For Many Female Athletes, Bone Stress and Missing Period Is the Norm

Three women running.

Q&A with Traci Carson and Carrie Karvonen-Gutierrez

 The culture of running promotes a body weight and size ideal that is unhealthy among elite female collegiate distance runners, according to preliminary findings from a series of interviews by University of Michigan School of Public Health researchers.

The topic recently gained media attention after former star Nike athlete Mary Cain's personal account of maltreatment she allegedly endured under head coach Alberto Salazar. After the allegations were published in The New York Times, the US Center for SafeSport placed Salazar on a temporarily banned list.

Michigan Public Health doctoral student Traci Carson has heard the story about elite athletes being pushed to the limit before. Carson and assistant professor of Epidemiology Carrie Karvonen-Gutierrez conducted interviews with elite collegiate distance runners that self-reported a personal experience with restrictive/disordered eating.The women shared personal stories of how body shaming from coaches, body size ideals of the sport, and mistrust of nutrition staff contributed to current and/or past eating and mental health disorders.

The researchers have also launched a study among NCAA female cross-country runners that aims to address the gap in our understating of culture of the sport and how it impacts the health of this population.

The researchers discuss their ongoing research.

How did you become interested in this issue?

Carson: As an athlete myself in college, I saw a lot of these things happening to my teammates and myself. There just was not a lot of information or resources out there for these women to seek help or have space to talk about the challenges they were going through, either related to mistreatment from coaches or body image and eating disorder issues that they were experiencing.

When I started my doctoral program, I knew I wanted to focus on the health of female athletes and aspects of the sport culture that promote undereating and overtraining and how it affects these athletes.What is the focus of your study?

Carson: During the summer of 2018, I did 30 qualitative interviews with Division I female distance runners just to understand more about the sport culture. All of these women screened into this study as being at risk for an eating disorder or already experiencing symptoms related to undereating and overtraining. And so there were some really powerful interviews. These women really shared a lot about their experience and were really open and vulnerable with me. Next, I put together a survey-based study where we randomly sampled current Division I female distance runners from over 300 teams across the country.

What is some of the preliminary data from that survey?

Carson: From about 177 participants so far, the vast majority are Caucasian, straight women from pretty high socioeconomic status backgrounds. About 30% of women have experienced irregular periods, which is a primary outcome that we're interested in understanding—the reproductive outcomes related to women in the sport of cross country. Also, about 41% of these women have experienced some kind of bone stress injury—either a fracture or something like a bone bruise or shin splints, those kinds of injuries. We also see pretty high prevalence of anxiety and depression.About 25% of women reported a clinical diagnosis of anxiety and about 15% reported clinical depression. So we would expect those to be even higher in terms of women who are not clinically diagnosed but still experiencing those types of symptoms. And then about a 15% prevalence of any type of eating disorder diagnosis. So these women are or have been really great and being truthful and honest with us, we hope so far. But these numbers are showing kind of what's coming out in the media recently as experienced by a lot of these women in the sport.

What does this tell us about the culture of sports and its effects on women?

Carson: All these women had suffered some kind of consequence of undereating and overtraining, so it was a special population. This experience is not unique to runners, however, this is the population our research focuses on. We learned a lot about the culture of running and how it promotes this ideal runner body image that isn't easy to achieve or healthy to achieve for a lot of women, and especially with the demands of training. And how much training and exercise is required for the sport just ending up in women not eating enough and how that affects their mental health and their body image issues. 

We also learned a lot about the culture that came from the coaches and the pressures to be thin and the idea that lighter is faster or thinner equals faster performance—but again, that being a pretty unhealthy message for a lot of these women and that resulting in a significant amount of burnout in the sport.They might be able to sustain not eating much and being a lighter body weight and performing well for a very short amount of time. However, that really catches up with them both physically and mentally where it ends up with them leaving the team or just not being able to sustain that level of training with such poor fueling and recovery. 

So those are a couple of the main themes that we found in the qualitative work. These women were very emotional and really committed to their sport. And they found so much of their identity in their sport, so when it didn't go well, it really affected how they saw themselves, but also their ability to continue to perform both in their sport and school and maintain relationships.

Do you think these expectations are different for women than they are for men?

Carson: There is no doubt that all athletes face complex body and performance expectations that are tied to their sport. My research focuses on the female experience, primarily due to my interest in expanding our understanding of the effects of undereating and overexercise on the menstrual cycle. From a feminist perspective, I'm also really interested in the dual social pressures that female atheltes face in meeting both the societal feminine body ideal with the sport body ideal that delivers perfomance outcomes. There is a fascinating physiologically competing interest there between body size and sustainable sport performance. 

What is the current state of your study?

Carson: The survey is out now and we have sampled five women from every Division I cross-country team across the nation. In addition, we have about 177 responses so far from the random sample that we did. Now, we're talking about doing another round of sampling. So we're hoping to double that sample size in this next round, hopefully.

Why is this study important?

Karvonen-Gutierrez: Although there are some specialized data sets in certain or restricted populations, a dataset with this breadth of coverage of questions and history of experience just simply didn’t exist.

Traci has created this amazing resource of rosters of all of the current female distance runners in the United States, which did not exist before her sampling. With this data, we hope to look at longer term outcomes in these women who continue to follow up over time as a prospective cohort study.

Looking forward, I think based on the stories that we've heard and knowledge about some of the biological mechanisms, we can speculate about how important these experiences might be. But at the moment, the data just doesn't exist to be able to fully describe that.

On the Podcast

Illustration of a college student's brain.Traci Carson appears on the University of Michigan School of Public Health's podcast, Population Healthy.

With other Michigan Public Health experts, Tracy discusses the state of mental health on campuses nationwide and the ways higher education can reshape learning environments to nurture and empower diverse student populations and, in turn, set them up for healthy lives. 

Listen to the episode "Mental Health on Campus: Reshaping Higher Ed to Help Students Thrive."