Original scientific article received: 2018-01-24 ANNALES KINESIOLOGIAE • 8 • 2017 • 2 UDC: 796.966-055.2:612.662 FEMALE ATHLETE TRIAD - PROBABLE BUT DIFFICULT TO CONFIRM IN FEMALE ICE HOCKEY PLAYERS Patricia K. DOYLE-BAKER12, Leanne MCLEAN1, Tak FUNG3 1 University of Calgary, Faculty of Kinesiology, Human Performance Lab 2 University of Calgary, Faculty of Environmental Design 3 University of Calgary, Research Computing Services, Information Technologies Corresponding author: Patricia K. DOYLE-BAKER Human Performance Lab, Faculty of Kinesiology University of Calgary, Calgary, Alberta, Canada T2N1N4 Tel.: 011 403 2207034 Email: pdoyleba@ucalgary.ca ABSTRACT Female hockey players have high energy expenditure and may enter a negative energy balance (EB) without noticeable body composition changes. Menstrual cycle (MC) and luteal phase (LP) length, EB, and bone mineral density (BMD) were tracked over nine months (mean, SD (±) in 12 ice hockey players (HP; age 21.1 ± 3.4 yrs; height (HT) 165.9 ± 4.6 cm; weight (WT) 64.7 ± 8.1 kg; body fat percent (BF %) 2.8 ± 3.8 %) and 12 non-athlete controls (C; age 21.4 ± 2.8yrs; HT 169.5 ± 5.5 cm; WT65.4 ± 5.4 kg; BF % 20.0 ± 3.1 %). HP MC (35.8 ± 11.2 days) was longer than C (29.8 ± 4.3 days) and HP LP (10.1 ± 2.1 days) was also longer than C (9.6 ± 2.8 days). Anovulation occurred in 50.0 % of HP versus 39.2 % of C. No group BMD differences were observed in lumbar spine (p = 0.9), hip (p = 0.5), and radial (p = 0.7) sites. A negative EB was identified (HP = -1026.52 ± 450.1; C = -780.00 ± 310.19 kcal /day), yet no significant within-group differences in WT (HPp = 0.7; Cp = 0.8), BF % (HPp = 0.97; C p = 0.6), or fat free mass (HP p = 0.6; C p = 0.98) were found over the study duration. Rigorous hockey schedule likely contributed to 28 % completion of the Basal Body Temperature and MC recordings in HP compared to 70 % in C. Both groups entered a state of negative EB, but did not exhibit a BF % change associated with the Female Athlete Triad. Keywords: menstrual cycle, female ice hockey players, bone mineral density. 69 ANNALES KINESIOLOGIAE • 8 • 2017 • 2 Patricia K. DOYLE-BAKER, Leanne MCLEAN, Tak FUNG: FEMALE ATHLETE TRIAD - PROBABLE BUT DIFFICULT TO CONFIRM ..., 69-92 ŽENSKA ŠPORTNA TRIADA - VERJETNA, A JO JE PRI HOKEJISTKAH TEŽKO DOKAZATI IZVLEČEK Za hokejistke je značilna visoka poraba energije, ki lahko vodi do negativnega energijskega ravnovesja (EB) brez opaznih sprememb v telesni sestavi. V obdobju 9 mesecev smo spremljali menstrualni ciklus (MC) in dolžino lutealne faze (LP), EB in mineralno gostoto kosti (BMD) pri 12 hokejistkah (HP; starost 21,1 ± 3,4 let; telesna višina (HT) 165,9 ± 4,6 cm; telesna masa (WT) 64,7± 8,1 kg; %telesnih maščob (BF %) 22,8 ± 3,8 %) in pri 12 kontrolnih ne-športnikih (C; starost 21,4 ± 2,8 let; HT 169,5 ± 5,5 cm; WT 65,4 ± 5,4 kg, BF % 20,0 ± 3,1 %). Pri skupini HP je bil zabeležen daljši MC (35,8 ± 11,2 dni) kot pri C (29,8 ± 4,3 dni) in pri HP je bil LP prav tako daljši (10,1 ± 2,1 dni) kot pri C (9,6 ± 2,8 dni). Pri 50,0 % HP je prišlo do anovulacije, medtem ko pri C le pri 39,2 %. Nismo ugotovili razlik v BMD na lumbarnih vretencih (p=0,9), medenici (p=0,5) in koželjnici (p=0,5). V času izvajanja študije smo zaznali negativno EB (HP =-1026,52 ± 450,1 kcal / dan; C = -780,00 ± 310,19 kcal / dan), ne pa tudi pomembnih razlik znotraj skupine pri WT (HP p = 0,7; C p = 0,8), BF % (HP p = 0,97; C p = 0,6), ali pusti masi (HP p = 0,6; C p = 0,98). Strog urnik hokejistkje najbrž razlog za zgolj 28 % popolnost njihovih zapisov bazalne temperature in MC, za razliko od 70 % poročanja pri C. Obe skupini sta dosegli negativno EB, ni pa bila vidna sprememba BF % v povezavi z žensko športno triado. Ključne besede: menstruacijski ciklus, hokejistke, mineralna gostota kosti INTRODUCTION There has been a dramatic increase in female athletic participation and intense physical activity (PA) in the past 30 years (Chen & Bryzyski, 1999; Highet, 1989; Nattiv, Agostini, Drinkwater, & Yeager, 1994; Prior, Vigna, & McKay, 1992). A growing concern among health care clinicians and practitioners is the potential detrimental effect of long term training on bone mineral density (BMD), which may be preceded by low energy availability (EA) (Olympic Charter, 2011). EA is defined as energy obtained through oral nutrition minus energy expended during exercise. It is reasonable to conclude that low energy may result because of increased energy expenditure (EE), decreased oral intake (either intentional or unintentional), or both (Kishner, 2016). Subsequently, musculoskeletal and reproductive dysfunction from this prolonged energy deficit may occur, inducing the amenorrhoeic condition (International Olympic Committee, 2005; Mountjoy et al., 2014; Nattiv et al., 1994; Otis, Drinkwater, Johnson, & Wilmore, 1997). BMD decreases with the number of missed menstrual cycles (MC) accumulated over months and years. More specifically, a regular MC with either anovu- 70 ANNALES KINESIOLOGIAE • 8 • 2017 • 2 Patricia K. DOYLE-BAKER, Leanne MCLEAN, Tak FUNG: FEMALE ATHLETE TRIAD - PROBABLE BUT DIFFICULT TO CONFIRM ..., 69-92 lation (absence of ovulation) or short luteal phase length (SLP) may pose also a risk for bone remodeling, imbalance and bone loss (Seifert-Klauss & Prior 2010). The Female Athlete Triad (Triad) and/or its individual components (decreased EA, menstrual dysfunction, and low BMD) have previously been identified in athletic women (Egan, Reilly, Whyte, Giacomoni, & Cable, 2003; Koehler, Achtzehn, Braun, Mester, & Schaenzer, 2013; Reed, De Souza, & Williams, 2013). All female athletes in any sport regardless of the competition level are at potential risk to develop the Triad. However, those females participating in endurance sports, such as track and field, swimming, and rowing, or in those events requiring subjective judging, such as gymnastics and figure skating, are most at risk (Martinsen & Sundgot-Borgen, 2013). The current risk profile of the Triad includes very little information on female athletes having 'average body weights and lean body mass' (LBM), who participate in predominantly team oriented, weight-bearing sports (e.g. ice hockey, field hockey, soccer, basketball, and volleyball). Female athletes in weight bearing sports may also be energy deficit without knowing it and have ovulatory disturbances leading to future bone loss (osteoporosis) or bone weakening (osteopenia). The sport of ice hockey requires a long-term commitment to skill development and physical fitness which may impact a player's EE levels. It is possible that over time players may enter a state of negative EB without noticeable body weight change. The prevalence of inadvertent low EA is unknown in female ice hockey players. Therefore, the primary purpose of this study was to describe menstrual disturbances using basal body temperature (BBT) analysis to determine luteal phase (LP) length, and occurrence of anovulatory cycles in a group of female ice hockey players (HP) (17-25 years of age) participating in the Olympic Oval High Performance Training Program (HPTP). Our control (C) group were non-athlete students recruited from the University of Calgary Community. We hypothesized that HP would: (Ho^ exhibit longer MC, shortened LP (<10 days), with a greater number of anovulatory cycles as indicated by the MC Diary and BBT measurements when compared with C; (Ho2) be in a state of negative EB in the absence of any change in body composition; and (Ho3) have greater baseline BMD values at the spine, hip, and radial site compared to C and the population reference standards. METHODS Our study took place over 9-months and encompassed the fall and winter university semesters (October to June). Recruitment occurred at the start of the fall semester (September 1999) and the data collection period had a staggered study start; October for HP and November for C. The staggered start was necessary because of scheduling issues and conflicts with booking the Dual Energy X-ray Absorptiometry (DXA) machine. Volunteers were invited to participate:1) if HP had a five-year history of hockey specific training and if they committed to four or more 75 minute training sessions per week at the Olympic Oval in Calgary, Alberta, 2) following completion of the 71 ANNALES KINESIOLOGIAE • 8 • 2017 • 2 Patricia K. DOYLE-BAKER, Leanne MCLEAN, Tak FUNG: FEMALE ATHLETE TRIAD - PROBABLE BUT DIFFICULT TO CONFIRM ..., 69-92 Baecke Questionnaire of Habitual Physical Activity (Baecke, Burema & Frijters, 1982), used to evaluate their physical activity level, and 3) following completion of the Eating Disorder Inventory (EDI-2) questionnaire and screening tool (EDI-SC) to identify predisposition towards disordered eating (Garner, 1991). Volunteers were excluded if they: (1) had used oral contraceptives during the preceding six months, (2) were smokers, (3) showed predispositions to disordered eating tendencies based on the EDI-2 and EDI-SC results, or (4) were involved in shift work (e.g. night shifts) as this would interfere with the accuracy of BBT methods (Prior, Vigna, Schulzer, Hall, & Bonen, 1990). Of the 38 volunteers, 4 HP and 5 C were excluded due to their use of oral contraceptives, and one HP scored positively for disordered eating tendencies and was referred to counseling. Data Collection Procedures and Measurement Participants attended a 2-hour information / education session during their study start week where demographic information, menstrual history and current menstrual status data were collected. A registered dietician provided education on how to correctly complete the 7-day dietary record including accurate recording of dietary intake, serving sizes, calories per serving, and how to read food labels and recall techniques. The participants were given similar detailed information on how to correctly complete the 7-day Activity Record, MC diary, and BBT measurements. During the study, multiple reminders (e.g. follow-up telephone contacts and emails) and assurances of confidentiality were incorporated into the data collection methods to increase response rate and decrease non-sampling errors (Ransdell, 1996). Menstrual Cycle Length MC was tracked on a calendar and participants were asked to identify the first day with a phone call to the research coordinator (RC). MC start was defined as the first day of menstrual flow and the final day was defined as the day before the onset of the next menstrual flow. MC length was calculated as the difference between the day before the onset of menstrual flow and the first day of the previous cycle and was calculated as the mean length of each recorded cycle from month 1 through to month 6 of the data collection period. Basal Body Temperature Participants were instructed to measure their oral BBT immediately upon waking and before standing using a low-reading digital thermometer read to the nearest 0.05°C. These measurements were recorded in the MC diary and in addition participants re- 72 ANNALES KINESIOLOGIAE • 8 • 2017 • 2 Patricia K. DOYLE-BAKER, Leanne MCLEAN, Tak FUNG: FEMALE ATHLETE TRIAD - PROBABLE BUT DIFFICULT TO CONFIRM ..., 69-92 corded their subjective observations about late rising, illness, amount of menstrual flow, emotions, and disturbed sleep. Participants also commented on subjective markers of ovulation such as mucous secretion and breast tenderness (Prior et al., 1990; Prior, 1996). Luteal Phase Length We chose the mean temperature method (MTM) to predict the onset of LP using pre-established criteria from Vollman (1977). According to Prior et al., (1990) the LP length determined by MTM is comparable to directly measured serum mid-cycle luteinizing hormone (LH) on the peak day (r = 0.891). The temperatures of a given MC were averaged and a corresponding mean line drawn across the graph of the data. The start of the LP was defined as the first temperature to rise above the mean line and remain above for three consecutive days. The end of the LP was defined as the day before the onset of the next menstrual flow (Prior et al., 1990). Temperatures of more than 0.5°C above the mean were discarded as febrile values (Vollman, 1977). SLP was defined as those cycles having LP length < 10 days within a cycle of normal length (Prior et al., 1990). Anovulation can be determined by a lack of thermal shift in BBT (Vollman, 1977). We designated anovulatory MCs as those cycles having irregular temperature patterns and the absence of a definite LP when a normal MC length of 21 to 36 days was maintained (Personal Communication, J. C. Prior, October 1999). The number of anovulatory cycles was expressed as a percentage of the total number of eligible cycles recorded for the study period. Total Energy Expenditure (TEE) EE includes the components of resting energy expenditure (REE), the thermic effect of food (TEF) and the energy expended through PA (EPA). REE is the largest single source of EE and accounts for approximately 50 to 75 % of an individual's TEE (Ma-han & Escott-Stump, 1996; Van Zant, 1992). TEE is defined as the energy expended due to resting physiological functions (e.g. ventilation, cardiovascular activity, protein, glycogen, and triglyceride synthesis, and electrical activity within the cells) (Thompson & Manore, 1996). We employed the Cunningham equation (1980) because of the ability to include fat free mass (FFM) in the calculation for estimated REE: (kcal / day) = 500 + 22 (FFM) (McArdle, Katch, & Katch, 1991). Thompson and Manore (1996) compared this equation against directly measured REE and to several predictive REE equations. The REE estimate derived from the Cunningham equation was the only estimate that was not significantly different than the directly measured REE in a study of 24 male and 13 female endurance athletes. 73 ANNALES KINESIOLOGIAE • 8 • 2017 • 2 Patricia K. DOYLE-BAKER, Leanne MCLEAN, Tak FUNG: FEMALE ATHLETE TRIAD - PROBABLE BUT DIFFICULT TO CONFIRM ..., 69-92 TEE was determined using estimated REE plus EPA and TEF (7 % of REE + EAP) (Personal Communication, K.A. Carter-Erdman, January 2000; Mahan & Escott-Stump, 1996). An estimate of the EPA was derived using the participants' 7-day Activity Records from three time points over the study collection period (October to June). Time 1 for the 7-day Activity Record started on the first day of menstrual flow during the month of October for HP and November for C. Records two and three were collected in similar fashion at two-month intervals. Participants were given instruction on recording daily activity into four 6-hour periods which included: (1) a general description of the activity (e.g. reclining, sitting, standing, walking, running, skating etc.); (2) an estimation of the effort involved (e.g. light, moderate, or vigorous effort); (3) a specific description of the activity performed (e.g. sitting-reading, standing-talking, walking to school etc.); (4) duration in minutes performing each activity; and (5) a check mark designating those activities that were sport-specific. Sport-specific activity was defined in this study as the performance of hockey related training. Verbal instructions with working examples were given regarding the accurate measurement and recording of activity type, intensity, duration and exercising radial pulse counts. The mean heart rate (HR) during exercise was calculated using HR taken at time 1, 2, and 3 as indicated on the Activity Records. Participants were also asked to record their weight each Monday during the study period. Each Activity Record was collected and evaluated at the end of the 7-day period and illegible and/or questionable entries were confirmed via telephone contact or personal interview. The accuracy of using Activity Records to estimate TEE is variable, with errors of various methods ranging from 6 to 30 % of actual energy need (Campbell, 1999). To establish the accuracy of several commonly employed methods of determining activity level, Miller, Freedson, and Kline (1994) tested five recording questionnaires against direct measurement of PA using a Caltrac accelerometer. The 7-day PA recall and the Caltrac were the only method that resulted in a significant Spearman rank order correlation coefficient (r = 0.79). EPA was also estimated based on each groups' habitual physical activity patterns and calculated as a percentage of REE: EPA = 75 % of REE for HP and 45 % of REE for C (Heyward, 1997; Mahalko & Johnson, 1980). This method is based on the factorial approach to calculating energy requirements of individuals (World Health Organization, 1985). Energy Intake EI was collected at the onset of the first day of menstrual flow from the 7-day dietary record. Diet records, three in total, were also collected at two-month intervals simultaneously with the collection of the 7-day Activity Records. To avoid recall bias, participants were instructed to record dietary intake within 30 minutes of ingestion and they were contacted via phone (RC) to fact-check their intake. A nutrition intern categorized data for entry into "Nutritionist 5.0 - version 1.6" software package (First 74 ANNALES KINESIOLOGIAE • 8 • 2017 • 2 Patricia K. DOYLE-BAKER, Leanne MCLEAN, Tak FUNG: FEMALE ATHLETE TRIAD - PROBABLE BUT DIFFICULT TO CONFIRM ..., 69-92 Data Bank, San Bruno, CA). Data were analysed to yield daily caloric intake, daily percentages for individual nutrients, and macro and micronutrient intakes. Energy Balance EB was calculated as the difference between the mean EI from the 7-day diet record and mean TEE calculated using REE, TEF, and EPA estimated by Heyward's (1997) approach, as stated above. Bone Mineral Density Baseline BMD testing of the lumbar spine (L1-L4), femoral neck, and distal radius occurred in week 1 for each group. DXA measurements were completed by a nuclear medicine technician (Hologic QDR2000- rectilinear scanner; Hologic, Inc.). Scan time was approximately 2 to 4 minutes and the coefficient of variation (CV) was better than 1.0 % for spinal measurements and approximately 2 to 3 % for femoral neck measurements (Hologic Manufacturers Inc., [On-line] August 1999; Personal Communication, Dr. R. Kloiber, April 2000). Individual BMD measurements in g/cm2 were compared to Hologic QDR 2000 reference standards of mean young adult BMD (T-score: standard deviation from the peak bone mass or young normal values of a female reference population) as well as across the groups (Kanis, Melton, Christiansen, Johnston & Khaltaev, 1994; Maggi, 1993). All reporting of the BMD values (BMD three decimal places; T-scores and Z-scores one decimal place) follow the Recommendations for Bone Mineral Density Reporting in Canada (Siminoski, et al., 2005). Body Composition A sport anthropometrist measured participant's height (HT), weight (WT), girths (10 sites), limb dimensions (8 sites), and skinfold thickness (15 sites) at start and end of the study, using a medical scale, Harpenden skinfold caliper, an anthropometer, and steel tape. The equations of Parizkova (1978) and Matiegka (1921) were used to estimate BF %, FFM (kg), and muscle mass percent (LMM %). Body composition in this study included: WT, BF, and FFM. 75 ANNALES KINESIOLOGIAE • 8 • 2017 • 2 Patricia K. DOYLE-BAKER, Leanne MCLEAN, Tak FUNG: FEMALE ATHLETE TRIAD - PROBABLE BUT DIFFICULT TO CONFIRM ..., 69-92 DATA ANALYSIS The main outcome was the identification of menstrual disturbances related to MC length (> 36 days oligomenorrhea vs < 21 days polymenorrhea), and SLP (< 10 days), as indicated by the MC diary and BBT measurements. The independent variables were: EI, TEE, EB, body composition, and BMD. Sample size Sample size was calculated from the results of a one-year prospective study investigating the proportion of menstrual disturbances in runners, as no available literature on female ice hockey players was found. Thirteen subjects (N = 66) were identified as experiencing menstrual disturbances based on their SLP (< 10 days) (Prior et al. 1990). Therefore, a conservative estimate of 20 participants was required to achieve a power of 80 % and an alpha of 0.05 for this study (Brant sample size calculator [On-line], August 1998). Statistics Statistical analyses were not performed because of the descriptive nature of the study; partly due to low compliance from HP. We report means (SD (±)) and box plots with median values, 25th and 75th percentiles, ranges, and outliers for percent change in WT, BF, FFM, BMD, T-Scores, Z-Scores, EI, TEE, EB, MC length and LP length. Percent change in WT, BF, and FFM were calculated to describe the pre (Tl)-post (T2) body composition change (Percent change = [(Time 2 - Time 1)/ Time 2]X100). RESULTS Three HPs were excluded because they did not provide MC diary data and one HP was excluded from the BMD analysis due to multiple missed appointments. Twelve hockey players (mean, SD (±): age = 21.1 ± 3.4 years; HT = 165.9 ± 4.6 cm; WT = 64.7 ± 8.1 kg; BF % 22.8 ± 3.8) and 12 non-athletes (age = 21.4 ± 2.8 years; HT = 169.5 ± 5.5 cm; WT = 65.4 ± 6.4 kg; BF % 20.0 ± 3.1) were enrolled in all testing sessions (n = 24). Anthropometric characteristics and exercise patterns for HP and C are listed in Table 1. No differences were observed between groups in anthropometric characteristics at the study start. The HP participated in l0.3 ± 4.1 as compared to the C 4.4 ± 1.8 number of exercise sessions per week. The calculated mean HR per exercise session was 151.1 ± 17.5 bpm and 137.2 ± 9.7 bpm in the HP and C, respectively. (see Table 1). 76 ANNALES KINESIOLOGIAE • 8 • 2017 • 2 Patricia K. DOYLE-BAKER, Leanne MCLEAN, Tak FUNG: FEMALE ATHLETE TRIAD - PROBABLE BUT DIFFICULT TO CONFIRM ..., 69-92 Table 1: Mean and standard deviations (SD (±)) of Hockey Player and Control group's anthropometric and exercise characteristics. Mean, SD Min Max HP (n = 12) Fat Free Mass (kg) 49.80 ± 5. l0 41.30 57.40 Muscle Mass (kg) 23.70 ± 4.30 16.70 31.80 Fat Mass (kg) 14.90 ± 3.90 10.50 21.60 Body Fat (%) 22.80 ± 3.80 17.00 29.20 Volume of thigh (cm3) 9217.90 ± 1336.70 7477.80 12130.20 Number of exercise / week 10.30 ± 4.10 5.00 21.00 Exercise duration / session (min.) 73.80 ± 14.90 60.00 90.00 Heart Rate / Session (bpm) 151.10 ± 17.50 125.00 175.00 C (n = 12) Fat Free Mass (kg) 52.20 ± 4.00 47.00 59.20 Muscle Mass (kg) 25.60 ± 3.10 21.40 32.90 Fat Mass (kg) 13.20 ± 3.10 8.50 18.80 Body Fat (%) 20.00 ± 3.10 14.90 25.40 Volume of thigh (cm3) 9185.90 ± 1011.20 7281.80 10392.80 Number of exercise / week 4.40 ± l.80 2.00 9.00 Exercise duration / session (min.) 56.70 ± 27.80 30.00 120.00 Heart Rate / Session (bpm) 137.18 ± 9.70 123.00 154.00 The median (25th and 75th percentile) WT percent change over the study duration for the HP and C was: -1.43 % (-2.45 % and 6.38 %) and 0.30 % (0.13 % and 2.53 %), respectively. The median (25th and 75th percentile) BF % percent change for the HP and C was: -4.42 % (-9.18 % and 0.34 %) and 4.73 % (-3.44 % and 9.28 %), respectively. No significant within group mean differences were observed for WT (HP p = 0.7; C p = 0.8), BF % (HP p = 0.97; C p = 0.6), and FFM (HP p = 0.6; C p = 0.98). 77 ANNALES KINESIOLOGIAE • 8 • 2017 • 2 Patricia K. DOYLE-BAKER, Leanne MCLEAN, Tak FUNG: FEMALE ATHLETE TRIAD - PROBABLE BUT DIFFICULT TO CONFIRM ..., 69-92 Bone Mineral Density Median values, 25th and 75th percentiles, ranges of the baseline BMD values (g / cm2) T-scores and Z-scores at the lumbar spine (L1-L4), total hip, and distal radius are presented in Table 2. Median lumbar spine and hip BMD were greater in the C (1.059 and 1.07 g / cm2) than in the HP (1.047 and 1.064 g / cm2). HP had one BMD measurement at the hip (1.357 g / cm2) that presented as an outlier (see Figure 1). There were no significant differences in mean lumbar spine, hip, or radial BMD values between the HP and C. However, the maximum value for all BMD measurement sites was greater in the HP. Median lumbar spine and hip T-scores were similar for HP and C. However median distal radius T-score was much larger for the HP (1.1) than C (0.5). The hip T-scores in the HP ranged from 0.1 to 3.4 as compared to a range of -0.9 to 2.6 in the C. The minimum lumbar spine (-0.7) and radial T-score (-0.9) in the HP and minimum T-score values at all sites in the C approached the WHO definition of osteopenia (-1.0 to -2.5). Figure 1 shows a comparison of HP and C T-scores values. Table 2: Bone mineral baseline values by site and group Median Percentile Range Median Percentile Range 25th 75th 25th 75th XI 1 , m Control Hocliey (n = 11) ^ = 12) Lumbar spine L1-L4 BMD g/cm2 1.047 0.993 1.149 0.968 -1.273 1.059 1.001 1.112 0.948 -1.251 T-Score 0.0 -0.5 0.1 -0.7 - 2.3 0.1 -0.4 0.7 -0.9 - 1.9 Z-score 0.2 -0.4 1.1 -0.5 - 2.4 0.2 -0.2 0.9 -0.9 - 2.1 Total hip BMD g/cm2 1.064 1.007 1.116 0.956 -1.357 1.07 0.982 1.12 0.838 -1.257 T-Score 1.0 0.5 1.8 0.1 - 3.4 1.0 0.3 1.5 -0.9 - 2.6 Z-score 1.1 0.5 2.6 0.1 - 3.4 1.2 0.5 l.4 -0.9 - 2.6 Distal radius BMD g/cm2 0.639 0.602 0.651 0.529 -0.691 0.606 0.602 0.651 0.545 -0.686 T-Score 1.1 0.4 1.3 -0.9 - 2.0 0.5 0.5 1.3 -0.6 - 1.9 Z-score 1.3 0.7 1.4 0.5 - 2.0 0.3 0.7 1.4 -0.5 - 1.9 Note: Outlier Total Hip HP 1.357 g/cm2 78 ANNALES KINESIOLOGIAE • 8 • 2017 • 2 Patricia K. DOYLE-BAKER, Leanne MCLEAN, Tak FUNG: FEMALE ATHLETE TRIAD - PROBABLE BUT DIFFICULT TO CONFIRM ..., 69-92 Figure 1: Baseline BMD T-Scores at three sites for Control and Hockey Players. Energy Expenditure Table 3 lists the mean group values of EPA, REE, TEF and TEE for the HP and C. The mean HP-TEE was greater than C-TEE due to the varying contributions of EPA, TEF, and REE. EPA and TEF were greater in the HP than the C. The mean REE was greater for C. Values of EPA, REE, and TEF for both HP and C were verified to be within recommended theoretical percentages of TEE. The median EI (25th and 75th percentile) values for the HP and C were: 1880.3 (1714.6 and 2080.85) and 1799.2 (1509.1 and 2038.5) kcal / day, respectively (see Table 4). One HP had an average daily energy intake of 1065.6 kcal / day and was represented as an outlier. The median (25th and 75th percentile) TEE for the HP and C groups were 2854.2 (2802.8 and 3080.28) and 2544.01 (2440.08 and 2659.55) kcal / day respectively. The frequency distribution for HP-TEE is left skewed. Daily mean caloric intakes for the HP and C were 11 % (HP -1026.52 ± 450.1 kcal / day) and 15 79 ANNALES KINESIOLOGIAE • 8 • 2017 • 2 Patricia K. DOYLE-BAKER, Leanne MCLEAN, Tak FUNG: FEMALE ATHLETE TRIAD - PROBABLE BUT DIFFICULT TO CONFIRM ..., 69-92 Table 3: Components of mean (SD (±)) Total Daily Energy Expenditure by group HP n = 12 C n = 12 kcal / day Mean, SD Min Max Mean, SD Min Max EPA 1116.48 ± 79.30 985.71 1234.42 741.75 ± 39.50 690.10 810.68 REE 1594.98 ± 113.30 1408.16 1763.46 1648.33 ± 87.80 1533.56 1801.52 TEF 189.80 ± 13.50 167.57 209.85 167.30 ± 8.90 155.66 182.85 TEE 2901.26 ± 206.10 2561.44 3207.73 2557.38 ± 136.1 2379.32 2795.06 Note: Estimated Energy of Physical Activity (EPA), Resting Energy Expenditure (REE), Thermic Effect of Food (TEF) and derived Total Daily Energy Expenditure (TEE) Table 4. HP and C Mean daily Energy Balance (calculated) Mean ± SD kcal / day hockey n = 12 Control n = 12 Daily Energy Intake 1882.89 ± 366.37 1777.3 l ± 328.62 Range 1065 to 2419 1212 to 2219 Total Energy Expenditure 2901.26 ±206.1 2557.38 ± 136.06 Mean Energy Balance -1018.37 ± 464.9 -780.07 ± 310.62 Note: Mean EB per day calculated as the difference between mean daily caloric intake (EI) and estimated total daily energy expenditure (TEE). % (C -780.00 ± 310.19 kcal / day) less than that recommended by Health and Welfare Canada (1990) for females aged 16 to 49 years (2100 kcal / day). There was a small difference of 105.5 kcal / day in daily EI between the HP and C but the number of exercise sessions per week and calculated mean HR per exercise session were also different. Thus, TEE between the HP and C was different and may have contributed to the difference in EB between the groups. Both groups maintained a state of negative EB for the study period as indicated by the mean TEE which exceeded daily caloric intake for both HP and C (see Table 4). The frequency distribution of HP-EB was symmetrical about the median and the median (25th and 75th percentile) was - 984.71 (- 1223.8 and - 767.7) kcal / day. The frequency distribution for C-EB 80 ANNALES KINESIOLOGIAE • 8 • 2017 • 2 Patricia K. DOYLE-BAKER, Leanne MCLEAN, Tak FUNG: FEMALE ATHLETE TRIAD - PROBABLE BUT DIFFICULT TO CONFIRM ..., 69-92 was right skewed and the median (25th and 75th percentile) was - 681.72 (- 1046.57 and - 595.25) kcal / day. Energy balance remained in a negative state despite corrections for errors (self-report corrected factor ~30 %) in estimating daily EI such that mean corrected EB for the HP and C was -641.8 and -424.6 kcal / day, respectively. Menstrual Cycle Characteristics Out of a possible 78 cycles for the HP and 72 cycles for the C, only 22 HP and 51 C cycles were included in the analysis due to incomplete data. The HP and C median (25th and 75th percentile) LP lengths were 9.0 (9 and 11) and 9.4 (8.3 and 10.5) days, respectively. Mean LP length for the C (9.4 ± l.9) was slightly less than the HP (9.9 ± 1 .7) days. Both groups were classified as having SLP (