make you more prone to injury.


Dr. Mike Patrick: I think a lot of parents out there would think, “Oh yeah, when my daughter runs cross country she stops having her period,” and so there may be this tendency to think that it’s only the increase in exercise that causes this to happen but this is really warning sign that there’s much more going on than just that.

Dr. Fisher: It used to be a badge of honor especially for the runners, and especially for the dancers. If you were still getting your period, you weren’t working hard enough. And now what we see is there are definitive health consequences because of that. And so we teach every athlete, it is never normal not to get your period. We teach the coaches, we teach the dance instructors, we’re teaching the parents, and we’re teaching the pediatricians. You know there used to be a lot of physicians who just expected that as a consequence in a high level athlete and we’re doing a lot of education to turn that around.

Dr. Mike Patrick: Really it’s a matter of the energy in – energy out and you want to make sure that you have enough energy in to take care of the energy out.

Dr. Fisher: Correct, it’s math.


Dr. Mike Patrick: And I guess another cause would be in terms of women and body image and what society says, a body images supposed to look like and in particular for specific athletes. Cross country runners are supposed to be thin, or gymnasts are supposed to be little, or divers were supposed to be slim. Could you speak to that a little bit?

Dr. Fisher: The way that we have typically referred to those in the research are lean build and non-lean build sports. And so you’re right, the ones that are lean build are either sport where your performance is affected by your weight. So if you’re lighter, you’re faster. If you’re lighter you can jump higher and throw more tricks in the air. So there are some sports like running, cross country skiing, gymnastics, diving where a low weight improves your performance. There are other sports where a low body weight improves your performance from an aesthetic value. So those tend to be the judged sport.


So think figure skating, think dancing, think gymnastics, think cheerleading. So we have that category of sports. And then we have the other sports that aren’t as directly affected by weight. We know that there’s a higher prevalence of female athlete triad in the lean build sports than there is in the none-lean build sports, so it’s a risk factor.

Dr. Mike Patrick: And I suspected there’s also some personality types that would be more likely to have this happen and parents know their children so if you know that your child is more of a compulsive, goal oriented, driven person they’re going to be at a high risk for this as well?

Dr. Fisher: Absolutely.

Dr. Mike Patrick: What are some of the unhealthy weight control methods that you see these student athletes are doing?

Jessica: A wide variety, again they’re teaching me more every day. So like what wrestling for instance with the male athlete, even things like spitting in a cup, or restricting for days and then having 500 or less calories in a day because they have to make weight by a certain time.


The cleanse diet are a big one right now where it’s just taking in various liquid components whether it’s lemonade or some recipe off the internet, or something you could find in the drug store. Everything is mostly just liquid based, so it’s supposed to be low in calories. Another one would be like the high protein diets. High protein diets are very popular also right now so in the weight loss is quicker than in diet that’s just well balanced. Also just restricting in general, just cutting back because they think that’s what they need in order to make way or feel their best or be at their best.

Dr. Mike Patrick: I suspect too there’s perhaps some embarrassment with the fact that they’re using these techniques. I mean do they just come out and say, “Oh yeah, this is what I’m doing'” or do you have to sort of tease that out of them?

Jessica: I kind of have to tease that out of them sometimes, or sometimes I’ll have an athlete unknowingly say something and they’ll like, “Oops that’s wrong,” you know or, “I shouldn’t have said that,” but others area kind of holding it in and then eventually it does come to surface whether it’s from the athlete themselves or their parents.


Dr. Mike Patrick: And at least we certainly want to encourage people to be open and talk about their health but the fact that they may try to hide it, at least let you know if that there is an internal barometer that hey this isn’t quite right and so I would in speaking to student athletes out there because we do have some teens who, listen to this program. I would say if that little voice in you is saying this isn’t right, it’s probably not right.

Jessica: I would agree.

Dr. Mike Patrick: So then what are some of the signs and symptoms of the female athlete triads? So we talked about the big ones that, I mean you have the disordered eating which leads to not enough energy that leads to menstrual problems and osteoporosis, or loss of mass in bones. What are some other signs that parents should be on the lookout for either subtle or not so subtle?


Jessica: It’s important to remember that you don’t have to necessarily have all three components of the triad to be diagnosed per se with female athlete triad. So it just might be one thing like a regular absent periods, you might come in to our clinic with a stress reaction or stress fracture, low bone mineral density that’s diagnosed by a DEXA scan or another method. This seemingly low energy intake, you know your children the best so it’s kind of one of those things like they’re not taking in enough as they usually do, or their appetite has changed, it could be things as subtle as this. Also pre-occupation with weight is a big one, just being concern how much their weight is, or how they’re compared to their peers or other things like that. It could also be noticeable weight loss, or obsessive – compulsive like eating habits, excessive fatigue, dizziness, things like that. They might seem like pretty general but they could be indicating a larger problem.


Dr. Mike Patrick: And we did have a program on eating disorder specifically a little bit later in the program, I’ll let you know exactly what show that was and how you can find that. But I suspect that there’s a continue, then from this to a Frank eating disorder and then the mental health issues that go along with that with low self-esteem, possible depression, thoughts of self-harm, suicidal ideation. Not to scare parents that every child with female athlete triads’ going to have that but it is something that you should at least think about.

Dr. Fisher: I think it is important to make the distinction between the two. The rates of anorexia and bulimia in the general population are the same as the rates in the athletic population. You are at no higher ever risk of developing an eating disorder just because you’re an athlete. but you are at the much higher risk of developing some type of disordered eating and it’s interesting because when you talk to the patients in the room, a lot of them will say, “Well I’m lactose intolerant” or, “I don’t like milk” or, “I’m a picky eater” or, “I only eat white bagels” or things like this.


A lot of times I think a lot of this is truly an advertent or because of the lack of education and those are the really fun kids to treat because once they learned, they get better. Most kids are going to be picked up and doesn’t respond very well and it’s not something to be concerned about but definitely something to take action on.

Dr. Mike Patrick: I would suspect that these kids, once they start getting enough fuel they actually improve their performance.

Dr. Fisher: A lot of them have and that’s been very satisfying. We take care of some very high level high school runners and some of them I’ve started taking care of when they were in middle school and they were state lever runners in middle school and now they’re carrying on to college and maybe after a year off where they’re kind of addressing their injuries and addressing their eating patterns which was very frustrating for them they’re coming out the other side and they’re performing exceptionally well which is very satisfying.


Dr. Mike Patrick: Now when you see a student athlete who sort of fails your screening, are there some other disease processes that you think about that could be a possibility?

Dr. Fisher: Certainly there’s any number of reasons why you could be thin. You know a lot of athletes will say, “Well my whole family is thin, we’re all thin” or, “None of us started our period until we were 16” or something like that. So there’s a genetic component that we see, so that’s one of our screening questions. As far as oligomenorrhea or amenorrhea which is either infrequent, less frequent, or absence of menstrual periods, truly in order to diagnose someone with a female athlete triad, it’s a diagnosis of exclusion. So we need to rule out a whole host of other gynecologic or hormonal disease processes that could be causing it instead. So if you’re doing the whole workup you might start for example with the pregnancy test, that’s one good reason to miss your periods and then we start looking usually at the thyroid, we start looking at the pituitary, we might look at ovarian hormones, we might even need to get to the point where we’re looking at a full physical exam or even ultrasounds that kind of evaluate anatomy.


But then if you’re not finding anything and you have someone who’s also at risk because of their weight and their sport, that’s when we’re going ahead in making the diagnosis.

Dr. Mike Patrick: Incidentally that eating disorder show’s able to look up at real quick, it’s PediaCast episode 248 and I’ll put a link to that in the show notes over at for this episode which is 285. So 249 was our eating disorder one and I guess that would be in your differential diagnoses as well. Jessica, the sports medicine physician does the screening picks up someone that they’re concern that it’s a diagnosis of exclusion, there’s nothing else that you’re concern about from a medical stand point. So we really do think this is female athlete triad.


And then they refer someone to you for nutritional counseling, what does that look like?

Jessica: It’s an appointment that’s usually the first appointment it’s usually about an hour. When I first tell parents that what are you going to talk to us about for the whole hour and usually at the end, I can’t believe it’s over. So what I’ll do is I educate basically just on what the macro-nutrients are. So carbohydrate, protein, and fat and their role within the adolescent’s body because for instance if I said you need to add a protein to your snack they’re not looking at me like a deer in the heads light like what’s that mean? What’s an example? They can be a pro-active part of their educational session. So they’ll come to me and what I do is I do a dietary recall. So I look at what they’re eating in a typical day and that’s before a none sport day and a sport day and kind of shows them this is about how much you need to be taking in, and this is how much you’re currently taking in. And usually with girls with the female athlete triad, there is a deficit that needs to be addressed and once you explain all the components of the triad and how energy in take place and to the role of that they understand and they’re usually without any underlying eating disorder issues, they make those changes and I teach them practical ways add healthy calories to their diet.


Dr. Mike Patrick: Is it usually just in your experience one time visit like that and then success, or is this a recurring visit we need to keep reinforcing this?

Jessica: Reinforcing, definitely I at least have the men at least for one more follow up just reiterate the importance of everything and parents also like it because it’s another voice, it’s coming from someone else and also the kids like it especially again we’re talking about the girls that are very goal oriented and male athletes as well who are very goal oriented, they want to follow up and say, “Look Jess I’m meeting this goal, here’s how I did it, what else have you got for me?” You know, what other goals can we set? So that’s also very encouraging.


Dr. Mike Patrick: That is fantastic. We’re talking energy-in, energy-out is really how this happens then I guess in addition to not enough energy in, too much energy out could also be an issue here. How do you advice student athletes in terms of what’s inappropriate amount of exercise? Can they overdo it?

Dr. Fisher: They can overdo it and that’s really difficult. There are a lot of different guidelines but they’re all sports based which can really be difficult. For example, for running we know if you’re running more than 40 miles a week, that’s way too much and those were the kids who are going to be much more prone to injury. There have been some previous guidelines that were published. I believe you have even on your show about injury prevention discussing more hours per week than years in your age is probably excessive. But we do have a lot of a sport who for example half hour of their day might be stretching and that’s very low energy intensive. We have other kids who are spending their entire hour and a half at vigorous levels of activity.


So the best thing that you can do is quantify it. Make sure that you build up slowly over time so that your bone and muscles get a chance to adjust to it and don’t fatigue in neither stress fracture or strain themselves. Make sure that you’re taking days of rest. Really all athletes should have at least one if not two days of rest per week, they should have three months off from a sport every year. It doesn’t mean they need to be sitting on the couch being a couch potato but for example even our high level gymnast can probably benefit from a couple of months of another activity that might help support gymnastics but be different to give different body parts a rest as well.

Dr. Mike Patrick: I would imagine that that these kind of recommendations is where even someone who doesn’t think they’re having any issues at all, it might be a good idea to see a sports medicine physician just to kind of go through what kind of training program you’re doing, and which sport that you’re involved in and is what you’re doing healthy and could you be doing it better?


Dr. Fisher: I agree, we’d much rather prevent injuries than treat injuries, so if there’s anything that we can do to pick them up early. One of the things we also have here at Nationwide Children’s is we have an athletic training department with certified strength and conditioning coaches who are very good at that. If you have a question certainly we can ask for their help as far as an exercise load goes.

Dr. Mike Patrick: Let’s say that a person is not picked up and they so have female athlete triad that is undiagnosed and continues for a long period of time which I suspect doesn’t happen as often now as it did maybe five, ten years ago even. What kinds of complications are we looking at other than just the first one we talked about with decreased and in your menstrual cycle and osteoporosis, what are the short complications can you see?

Dr. Fisher: One of the things we see that I think is the most applicable for our high school athletes, as we see increased injury rates. What’s interesting about that is originally we saw the relationship between bone mineral density and we saw the relationship between stress fracture so we know that the more periods you missed or the longer that you have in frequent periods the higher risk you are for stress fractures.


But some of the more recent literature in the last year or two shows that you’re at a higher risk of any injury. So it could be an ankle sprain, it could be patellofemoral syndrome, we’re seeing evidence that your injury recovery is longer than it would’ve been had you had normal or adequate energy intake. Overtime one of the biggest consequences is we start to see bone mineral density decline. We know that during the adolescents you’re responsible for putting on about 60% of the bone mineral density of your skeleton and if during that time of growth you are decreasing your bone mineral density, it’s a double whammy. You missed six periods in a row and your bone mineral density is going down instead of up and the concern is that you’ll never reach that peak bone mineral density which will protect you for the rest of your life.


Dr. Mike Patrick: Really one complication can be increased fractures during your elderly years because of female athlete triad during your teenage years.

Dr. Fisher: Absolutely. If you’re a person who’re going to be prone to osteopenia or osteoporosis you will reach that at an earlier age than you would’ve otherwise.

Dr. Mike Patrick: Jessica in terms of long term outlook, so once a student athlete becomes an adult athlete or just maintaining a healthy, active lifestyle as an adult, is this something that reoccurs or is it really just isolated to the teenage years?

Jessica: The long term outlook, it can definitely be beneficial and treated early like the lifelong expectancy, it’s completely fine. However this is something that could definitely translate into adult women as well as athlete. I’ve personally seen like a couple women in my clinic even though it’s not pediatrics I do see adults here and there that had no idea and they want to know why menstrual function was never picked up on their screenings by their primary care provider, whoever.


SO education is life long and it’s important to remember also that menstrual functions in female athlete triad are non-evadable result of being an athlete. There’s lots of ways that we can prevent the female athlete triad, so that’s keeping all of those components in mind.

Dr. Mike Patrick: I suspect, do you sometimes pick up parents of teenagers, so when the teenage daughter finds out she has female athlete triad, the mom’s like, “Oh wait a minute.”

Jessica: Exactly, or she says, “Oh you know what, during my teenage years I was told this was normal.” Then they start asking more questions and things like that, it’s where the educational hands out became very important.

Dr. Mike Patrick: We’ve talked about prevention being better than treating. Is there advice that you have for preventing this from happening in the first place?


Jessica: Yes. As we talked about before, math make sure that your energy intake is meeting what you’re expending and I know that’s easier said than done sometimes but dietician, sports medicine physicians were altering to get you to help that you need. We can absolutely help you quantify those numbers. Also keeping up to date with your primary care physician, keeping in touch with them, making sure you’re going to your appointments, listening to things like PediaCast, making sure that you’re up to date like on all the literature and making sure that you’re preventing this at all cost.

Dr. Mike Patrick: And tracking menstrual periods.

Dr. Fisher: Exactly. I was just going to bring that up. There’s some really neat apps that you can get on the phone especially on the teenage girls prefer to do this privately rather than publicly. They’re really neat because the apps themselves will track how many days did you go between cycles, how long were your cycles and they give you a summary. So if you see that you’re periods are going longer than 35 days, in between them, if you see that you’re getting less than nine in a year then you should bring it up, if not to a parent then to a coach, an athletic trainer, a school nurse or to your physician.


Dr. Mike Patrick: What are some hot topics in research right now regarding the female athlete triad?

Dr. Fisher: You know one thing we’re still trying to do is most of the original research was on adult women, kind of as Jessica was talking about before. And so we’re still collecting data on the high schoolgirls. So we have some good prevalence data but we’re still working on it. One of the things that we’re recently discovering is it’s not just athletes who get the female athlete triad. A lot of girls are either dieting or very body image conscious and then prone to osteoporosis or decreased bone mineral density in the future as well. So one thing we’re trying to do is figure out how much of it is out there. The next thing we’re trying to do is figure out what else can we do to get it better. So certainly ideally you correct your nutrition and you go forward from there. But there are some question too about how else can I help my bone mineral density if it’s been in the tank for a while.


So can I do a strengthening conditioning program and show that my bone mineral density will improve. Are there any hormonal treatments that I can do because my hormones are deficient due to this and with that help hasten my recovery. Mainly that’s where it’s going on. We’re also still trying to figure out what else is related? So for example in dancers we have found out that they are also prone to endothelial dysfunction which is a blood vessel condition that may point in the future to cardio vascular risk and we know that’s related to their nutrition and their periods as well. So we’re looking to see well is that just dancers? Is that everybody? What can we do about that?

Dr. Mike Patrick: As time goes by and we find out more it’s going to make it easier to screen, to treat, to prevent all those things. Tell us a little bit about the sports medicine clinic here at Nationwide Children’s.

Dr. Fisher: The sport medicine clinic’s where we’re seeing our patients. It’s kind of like we referred to earlier, every female athlete who comes in is getting screened, they’re getting BMI, they’re getting a menstrual history, physician is talking with them about it.


If we’re finding girls who meet certain risk criteria, then we’re going ahead and we’re doing more work up. For example we don’t need to get a bone mineral density study on every girl, if they have low levels of energy deficiency, if they haven’t had menstrual dysfunction as long, if they have a healthy weight for height ratio, those are kids who we can kind of just follow, maybe Jessica take a look at them and see how close they are. But other girls are needing lab work ups. So sometimes we’re getting a bone mineral density, we’re checking their vitamin D levels, if we need to go down the hormonal root, sometimes we’re needing to send them on for an evaluation from their menstrual dysfunction as a primary disease process.

Dr. Mike Patrick: If parents are concerned about this and they want to see a sports medicine physician here, is this something they can just call and make an appointment themselves or do they need a referral from their primary care doctor?

Dr. Fisher: They can just call up and come on in.


Dr. Mike Patrick: And we’ll put a link in the show notes to make it easy for people to do that. We’ll have a link to the sports medicine page, the main landing page at nationwidechildrens. And then we also have a link that you can connect now with a sports medicine specialist. It just sends folks to the welcome centers so they can get in touch with some one that helps them to make an appointment. So we’ll make sure we put all those links in the show notes for this episode which is 285. And then the sports medicine clinic, really it’s multi-disciplinary. You’ve got sports medicine physicians, athletic trainers, we got dietitians. Really you’ve got access to whatever resources you need.

Dr. Fisher: We do.

Dr. Mike Patrick: And we talked a little bit about the mental health aspect and so if you needed referral to the eating disorders program, or to adolescent medicine for more of a medical condition that you pick up in your screening, that can be done. And if they actually have fracture, we have access to orthopedics and all that.


Dr. Fisher: Absolutely. Full service.

Dr. Mike Patrick: There’s a couple other links as well. The female athlete triad from the American College of Sports Medicine, they have a really nice brochure that is incredibly detailed and in language that parents can understand. I think it’s a great resource not only for parents, but for coaches as well and I’ll put a link to that in the show notes. And then we did a video, it’s Reagan’s story on the female athlete triad and I’ll put a link to that in the show notes as well so parents can actually see it, a personal story on this.

Dr. Fisher: Great.

Dr. Mike Patrick: We really appreciate both of you stopping by today.

Dr. Fisher: Thank you.

Jessica: Thank you.

Dr. Mike Patrick: Thank you for sharing your expertise. We are going to take a quick break and I will be back to talk about distracted teenage drivers right after this.



Dr. Mike Patrick: We are back. Motor vehicle crashes rank as the leading cause of teenage deaths. And in 2008 16% of all distraction related fatal automobile crashes involved drivers under 20 years of age. These grim statistics, coupled with an increasing nationwide awareness of the dangers of distracted driving for all ages, prompted the publication of an important supplement to the Journal of Adolescent Health that explores the causes of distracted driving and offers practical recommendations to reduce the incidence of distracted driving among teens.


Dr. Raymond Bingham guest editor of the Supplement and faculty member of the University of Michigan Transportation Research Institute says, “Although public health efforts have made some progress in reducing the risk of adolescent motor vehicle crashes over the last three decades, new technologies and evolving behavior patterns have focused attention on the risk of distracted driving. For many of the same reasons that alcohol-impaired driving represents a distinct risk for adolescents, distracted driving has an elevated impact on this age group. The unique challenge posed by the proliferation of new technological distractions may accelerate this risk behavior and may lend itself to innovative prevention efforts…. The issues involved are not simple. While there are many different causes of distracted driving, the aim of the journal Supplement is to take a broad view of the topic instead of focusing on the individual sources of distraction. The goal is to give researchers, doctors, lawmakers, parents, and teenagers a better understanding of why distracted driving is a potentially deadly activity and steps that might be taken to reduce the number of crashes it causes.


Former United States Secretary of Transportation Ray LaHood thinks this is an important issue for the public as well as legislators. He says, this special Journal of Adolescent Health supplement brings the important issue of driver distraction and young drivers into focus. The articles presented cover a variety of the influences on young drivers’ distractibility and safety as well as the important influence of parents, peers, and technology. While there is no single (simple or quick) solution to this problem, this research does lay a foundation for additional debate and informed and effective policies to address the complex problem of distracted driving among young drivers and the larger driving population as a whole…. The supplement examines the issues surrounding distracted driving by teens, exploring developmental states and changes that are associated with teen distractibility and their relation to driving. It examines patterns of distraction among newly licensed adolescents as well as brain function, considering the potential role played by parental modeling of distracted behavior while driving, accounting for the role of technology and the influence of peer passengers and society norms, and investigating policy, legislation, and intervention.


One of the ideas that the supplement highlights is that there are a multitude of complicated factors that result in teens being more vulnerable to the effects of distracted driving than other age groups. One of the article in the supplement is called “Adolescence, Attention Allocation, and Driving Safety,” and in it Dr. Daniel Romer explore the explanations behind why teens fail to pay attention, including brain immaturity and lack of driving experience. Their review points to extensive new driver training as a way to help compensate for the unique problems teenage drivers face when it comes to focusing on the road. In another article entitled “Young Driver Distraction: State of the Evidence and Directions for Behavior Change Programs,… Dr. Lisa Buckley and colleagues discussed different methods used to both educate and prevent distracted driving. While the authors argue that legislative interventions can be effective prevention strategies, they also recognize the unmet need for behavioral change programs designed to pinpoint the most at-risk groups, identify their risk and protective factors, and then design effective interventions tailored to their specific needs.


What about laws currently in the books and limiting cell phone use for talking and texting while driving. While in the article “The Impact of Text Messaging Restriction on Motor Vehicle Crashes,… Dr. Johnathon Ehsani argues that these laws are either ineffective or may have an unintended effects. As a conclusion Dr. Bingham says, In the near future, and perhaps for years to come, reducing driver distraction to increase roadway safety is going to be increasing challenge. As automated functions increase in vehicles, drivers are likely to feel their attention to the road is less necessary. Cultural attitudes and values and the public’s tolerance for distracted driving need to be targeted by informative and persuasive public health campaigns that make evident the need and create a public demand for individual behavior change.”


So you can take a look at the Supplement for yourself. It really contains a number of interesting articles and if you like to do that I’ll put a link to it in the show notes for this episode 285 over at or you can take my word for it. Don’t talk on your cell phone, don’t text, don’t surf the internet, don’t watch YouTube videos while you’re operating a motor vehicle. Teach your kids, these things are no-no’s from an early age by modeling safe behavior when you drive. Reinforce these concepts during the teenage years and continue to practice distraction free driving well after the kids have flown the coup. You got to pay attention on the road, why? Because all the other drivers out there, the ones who remain distracted, and that’s my final word. I want to thank all of you for taking time out to your day to join us today. I can’t even express how much that I appreciate the support of the listeners in the PediaCast audience, just really appreciate it.


I know there’re a lot of you out there who have held on strong during this program. You don’t even know any female athletes and so I really appreciate that. But if you know folks who have kids who are teen age athletes, maybe they’re gymnast, maybe they swim, they run cross country or track, be sure to let them know about this program because you may be able to help their kid with a problem that no one even knows that the child has. If you could share this particular episode with all your friends and family who have teenage athletes particularly girls at home. I’d be over so appreciative if you would share that. I also want to thank Dr. Stacy Fisher and Jessica Bushman for stopping by the studio today. That does wrap up our time together. PediaCast is a production of Nationwide Children’s Hospital. Don’t forget that PediaCast and our single topic short format programs PediaBytes are both available on iHeart Radio Talk which you’ll find on the web and iHeart Radio app for mobile devices.


Our show archive which includes over 250 programs as well as our show notes, transcriptions, terms of use and contact page are available at our landing site which is We’re also on iTunes under the kids and family section of their podcast directory. Reviews there are always appreciated. You’ll find PediaCast on Stitcher, TuneIn, Downcast, iCatcher, Podbay and most other podcasting apps for iPhone and android. We’re also on Facebook, Twitter, Google Plus and Pinterest and of course we really appreciate you connecting with us there and sharing, re-tweeting, re-penning all of our posts so you can tell your own online audience about our little show. We also appreciate you talking us up with your family, friends, neighbors, and co-workers, anyone with kids or anyone who takes care of children. And as always be sure to tell your child’s doctor about the program. Posters are available under the resources tab at And until next time this is Dr. Mike saying stay safe, stay healthy, and stay involve with your kids, so long everybody.



Announcer 2: This program is a production of Nationwide Children’s, thank you for listening. We’ll see you next time on PediaCast.



ay involve with your kids, so long everybody.



Announcer 2: This program is a production of Nationwide Children’s, thank you for listening.  We’ll see you next time on PediaCast.





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