Women and Exercise Physiology and Sport Medicine PDF

Women and Exercise:
Physiology and Sports Medicine

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Women and Exercise:
Physiology and Sports Medicine
2nd Edition
MONA M. SHANGOLD, M.D.

Professor of Obstetrics and Gynecology
Director, Division of Reproductive Endocrinology
Director of the Sports Gynecology and Women's Life Cycle Center
Hahnemann University
Philadelphia, Pennsylvania
GABE MIRKIN, M.D.

Associate Clinical Professor
Georgetown University School of Medicine
Washington, D.C.
F. A. DAVIS COMPANY • Philadelphia

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Copyright © 1994 by F. A. Davis Company
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Library of Congress Cataloging-in-Publication Data
Women and exercise : physiology and sports medicine / [edited by] Mona
M. Shangold, Gabe Mirkin.—Ed. 2.
p. cm.
Includes bibliographical references and index.
ISBN 0-8036-7817-7
1. Women athletes—Physiology. 2. Exercise for women-
-Physiological aspects. 3. Sports for women—Physiological aspects.
4. Sports medicine. I. Shangold, Mona M. II. Mirkin, Gabe.
[DNLM: 1. Physical Fitness. 2. Sports. 3. Sports Medicine.
4. Women. 5. Exercise. QT260 W8715 1993]
RC1218.W65W65 1993
613.7'11'082—dc20
DNLM/DLC 93-17937
for Library of Congress CIP
Authorization to photocopy items for internal and personal use, or the internal or personal use of specific clients,
is granted by F.A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional
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For those organizations that have been granted a photocopy license by CCC, a separate system of payment has
been arranged. The fee code for users of the Transactional Reporting Service is: 8036-7817/7 0 + $.10.
To Kenneth,
Our greatest treasure
and
Our greatest joy
Preface to the Second Edition
The success and warm reception of the first edition and the many advances
in this field have led to the development of this second edition, in which all ma-
terial has been updated and expanded. Much has happened since the publication
of the first edition: Women athletes have set many new records; researchers have
devoted increased attention to the consequences of exercise for women; clini-
cians have devoted greater attention to the needs and concerns of exercising
women; and increasing numbers of female couch potatoes have acknowledged
that exercise is beneficial and desirable.
The contributors remain accepted authorities and leaders in their fields. The
same blend of basic and clinical science is presented, providing comprehensive
coverage for both researchers and clinicians. Those caring for athletic women
have shared their vast experience in a valuable composite of science and art. We
believe this edition is even better than the first, and we hope it will surpass the
first edition in providing satisfaction and inspiration.
Mona Shangold, M.D.

Gabe Mirkin, M.D.
vii
Preface to the First Edition
We have prepared this book to assist physicians and other health care pro-
fessionals in caring for women who exercise. Included are chapters covering the
many fields necessary to provide comprehensive care to women who range from
novice exercisers to elite athletes and who may require information about train-
ing, health maintenance, treatment of disease or injury, and rehabilitation. Chap-
ters have been written by leading authorities in each of these fields to supply the
necessary depth of scientific background and clinical experience. In each case,
relevant basic science is explained, and pertinent literature is reviewed and in-
terpreted. When sufficient data are present, most authors have outlined and jus-
tified their personal recommendations, based on these data. Because clinical
medicine often requires action even when sufficient data are lacking or inconclu-
sive, many contributors have outlined their advice for these situations, based on
their own expertise and clinical experience. We believe readers will find these
recommendations invaluable.
Contributors to this volume include both basic scientists and practicing
physicians. We purposely have encouraged some basic scientists and clinicians
to cover the same topics from their different perspectives. We feel that this ap-
proach adds greatly to the value of this book.
Although elementary textbooks must oversimplify in order to teach stu-
dents, this book is aimed at scientists and educators, who appreciate that re-
search may, at times, lead to conflicting conclusions and different recommen-
dations based upon these conclusions. We are confident that the sophisticated
reader will find the controversy generated by these different perspectives re-
freshing, stimulating, and representative of the state of the art in this field.
No other book to date has covered so many relevant topics dealing with ex-
ercise and sports medicine for women in the depth that is provided in this vol-
ume. We hope this volume meets the needs of generalists caring for women ath-
letes and specialists wanting information outside of their own specialty. Above
all, we hope it will enable exercising women to receive the best care possible.
Mona Shangold, M.D.

Gabe Mirkin, M.D.
viii
Contributors
Oded Bar-Or, M.D

Professor of Pediatrics Associate Professor of Medicine
Director, Children's Exercise and Nutrition Harvard Medical School
Centre Boston, Massachusetts
McMaster University
Hamilton, Ontario, Canada Thomas D. Fahey, Ed.D.
Professor of Physical Education
Kelly D. Brownell, Ph.D. California State University
Professor of Psychology Chico, California
Professor of Epidemiology and Public
Health Catherine Gilligan, B.A.
Co-Director, Yale Center for Eating and Associate Researcher
Weight Disorders Biogerontology Laboratory
Yale University University of Wisconsin
New Haven, Connecticut Madison, Wisconsin
LethaY. Griffin, M.D., Ph.D.
Marshall W. Carpenter, M.D. Staff Physician,
Associate Professor, Obstetrics and Peachtree Orthopaedic Clinic
Gynecology Team Physician,
Brown University Georgie State University
Director of Maternal-Fetal Medicine Atlanta, Georgia
Department of Obstetrics and Gynecology
Women and Infants Hospital of Rhode Carlos M. Grilo, Ph.D.
Island Director of Psychology
Providence, Rhode Island Yale Psychiatric Institute
Assistant Professor in
David H. Clarke, Ph.D. Psychiatry
Chair, Department of Kinesiology Yale University School of Medicine
University of Maryland New Haven, Connecticut
College Park, Maryland
Christine Haycock, M.D.
Pamela S. Douglas, M.D. Professor Emeritus
Director of Nonlnvasive Cardiology UMDNJ, New Jersey Medical School
Beth Israel Hospital Newark, New Jersey
Ix
X Contributors
Jack L. Katz, M.D. Department of Orthopaedic Surgery

Professor of Clinical Psychiatry Memphis, Tennessee
Cornell University Medical College
New York, New York Mona M. Shangold, M.D.
Chairman, Department of Psychiatry Professor of Obstetrics and Gynecology
North Shore University Hospital Director, Division of Reproductive
Manhasset, New York Endocrinology
Director of the Sports Gynecology and
Robert M. Malina, Ph.D. Women's Life Cycle Center
Professor Hahnemann University
Departments of Kinesiology and Health Philadelphia, Pennsylvania
Education and of Anthropology
University of Texas Arthur J. Siegel, M.D.
Austin, Texas Assistant Professor of Medicine
Harvard Medical School
Gabe Mirkin, M.D. Chief, Internal Medicine Department
Associate Clinical Professor McLean Hospital
Georgetown University School of Medicine Belmont, Massachusetts
Washington, D.C.
Everett L. Smith, Ph.D.
Director, Biogerontology Laboratory
Morris Notelovitz, M.D., Ph.D.
Department of Preventive Medicine
President and Medical Director University of Wisconsin
Women's Medical and Diagnostic Center Madison, Wisconsin
The Climacteric Clinic, Inc. and
Midlife Centers of America, Inc. Denise E. Wilfley, Ph.D.
Gainesville, Florida
Research Scientist and Lecturer
Clinical Director Department of Psychology
Mary L. OToole, Ph.D. Yale Center for Eating and Weight
Associate Professor Disorders
Director, Human Performance Laboratory Yale University
University of Tennessee-Campbell Clinic New Haven, Connecticut
Contents
PARTI
BASIC CONCEPTS OF EXERCISE PHYSIOLOGY 1
1. Fitness: Definition and Development 3

Mary L. O'Toole, Ph.D., and Pamela S. Douglas, M.D.
Components of Fitness 4
Muscular Strength and Endurance 4
Body Composition 4
Flexibility 4
Cardiovascular-Respiratory Capacity 4
Benefits of Fitness 5
For Healthy Individuals 5
Medical Implications 6
Fitness Evaluation 8
Muscular Strength and Endurance 8
Body Composition 9
Flexibility 9
Functional Capacity 9
Fitness Development and Maintenance 14
Fitness Development 14
Fitness Maintenance 16
Factors Affecting Fitness Development and Maintenance 17
Training for Competition 19
Interval Training 19
Cross Training 20
2. Exercise and Regulation of Body Weight 27

Denise E. Wilfley, Ph.D., Carlos M. Grilo, Ph.D., and Kelly D. Brownell, Ph.D.
The Nature and Severity of Weight Disorders 28
The Association Between Physical Activity and Weight 31
Exercise and Weight Control 32
Likely Mechanisms Linking Exercise and Weight Control 33
Energy Expenditure 34
xi
Xll Contents
Appetite and Hunger 36

Body Composition 37
Physical Activity and Health 37
Psychologic Changes 38
The Challenge of Adherence 39
Adherence and the Demographics of Obesity 39
Obstacles to Exercise for the Overweight Individual 39
Adherence Studies 40
Program Recommendations 43
Avoid a Threshold Mentality 43
Consistency May be More Important than the Type or Amount of Exercise ... 44
Provide Thorough Education 45
Be Sensitive to the Special Needs of Overweight Persons 45
Special Issues 45
The Role of Exercise in the Search for the Perfect Body 45
Ideal Versus Healthy Versus Reasonable Weight 45
Exercise Overuse (Abuse) 47
3. Training for Strength 60

David H. Clarke, Ph.D.
Definition of Strength 60
Isotonic Training 61
Isometric Training 63
Isotonic Versus Isometric Traning 64
Eccentric Training 65
Isokinetic Exercise 67
Hypertrophy of Skeletal Muscle 68
Aging and Strength Development 69
4. Endurance Training 73
Thomas D. Fahey, Ed.D.
Factors that Determine Success in Endurance Events 73
Maximal Oxygen Consumption 74
Mitochondrial Density 77
Performance Efficiency 78
Body Composition 79
Sex Differences in Endurance Performance 80
Training for Endurance 82
Components of Overload 83
Principles of Training 84
5. Bone Concerns 89
Everett L. Smith, Ph.D.
Catherine Gilligan, B.A.
Incidence and Cost of Osteoporosis 90
Effects of Calcium Intake 91
Mechanism of Exercise Benefits 93
Effects of Inactivity 94
Effects of Exercise 96
Athletic Amenorrhea and Bone 97
Problems in Studying Exercise Effects 98
Contents Xiii
6. Nutrition for Sports 102

Gabe Mirkin, M.D.
Nutrients 103
Carbohydrates 103
Proteins 103
Fats 105
Energy Storage 105
Comparing Women and Men 106
Endurance 106
"Hitting the Wall": Depletion of Muscle Glycogen 106
"Bonking": Depletion of Liver Glycogen 107
Increasing Endurance 107
Training to Increase Endurance 107
Utilizing Fat Instead of Glycogen 107
Diet and Endurance 108
Food Intake During the Week Before Competition 108
Eating the Night Before Competition 109
Eating the Meal Before Competition 109
Eating Before Exercising 110
Eating During Competition 110
Drinking Before Competition 1ll
Drinking During Competition Ill
Dehydration and "Heat Cramps" Ill
Women May Need Less Fluid Than Men 112
When to Drink 112
What to Drink 112
Cold or Warm? 113
Eating and Drinking After Competition 113
Protein Requirements 113
Vitamins 114
Mechanism of Function 114
Vitamin Needs of Female Athletes 115
Vitamin C and Colds 115
Vitamins and Birth Control Pills 115
Vitamins and Premenstrual Syndrome 116
Minerals 116
Iron 116
Calcium 117
Sodium 118
Potassium 118
Trace Minerals 119
The Athlete's Diet 119
PART II
DEVELOPMENTAL PHASES 127
7. The Prepubescent Female 129

Oded Bar-Or, M.D.
Physiologic Response to Short-Term Exercise 130
Submaximal Oxygen Uptake 130
Maximal Aerobic Power 131
XlV Contents
Anaerobic Power and Muscle Endurance 131

Muscle Strength 132
Trainability 132
Thermoregulatory Capacity 133
Response to Hot Climate 133
Response to Cold Climate 134
High-Risk Groups for Heat- or Cold-Related Disorders 135
Growth, Pubertal Changes, and Athletic Training 135
Coeducational Participation in Contact and Collision Sports 137
8. Growth, Performance, Activity, and Training During Adolescence 141

Robert M. Molina, Ph.D.
The Adolescent Growth Spurt 142
Body Size 142
Body Composition 142
Menarche 142
Physical Performance and Activity During Adolescence 143
Strength 143
Motor Performance 144
Maximal Aerobic Power 144
Physical Activity Habits 145
Significance of the Adolescent Plateau in Performance 145
Influence of Training on the Tempo of Growth and Maturation During
Adolescence 146
Stature and Body Composition 146
Sexual Maturation 147
Hormonal Responses 148
Fatness and Menarche 149
Other Maturity Indicators 149
Overtraining 149
9. Menstruation and Menstrual Disorders 152

Mono M. Shangold, M.D.
Prevalence of Menstrual Dysfunction Among Athletes 152
Review of Menstrual Physiology 154
Types of Menstrual Dysfunction 154
Menstrual Cycle Changes with Exercise and Training 156
Weight Loss and Thinness 156
Physical and Emotional Stress 157
Dietary Factors 157
Hormonal Changes with Exercise and Training 159
Acute Hormone Alterations with Exercise 159
Chronic Hormone Alterations with Training 159
Consequences of Menstrual Dysfunction 162
Luteal Phase Deficiency 162
Anovulatory Oligomenorrhea 162
Hypoestrogenic Amenorrhea 163
Diagnostic Evaluation of Menstrual Dysfunction in Athletes 165
Treatment of Menstrual Dysfunction in Athletes 166
Evaluation and Treatment of Primary Amenorrhea 168
Contents XV
10. Pregnancy 172

Marshall W. Carpenter, M.D.
Physiologic Changes of Pregnancy 173
Acute Physiologic Response to Exertion in the Nonpregnant State 173
Acute Metabolic Response to Exertion 174
Effect of Pregnancy on the Acute Physiologic Response to Exertion 175
Effect of Pregnancy on the Acute Metabolic Response to Exertion 176
Maternal Thermoregulation During Exercise 177
Acute Effects of Maternal Exertion on the Fetus 178
Maternal Exercise Training Effects on Fetal Growth and Perinatal Outcome . . . . 179
Recommendations About Recreational Exercise 180
11. Menopause 187

Morris Notelovitz, M.D., Ph.D., and Mono M. Shangold, M.D.
Menopause in Perspective 187
Osteoporosis and Bone Health 189
Osteogenesis: A Brief Overview 189
Exercise and Osteogenesis: Clinical Research 192
Atherogenic Disease and Cardiorespiratory Fitness 196
Lipids, Lipoproteins, and Exercise 196
Aerobic Power 198
Muscle Tissue and Strength 202
Age-Related Loss of Muscle Tissue and Strength 202
Strength Training 205
Other Menopausal Problems: Vasomotor Symptoms 205
Other Age-Related Changes 205
Exercise and Adipose Tissue 205
Exercise and Osteoarthrosis 206
Exercise and Well-Being 206
PART III
SPECIAL ISSUES AND CONCERNS 215
12. The Breast 217
Christine E. Haycock, M.D.
Breast Support 217
Nipple Injury 219
Trauma 219
Breast Augmentation and Reduction 219
Pregnancy and Lactation 220
Premenstrual Changes and Fibrocystic Breasts 220
Exercise Following Trauma or Surgery 221
13. Gynecologic Concerns in Exercise and Training 223

Mono M. Shangold, M.D.
Contraception 223
Oral Contraceptives 224
Intrauterine Devices (lUDs) 225
Mechanical (Barrier) Methods 225
XVi Contents
Norplant 225
Choosing a Contraceptive 226
Dysmenorrhea 226
Endometriosis 227
Premenstrual Syndrome 227
Fertility 229
Stress Urinary Incontinence 229
Postoperative Training and Recovery 230
Effect of Menstrual Cycle on Performance 231
14. Orthopedic Concerns 234

Letha Y. Griffin, M.D., Ph.D.
Patella Pain 235
Anatomy of the Patella 235
Sources of Pain 236
Evaluating Patella Pain 238
Acute Traumatic Patella Dislocation 242
Patella Subluxation 245
Patellofemoral Stress Syndrome 247
Patella Plica 249
Patella Pain: Summary 249
Impingement Syndromes 249
Ankle Impingement 250
Wrist Impingement 250
Shoulder Impingement 251
Other Common Conditions 253
Achilles Tendinitis 253
Shin Splints 254
Stress Fractures 255
Low Back Pain 256
Bunions 257
Morton's Neuroma 258
15. Medical Conditions Arising During Sports 261

Arthur J. Siegel, M.D.
The Physiology of Athletes 262
Cardiac Changes with Exercise and Training: Risks and Benefits 263
Primary and Secondary Prevention of Heart Disease Through Exercise 263
Exercise and Cancer Risk 264
Hazards of Exercise 264
Heat Stress 264
Hematologic Effects: Iron Status and Anemia 267
"Runner's Diarrhea" 269
Effects on the Urinary Tract 269
Exercise-Induced Asthma 270
Exercise-Induced Anaphylaxis 272
Exercise-Induced Urticaria 273
Pseudosyndromes in Athletes 273
Pseudoanemia ("Runner's Anemia") 273
"Athletic Pseudonephritis" 273
Contents xvii
Serum Enzyme Abnormalities: Muscle Injury and Pseudohepatitis 274

Pseudomyocarditis 274
Screening the Athlete for Medical Clearance 275
Caution: When Not to Exercise 275
16. Cardiovascular Issues 282

Pamela S. Douglas, M.D.
Aerobic Capacity 282
Cardiac Function in Response to Exercise 283
Exercise Electrocardiographic Testing 286
Exercise Limitations in Heart Disease 287
Mitral Valve Prolapse 287
Anorexia Nervosa 288
Sudden Death 288
Other Forms of Heart Disease 289
17. Eating Disorders 292

Jack L Katz, M.D.
Epidemiology 293
Setting and Onset 293
Bulimia Nervosa 294
Clinical Features 295
Bulimia Nervosa 297
Biology of Eating Disorders 298
Physical Sequelae 298
Laboratory Findings 299
Endocrine Abnormalities: Hypothalamic Implications 300
Diagnosis, Course, and Prognosis of the Eating Disorders 301
Co-Morbidity 302
Theories of Etiology 303
Treatment 305
Exercise and Eating Disorders 307
Eating Disorders and Other Special Subcultures 309
APPENDIX A 313
Exercise Following Injury, Surgery, or Infection 313
INDEX 319
I
Basic Concepts
of Exercise
Physiology
CHAPTER 1
Fitness: Definition
and Development
MARY L. OTOOLE, Ph.D., and PAMELA S. DOUGLAS, M.D.
COMPONENTS OF FITNESS Flexibility

Muscular Strength and Endurance Functional Capacity
Body Composition
FITNESS DEVELOPMENT AND
Flexibility
MAINTENANCE
Cardiovascular-Respiratory Capacity
Fitness Development
BENEFITS OF FITNESS Fitness Maintenance
For Healthy Individuals Factors Affecting Fitness
Medical Implications Development and Maintenance
FITNESS EVALUATION TRAINING FOR COMPETITION
Muscular Strength and Endurance Interval Training
Body Composition Cross Training
T he term "physical fitness" connotes a state of optimal physical well-being.

However, a universally accepted definition of physical fitness is difficult to find.
Cureton,1 a pioneer in the fitness movement, defined it as "the ability to handle
the body well and the capacity to work hard over a long period of time without
diminished efficiency." Others have used physical fitness to describe a quality of
life rather than a precise set of conditions. For example, in monographs pub-
lished by the President's Council on Physical Fitness2,3 to offer guidance to those
interested in improving their physical fitness, a physically fit individual is
described as one able to perform vigorous work without undue fatigue and still
have enough energy left for enjoying hobbies and recreational activities, as well
as for meeting emergencies. Exercise physiology texts4-8 have similar descrip-
tive rather than quantitative definitions of physical fitness. For example, Lamb6
defines it as "the capacity to meet successfully the present and potential physical
challenges of life." So, despite all the interest generated by physical fitness, a
need remains for a clear definition of fitness to allow accurate assessment of an
individual's level of fitness.
The most successful definitions used to quantify "fitness" have been based
on its measurable components. Muscular strength and endurance, body com-
3
4 Basic Concepts of Exercise Physiology
position, flexibility, and cardiovascular-res- their muscles for strength and endurance
piratory capacity are generally agreed upon performance is similar to that of men. The
as the major components of physical fit- topics of muscular strength and endurance
ness.9 Therefore, for the purposes of this are covered in detail in Chapters 3 and 4.
text, an operational measure of fitness based
on combined capabilities in these four com-
ponents will be assumed to quantify an indi- Body Composition
vidual's level of physical fitness. Body composition makes an important
A further problem in evaluating fitness contribution to an individual's level of phys-
is the wide variation in individual need for ical fitness. Performance, particularly in ac-
physical work capacity. For example, an tivities that require one to carry one's body
adult who wishes to enjoy optimal health weight over distance, will be facilitated by a
must maintain a certain degree of physical large proportion of active tissue (muscle) in
fitness, while a competitive ultraendurance relation to a small proportion of inactive tis-
athlete needs to maintain a greater capacity sue (fat).14 In general, women have a greater
for physical work. Therefore, the adequacy percentage of fat than do men, whether
of one's physical fitness cannot be judged trained or untrained. Therefore, when per-
simply by the attainment of some magic forming a weight-bearing activity such as
number. However, normative values for the distance running, women tend to be at a dis-
parameters of muscular strength and endur-
advantage compared with their male coun-
ance, body composition, flexibility, and car- terparts. The role of exercise in reaching
diovascular-respiratory capacity have been and maintaining a desirable weight and per-
developed based on age, gender, and habit- centage of body fat is discussed at length in
ual activity level.10-12 An interested individ- Chapter 2.
ual can compare her own values to the
appropriate (based on desired activity
level) normative values to assess the ade- Flexibility
quacy of her "fitness level."
Flexibility is the degree to which body
segments can move or be moved around a
COMPONENTS OF FITNESS joint. 56 The flexibility, or range of motion
around a particular joint, is determined by
Muscular Strength and the configuration of bony structures and the
Endurance length and elasticity of ligaments, tendons,
Muscular strength refers to the force or and muscles surrounding the joint.5,6 Al-
tension that can be generated by a muscle or though there are no research data to sup-
muscle group during one maximal effort.5,6,9 port the concept that flexibility aids in co-
Muscular endurance is the ability to perform ordinated movements, it certainly makes
many repetitions at submaximal loads.5,6,13 sense that by allowing free movement with-
For example, it takes a certain amount of out unnecessary restriction, the body's effi-
strength to lift and swing a tennis racquet, ciency and grace would be increased and
but it takes muscular endurance to repeat the potential for injury reduced.15
that swing hundreds of times during the
course of a 2-hour match. An individual may Cardiovascular- Respiratory
have a great deal of strength but little endur- Capacity
ance, or may have extraordinary strength in
one muscle group but not in others. Al- The cardiovascular-respiratory compo-
though women usually have a smaller mus- nent of fitness reflects the integrity of the
cle fiber area and, therefore, lower absolute heart and lungs as well as the ability of the
strength levels than men, the trainability of muscle cells to use oxygen as fuel. It there-
Fitness: Definition and Development 5
fore reflects the degree to which an individ- aged women and men responded to the ex-
ual can increase metabolism above resting ercise training program in a similar fashion,
levels.4 6,8,9 Incremental tests up to maximal with a 21% increase in aerobic capacity and
oxygen uptake (Vo2 max) are used to mea- a 6% decrease in submaximal heart rates
sure this component and to define the limits during posttraining exercise tests.
of physical work capacity. This measure- There have also been suggestions that ex-
ment is considered to be the best single ercise may affect longevity, or that a "rever-
measure of an individual's overall functional sal of aging" may occur. A number of epide-
capacity.16 This and other measures of fit- miologic studies have attempted to examine
ness will be discussed below. the long-term effects of exercise upon lon-
gevity. Although no study has yet demon-
strated a negative effect, in general such
studies may have limited applicability be-
BENEFITS OF FITNESS cause of the many methodologic problems
inherent in choosing subject populations for
this type of study. From the viewpoint of this
Regular physical activity, resulting in fit- text, of primary importance is the fact that
ness, has benefits to disease-free individu- few have examined female populations.
als as well as implications for the medical Other limitations include the inclusion of
care of individuals with certain dis- ex-athletes who may have had intense ex-
eases.4'1"82°-23,25-28 There is general agree- ercise training for short periods of time;
ment that exercise performed by healthy in- classification of activity level based on
dividuals has both physical and psychologic workplace activity; and the interaction of a
benefits, including improved physical per- number of covariables such as obesity,
formance and enhanced quality of life. In smoking, environment, other life habits, and
contrast, although exercise clearly does not importantly, concomitant medical diseases.
change the course of most diseases, there Exercise training, however, has been well
are certain medical implications that are im- documented to modify or retard aspects of
portant. the aging process.20,21 Exercise training
slows the normal age-related declines in
For Healthy Individuals peak performance and maximal aerobic ca-
pacity, and it retards the loss of muscle and
Physical Benefits
bone mass and the increase in body fat. The
In reviewing the physiologic aspects of ex- exercising older woman has an aerobic
ercise in women, Drinkwater17 cites numer- capacity and body composition similar
ous studies that support the hypothesis that to those of much younger, sedentary
women of all ages benefit from programs women.22,23 It has been suggested that the
of physical conditioning. The observed rate of decline in many physiologic param-
changes in the women are similar to those in eters may be reduced by approximately 50%
men and include increases in maximal aer- in physically fit as compared with sedentary
obic capacity, maximal minute ventilation, women.24
02 pulse, and increases in submaximal work
performance.18,19 With training, one can per-
form the same amount of work with lower Psychologic Benefits
heart and respiratory rates and with a lower Although subjective parameters are ex-
systolic blood pressure. Some studies show traordinarily difficult to measure, and a
that beneficial effects occur after as little as small number of participants may note a
4 weeks of training.17 Improvements re- negative effect of exercise, it is generally
ported by Getchell and Moore27 are typical thought that fitness leads to an improved
of the expected responses; that is, middle- quality of life. In several studies, the major-
ity of participants in an exercise program duced or, less often, an unchanged risk
noted an enhancement of mood, self-confi- associated with higher levels of physical ac-
dence, and feelings of satisfaction, achieve- tivity.29,31-36 Unfortunately, methodologic
ment, and self-sufficiency.25-28 Interestingly, problems similar to those inherent in stud-
in one study, those with the greatest im- ies of longevity also limit the applicability of
provement in endurance also had a more many of these studies to women. One pro-
marked improvement on psychologic test- spective study that did include 3120 women
ing.25 In general, women who exercise regu- reported a decrease in both all-cause and
larly are more likely to be more comfortable cardiovascular disease mortality rates in
with day-to-day physical exertion and to physically fit versus inactive women.30
have reduced anxiety and an improved body The amount of activity necessary to re-
image.26-28 duce cardiovascular risk is similarly un-
clear. It appears that no amount of exercise
will lower the incidence of cardiovascular
Medical Implications disease in those at especially high risk.
Women with medical illnesses may have a However, in women at "usual" risk, it is
lower level of fitness than their counterparts likely that, as with men, moderate amounts
in a comparable but healthy, sedentary pop- of exercise are protective, with benefit ac-
ulation. Although this may be due to limita- cruing to those expending 200 to 500 kcal/d
tions imposed by either the primary or an or 2000 kcal/wk pursuing vigorous activity.
associated illness, it may also be related to No studies have yet been performed to doc-
the adoption of a less active lifestyle. In the ument this effect in women.37-39 Although
latter case, increased fitness through partic- most studies have examined the effects of
ipation in regular exercise programs en- aerobic exercise, studies have shown that
courages the patient to increase her level of cardiovascular endurance may be increased
activity in daily life and in recreation, thus by resistive exercise as well.40
yielding at least a subjective improvement in The mechanisms by which exercise may
health. improve cardiovascular health are unclear.
Fitness or exercise training may have sal- Certainly, training enhances cardiac effi-
utary effects upon specific medical disease ciency, allowing a given work rate to be
in three ways: (1) as primary prevention achieved at a lower heart rate and blood
(e.g., in modifying factors known to increase pressure level. This is equally true in the
the risk of acquiring heart disease); (2) as healthy individual and in a patient with
secondary prevention or modification of the known coronary disease. Table 1-1 groups
natural history of a disorder (e.g., decreases these and other physiologic changes occur-
in both systolic and diastolic resting blood ring in the cardiovascular system with ex-
pressures); and (3) for rehabilitation or pal- ercise according to the method by which
liation of a specific disorder. The last is they might prevent coronary heart disease,
more closely related to task-specific exer- additionally noting the likelihood of each
cise and is beyond our consideration of the adaptation of being an important factor in
benefits of overall fitness. prevention.41 The beneficial effects of exer-
cise are likely multifactorial, and the mech-
Cardiovascular Disease
anisms are still unclear.
Exercise may also affect cardiovascular
Coronary Artery Disease. Although cor- disease by altering risk factors for its devel-
onary artery disease is more common in opment. In healthy women, higher levels of
men, it is the leading cause of death in fitness, as determined by exercise duration
women as well. Studies examining the ef- on treadmill testing, have been associated
fects of fitness upon the risk of developing with lower body weight, a lower percentage
coronary artery disease find either a re- of body fat, lower incidence of cigarette
Table 1-1. BIOLOGIC MECHANISMS BY WHICH EXERCISE MAY CONTRIBUTE TO THE

PRIMARY OR SECONDARY PREVENTION OF CORONARY HEART DISEASE*
Maintain or increase myocardial oxygen supply

Delay progression of coronary atherosclerosis (possible).
Improve lipoprotein profile (increase HDL-C/LDL-C ratio) (probable).
Improve carbohydrate metabolism (increase insulin sensitivity) (probable).
Decrease platelet aggregation and increase fibrinolysis (probable).
Decrease adiposity (usually).
Increase coronary collateral vascularization (unlikely).
Increase coronary blood flow (myocardial perfusion) or distribution (unlikely).
Decrease myocardial work and oxygen demand
Decrease heart rate at rest and submaximal exercise (usually).
Decrease systolic and mean systemic arterial pressure during submaximal exercise (usually) and at rest
(possible).
Decrease cardiac output during submaximal exercise (probable).
Decrease circulating plasma catecholamine levels (decrease sympathetic tone) at rest (probable) and at
submaximal exercise (usually).
Increase myocardial function
Increase stroke volume at rest and in submaximal and maximal exercise (likely).
Increase ejection fraction at rest and in exercise (possible).
Increase intrinsic myocardial contractility (unlikely).
Increase myocardial function resulting from decreased "afterload" (probable).
Increase myocardial hypertrophy (probable); but this may not reduce CHD risk.
Increase electrical stability of myocardium
Decrease regional ischemia at rest or at submaximal exercise (possible).
Decrease catecholamines in myocardium at rest and at submaximal exercise (probable).
Increase ventricular fibrillation threshold due to reduction in cyclic AMP (possible).
'Expression of likelihood that effect will occur for an individual participating in endurance-type training program
for 16 wk or longer at 65-80% of functional capacity for 25 min or longer per session (300 kcal) for 3 or more
sessions per week ranges from unlikely, possible, likely, probable, to usually.
Abbreviations: HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; CHD =
coronary heart disease; AMP = adenosine monophosphate.
Source: Haskell,41 p. 65, with permission.
smoking, lower systolic and diastolic blood tion of preexisting coronary disease are
pressures, lower total cholesterol with a much less clear. At least one well-controlled
higher high-density lipoprotein (HDL) study in men with heart disease showed a
subtraction, lower triglycerides, and, most modest decrease in deaths due to myocar-
importantly, a lower incidence of cardiovas- dial infarction, with a trend toward a reduc-
cular disease and lower mortality rate.42 tion in deaths from all causes in individuals
Using multiple regression analysis, Gibbons pursuing exercise programs.45 Although car-
and colleagues42 demonstrated independent diac patients are generally encouraged to
associations between fitness level and lipid avoid resistive exercise because of the re-
profiles, blood pressure, and smoking, sug- sultant unfavorable cardiac-loading condi-
gesting that risk factors for coronary heart tions, some successfully used forms of
disease may be modified by fitness level. exercise (e.g., rowing, bicycling) have sig-
Other studies have partly confirmed these nificant resistive as well as aerobic compo-
results, finding more favorable lipid profiles nents. No study has demonstrated a harmful
in active women;43 however, an exercise- effect of carefully performed exercise in se-
related increase in HDL cholesterol has lected cardiac patients.
been demonstrated only in men, not in Hypertension. Appropriately tailored ex-
women.44 ercise programs have been shown to result
The benefits of exercise in the modifica- in 5- to 10-mm decreases in both systolic
and diastolic resting blood pressures.46 48 ity or disuse. Further, most studies of ath-
Although the mechanisms of these changes letes engaged in weight-bearing exercise
are unknown, exercise may be a useful ad- (e.g., not swimmers) have shown up to a 40%
junct to more conventional therapy. Care increase in bone mass over more sedentary
must be taken in the exercise prescription, control subjects.52,53 Controlled trials, with
however, because the normal increases in or without calcium supplementation, have
systolic and diastolic blood pressure levels demonstrated that exercise may retard or
with exercise are enhanced in patients with even reverse the normal loss of bone min-
hypertension. Further, exercise blood pres- eral content.54-56 Thus, stresses imposed by
sure has been correlated with left ventricu- exercise may be beneficial in preventing os-
lar mass, an independent risk factor for car- teoporosis. However, exercise is more effec-
diovascular mortality.49 Thus, it is important tive when estrogen and calcium supple-
for the hypertensive individual to pursue ments are also given.
dynamic or aerobic types of exercise that
have less marked increases in blood pres-
Selected Other Diseases
sure than those requiring resistive activity.
Associated with hypertensive disease are Exercise training has been found to be of
cerebrovascular accidents. Exercise has benefit in a variety of other chronic dis-
been shown to enhance fibrinolysis and may eases. In general, it improves cardiovascular
therefore reduce the incidence of or mor- function, muscle strength, endurance, flexi-
bidity from stroke.50 bility, adjustment to disease, activity level,
and overall well-being. Additional benefits
may be specific to the underlying disease.
Obesity
For example, in patients with chronic ob-
The benefits of exercise with regard to structive airways disease, exercise is useful
obesity are discussed in detail in Chapter 2. for ventilatory muscle training, increased
Obesity is probably an independent risk fac- tolerance of dyspnea, and reduction in as-
tor for cardiovascular disease in both sexes; sociated anxiety.57 In those with end-stage
its reduction would therefore be expected to renal disease, exercise may lower blood
contribute to cardiac health.51 Exercise pressure and otherwise modify cardiovas-
clearly increases caloric expenditure cular risk.58 Additionally, in patients with
through the effort necessary to maintain ac- both insulin-dependent and insulin-inde-
tivity, favorably alters metabolic rate and pendent diabetes mellitus, a regularly fol-
heat production, and is useful in preserving lowed exercise regimen may decrease insu-
muscle mass during dieting. In addition to lin resistance, requirements, and circulating
the subjective enhancement of perceived levels and improve glucose tolerance,
health, the toning effects of exercise may thereby decreasing all diabetic "complica-
have a positive effect on self-image and may tions," especially cardiovascular disease. In
therefore encourage the dieter to adhere to patients with depression, exercise seems to
both exercise and dietary programs. improve mood or at least provide a physical
vigor important in counteracting affective
illness.59
Osteoporosis
With aging, the mineral content of bone
decreases much more rapidly in women FITNESS EVALUATION
than in men, such that, after menopause, up
to 8% of bone mass may be lost per decade. Muscular Strength and
Although this has been regarded as an in- Endurance
evitable effect of aging and hormonal The strength of a particular muscle group
changes, it is clearly accelerated by inactiv- can be quantified in several ways. Maximal
isometric strength is the force generated digitizing of video, high-speed film analysis,
during a maximal contraction against im- or electrogoniometers. For a complete as-
movable resistance. Strain gauge tensiome- sessment of movement during activity,
ters have long been used to measure iso- range of motion must be measured simulta-
metric strength. Maximal isotonic strength neously in several planes. A less precise as-
is the greatest amount of weight that can be sessment of flexibility can be obtained using
moved through the full range of motion only field tests such as the sit-and-reach test of
once (one repetition maximum, or 1 RM). Wells and Dillon60 or the trunk flexion/exten-
Free weights or various pulley devices can sion tests of Cureton.1
be used to measure isotonic strength. Isoki- As with the other components of fitness,
netic strength is a measure of the maximal each individual's need for flexibility may dif-
force that can be generated throughout the fer. However, the prevailing clinical opinion
range of motion at a constant speed. Sophis- is that a normal range of motion for each
ticated isokinetic dynamometers can mea- joint is necessary for pain-free movement.
sure both concentric and eccentric muscle These normal values can be found in texts
performance at varying speeds. Muscular on athletic training61 or physical therapy.62
endurance can be assessed by multiple rep- The need for any additional flexibility varies
etitions (e.g., 20 to 30 RM) either isotoni- among individuals and with activity inter-
cally or isokinetically. As with the other ests.61
components of physical fitness, individual
needs or desire for muscular strength and
endurance will vary. The choice of methods Functional Capacity
to evaluate muscle performance will de- Terminology
pend, in part, on the importance that the ex-
erciser places on this component of physical Oxygen uptake measurements or estima-
fitness. See Chapter 3 for a complete discus- tions used to quantify activity or exercise
sion of muscular strength and endurance. can be reported in several different ways. In
absolute terms, it is simply liters of oxygen
used per minute. Because 1 L of oxygen is
Body Composition
roughly equivalent to 5 kcal,9 the approxi-
Evaluation of body composition is based mate energy cost for any particular activity
on the classification of body components as level can be calculated. One disadvantage of
either lean body mass or body fat. Com- using liters per minute is the discrepancy
monly used methods for assessing body between energy costs for individuals of
composition are hydrostatic weighing, an- varying weights.9 For example, a 200-lb man
thropometric and skinfold thickness mea- will consume more oxygen during activity
surements, and bioelectric impedance mea- (or even sitting at rest) than will a 100-lb
surements. A further discussion of body woman. For this reason, oxygen uptake is
weight and body composition can be found more often reported as milliliters of oxygen
in Chapter 2. consumed per kilogram of body weight per
minute (mL.kg - 1 -min - 1 ). This allows the
Flexibility energy cost of various tasks to be compared
among individuals without the bias of body
Flexibility can be measured directly or as- weight. It is in these terms that Vo2 max is
sessed indirectly during movement tasks.5 most often reported for athletes. Although a
Direct measurement of resting or static high Vo2 max may be taken as a "badge of
range of motion around a specific joint can honor" by endurance athletes, it actually
be obtained with a goniometer. Dynamic has poor predictive ability for sports perfor-
flexibility or movement around a particular mance.4 Nonetheless, a high Vo2 max is in-
joint during an activity can be measured by dicative of a large aerobic capacity. The
1O Basic Concepts of Exercise Phvsioloav
highest Vo2 max reported in the literature Measurement

for men is 14 mL-kg - 1 -min - 1 higher than
that reported for women.63,64 (This apparent Maximal oxygen uptake (Vo2 max) is the
gender discrepancy will be discussed later.) best single measure of the overall functional
With the advent of large-scale exercise capacity of an individual. Since human me-
testing and prescription at hospitals, univer- tabolism depends on oxygen utilization, an
sities, and health clubs, energy expenditure indirect estimate of energy metabolism can
has been classified in metabolic equivalents be made by measuring the amount of oxygen
(METs). One MET is the equivalent of rest- required to perform a given task. Oxygen up-
ing oxygen consumption taken in a sitting take is frequently used to quantify an indi-
position. For an average man, that is approx- vidual's maximal exercise capacity.
imately 250 mL/min, and for an average Vo2 max can be calculated from the actual
woman, 200 mL/min.9 METs can also be ex- measurement of expired oxygen and carbon
pressed in terms of oxygen consumption per dioxide during any exercise task of sufficient
unit of body weight, in which case, 1 MET is intensity and duration to require maximal
equivalent to 3.5 mL/kg per minute (mL- use of aerobic energy systems.4,6,9 The most
kg - 1 -min - 1 ). One MET is also equal to 1 commonly used exercise tests make use of a
kcal/kg per hour (kcal-kg -1 -hr -1 ). 70 The treadmill, cycle ergometer, or rowing er-
MET cost of a particular exercise can be cal- gometer. Any other device, such as bench
culated by dividing the metabolic rate (Vo2) stepping or simulated stair-climbing ma-
during exercise by the resting metabolic chines, that can be calibrated to allow the
rate. The American College of Sports Medi- quantification of the exercise work, can also
cine (ACSM) has constructed tables listing be used.66 The volume and concentration of
the energy cost in METs for walking, jogging, respiratory gases is measured either breath
and running during a range of speeds and by breath or averaged for a certain time pe-
grades of the treadmill (Tables 1-2 and 1- riod (e.g., 15 seconds), using some kind of
3).65 Similar tables have been constructed volume-metering device such as a Tissot
for MET levels during bicycle ergometry and spirometer or volume transducer, along
bench-stepping (Tables 1-4 and 1-5).65 with oxygen and carbon dioxide analyzers.
These tables are equally applicable to men Commercial metabolic carts with these com-
and women. ponents are available.
Table 1-2. APPROXIMATE ENERGY REQUIREMENTS IN METS FOR HORIZONTAL AND

GRADE WALKING
mph 1.7 2.0 2.5 3.0 3.4 3.75
% Grade m/min 45.6 53.7 67.0 80.5 91.2 100.5
0 2.3 2.5 2.9 3.3 3.6 3.9
2.5 2.9 3.2 3.8 4.3 4.8 5.2
5.0 3.5 3.9 4.6 5.4 5.9 6.5
7.5 4.1 4.6 5.5 6.4 7.1 7.8
10.0 4.6 5.3 6.3 7.4 8.3 9.1
12.5 5.2 6.0 7.2 8.5 9.5 10.4
15.0 5.8 6.6 8.1 9.5 10.6 11.7
17.5 6.4 7.3 8.9 10.5 11.8 12.9
20.0 7.0 8.0 9.8 11.6 13.0 14.2
22.5 7.6 8.7 10.6 12.6 14.2 15.5
25.0 8.2 9.4 11.5 13.6 15.3 16.8
Source: American College of Sports Medicine,65 with permission.
Table 1-3. ENERGY REQUIREMENTS IN METS FOR HORIZONTAL AND UPHILL JOGGING/
RUNNING*
a. Outdoors on Solid Surface
mph 5 6 7 7.5 8 9 10
% Grade m/min 134 161 188 201 215 241 268
0 8.6 10.2 11.7 12.5 13.3 14.8 16.3

2.5 10.3 12.3 14.1 15.1 16.1 17.9 19.7
5.0 12.0 14.3 16.5 17.7 18.8 21.0 23.2
7.5 13.8 16.4 18.9 20.2 21.6 24.1 26.6
10.0 15.5 18.5 21.4 22.8 24.3 27.2
12.5 17.2 20.6 23.8 25.4 27.1
b. On the Treadmill
mph 5 6 7 7.5 8 9 10
% Grade m/min 134 161 188 201 215 241 268
0 8.6 10.2 11.7 12.5 13.3 14.8 16.3

2.5 9.5 11.2 12.9 13.8 14.7 16.3 18.0
5.0 10.3 12.3 14.1 15.1 16.1 17.9 19.7
7.5 11.2 13.3 15.3 16.4 17.4 19.4 21.4
10.0 12.0 14.3 16.5 17.7 18.8 21.0 23.2
12.5 12.9 15.4 17.7 19.0 20.2 22.5 24.9
15.0 13.8 16.4 18.9 20.3 21.6 24.1 26.6
*Differences in energy expenditures are accounted for by the effects of wind resistance.
Most often the test is incremental, with quires an oxygen uptake of approximately 24
the work rate increased at the beginning of m L - k g - 1 - m i n - 1 . Work increments should
each of several stages.4,6,9 During an incre- require 3 to 7 m L - k g - 1 - m i n - 1 increases in
mental test, oxygen uptake will increase in a oxygen uptake. Because of expected higher
linear relationship with the increasing work maximal capacities, endurance athletes can
rate. The test protocol ideally should reflect be started at work rates greater than 30 mL-
the exercise capabilities of the subject pop- kg~'-min - 1 with increments of 3 to 7 mL-
ulation being tested. Healthy individuals kg - 1 -min - 1 . Elderly women or those with
can usually begin with a work rate that re- known or suspected limitations should
Table 1-4. ENERGY EXPENDITURE IN METS DURING BICYCLE ERGOMETRY

Exercise Rate (kg/mln and watts)
Body Weight
300 450 600 750 900 1050 1200 (kg/min)
kg Ib 50 75 100 125 150 175 200 (watts)
50 110 5.1 6.9 8.6 10.3 12.0 13.7 15.4
60 132 4.3 5.7 7.1 8.6 10.0 11.4 12.9
70 154 3.7 4.9 6.1 7.3 8.6 9.8 11.0
80 176 3.2 4.3 5.4 6.4 7.5 8.6 9.6
90 198 2.9 3.8 4.8 5.7 6.7 7.6 8.6
100 220 2.6 3.4 4.3 5.1 6.0 6.9 7.7
Note: Vo2 for zero-load pedaling is approximately 550 mL/min for 70- to 80-kg subjects.
Table 1-5. ENERGY EXPENDITURE IN work rate will not be accompanied by an in-
METS DURING STEPPING AT DIFFERENT crease in oxygen uptake.6
RATES ON STEPS OF DIFFERENT HEIGHTS
Because the direct measurement of maxi-
Step Height Step is/mill mal oxygen uptake depends on subject mo-
tivation and the use of rather elaborate lab-
cm in 12 IS 24 30 oratory equipment, various submaximal
0 0 1.2 1.8 2.4 3.0 laboratory tests and field tests have been de-
4 1.6 1.5 2.3 3.1 3.8 vised to estimate maximal aerobic capacity.
8 3.2 1.9 2.8 3.7 4.6 Many of the submaximal predictive tests are
12 4.7 2.2 3.3 4.4 5.5
16 6.3 2.5 3.8 5.0 6.3
based on a linear relationship between heart
20 7.9 2.8 4.3 5.7 7.1 rate and oxygen uptake.4'6'9 The slope of this
24 9.4 3.2 4.8 6.3 7.9 line is unique to each individual and de-
28 11.0 3.5 5.2 7.0 8.7 pends on state of training but not on gender
32 12.6 3.8 5.7 7.7 9.6 (Fig. 1-1). A widely used predictive test is
36 14.2 4.1 6.2 8.3 10.4
40 15.8 4.5 6.7 9.0 11.2
the Astrand-Rhyming Nomogram.4 This no-
mogram allows the prediction of Vo2 max
Source: American College of Sports Medicine,65 with from the heart rate attained during one 6-
permission.
minute work bout on a cycle ergometer, but
can also be used with a step-test protocol.
Alternately, if oxygen uptake and heart rate
begin much lower and increase the work are measured at two submaximal exercise
rate more gradually. Duration of the early intensities, the line representing the rela-
stages should be at least 2 minutes to ensure tionship between heart rate and oxygen up-
gradual physiologic adjustments. The later take can then be extrapolated to the age-pre-
stages can be 1 minute in duration. When the dicted maximal heart rate (200 — age) and
maximal capacity for aerobic energy trans- Vo2 max estimated (Fig. 1-2). McArdle and
fer has been reached, a further increase in associates9 have also developed a set of
Figure 1-1. HR-Vo2 line for a 20-year-old woman before and after a 10-week aerobic conditioning
program. (From McArdle, Katch, and Katch,9 with permission.)
Figure 1-2. Application of the linear relation-

ship between submaximal heart rate and ox-
ygen consumption to predict Vo2 max. (From
McArdle, Katch, and Katch,9 with permis-
sion.)
norms for the estimation of Vo2 max from relation (r = 0.67) between these two mea-
measurement of recovery heart rate follow- surements in 36 untrained female subjects.
ing a bench-stepping protocol. Since one of Because factors such as body weight, body
the more practical uses of Vo2 max test data fatness, and movement efficiency contribute
is for monitoring an individual's progress in to distance covered, these tests have error
fitness programs over a period of time, it is ranges of from 10% to 20% of actual maximal
unimportant which protocol is used as long oxygen uptake.9 They can be used only as a
as the same one is used in follow-up tests. rough estimate of aerobic capacity.
Several tests of distance covered in a
given time period (walking, running, or a
Anaerobic Threshold
combination of the two) have also been used
to predict aerobic capacity. The most widely Traditionally, the term "anaerobic
known is the 12-minute walk/run test first threshold" has been used to describe the
suggested by Cooper in Aerobics.61 Cooper68 level of exercise at which aerobic metabo-
reported a correlation (based on tests of 47 lism becomes insufficient to meet the re-
male military personnel) of 0.90 between quired energy demands. This is assumed to
distance covered and maximal oxygen up- be the point at which the resultant increase
take actually measured in the laboratory. in anaerobic glycolysis causes lactate to ac-
However, Maksud and colleagues,69 repeat- cumulate in the muscles and blood.6 Be-
ing this correlation for women, reported a cause this explanation is no doubt an over-
correlation of only 0.70 between actually simplification of the physiologic changes
measured oxygen uptake and distance cov- occurring, many investigators now avoid the
ered, in a group of 26 female athletes. Katch term "anaerobic threshold" and prefer ei-
and co-workers70 noted a similarly low cor- ther "lactate breaking point" or "ventilation
breaking point" to describe this alteration in FITNESS DEVELOPMENT AND

metabolism.71 MAINTENANCE
During light and moderate exercise, min-
ute ventilation increases in a linear manner Fitness Development
with increasing exercise intensity (oxygen
Flexibility
uptake). However, at some point during the
increasing exercise, the ventilation in- Flexibility can best be improved through
creases out of proportion to the increase in the use of sustained static stretches.5,6,13 The
oxygen consumption. This point has been muscles and connective tissue to be
designated as the "ventilation breaking stretched should be slowly elongated to the
point." In an untrained individual, this point point at which the exerciser feels a mild ten-
generally falls between 40% and 60% of Vo2 sion.5'13 Usually, this position is then held for
max and is associated with a more rapid rise between 10 and 30 seconds.13 During this
in blood lactate to a concentration of 2 mil- time period, the exerciser should feel a
limoles (mmol) per liter (20 mg/dL blood). gradual release of this feeling of tension as
A second upswing in both ventilation and the stretch or myotatic reflex is overcome.
blood lactate can be seen at between 65% As the tension is released, the exerciser
and 90% Vo2 max and a lactate concentration should slowly move a fraction further, again
of 4 mmol/L (36 mg/dL).72 In highly trained to the point of tension, and continue to hold
athletes, these ventilation breaking points for approximately 30 seconds.13 Stretching
occur at higher percentages of Vo2 max. following an exercise session, when the
The mechanism of the ventilation break- muscle and connective tissues are warm,
ing point has not been satisfactorily ex- has been found to be the best time for im-
plained but is usually associated with the ac- proving flexibility.6
cumulation of lactic acid in the blood
(hence, the appearance and rise of blood
Cardiovascular Fitness
lactate).6 The need to dispose of excess car-
bon dioxide produced from the buffering of The ACSM has developed guidelines for
excess hydrogen ions (from the lactic acid) building and maintaining fitness in healthy
drives the peripheral chemoreceptors that adults.65,73 In recommending the quantity
stimulate increased ventilation. Ventilation and quality of exercise, the ACSM cites five
breaking points can be found during gas ex- components that are applicable to the de-
change measurements, whereas lactate sign of exercise programs for adults regard-
breaking points can be found through fre- less of age, gender, or initial level of fitness:
quent analysis of a small amount of blood, (1) type of activity, (2) intensity, (3) dura-
usually taken by a fingerstick. Most experi- tion, (4) frequency, and (5) progression.
ments with highly trained athletes use the 4- Type of Activity. The exercise program
mmol value rather than the more reproduc- should include activities that use large mus-
ible 2-mmol value, since athletes can exer- cle groups in a continuous rhythmic man-
cise for several hours with lactate values ner. Activities such as walking, hiking, jog-
greater than 2 mmol but less than 4 mmol. As ging/running, swimming, bicycling, rowing,
with the ventilation breaking point, there is cross-country skiing, skating, dancing, and
no universally accepted explanation for the rope skipping are ideal. Because control of
lactate breaking point. Among the explana- exercise intensity within rather precise lim-
tions offered are increased production of its is often desirable at the beginning of an
lactate, decreased clearance of lactate, a exercise program, the most easily quantified
combination of these two, and increased re- activities, such as walking or stationary cy-
cruitment of fast-twitch (glycolytic) motor cling, are particularly useful. Various endur-
units. ance game activities such as field hockey,
soccer, and lacrosse may also be suitable translated into MET levels. The intensity of
but may have high-intensity components, training sessions comprised of most activi-
and therefore should not be used in the ex- ties can be monitored through the use of tar-
ercise prescription until participants are get heart rates (Fig. 1-3) or through MET
able to exercise comfortably at a minimum levels. The energy cost in METs of various
level of 5 METs.65 If intensity, duration, and activities can be found in the ACSM Guide-
frequency are similar, the training result ap- lines for Exercise Testing and Exercise Pre-
pears to be independent of the mode of aer- scription (see Tables 1-2 through 1-5).65 Ac-
obic activity. Therefore, a similar training ef- curate quantification of some activities may
fect on functional capacity can be expected, be difficult. For example, target heart rates
regardless of which endurance activity is derived from treadmill exercise tests may
used. not adequately quantify swimming or vari-
Intensity. The conditioning intensity of ous other activities with a large upper-body
the aerobic portion of the exercise session is component, such as aerobic dance.75
best expressed as a percentage of the indi- Duration. Each training session should
vidual's maximal or functional capacity. Ef- last between 15 and 60 minutes, with an aer-
fective training intensities are from 50% to obic component of at least 15 minutes. Typ-
85% of Vo2 max or 60% to 90% of the maxi- ically, an exercise session should include a
mum heart rate achieved during a graded 5- to 10-minute warm-up, 15 to 60 minutes of
exercise test.65'73'74 These intensities can be aerobic exercise at the appropriate training
Figure 1-3. Maximal heart rates and training-sensitive zones for use in aerobic training programs for
people of different ages. (From McArdle, Katch, and Katch,9 with permission.)
level, and a cool-down of 5 to 10 min- the largest changes usually seen in the in-
utes.65,73,74 The function of the warm-up is dividuals who have the lowest initial fitness
gradually to increase the metabolic rate levels.76 Both men and women respond to
from the 1-MET level to the MET level re- aerobic training with similar increments in
quired for conditioning. In planning the aer- maximal oxygen uptake.73 An individual
obic portion of the workout, one must con- starting a fitness program can expect a sig-
sider that duration and intensity are nificant improvement in functional capacity
inversely related. That is, the lower the ex- to occur during the first 6 to 8 weeks.4,6,9 The
ercise intensity, the longer the workout length of time necessary to reach one's true
needs to be. Although significant cardiovas- Vo2 max depends on the initial fitness level
cular improvements can be made with very and intensity of training. As conditioning
intense (more than 90% Vo2 max) exercise takes place, the exercise intensity will need
done for short periods of time (5 to 10 min- adjustment in order to keep the participant
utes), high-intensity, short-duration ses- exercising in the training range. During the
sions are not appropriate for individuals initial phases of a program, this is best done
starting a fitness program.65 Because of po- by changing the MET level to correspond to
tential hazards (including an unnecessary the desired exercise heart rate. Since with
risk of injury) for untrained individuals em- conditioning the heart rate will drop for any
barking on a high-intensity program, low to given submaxirnal work rate, intensity ad-
moderate intensity for longer durations is justments will result in more actual work
recommended for those beginning a fitness being done during each exercise session.65
program. Although the recommended dura- Follow-up graded exercise tests should be
tion of the aerobic or conditioning part of done during the first year of the program to
the workout is 15 to 60 minutes, an adequate help in the intensity adjustment and in mo-
training response can be elicited by main- tivating the participant. The goals of the par-
taining the prescribed exercise intensity for ticipant need to be taken into account to de-
a period of approximately 15 minutes.65 With termine when the exercise program can be
the warm-up and cool-down, a reasonable changed from one with a goal of increasing
amount of total workout time for a person fitness level to one with the goal of maintain-
beginning an exercise program would be 30 ing the newly acquired level. Sample exer-
minutes. The cool-down phase should in- cise programs for sedentary, active, and
clude exercise of diminishing intensity to re- competing women are shown in Appendix
turn the physiologic systems of the body to 1-1. It must be stressed that no program
their resting states. should be undertaken lightly and that, for
Frequency. The frequency of exercise many women, the ideal program may be a
sessions is somewhat dependent on the in- highly individualized "exercise prescrip-
tensity and duration of the exercise. For ex- tion" developed in conjunction with a phy-
ample, exercise programs for individuals sician and exercise physiologist.
with very low functional capacities (less
than 5 METs) may start out with several Fitness Maintenance
short (5-minute) sessions per day. For most
individuals, exercise programs for improv- Activity Level
ing one's fitness level should be done three Exercise must be continued on a regular
to five times per week.65 basis in order to maintain a given fitness
Progression. The degree of improvement level. Hickson and colleagues28,77,78 have
in Vo2 max (the best measure of functional shown that the duration and frequency of
capacity) is directly related to the intensity, exercise may be reduced by as much as two
duration, and frequency of the training. Re- thirds without affecting the training-induced
search has documented improvements in Vo2 max, but intensity plays a critical role in
Vo2 max ranging between 5% and 25%, with maintaining the training-induced changes.
When the duration of exercise sessions fol- developing and maintaining fitness can be
lowing 10 weeks of training was reduced used for training.65,73 Many recreational ac-
from 40 minutes per day to 26 or 13 minutes tivities, however, are intermittent in nature
per day for the next 5 weeks, no reduction in and their energy expenditure is difficult to
the exercise-induced Vo2 max was seen.77 quantify. Although there are tables listing
Similarly, when sessions were reduced from average energy expenditures,9,73 the amount
6 days/wk to 4 or 2 days/wk, there again was of energy expended often depends on the
no reduction in Vo2 max.78 However, data skill of the participants. For example, it is dif-
suggest that in order to maintain training- ficult to imagine that the energy expended
induced gains, an individual must continue by a professional tennis player such as Mon-
to exercise at an intensity of at least 70% of ica Seles is in any way similar to that ex-
the training intensity.28 Therefore, after pended by some weekend players. Recrea-
achieving a desired level of fitness, an indi- tional activities, then, are best used to
vidual can theoretically be expected to supplement a planned program for the de-
maintain this level by exercising at least velopment and maintenance of physical fit-
twice a week at 70% or more of her training ness.
intensity for a minimum of 13 minutes per
session. Factors Affecting Fitness
Caution is advised, however, in the inter- Development and Maintenance
pretation of these data, since the subjects
from whom these conclusions were reached Age
were highly conditioned men and women, Increased age alone is not a contraindi-
and the results may not be applicable to in- cation to participation in a fitness program.
dividuals training at lower intensities. It Regular training will result in positive phys-
should also be kept in mind that body com- iologic adaptations, regardless of age.6,73,79
position is one of the components of "phys- Some studies have shown that older individ-
ical fitness." Thus, if the participant is using uals may require longer to adjust to physical
the exercise program to maintain caloric training programs and may not make as
balance and to keep body fat at a reasonable large an absolute improvement in fitness
level, a maintenance program of 4 to 5 days/ level as a younger person.73 However, a com-
wk would be a better choice. parison of improvements is often difficult
When an individual stops training, a sig- because younger individuals tend to train at
nificant detraining effect occurs within 2 higher intensities than do older individuals.
weeks, as measured by a decrease in physi- As an individual ages, there will be some de-
cal work capacity.9 A 50% reduction of the crease in Vo2 max regardless of training,
newly acquired gain in fitness has been since there is an age-related drop in maxi-
shown to occur by 4 to 12 weeks after ces- mal heart rate, which, in turn, reduces max-
sation of training, while a return to pretrain- imal cardiac output.4 An age-related de-
ing fitness level can be expected after ces- crease in Vo2 max does not imply that an
sation of training between 4 weeks and 8 older individual cannot or should not partic-
months.73 Although much of this research is ipate in activities requiring a great deal of fit-
based on information from male subjects, ness. For example, each year there are sev-
the deconditioning pattern and time-course eral contestants and finishers over age 70
are expected to be similar in women.76 years in the Hawaiian Ironman Triathlon, a
contest that takes 9 to 17 hours to complete.
Role of Recreational Sports
Gender
Recreational sports that require an en-
ergy expenditure of sufficient intensity and Although most of the research supporting
duration to fall within ACSM guidelines for the quantity and quality of exercise neces-
sary to develop and maintain fitness was ini- excluded from exercise, many patients will
tially derived from male subject data, it ap- need special considerations in the design
pears to be equally applicable to women. and implementation of appropriate exercise
Numerous recent studies have documented training. Any aspect of an exercise program
similar training responses for men and may be changed to adapt to the individual's
women.73 Before puberty, there is no differ- needs, as long as the core features of exer-
ence in maximal aerobic power between cise mode, intensity, duration, and fre-
boys and girls.4 After that, however, the po- quency are preserved. Although reductions
tential for absolute magnitude of aerobic ca- in intensity are most common, exercise mo-
pacity is higher for men. There seem to be at dality may be altered (e.g., using non-
least three basic physiologic differences be- weight-bearing or low-impact activities for
tween men and women that affect the capac- the patient with arthritis, extreme obesity,
ity for aerobic power.17'19 Women usually or musculoskeletal abnormalities). Regard-
have a higher percentage of body fat, a less of initial fitness level or absolute level of
smaller oxygen-carrying capacity, and a achievement, the positive effects of en-
smaller muscle-fiber area than do men. hanced well-being, muscular strength, and
When the effects of body weight and per- activity tolerance may be expected. Moni-
centage of body fat are corrected mathemat- toring methods may also need to be adapted
ically, the differences in Vo2 max are to the individual situation (e.g., use of res-
lessened. Studies have averaged these dif- piratory rate rather than heart rate for ex-
ferences to be approximately 50%, 20%, and ercise intensity in the patient with a pace-
9% when Vo2 max is expressed as liters per maker). Detailed discussion of exercise
minute, milliliters per kilogram per minute, prescription is beyond the scope of this
and milliliters per kilogram fat-free mass, re- chapter.
spectively. The remaining difference (ap-
proximately 9%) is either still a difference in
Sudden Death
conditioning or more probably a gender-
linked difference in the ability to transport Sudden death during exercise has been
and utilize oxygen. Since women usually well publicized, yet is extremely rare and
have a lower hemoglobin concentration most unlikely in an otherwise healthy indi-
than men (normal range equals 12 to 16 g/dL vidual without known cardiac disease.80-85
for women; 14 to 18 g/dL for men) and a Although sudden death may occur more
smaller blood volume, they have a smaller often during activity than during rest, most
maximal oxygen-carrying capacity than occurrences are related to usual daily activ-
men. In addition, endurance-trained women ities and not to exercise programs.
have approximately 85% of the muscle-fiber The causes of sudden death during exer-
areas of endurance-trained men. Although cise have been examined in male athletes.83
the fiber area is different, the muscle com- In the young, nearly 65% have some form of
position is much the same for male and fe- hypertrophic cardiomyopathy, 14% have
male endurance athletes.17 congenital coronary artery anomalies, 10%
have coronary heart disease, and 7% have
ruptured aorta or Marfan's syndrome. In
Underlying Disease
contrast, of those dying suddenly after age
For any woman with known or suspected 35, more than 80% have coronary heart dis-
medical illness, embarking upon a fitness ease. Other associated diseases include hy-
program should be preceded by consulta- pertrophic cardiomyopathy, mitral valve
tion with a physician with special training in prolapse, and acquired valvular disease. For
the patient's disease and, when indicated, this reason, women with known or sus-
by continued close medical supervision. Al- pected cardiovascular disease and previ-
though it is rare that an individual should be ously sedentary individuals over 50 years of
age should seek the advice of an internist or exercise clothing, or much more. Costs for
cardiologist before pursuing a vigorous ex- the use of facilities can be from less than
ercise program. While most cardiovascular $100 per year for a YMCA/YWCA or local
illnesses do not preclude the achievement university-based program to $500 or $600
of fitness, the exercise program should be per year for a health club membership. In-
individually tailored to meet the needs and dividuals can join exercise classes, such as
limitations of the participant. Further, there one in aerobic dance, or they may choose to
are a small number of illnesses in which any carry out their prescription on their own
form of vigorous activity should be strictly Equipment for walking or jogging programs
limited. is minimal, but that for a bicycling program
is more.
Injury
Most of the injuries resulting from partic- TRAINING FOR COMPETITION
ipation in fitness programs are musculoskel-
etal injuries. Although occasionally there Training for competition differs from
are traumatic injuries, such as fractures and training for fitness in that its main objective
torn ligaments, more frequently the injuries is improvement of performance rather than
are the result of chronic microtrauma or improvement of health. Training for com-
overuse. These injuries include muscle petition should begin by using the same
strains, tendinitis, synovitis, bursitis, and ACSM guidelines for intensity, frequency,
stress fractures. In most cases, these inju- and duration. A period of approximately 8
ries are not serious enough to prevent train- weeks is necessary to lay the groundwork
ing but often require alterations in training for a more intense training program.6 Phys-
patterns. Overuse injuries have been attrib- iologic adaptations occurring in ligaments
uted mainly to errors in training, such as and muscles during that time make them
progressing too fast and not allowing less susceptible to overuse injuries, which
enough time for recovery and adaptation.84 otherwise might occur as a result of high-in-
tensity training. Once the fitness base is laid,
the competitive athlete must overload her
Practical Considerations
system further to continue improving. The
Practical considerations are often critical overload should be progressive and individ-
to whether or not an individual participates ualized to the specific goals of the athlete. At
in a fitness program. The most important of this point, training should be as specific to
these considerations for most people is the competition as possible. That is, the ex-
time. Everyone has certain constraints on erciser needs to train the specific muscles to
her time, whether they be job-related or be involved in the desired performance in a
home-related. An individual wishing to par- manner specific to the competition.
ticipate in an exercise program to improve
fitness must make a time commitment. A Interval Training
minimum of at least 1 hour three times per
week is necessary. This could comprise a Because most competition involves an el-
bare minimum of 30-minute exercise ses- ement of speed, the exerciser may benefit
sions plus time to change clothes, travel, from interval as well as continuous training.6
and so forth. Cost is another factor to be con- Interval training is a means of accomplish-
sidered. Most exercise test evaluations with ing a great deal of work in a short period of
an exercise prescription cost between $100 time by interspersing work intervals with
and $400. Following this initialfinancialou rest intervals. The work intervals may be of
lay, each individual can spend as little as the any desired length, from just a few seconds
cost of a good pair of shoes and comfortable to several minutes. The length of the work
interval is determined by the specific de- for general well-being and protection
mands of the competition and by the energy against some disease states. A greater de-
system the athlete wishes to train. Intervals gree of fitness is beneficial for certain rec-
of less than 4 seconds can be used to de- reational and competitive sport activities.
velop strength and power for activities such Cardiovascular fitness can be developed ac-
as a high jump, shot put, golf swing, or tennis cording to the guidelines of the ACSM. Rate
stroke. Intervals of up to 10 seconds are and degree of improvement for women can
used to develop sustained power for activi- be expected to be similar to that for men and
ties such as sprints, fast breaks, and so on. depends on intensity, duration, and fre-
The length of these intervals forces the body quency of exercise sessions.
to use immediate, short-term energy sys-
tems. Intervals of up to 11/2minutes are used
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APPENDIX 1-1
Sample Training Programs

The following are sample training schedules for women starting a fitness
program. They are, however, only examples of types of activities that would be
appropriate for women in these categories and should not be undertaken without
proper medical and fitness evaluation. Also included are general guidelines to be
followed by an athlete training for competition. Since a competitive athlete must
train specifically for the requirements of her sport, a program appropriate for one
athlete may be of little benefit to someone in another sport.
SAMPLE 8-WEEK PROGRAM FOR A SEDENTARY

30-YEAR-OLD WOMAN
Weeks 1-4. (Initial Stage—The energy cost of the exercise in this stage should
be approximately 200 kcal per session. Exercise sessions should be three
times per week or every other day.)
Warm-up. 5 min walking (heart rate [HR] = 110 beats per minute [bpm]; 5
min stretching (areas to stretch: Achilles tendon, hamstrings, lower
back, and shoulders).
Aerobic Phase. 15 min vigorous walking, jogging, stationary cycling, or any
combination of these (HR = 135-145 bpm). After the second week, the
time for this phase should be gradually increased (by 1 min every other
day) to 20 min.
Cool-down. 5 min walking (HR = 100-110 bpm); 5 min stretching (same as
in warm-up).
Weeks 4-8. (Improvement Stage—The energy cost of exercise in this stage
should be approximately 300 kcal per session. Exercise sessions should be
three to five times per week.)
Warm-up. 5 min walking (HR =115 bpm); 5 min stretching, as previously.
Aerobic Phase. 20 min initially; gradually increase to 25 min, as above. Aer-
obic activities can include walking, jogging, cycling, or any other con-
tinuous, rhythmic exercise. (HR = 140-150 bpm.)
Cool-down. 5 min walking (HR = 100-110 bpm); 5 min stretching, as

previously.
Week 8 and Afterward. (Maintenance Stage—The energy cost should still be
approximately 300 kcal per session.)
Warm-up. Same as above.
Aerobic Phase. Intensity and duration of sessions should be the same as in
Improvement Stage. Exercise should be done at least 3 times per week.
Recreational sport activities of approximately the same intensity may
be substituted 1 day per week.
Cool-down. Same as above.
SAMPLE 8-WEEK PROGRAM FOR SEDENTARY 60-

YEAR-OLD WOMAN
Weeks 1-4. (Initial Stage—200 kcal per session; three times per week.)
Warm-up. 5 min walking (HR = 100 bpm); 5 min stretching (areas to stretch:
Achilles tendon, hamstrings, lower back, and shoulders).
Aerobic Phase. 12-15 min vigorous walking or stationary cycling (HR = 110-
120 bpm).
previously.
Weeks 4-8. (Improvement Stage—300 kcal per session, three to five times per
week.)
Warm-up. 5 min walking (HR =110 bpm); 5 min stretching, as previously.
Aerobic Phase. 15 min initially; gradually increase to 25 min of walking, jog-
ging, stationary cycling, or any combination of these (HR = 120-130
bpm).
previously.
Week 8 and Afterward. (Maintenance Stage—The energy cost per session
should remain at 300 kcal. Exercise should be done at least three times per
week.) Exercise program can remain the same as in the Improvement Stage
with recreational sport activities substituted once a week if desired.
SAMPLE 8-WEEK PROGRAM FOR A MODERATELY

ACTIVE 45-YEAR-OLD WOMAN
Weeks 1-2. (Initial Stage—Energy cost approximately 300 kcal per session. The
purpose of this stage in a moderately active woman is to allow adaptation
[particularly musculoskeletal] to occur in response to specific aerobic activ-
ity, such as jogging.)
Warm-up. 5 min walking or slow jogging (HR = 120-125 bpm); 5 min stretch-
ing (Achilles tendon, hamstrings, lower back, shoulders).
Aerobic Phase. 25 min of vigorous walking, jogging, stationary cycling, row-

ing, or any other continuous, rhythmic activity of choice. (HR = 135-
140 bpm.)
Cool-down. 5 min slow jogging and/or walking (HR =110 bpm); 5 min of
stretching, as previously.
Weeks 3-8. (Improvement Stage—300-500 kcal per session.)
Warm-up. 10 min (same as previously).
Aerobic Phase. 25 min initially; gradually increase to 45 min per session. Any
activity that will keep the heart rate 140-145 bpm for this length of time
may be used.
Cool-down. 10 min (same as previously).
Week 8 and Afterward. (Maintenance Stage—Exercise sessions should be sim-
ilar to those in the Improvement Stage and should be done at least three
times per week with an energy cost of 500 kcal per session.)
GUIDELINES FOR THE COMPETITIVE ATHLETE
1 Training should be in three stages, comparable to those shown earlier but

on a higher level—laying a base, increasing intensity, and fine tuning.
2 When adding sport-specific activities, training should be under conditions
as similar to competitive conditions as possible.
3 Set reasonable goals in a reasonable time frame.
4 Keep a training diary to discover your own personal pattern of optimal
training and to discover practices that lead to injury for you.
5 Use an overload/adaptation/progression system. That is, allow enough
time for adaptation to occur after a hard workout, by following the hard
workout with several easy or moderate ones. For example, after a race,
some running coaches suggest waiting one day for each mile that was run
before beginning the next hard workout.
6 Balance the high energy output of training with a high caloric intake.
SAMPLE PROGRAM FOR A USTS DISTANCE

TRIATHLETE
(0.9-mile swim, 25-mile bike, 6.2-mile run)

Weeks 1-4. (Initial Stage—Goals are gradually to increase weekly mileage to 3
miles of swimming, 45 miles of bicycling, and 20 miles of running.)
Each workout should follow the format given previously (that is, warm-up,
aerobic phase, and cool-down). The warm-up and cool-down phases
should include gradual transition from rest to swimming, cycling, or
running, as well as stretching of the muscles specific to that activity.
Each activity should be done three times per week, or nine total workouts
for the week. Since there are a variety of muscle groups being used, each
with its own stresses, the triathlete can safely exercise every day. In
order to complete the nine workouts, single workouts can be done on 5

days, and double workouts on 2 other days. Workouts in the same sport
should not be done on 2 consecutive days.
Training mileages per workout should be up to 1500 meters swimming, 25
miles cycling, and 6 miles running. No interval training should be done.
All training mileages should be accomplished aerobically; that is, at the
end of the workout, the triathlete should feel that she could repeat the
workout immediately.
Weeks 4-12. (Improvement Stage—The time to increase the intensity of the
workouts.)
Mileages should be increased to 5 miles of swimming, 75 miles of bicycling,
and 25 miles of running per week.
During this stage, the emphasis should be on increasing the mileages so that
some workouts are done slower than race pace at distances longer than
race distances. Other workouts should be done using interval training.
One interval training workout per week per sport is sufficient, and inter-
val training should probably not be done on consecutive days. Time tri-
als at race distances can be added during this phase.
Each activity should be done four or five times per week for a total of no more
than 15 workouts per week. Hard workouts should be followed by easy
workouts in each activity so that hard workouts are not done on two
consecutive days. Occasionally, a swim workout should be immediately
followed by a bike workout and a bike workout immediately followed by
a run.
Weeks 12 Through the Competitive Season. The emphasis during this time
should be on race performance. The total amount of training should be cut
down, particularly on weeks when the triathlete is competing. The emphasis
in workouts should be on quality rather than quantity. Short intervals con-
centrating on speed rather than endurance should be done once a week for
each activity. Other days can either be at race pace for distances shorter
than the race, or slower for longer distances. One day a week can be com-
plete rest or a very easy workout.
CHAPTER 2
Exercise and Regulation

of Body Weight*
DENISE E. WILFLEY, Ph.D., CARLOS M. GRILO, Ph.D., and
KELLY D. BROWNELL, Ph.D.
THE NATURE AND SEVERITY OF Obstacles to Exercise for the

WEIGHT DISORDERS Overweight Individual
Adherence Studies
THE ASSOCIATION BETWEEN
PHYSICAL ACTIVITY AND PROGRAM RECOMMENDATIONS
WEIGHT Avoid a Threshold Mentality
Consistency May Be More Important
EXERCISE AND WEIGHT
than the Type or Amount of
CONTROL
Exercise
LIKELY MECHANISMS LINKING Provide Thorough Education
EXERCISE AND WEIGHT Be Sensitive to the Special Needs of
CONTROL Overweight Persons
Energy Expenditure
SPECIAL ISSUES
Appetite and Hunger
The Role of Exercise in the Search for
Body Composition
the Perfect Body
Physical Activity and Health
Ideal Versus Healthy Versus
Psychologic Changes
Reasonable Weight
THE CHALLENGE OF ADHERENCE Exercise Overuse (Abuse)
Adherence and the Demographics of
Obesity
p
1 eople are searching frantically for the ideal body. In 1989, U.S. consumers
spent an estimated $32 billion on weight control programs and products.1 This
drive for thinness has created a burgeoning marketplace for physical fitness
equipment, attire, and health clubs. This stems from a clear belief that exercise
aids in weight maintenance in persons at normal weight and in weight loss in
overweight individuals. In fact, women often state that exercise is one of their
primary methods of weight control.
The concern for thinness and dieting behavior is especially prevalent among
* Preparation of this chapter was supported in Jenny Craig Foundation for the Fellowship Pro-
part by a MacArthur Foundation Fellowship to gram of the Yale Center for Eating and Weight
Carlos M. Grilo and in part by a grant from the Disorders.
27
women. The eating disorders of anorexia and 50% of men reported they were cur-
and bulimia, both of which involve preoc- rently either trying to lose weight or to
cupation with weight, are seen almost exclu- maintain their current weight.4
sively in women. Obesity occurs equally in There are countless variations among
women and men, yet women are more fre- women in the combinations of diet and ex-
quently the consumers of weight control ercise programs they follow. It is important,
products and are more likely to attend clin- therefore, to understand the physiologic
ical programs. and psychologic effects of such programs
In our culture, the search for the perfect and to identify approaches that are safe and
body begins at a young age and is especially effective. Exercise physiology and sports
pronounced among women. A recent sur- medicine are central to this endeavor. In
vey, the Youth Risk Behavior Surveillance spite of the fitness boom, many women and
System (YRBSS), revealed interesting find- men are too inactive to attain the psycho-
ings regarding weight control practices logic and health benefits of exercise, and
among adolescents. Using self-administered many of those who begin exercise programs
questionnaires in comparable national, do not continue exercising long enough to
state, and local surveys, the YRBSS mea- achieve their health and fitness goals.5
sures the prevalence of health-risk behav- In this chapter, we discuss the prevalence,
iors of adolescents.2,3,4 The 1990 YRBSS severity, and refractory nature of weight
included 11,631 students from grades 9 problems. The effects of exercise on food in-
through 12. take, metabolism, and regulation of body
Substantial differences were found in the weight are outlined, with specific focus on
weight perceptions of boys and girls. Female the effects of exercise on women. We discuss
students were twice as likely as male stu- mechanisms by which exercise facilitates
dents to consider themselves "too fat" (34% long-term weight loss, because there appear
versus 15%, respectively). Moreover, many to be multiple pathways linking exercise to
more female students were engaging in weight change. We then discuss ways to in-
weight control strategies. Among female stu- crease adherence, with particular focus on
dents, 44% reported that they were cur- the importance of tailoring exercise inter-
rently trying to lose weight, 26% were trying ventions to the special physical and psycho-
to keep from gaining weight, 7% were try- social needs of overweight persons. We also
ing to gain weight, and only 23% were not examine special issues such as how our cul-
trying to do anything about their weight. ture's preoccupation with shape and weight
Among male students, 15% reported that may perpetuate unhealthy attitudes toward
they were trying to lose weight, 15% were dieting and exercise, how to establish crite-
trying to keep from gaining weight, 26% were ria for a "reasonable weight" for an individ-
trying to gain weight, and 44% were not try- ual, and when exercise can be psychologi-
ing to do anything about their weight. Fe- cally and/or physically harmful. We end by
male students reported using exercise describing the role exercise can play in
(51%) and skipping meals (49%) as the two weight regulation and by outlining an ap-
most common means of weight control. proach to exercise that accounts for meta-
In sum, weight control is widely sought bolic variables, cultural factors, psychologic
after by both female adolescents and adults issues, and the challenge of long-term ad-
in the United States.4 Among high school herence.
girls in 1990, 70% of girls versus 30% of boys
reported that they were either trying to lose
weight or maintain their current weight. THE NATURE AND SEVERITY
Data collected on adults looks very similar. OF WEIGHT DISORDERS
Among 60,912 adults in the 1989 Behavior
Survey and Behavioral Risk Factor Surveil- Overweight is a prevalent problem with
lance System (BRFSS), about 70% of women serious adverse effects on health and Ion-
Exercise and Regulation of Body Weight 29
gevity. Approximately 27% of women and ronmental, cultural, socioeconomic, and

24% of men are overweight, using a criterion psychologic factors.
of 20% or more above desirable weight.6 Careful measurement of height and weight
Overweight is associated with elevated is currently the first step in the clinical as-
serum cholesterol, elevated blood pressure, sessment of the overweight.10 The body
cardiovascular disease, and noninsulin-de- mass index (BMI), the weight in kilograms
pendent diabetes.7'8 It also increases the risk divided by the square of the height in me-
for gallbladder disease and some types of ters, a measure of relative weight, is a more
cancer, and it has been implicated in the de- useful measurement of degree of overweight
velopment of osteoarthritis of the weight- than weight tables, since it correlates highly
bearing joints.9 (0.8) with more precise laboratory assess-
Overweight clearly affects a large propor- ments of body composition and is adjusted
tion of the U.S. population. The burdens of for height in order to compare body weight
overweight are shouldered disproportion- across individuals or groups.7 For persons of
ately by the poor and members of certain average weight, one BMI unit is equivalent
ethnic groups. Overweight is multideter- to approximately 6.8 Ib in men and 5.8 Ib in
mined in nature, reflecting biologic, envi- women (Fig. 2-1). Since risk is approxi-
Figure 2-1. Nomogram for body

mass index (BMI). To determine
BMI, place a ruler or other
straightedge between the body
weight column on the left and the
height column on the right and
read the BMI from the point
where it crosses the center.
(®George A. Bray, M.D., 1978, re-
printed with permission.)
ing and physical activity to the point where

body weight drops low enough to be life-
threatening. It occurs primarily in adoles-
cents and young adults in their early 20s,
and with few exceptions is confined to fe-
males. It is not the "flip side" of obesity. An-
orexics have characteristic family back-
grounds and patterns that are not common
among the overweight. There are also few
overweight persons who develop anorexia
nervosa.
Another eating disorder characterized by
excessive weight preoccupation and con-
cerns is bulimia nervosa. It involves fluctu-
ations between extreme dietary restriction
and out-of-control eating (binge eating).
Most women with bulimia nervosa report
the onset of binge eating following a severe
diet.12 The binge eating is followed by some
compensatory behavior such as self-in-
duced vomiting, use of diuretics or laxatives,
strict dieting or fasting, or vigorous exercise
in order to prevent weight gain. As with an-
orexia nervosa, bulimia nervosa is most
common among females. Among the con-
tributing factors are cultural pressures to be
thin, mothers' criticism of daughters' weight
and appearance, dysfunctional family pat-
Figure 2-2. Risk classification algorithm. After measur-
ing the BMI, the individual risk is increased or de- terns, low self-esteem, social self-conscious-
creased based on the presence of complicating factors. ness, and dieting itself. 13-15
(George A. Bray, M.D., 1988, reprinted with permis- Both anorexia nervosa and bulimia ner-
sion.)
vosa are most common in the populations
who are most invested in dieting and weight
loss—predominately white, middle to upper
mately proportional to degree of over- class females.16 In contrast, obesity is nega-
weight, Bray10 classifies the degree of risk on tively correlated with socioeconomic sta-
a scale from Class 0, very low risk, to Class tus.17 There is an overall correlation be-
IV, very high risk (Fig. 2-2). tween the cultural pressure to be thin and
Weight loss programs have shown dra- prevalence of eating disorders, both across
matically improved short-term results over and within ethnic groups.18 It is also well
the past two decades, but long-term results documented that eating disorders are more
are still discouraging. This resistance to prevalent in occupations (e.g., modeling)
treatment, combined with the high preva- and other life activities (e.g., gymnastics)
lence and striking severity noted earlier, that place pressure on females to be thin.19
make obesity a public health problem of In each of these disorders, complex inter-
considerable magnitude.11 actions exist among food intake, physical ac-
At the other end of the continuum of tivity, metabolism, psychology, and culture.
weight concerns lies anorexia nervosa (see The remainder of this chapter will discuss
Chapter 17). This involves a morbid and the interplay of these factors in the lives and
persistent dread of fat, with pathologic diet- health of women.
THE ASSOCIATION BETWEEN cert with the significant decline in physical

PHYSICAL ACTIVITY AND activity. Given the effects of changes in di-
WEIGHT etary composition and exercise on metabo-
lism and body composition, it is not difficult
During the last century, overweight has to posit a relationship between these factors
become increasingly common despite an and increased obesity.
overall decrease in the average daily caloric Research generally shows that over-
intake of the population.11,'20,21 Several impor- weight individuals are less active than their
tant changes have occurred during this pe- average-weight peers.26 Physical activity is
riod of time that may help explain this phe- inversely related to body weight, body com-
nomenon. Daily energy expenditure has position,27'28 and waist-to-hip ratio, although
decreased as society has progressed from its relation to different degrees of obesity is
an agricultural, to an industrial, to an infor- less clear. There are factors, however, that
mation-based economy, with fewer and must be considered when interpreting these
fewer jobs requiring physical exertion. Our results. First, many studies with both chil-
culture has also adopted a technology-ori- dren and adults have failed to find meaning-
ented philosophy of saving energy and in- ful differences in activity levels between
creasing comfort. As a result, daily energy overweight and average-weight persons.26
expenditure has dropped dramatically dur- Studies with those who are extremely over-
ing this century. weight, however, have found significantly
In 1984, the U.S. Department of Agricul- lower activity levels than for average-weight
ture estimated that between the years of persons. A second factor is that lower levels
1965 and 1977 the average daily energy ex- of activity may not necessarily represent a
penditure dropped by 200 calories per day lower energy expenditure. For example, an
(the equivalent of almost 21 lb/y).22 A report overweight person will require more energy
issued by the Centers for Disease Control to perform the same activity than a normal-
(CDC) in 1992, based on the national school- weight person because of additional energy
based Youth Risk Behavior Survey, esti- required to carry the excess weight. There-
mated that only 37% of students in grades 9 fore, an overweight person may actually ex-
to 12 were vigorously active three or more pend more calories than a lighter-weight
times per week. A comparison of these 1992 person who exercises more. A third factor
CDC findings with the 1984 report issued by may be the most important. Although over-
the National Children and Youth Fitness weight individuals may be less active than
Study, suggests that participation in vigor- average-weight persons, it is possible that
ous activity in adolescents is decreas- physical inactivity is a consequence—not a
ing.2,23,24 Another report issued by the CDC in cause—of being overweight. We speculate
1987 revealed that fewer than 20% of U.S. that since physical activity becomes in-
adults engage in regular vigorous activity, creasingly difficult with increased weight,
while approximately 50% lead sedentary this may lead to marked declines in exer-
lives.24,25 These declines in physical activity cise.
among adolescents and adults are unques- We have addressed the underuse of activ-
tionably related to the increased prevalence ity and its association with increased
of obesity in the United States. weight. Later we will address the overuse
During this century, more has changed (abuse) of activity. Discussing both the un-
than physical activity. Despite lower caloric deruse and overuse of exercise is important
intake, changes in dietary habits may play a for understanding the relationship between
role in increased weight. These changes in- exercise and weight regulation. We will now
clude increased fat consumption and meal discuss the role that exercise plays in weight
irregularity (fewer meals are consumed). loss and maintenance and outline possible
These changes must be considered in con- links between them.
EXERCISE AND WEIGHT have found that combining exercise and di-
CONTROL etary change produces greater weight loss
than diet change alone.
Data reveal a pattern of weight regain It appears, however, that exercise exerts a
when dietary interventions are used alone special impact on weight maintenance. Be-
to control weight, whereas diet combined havior modification dietary programs, ex-
with exercise leads to better maintenance.29 ercise, and combinations of diet and exer-
The importance of exercise for weight con- cise have about the same short-term effect
trol is clear: regular exercise is a central on weight loss.26 Thus, physical activity has
component of losing weight and is the single a modest effect on initial weight loss, per-
best predictor of long-term weight mainte- haps because dietary compliance is good
nance.11'29-37 early in a program and there is little room
Correlational studies reveal consistently for additional weight loss. However, long-
that exercise is associated with successful term effects are clear: exercise is critical for
weight loss and maintenance.35,38-41 Kayman weight maintenance. When the participants
and associates35 studied formerly obese in experimental studies are followed for 1 or
women who lost weight and kept it off and 2 years, striking effects of exercise emerge.
compared them with obese women who had A study by Pavlou and colleagues29 provides
lost weight and regained. Of the maintain- persuasive evidence for the benefit of exer-
ers, 90% were exercising regularly (mini- cise in weight maintenance—regardless of
mum of three times a week for >30 min- the type of dietary intervention. In this
utes), compared to only 34% of the regainers study, 160 male members of the Boston Po-
(Fig. 2-3). lice Department and the Metropolitan Dis-
Experimental weight loss treatment stud- trict Commission were randomly assigned
ies with random assignment and control to one of four 12-week programs (balanced
groups comparing exercise to no exercise caloric-deficit diet [BCDD] of 100 kcal; a
provide the strongest scientific support for ketogenic protein-sparing modified fast
the role of exercise in weight control. Many [PSMF]; and two liquid forms of these bal-
of these studies,29,34,37,42-46 but not all, 47-49 anced and ketogenic diets [DPC-70 and DPC-
Figure 2-3. Maintenance and re-

lapse after weight loss in women.
(Adapted from Kayman et al,35 p
803, with permission.)
800]) and to either an exercise or nonexer- which bolster energy expenditure by as lit-
cise group. Figure 2-4 displays 8- and 18- tle as 200 to 400 calories per day, result in
month follow-up data,29 showing no differ- enhanced maintenance in children.51,52 We
ence between the initial and the 18-month would like to underscore the connection be-
follow-up weight for those who did not ex- tween exercise and weight maintenance, be-
ercise, regardless of the four types of diets cause for many people, keeping the weight
used for weight loss. In sharp contrast, the off is a greater challenge than losing weight
exercise group maintained weight loss. Fur- initially.
thermore, whether one added or stopped
exercise following treatment predicted
weight maintenance. As shown in Fig. 2-5, LIKELY MECHANISMS LINKING
participants who ceased exercise at the end EXERCISE AND WEIGHT
of treatment regained weight, whereas those CONTROL
who started exercise at the end of treatment
maintained their weight loss at an 18-month Conventional wisdom suggests that over-
follow-up. In sum, exercisers were much less weight persons should exercise more, pre-
likely to regain their weight during follow- sumably because "it burns calories." It is
up. No comparable studies have been per- unlikely, however, that exercise exerts its
formed using women, but we may tentatively powerful effects on weight control simply
assume that the findings would be similar. because it burns calories. Exercise can alter
Exercise facilitates maintenance with body weight, body composition, appetite,
both balanced diets29,50 and very low calorie and basal metabolism, and can affect health,
diets.29,37 Furthermore, even minimal in- independent of weight loss. Moreover, ex-
creases in lifestyle activities (e.g., walking ercise can enhance psychologic well-being,
instead of riding, doing errands by walking), improve self-esteem, and increase motiva-
Figure 2-4. Exercise as an adjunct to weight-loss maintenance in moderately obese subjects. Follow-up data after
18 months confirm the long-term effectiveness of exercise intervention for as short a period as 8 weeks. There is no
difference between initial and 18-month follow-up weight for those who did not exercise, 29regardless of the diet used
for weight loss. In contrast, the exercise group maintained weight loss. (From Pavlou et al, p 1121, with permission.)
Figure 2-5. The addition or removal of learned exercise would appear to be a major contributing factor relative to
weight maintenance. Subjects who ceased exercise regained or demonstrated a strong tendency to return to pre-
study weights. Poststudy introduction of exercise (learned but nonsupervised) creates a positive effect. (Number of
subjects given in parentheses.) (From Pavlou et al,29 p 1122, with permission.)
tion. Although the exact links are not fully for individuals. For example, if metabolic
understood, there are multiple pathways by variables emerge as important, the types
which exercise may aid in weight control and amount of exercise needed to boost
(Table 2-1). metabolic rate should be prescribed. If psy-
Understanding the potential mechanisms chologic mechanisms are important, consis-
is crucial for prescribing exercise programs tency, rather than type or amount, may be
the central feature of a program. As a result,
Table 2-1. POSSIBLE LINKS BETWEEN different programs might be prescribed de-
EXERCISE AND WEIGHT CONTROL pending on the nature of the links between
1. Exercise expends energy.
exercise and weight control.
2. Exercise may decrease appetite.
3. Exercise may enhance metabolic rate.
4. Exercise may preserve lean body tissue. Energy Expenditure
5. Exercise may limit preference for dietary fat.
6. Exercise enhances health. Exercise Expends Energy
7. Exercise improves risk factors associated with
overweight. Any activity uses energy, so any increase
8. Exercise has positive psychologic effects: in activity can aid in weight control. Table 2-
Improves self-esteem and psychologic well-
being, 2 provides values for caloric expenditure of
Decreases mild stress and anxiety, various physical activities. Several impor-
Increases confidence, tant points are highlighted by this chart.
May enhance dietary adherence. First, routine activities like using stairs and
Source: Adapted from Grilo et al.,26 p 257, with walking are useful ways of expending en-
permission. ergy. For example, walking up and down two
Table 2-2. CALORIC VALUES FOR 10

MINUTES OF ACTIVITY
Body Weight Body Weight
125 175 250 125 175 250
Personal Necessities Light Work

Sleeping 10 14 20 Assembly line 20 28 40
Sitting (watching TV) 10 14 18 Auto repair 35 48 69
Sitting (talking) 15 21 30 Carpentry 32 44 64
Dressing or washing 26 37 53 Bricklaying 28 40 57
Standing 12 16 24 Farming chores 32 44 64
House painting 29 40 58
Locomotion
Walking downstairs 56 78 111 Heavy Work
Walking upstairs 146 202 288 Pick and shovel work 56 78 110
Walking at 2 mph 29 40 58 Chopping wood 60 84 121
Walking at 4 mph 52 72 102 Dragging logs 158 220 315
Running at 5.5 mph 90 125 178 Drilling coal 79 111 159
Running at 7 mph 118 164 232
Running at 12 mph 164 228 326 Recreation
Cycling at 5.5 mph 42 58 83 Badminton 43 65 94
Cycling at 13 mph 89 124 178 Baseball 39 54 78
Basketball 58 82 117
Housework Bowling (nonstop) 56 78 111
Making beds 32 46 65 Canoeing (4 mph) 90 128 182
Washing floors 38 53 75 Dancing (moderate) 35 48 69
Washing windows 35 48 69 Dancing (vigorous) 48 66 94
Dusting 22 31 44 Football 69 96 137
Preparing a meal 32 46 65 Golfing 33 48 68
Shoveling snow 65 89 130 Horseback riding 56 78 112
Light gardening 30 42 59 Ping-pong 32 45 64
Weeding garden 49 68 98 Racquetball 75 104 144
Mowing grass (power) 34 47 67 Skiing (alpine) 80 112 160
Mowing grass (manual) 38 52 74 Skiing (water) 60 88 130
Skiing (cross-country) 98 138 194
Sedentary Occupation
Squash 75 104 144
Silting writing 15 21 30 Swimming (backstroke) 32 45 64
Light office work 25 34 50 Swimming (crawl) 40 56 80
Standing, light activity 20 28 40 Tennis 56 80 115
Typing (electric) 19 27 39 Volleyball 43 65 94
Source: From Brownell,135 pp 66-67, with permission.
flights of stairs per day, in place of using an typical fast-food meal consisting of a quar-
elevator, would account for approximately 6 ter-pound cheeseburger, a small order of
Ib of weight loss per year for an average- french fries, and a chocolate shake contains
weight man.53 Second, heavier people burn about 1100 calories. To expend 1100 calories
more calories than normal-weight people through exercise would require running 11
while doing the same activity, because more miles or playing tennis for 3 hours.
energy is required to move the extra mass. However, Bray55 and others have ob-
Despite these facts, many people are dis- served that weight loss in people who exer-
appointed when they learn that even very cise tends to be greater than would be ex-
rigorous physical activities produce rela- pected through the direct expenditure of
tively small energy deficits.54 For example, a energy. Consequently, other physiologic or
psychologic mechanisms are likely to be im- ventions with weight-cyclers, as they may
portant. bolster RMR.46
Exercise May Enhance Metabolic Rate Appetite and Hunger

Resting metabolic rate (RMR) accounts Exercise May Decrease Appetite
for approximately 60% to 75% of a person's
total daily energy needs.55–57 Thus, small A number of studies with both humans
changes that either decrease or increase and animals have examined the association
RMR can have a dramatic effect on a per- between exercise and appetite.26 A frequent
son's total daily energy expenditure. For in- misconception is that increased activity will
stance, dieting can lead to a rapid and sig- be met with increased food intake, so there
nificant reduction in RMR.55,57–62 Since is no net benefit of the exercise. Although
dieting and weight loss often lower RMR, it the effects of exercise on appetite are com-
is important to find ways to help offset this plex, this regulatory mechanism tends to be
metabolic slowdown.57,63 in effect for only certain levels of activity.26
Exercise may prevent or at least reduce Studies with humans suggest that exercise
the decline in the body's metabolic rate pro- can be effective in regulating appetite. In-
duced by dieting.57,60,64,65 Tremblay and creasing physical activity moderately tends
colleagues65 found a significant increase in to decrease appetite, food intake, and body
RMR (8% of pretraining value) in obese in- weight, whereas increasing exercise to vig-
dividuals who engaged in an 11-week train- orous levels leads to increased appetite but
ing program, despite significant reductions stable body weight.67–70 However, women
in body weight and body fat mass. Broeder may benefit less from the suppression ef-
and colleagues66 observed that 12 weeks of fects of exercise on appetite than do men.67
either high-intensity endurance or resist- Some studies have found that increased
ance training helped to prevent an attenua- physical activity does not decrease appetite
tion in RMR normally observed during ex- in lean women, and that they may in fact eat
tended periods of negative energy balance, more,67,70,71 although their appetite does not
by either preserving the person's fat-free appear to increase beyond the level needed
mass via endurance training, or increasing it to maintain weight.
via resistance training. In contrast, Phinney In sum, exercise is unlikely to increase ap-
and colleagues49 found that when physical petite beyond the level to keep body weight
activity was added while on a very low cal- stable, and often may lead to decreased food
orie diet, it further depressed the metabolic intake. However, a potential problem exists,
rate rather than raised it. These conflicting since people may "believe" they will be hun-
findings underscore the need for more re- grier after they exercise. Monitoring one's
search to define the amount and types of ex- feelings of hunger before and after exercise
ercise that have the most beneficial meta- may help dispel this myth. In fact, some in-
bolic effects. dividuals find it useful to exercise at times
Another dilemma confronting dieters is when they are tempted to overeat.
the potential metabolic consequences of
successive episodes of weight loss followed
Exercise May Limit Preference for
by regain (i.e., weight cycling or yo-yo diet-
ing). There is inconclusive evidence about Dietary Fat
whether weight cycling produces greater Another potential benefit of exercise may
drops in RMR with repeated dieting efforts.26 be its influence on the intake of fat in the
To the extent that this does occur, it may be diet. Several animal studies have found that
particularly important to use exercise inter- weight cycling (repeated cycles of weight
loss and regain) results in a higher con- exists that regular physical activity is asso-
sumption of dietary fat,72,73 accompanied by ciated with good health.82–84 Moreover, even
larger adipose tissue depots.72 Exercise, modest levels of exercise are sufficient for
however, seems to limit this increased di- significant health benefits.79,85,86 Lee87 re-
etary fat selection in weight-cycled female viewed the literature pertaining to women
rats, and reduces the amount of body fat re- and aerobic exercise and concluded that
gained during refeeding periods.73 These middle-aged and older women incur the
findings may have important implications same physiologic and health benefits from
for the treatment of overweight in humans, exercise as do men (see Appendices 2-1 and
since weight cycling is common. 2-2).
One study provides convincing evidence
that even low levels of activity can have
Body Composition a substantial health impact. Blair and
Exercise May Preserve Lean (Muscle) colleagues79 calculated the age-adjusted all-
Tissue cause death rates over an 8-year period in
10,224 men and 3120 women who were ap-
Unfortunately, weight loss is not due parently healthy at baseline. Each person
solely to the loss of body fat. Weight loss is was assigned to a fitness category (based on
accounted for by several changes, including entry maximal treadmill testing), ranging
the loss of both lean and fat body tissue. As from the very unfit (Fitness Level 1) to the
much as 25% of the weight lost by dieting very fit (Fitness Level 5). In all BMI strata,
alone can be lean body mass (LBM).57 In the low-fit men and women had higher death
fact, the often observed slowing of weight rates than moderate- and high-fit subjects.
loss despite continued dieting (reaching a Therefore, physically fit individuals had
plateau) may be due partly to the loss of lean much lower mortality rates (Fig. 2-6). The
tissue, since lean tissue requires more en- largest reductions in risk, however, came
ergy to sustain itself. from moving from very low to moderate lev-
The loss of LBM decreases when exercise els of fitness, not from being extremely ac-
(even low to moderate) is combined with tive. This study and others have helped
diet.74 Several studies have found that regu- counter the notion that one must exercise
lar aerobic exercise, even in the absence of vigorously to obtain the health benefits of
dietary restriction, can produce significant exercise,83,85 and is critically important for
body fat loss with minimal loss of lean tis- overweight persons, in whom adherence is
sue.75–77 More recently, resistance training
has been used to improve the ratio of lean to
fat tissue, which may have the added benefit
of increasing energy expenditure.78 Since in-
creasing LBM and decreasing body fat may
increase metabolic rate (because muscle re-
quires more calories than does fat), exercise
prescriptions with this goal in mind may be
especially useful.
Physical Activity and Health

Prospective studies reveal an inverse re-
lationship between exercise or fitness level
Figure 2-6. The relationship between fitness level and
and morbidity and mortality in overweight death rate in women. (From Brownell,135 p 178, with
men and women.79–82 Substantial evidence permission, based on findings of Blair et al.79)
greatest in the low to moderate intensity diet was related to adherence to exercise,
range.5,33,51 and that adherence was better in programs
with lower rather than higher caloric expen-
diture.
Exercise Improves Medical Conditions In these studies,51,96 low calorie expendi-
Often Associated with Overweight ture was related to increased dietary adher-
Exercise helps offset medical conditions ence and weight loss. Physiologic factors
prevalent in the overweight. Conditions (e.g., increased metabolic rate) alone can-
such as high blood pressure, elevated cho- not account for the weight loss when the
lesterol, and diabetes improve with exer- amount of exercise is so minimal. These
cise.83 Exercise can provide these benefits findings raise the important issue of
independent of weight loss.53,54,83,88,89 Several whether perceived or actual fitness is the
studies have now shown an association be- key factor in linking exercise to weight con-
tween distribution of body fat (abdomi- trol. Since adherence is better for low- to
nal fat) and increased health risk (e.g., moderate-intensity exercise, low levels may
higher incidence of myocardial infarctions evoke feelings of mastery. Improved self-
and strokes).90 Recent population-based concept due to exercising may then gener-
studies show that physically active men and alize to other aspects of functioning, thereby
women have lower (more favorable) waist- increasing confidence for controlling di-
to-hip ratios.91–94 Therefore, in the absence etary practices. One's perception of being
of clinical intervention data, it seems rea- physically fit thus may be more important
sonable to recommend exercise for over- than physical fitness per se.95 Developing
weight persons with a high waist-to-hip the self-image of an exerciser should en-
ratio, although research is needed to docu- hance self-efficacy, which could lead to in-
ment whether exercise reduces abdominal creased self-determination.
fat. Collectively, these studies show that ex-
ercise of low to moderate intensity is asso-
ciated with improved dietary patterns and
weight loss. These results parallel others
Psychologic Changes
that suggest that exercise may not need to
Exercise has important psychologic ef- be aerobic or of high intensity to engender
fects and is associated with positive psycho- positive psychologic correlates.98–101 In-
logic health. Physical activity improves deed, high-intensity exercise can increase
mood, psychologic well-being (especially negative mood states such as tension, anxi-
immediately following exercise), and self- ety, and fatigue.102 Such negative conse-
concept, and also decreases mild anxiety, quences are important to avoid, since they
depression, and stress.95,96 In persons at- represent potential barriers to exercise ad-
tempting to lose or maintain weight, exer- herence.
cise may relieve stress or other negative In sum, exercise is an important predictor
feelings that precede dietary lapses.97 of success at weight reduction and mainte-
Surprisingly low levels of exercise seem to nance and has numerous health and
complement dieting by increasing dietary psychologic benefits. The link between ex-
adherence.51,96 Rodin and Plante96 reported ercise, weight control, and positive psycho-
that findings from their weight control stud- logic functioning dictates the importance of
ies suggest that people who engage in mod- finding strategies to help individuals be-
est exercise (i.e., jumping jacks for 10 min- come more active. In the next section, we
utes a day, three times a week) are will discuss the challenge of adherence and
substantially more successful at weight con- suggest ways to maximize an overweight
trol than nonexercisers. Similarly, Epstein person's ability to comply with exercise reg-
and colleagues51 found that adherence to imens.
THE CHALLENGE OF Table 2-3. POTENTIAL PHYSICAL AND

ADHERENCE PSYCHOLOGIC BARRIERS TO EXERCISE IN
OVERWEIGHT PERSONS
Poor adherence has long been considered
a challenge in exercise programs. Although Physical Barriers
there have been over 200 studies conducted Poor fitness
Excess weight
in the past 20 years on various determinants
of exercise behavior,103 little systematic in- Psychologic Barriers
vestigation has been conducted on over- Negative experiences
weight persons. We will draw from the exist- Teased by peers
ing studies on adherence relevant for Picked last for teams
Social Anxiety
overweight persons and suggest ways to de- Shame of being observed
velop a program. The reader is referred to Body image dissatisfaction
prior reviews for a more general overview of Lack of confidence
exercise adherence, since they provide Lack of knowledge or experience
a framework from which a program for Source: Adapted from Grilo et al,26 p 264, with
the overweight individual can be estab- permission.
lished.5,26,83,103
physical and psychologic barriers to exer-
Adherence and the cise among overweight individuals is criti-
Demographics of Obesity cal. Table 2-3 summarizes potential barriers
to exercise.
Although most people who are over-
weight know that increased exercise may
help them lose weight, many are unable to Physical Burden
establish and maintain a personal exercise For many overweight persons, exercise is
program. Professionals are confronted with unpleasant due to poor physical condition-
the challenge of helping these individuals ing and excess weight. Weight becomes a
increase their level of physical activity. burden that must be overcome. Increasing
One reason that exercise adherence is a physical activity may be difficult, painful,
special challenge in overweight persons is and fatiguing. Starting a program too quickly
that groups most likely to be overweight are or vigorously may lead to excess fatigue,
also least likely to exercise. Overweight oc- physical discomfort, and injuries, each of
curs with especially high prevalence in mi- which can deter a person from future efforts.
nority populations104,105and in persons with Starting overweight people with a low- to
lower socioeconomic status (SES).21,106 In ad- moderate-paced program is crucial for pre-
dition, the incidence of obesity increases venting injuries, enhancing exercise self-
with age, particularly in women.21,107 For Af- efficacy, and sustaining adherence.
rican-American women ages 45 to 75 years,
obesity rates are as high as 60%.21 Exercise
rates for obese persons, the elderly, minor- Negative Associations
ity groups, and those with low SES, however, Psychologic barriers are sometimes for-
are very low.103,108 midable obstacles for overweight people to
overcome in order to exercise regularly. For
Obstacles to Exercise for the people who have been overweight since
Overweight Individual childhood, early memories such as being
teased, being picked last for teams, and suf-
Several obstacles can impede the transi- fering from poor athletic performance leave
tion from the desire to exercise to the act of many obese persons ashamed and self-con-
exercising. Careful attention to potential scious about their bodies.109,110 Overweight is
often associated with social rejection.111,112 diet for weight control. It will be important
Consequently, many overweight persons to keep this inexperience in mind when de-
manifest disturbances in areas of life af- veloping exercise programs for these indi-
fected by weight, such as body image, social viduals.
interactions, and self-esteem.112
It is not surprising that thoughts of exer-
cise may evoke unpleasant memories, feel- Adherence Studies
ings of inadequacy, and shame at the pros- Exercise adherence has been understud-
pect of being observed. Not only does the ied with overweight persons. This is unfor-
excess weight add a physical burden, but a tunate, since overweight persons have low
persistent negative body image may dis- exercise participation rates and are at a high
courage a person from exercising with oth- risk for health problems that can be im-
ers, and the lack of self-confidence may pre- proved with exercise.103 For instance,
vent a person from starting an exercise Gwinup115 found that only 32% of overweight
program. It is important to be sensitive to women enrolled in a walking exercise pro-
such experiences and to create a supportive gram remained in the program for 1 year. In
atmosphere so that overweight persons can a prospective study with a large community
identify and initiate activities they enjoy in a sample, Sallis and co-workers116 found that
positive way. Helping overweight persons overweight subjects were less likely to adopt
identify clothing that they feel comfortable exercise than were normal-weight subjects.
wearing, from shoes to workout apparel, and
explaining where to obtain exercise clothing
Intensity
in large sizes is useful and appreciated. It is
essential to encourage patients to experi- Less intense, "lifestyle" activity or mod-
ment with different activities until they ex- erate-intensity activities (those that require
perience pleasure and satisfaction. This less than 60% of maximal capacity, such as
may include exploring community options walking) generally have superior initiation
that provide opportunities to exercise with and adherence rates and lower drop-out
other overweight individuals. rates than do vigorous activities.51,83,87,116,117
This seems to hold true among widely di-
verse groups of people. A large community
Developmental and Gender Issues
study in California116 found that both men
Exercise initiation and maintenance may and women were more likely to adopt mod-
be enhanced by tailoring interventions to erate activity than a vigorous fitness regi-
specific developmental milestones.113 An ex- men. Moderate activity programs showed a
ecutive woman with an ill mother will have dropout rate (25% to 35%) roughly one half
different developmental and practical issues of that seen for vigorous exercise (50%). Ad-
than a teenager with minimal responsibili- ditionally, moderate activity appears to be
ties. Table 2-4 presents features and exam- more readily maintained over the life span,
ples of physical activity programs for sev- whereas participation in vigorous activity
eral important periods. It is also important declines dramatically with age.118 This is es-
to tailor interventions specifically for pecially important to consider with over-
women. For example, many women have not weight persons, since overweight increases
been involved in physical activity programs. with age. In fact, low-intensity exercise (30%
The fact that inactivity is considered a prob- to 45% MHR) has produced significant in-
lem for women reflects a substantial shift in creases in fitness for women in their 60s and
attitudes in the past 25 years.114 Many 70s.119 Overweight children also do better
women over 30 were never encouraged to when low-intensity, lifestyle exercise regi-
participate in team sports or recreational mens are prescribed, versus high-intensity
physical activity; instead, many learned to activities; Epstein and colleagues52,120 found
Table 2-4. PHYSICAL ACTIVITY PROGRAMS FOR SEVERAL MAJOR DEVELOPMENTAL

MILESTONES
Milestone
(Critical Period) Specific Features Goals/Strategies
Adolescence Rapid physical and emotional changes Exercise as part of a program of healthy weight
Increased concern with appearance regulation (both sexes)
and weight Noncompetitive activities that are fun, varied
Need for independence Emphasis on independence, choice
Short-term perspective Focus on proximal outcomes (e.g., body image,
Increased peer influence stress management)
Peer involvement, support
Initial work entry Increased time and scheduling Choice of activities that are convenient, enjoyable
constraints Focus on proximal outcomes
Short-term perspective Involvement of worksite (environmental
Employer demands prompts, incentives)
Realistic goal setting, injury prevention
Coeducational, noncompetitive activities
Parenting Increased family demands and time Emphasis on benefits to self and family (e.g.,
constraints stress management, weight control, well-being)
Family-directed focus Activities appropriate with children (e.g.,
Postpartum effects on weight, mood walking)
Flexible, convenient, personalized regimen
Inclusion of activities of daily living
Neighborhood involvement, focus
Family-based public monitoring, goal-setting
Availability of child-related services (child care)
Retirement age Increased time availability and Identification of current and previous enjoyable
flexibility activities
Longer-term perspective on health; Matching of activities to current health status
increased health concerns, Emphasis on mild- and moderate-intensity
"readiness" activities, including activities of daily living
Caregiving duties, responsibilities Use of "life path point" information and prompts
(parents, spouse, children, or Emphasis on activities engendering
grandchildren) independence
Garnering support of family members, peers
Availability of necessary services (e.g.,
caretaking services for significant other)
Source: From King,113 p 250, with permission.
that lifestyle exercise was superior to pro- extreme effort. Adherence is increased
grammed aerobic exercise for long-term when the activity can be readily incorpo-
weight maintenance (Fig. 2-7). It may be rated into daily life; this, in turn, may en-
that since lifestyle programs are more flexi- hance one's confidence in the ability to per-
ble and easily incorporated into one's daily form physical activity (self-efficacy), which
routine, fewer barriers emerge to preclude may improve adherence. Moderate-inten-
continued participation.51,121 sity activity has many of the health benefits
In sum, prescription of lifestyle activity of vigorous exercise,79,116,122 with the added
over vigorous, programmed exercise may benefit of easier maintenance.83
represent one key to adherence for over-
weight persons. Beginning individuals with
Relapse Prevention Strategies
modest activity goals that are readily incor-
porated into their daily life is preferable to Cognitive behavioral therapy (CBT) pro-
approaches that promote sweat, pain, and grams for exercise adherence that have in-
Figure 2-7. Percent overweight for

children in three groups (calis-
thenics, programmed aerobic ex-
ercise, and lifestyle exercise) at 0,
2, 6, 12, and 24 months. (From Ep-
stein et al,120 p 351, with permis-
sion.)
corporated components of Marlatt and nance of exercise and proposed that indi-
Gordon's123 relapse prevention model result viduals in the different stages may require
in better physical activity rates at follow- different cognitive and behavioral ap-
up.124–128 Although originally developed for proaches.5,129,130 This model proposes that
other areas such as smoking and alcohol, people proceed through five stages: precon-
this model offers several important sugges- templation, contemplation, preparation, ac-
tions to persons trying to maintain any be- tion, and maintenance, as follows:131
havior change. Three elements are particu-
larly useful for increasing adherence: (1) Precontemplation. Precontemplators do
flexible rather than rigid exercise goals,128 not intend to change their behavior in
(2) training individuals in specific tech- the foreseeable future. These individu-
niques to cope with missed exercise ses- als are unaware of the benefits of exer-
sions,126 and (3) identifying potential situa- cise or are uncertain about whether the
tions that might interfere with exercise or benefits are greater than the negative
lifestyle changes and developing plans for aspects. Movement to the next stage
coping with those high-risk situations and would require acknowledging and be-
setbacks.124 Moreover, relapse training, in coming more aware of the negative as-
comparison to a treatment with no relapse pects of their lack of exercise.
training, results in significantly greater Contemplation. Contemplators are aware
weight maintenance.124 Even minimal inter- of the negative aspects of their lack of
vention strategies such as telephone con- exercise and are seriously considering
tacts or mailings, however, may enhance ad- taking action. Both the positive and
herence and maintenance of weight loss.31,36 negative aspects are considered. Con-
templators have not, however, commit-
ted themselves to the necessary steps
Stages of Change in Exercise Adoption
for change. Exercisers will progress to
and Maintenance
the next stage only after a decision to
Recently, several researchers have sug- change their lack of exercise.
gested that individuals proceed through Preparation. Exercisers in the prepara-
specific stages in the initiation and mainte- tion stage are characterized by a readi-
ness and intention to begin exercise or study134 found a significant interaction be-
change their behavior in the foreseea- tween weight loss treatment and gender:
ble future. These individuals have eval- women did better when treated with their
uated past successes and failures and spouses, whereas men did better when
are on the verge of taking action. Move- treated alone. This study is an example of
ment to the next stage requires setting the potential need to match particular sup-
attainable goals and steps for action. port interventions to the individual's needs
Action. Persons in the action stage begin and characteristics.
to make changes in their behavior. A Equivalent studies looking at social sup-
central focus is setting appropriate port and exercise adherence in overweight
goals and taking action to implement persons have not been done. Our clinical ex-
them. They are aware of the cognitive, perience suggests, however, that there tend
behavioral, and/or environmental fac- to be "solo" versus "social" exercisers. The
tors that may interfere with continued "solo" type individual typically does not de-
progress. sire the company of others and tends to se-
Maintenance. Persons in the mainte- lect activities such as walking or jogging
nance stage focus their attention on alone. A "social" exerciser may prefer an
preventing relapse to former behaviors aerobics class or jogging with a partner. Our
as well as continuing the exercise pat- experience is that a better match between
terns begun in the action stage. Exercis- personality type and type of exercise results
ers in the maintenance stage are con- in a better fit.135
centrating on identifying potential Further research is needed to identify the
situations that may interfere with their factors that predict success with spouse,
continued success. family, or peer interventions for exercise
and dietary adherence with obese persons.
A potential major contribution of this Brownell135 and Brownell and Rodin136 pro-
model for increasing and maintaining exer- vide specific strategies and techniques to
cise lies in its consideration of the readiness aid overweight individuals in identifying
of individuals for change.5 Awareness of and pursuing the type of social support they
variables such as readiness can facilitate pa- need.
tient-treatment matching, thus improving
outcome.132 In fact, a recent study129 found
that exercise programs must accommodate PROGRAM
the large percentage of individuals who are RECOMMENDATIONS
not ready to change their exercise habits.
Research is needed on how to best match Three basic issues confront the clinician:
exercise interventions to patient's stages of (1) the type of exercise to prescribe, (2)
change. The concepts of readiness and ways to maximize adherence, and (3) re-
patient-treatment matching apply not only lapse prevention. Table 2-5 outlines our rec-
to exercise in overweight persons, but also ommendations for exercise programs for
to dieting itself.11 overweight persons. Important elements are
discussed below.
Social Support
Avoid a Threshold Mentality
All health behaviors, including exercise,
are Influenced by social context. Attempts to Any activity, even those not normally la-
improve weight loss by involving significant beled as exercise, can provide substantial
others have met with mixed results,133 per- benefit. It is important to avoid the trap of
haps because of a failure to assess the needs defining physical activity in traditional
and characteristics of the target groups. One terms (70% of maximal heart rate, three
Table 2-5. RECOMMENDATIONS FOR d. Use exercise following dietary lapses to

MAXIMIZING EXERCISE ADHERENCE IN psychologically regain a sense of control,
OBESE PERSONS mastery, and commitment.
e. Convey philosophy that a lapse can be used as a
General Principles signal to re-initiate small amounts of physical
1. Be sensitive to psychologic barriers. activity (e.g., a 2-minute walk). Encourage
2. Be sensitive to physical barriers. notion that all exercise has a cumulative effect
3. Decrease focus on exercise threshold. on a number of domains (health, mood, sense of
4. Increase focus on enhanced self-efficacy. mastery).
5. Emphasize consistency and enjoyment, not f. Use of minimal intervention strategies, including
amount and type. phone contacts, may foster exercise
6. Begin at a person's level of fitness. maintenance.
7. Encourage people to define routine activities as
Source: Adapted from Grilo et al,26 p 266, with
"exercise."
permission.
8. Focus on compliance and avoid emphasis on
minor metabolic issues (e.g., whether to exercise
before or after a meal).
9. Consider life-span developmental context. times per week, for at least 15 minutes). This
10. Consider sociocultural issues and gender three-part equation (frequency, intensity,
influences. and duration) has been defined as essential
11. Evaluate social support network. for cardiorespiratory conditioning,57 but it
12. Evaluate stage of change and intervene implies an exercise "threshold"—that is,
accordingly.
that exercise must occur in a specific
Specific Interventions amount to be beneficial. This threshold may
1. Prescription motivate physically active or athletic per-
a. Provide clear information about importance of sons, but it may deter others, including the
activity, including the psychologic benefits. overweight. Since any exercise is worth-
b. Maximize routine activity. Define daily activities while, the threshold mentality may hinder
as exercise. more than help. As a professional working
c. Maximize walking (e.g., walk while doing
errands). with overweight people, it is important for
d. Increase use of stairs in lieu of escalators and you to stress that low to moderate levels of
elevators. exercise provide many health,79 psycho-
e. Incorporate a programmed activity that is logic,96 and weight-loss benefits.52,120 Show-
enjoyable, fits with lifestyle, and is feasible as ing overweight persons data such as Figure
client's fitness improves.
2. Behavioral 2-6 can help make this point.
a. Introduce self-monitoring, feedback, and goal-
setting techniques.
b. Identify important targets other than weight Consistency May Be More
loss, including physical changes, increased Important than the Type or
mobility (flexibility, endurance, ease), and Amount of Exercise
lowered heart rate.
c. Suggest that exercise may help soothe emotional We believe the most important question to
distress when risk for overeating is high. ask about exercise is, "Will 1 be doing this a
d. Stimulus control: increase exercise cues (e.g., year from now?" It is important to help pa-
reminders for increasing activity) and decrease tients choose activities that will be enjoya-
competing cues (e.g., do not schedule exercise
when it might conflict with work or social
ble in the long run. Developing a consistent
obligations). form of activity, or a consistent set of activ-
3. Maintenance and relapse prevention ities, is the primary focus. It is preferable to
a. Use flexible guidelines and goal-setting, but have a person regularly play tennis twice a
avoid rigid rules. week and walk for one additional day than to
b. Identify potential high-risk situations for
skipping exercise (e.g., stressful times, busy
run 4 miles/d for a week and then stop en-
schedule). tirely. Lifestyle change, consistency, and
c. Develop plans to cope with high-risk situations. moderation are the key goals.
Provide Thorough Education for the increase in dieting and exercise be-
havior.137 Consumers are frantically search-
It is important to emphasize that even ing for information to achieve the perfect
low-intensity exercise leads to enhanced di-
body. One need only look at the multibillion
etary adherence and weight control. Other- dollar industry to help people look more at-
wise, people will feel they are always exer-
cising "less than they should." Education tractive—diets, exercise paraphernalia,
regarding the physical and psychologic ben- cosmetics, fashions, and various forms of
efits of exercise can expand the patient's un- cosmetic surgery—to realize the extent to
derstanding of the potential benefits. Dis- which there is societal pressure to "look
pelling erroneous notions such as "no pain, good."141
Two beliefs fuel this search for the "ideal"
no gain" is an essential component. Poor
health behaviors can result from inadequate body. The first belief is that the body is infi-
information as well as nonadherence. nitely malleable, and that with the right diet,
exercise program, and personal effort, an in-
dividual can achieve the aesthetic ideal. The
Be Sensitive to the Special second belief is that once the ideal is
Needs of Overweight Persons achieved, there will be considerable re-
Since obese persons have special psycho- wards, such as career advancement, wealth,
interpersonal attraction, and happiness.137
logic and physical barriers to exercise, help-
ing them feel comfortable with exercise and
helping them define even low levels of activ- Ideal Versus Healthy Versus
ity as exercise is an important step toward Reasonable Weight
adherence. Simply conveying understand- The body cannot be shaped at will. Ge-
ing and sensitivity can be helpful. netic factors play a substantial role in limit-
ing our ability to change body weight142,143
and body shape.144 Certain individuals may
SPECIAL ISSUES be prone to gain weight or to have specific
body shapes and these factors may resist at-
It is important to develop "reasonable" tempts to lose weight.11 This creates a mis-
weight-loss goals and healthy attitudes re- match between cultural pressures and bio-
garding exercise and diet. Our culture's pre- logic realities.137
occupation with shape and weight may This collision between cultural pressures
foster unhealthy attitudes. Health care pro- and biologic realities leads to the critical
fessionals should be aware of methods to question of how much control a person has
encourage the pursuit of "reasonable" over weight and shape.145 Scientists have es-
weight-loss goals. timated that current aesthetic ideals (popu-
lar models and actresses) have 10% to 15%
body fat, compared with 22% to 26% for
The Role of Exercise In the
healthy, normal-weight women.137,140,146 For
Search for the Perfect Body instance, a study by Wiseman and
Today's aesthetic ideal is becoming in- colleagues140 found that the majority of Play-
creasingly lean, coupled with an added pres- boy centerfolds and Miss America contes-
sure to be physicallyfit.137–140The symbolic tants were 15% or more below their ex-
connotations of having the ideal body (suc- pected weight, one of the criteria for
cess, self-control, acceptance), current stan- anorexia nervosa. One may speculate that
dards about ideal body weight and shape, many of our "ideals" have eating disorders.
and the overstated health benefits of slen- Miss America contestants work out an aver-
derness are important factors responsible age of 14 hours per week, with some ap-
preaching 35 hours.147 Although the current weight, but a reasonable weight. Table 2-6
societal ideal is unattainable and/or unreal- lists questions to formulate a reasonable
istic for most people, those who do not meet weight for an individual patient. The calcu-
the ideal are often judged to be lazy, indul- lation of reasonable weight would take into
gent, and lacking willpower. The exercise account the individual's weight history, de-
and weight loss needed to pursue the aes- velopmental stage, social circumstances,
thetic ideal, however, is far in excess of what metabolic profile, and other factors. For in-
is necessary (or recommended) for healthy stance, specific milestones, transitions, and
living.146 life periods affect how women feel toward
Weight-loss programs typically identify their bodies. Females begin life with more
some "goal weight" or "ideal weight" as the body fat than males, and this difference con-
desired outcome. Moreover, whether or not tinues to increase during specific develop-
there are formal goals developed by pro- mental stages over the life span (at puberty,
gram staff, patients often have self-imposed pregnancy, and menopause). These physi-
goals influenced by visualizations of an aes- ologic changes promote weight gain.148 Dis-
thetic ideal. The notion of ideal weight may cussing these developmental transitions
be useful for people who are only mildly can help women develop an acceptance and
overweight (because the ideal is potentially understanding of the physiologic changes
attainable), or for prevention efforts in while also using this information to formu-
which excess weight beyond the standard late a reasonable weight goal.
signals the need for intervention. For many In some cases, reasonable weight and
people, however, the ideal generates a health ideals may be the same (e.g., the in-
search for an elusive goal, which often leads dividual can sustain the effort, calorie re-
to poor long-term results. striction, and exercise necessary to main-
Brownell and Wadden11 suggest that it is tain that weight). On the other hand, the
important to think not only of an ideal reasonable weight might exceed the ideal
weight if biologic, psychologic, develop-
mental, or cultural variables interfere.
Nonetheless, any weight loss is likely to
Table 2-6. QUESTIONS USED AS CLINICAL
CRITERIA TO HELP ESTABLISH A be beneficial, particularly if it can be main-
"REASONABLE WEIGHT" FOR AN tained. For some individuals, a small weight
INDIVIDUAL* loss can lead to significant improvements in
medical conditions149,150 and may have a
1 . Is there a history of excess weight in your parents
or grandparents? number of positive outcomes, such as feel-
2. What is the lowest weight you have maintained as ing more energetic, improved mobility, or
an adult for at least one year? less dependence on others for basic needs.
3. What is the largest size of clothes that you feel Thus, patients should be encouraged to set
comfortable in, at the point you say "I look pretty goals according to several parameters, since
good considering where I have been"? At what
weight would you wear these clothes? this may help to prevent the common trap of
4. Think of a friend or family member (with your age viewing anything but goal weight as failure.
and body frame) who looks "normal" to you. What Tracking changes in physiologic factors that
does the person weigh? are likely to change with increased physical
5. At what weight do you believe you can live with the activity and weight loss (e.g., blood sugar,
required changes in eating and/or exercise?
blood pressure, serum cholesterol); anthro-
*Thesequestions are based in part on criteria proposed pometric measures (e.g., skinfold thickness
by Brownell and Rodin136 and represent clinical im- and circumferences); and psychologic
pression. Research-based criteria have not been
established. changes may provide clear evidence of ac-
Source: Reprinted from Brownell and Wadden,11 p 509, complishment to both patients and health
with permission. professionals. Maintaining these benefits
can be one central goal of treatment, even if males said that they were often, usually, or
more weight is to be lost. always "terrified of being fat."
This "terror of being fat" can cause some
individuals to fall into the trap of excessively
Exercise Overuse (Abuse) exercising while still falling short of the
"perfect body." Many studies evaluate
As we have noted, exercise is an impor- whether people diet or exercise, but mini-
tant aspect of weight control and is gener- mal attention has been paid to why they do
ally viewed as a healthy and positive en- so. A substantial subset of runners may be
deavor. Unfortunately, exercise can become motivated by the fear of being fat and may be
compulsive when done in pursuit of exces- running away from a vision of being fat. Be-
sive thinness. An enduring fear of being fat cause both diet and exercise are excessive
is a hallmark of anorexia nervosa and bu- in some individuals, knowing the motivation
limia nervosa.14,151–153 Vigorous exercise can may be helpful in detecting unhealthy exer-
be a means of weight loss or one of several cise and dietary behaviors. Table 2-7 pre-
tactics used by the individual to counteract sents questions that might aid health profes-
the ingestion of excess calories or deal with sionals in determining whether exercise is
body image concerns. Intense fears of be- excessive or potentially problematic.158
coming fat may exist in people across all These questions are based on our clinical
weight groups and body shapes. experience and may not predict exercise
Even exceptionally lean persons may abuse. Rather, affirmative responses sug-
have body image disparagement. In fact, a gest the need for further evaluation and un-
growing body of research with athletes sug- derstanding of that individual's use (or po-
gests that a disproportionately high rate of tential abuse) of exercise. It is critically
fear of fatness and extreme dieting measures
may exist in these lean and fit individuals.19
One group of researchers investigated the
functional role of exercise in a group of 112 Table 2-7. ASSESSMENT QUESTIONS TO
women who were regular exercise partici- SCREEN FOR POTENTIAL EXERCISE
ABUSE
pants.154 While only a handful were over-
weight, 77% of these relatively slender and 1 . Are there times during the day when you feel
active women wanted to lose weight, and unable to stop thinking about exercise, even if you
most of them were dieting (57%). Another want to?
2. Do you feel anxious, irritable, or uncomfortable
study revealed that 19% of a group of female when you miss an exercise session?
runners met diagnostic criteria for bulimia 3. If you miss an exercise session, do you feel that you
nervosa,155 which is a much higher preva- need to make up for it (e.g., by staying up later or
lence than expected in this group.156 Of the getting up earlier to do it, by increasing the amount
bulimic women, most cited exercise as their of exercise you do the next day)?
4. Have you sometimes exercised despite being
most common compensation tactic for advised against it (i.e., by a doctor, friend, family
binge-eating episodes. Results did not indi- member)? What advice was given? Why did you
cate a particular weight or running profile exercise?
(that is, the bulimics were not significantly 5. Do you try to increase your exercise session (or
different on mileage per week or fastest time add an additional exercise) when you feel you have
overeaten or when you eat "junk foods"?
for a 10-K race than nonbulimics), but did 6. Do you worry about putting on weight or becoming
reveal associated psychologic factors (di- fat if you miss an exercise session?
etary restraint and depression). A survey 7. When you exercise, do you think about the calories
conducted in Runner's World magazine157 re- or the amount of fat you are burning off?
vealed that among the 4000 runners who re- Source: From Grilo and Wilfley,158 p 163, with
sponded, 48% of the females and 21% of the permission.
important for health professionals to rec- adolescents and adults: Youth risk behavior
ognize possible signs and symptoms of ex- survey and behavioral risk factor surveil-
ercise abuse. lance system. In Methods for Voluntary
Weight Loss and Control. NIH Technology
Assessment Conference, 1992, p 46.
5. Dishman RK: Increasing and maintaining
SUMMARY exercise and physical activity. Behav Ther
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many women are in pursuit of the current tenance treatment and 6-month outcome for
societal ideal, which is often unattainable bulimic patients who respond to initial
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141. Rodin J: Cultural and psychosocial deter- 157. Brownell KD, Rodin J, and Wilmore JH: Eat,
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142. Stunkard AJ, Foch TT, and Hrubec Z: A twin trol Digest 2:161, 1992.
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143. Stunkard AJ, Harris JR, Pedersen NL, effects of an exercise training regimen upon
McClearn GE: The body mass index of women aged 52 to 79. J Gerontol 28:50,
twins who have been reared apart. N Engl 1973.
JMed 322:1483,1990. 160. Badenhop DT, Cleary PA, et al: Physiologi-
144. Bouchard C, and Johnson FE (eds): Fat dis- cal adjustments to higher- or lower-inten-
tribution during growth and later health sity exercise in elders. Med Sci Sports Exerc
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145. Brownell KD: Personal responsibility and 161. Bassey EJ, Patrick JM, Irving JM, Blecher A,
control over our health: When expectation and Fenten PH: An unsupervised "aerobics"
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1991. aged factory workers: Feasibility, validation
146. Katch FI, and McArdle WD: Nutrition, and responses. Eur J Appl Physiol 52:120,
Weight Control and Exercise, ed 3. Lea and 1983.
Febiger, Philadelphia, 1988. 162. Blumenthal JA, Schocker DD, Needels TL,
147. Trebbe A: Ideal is body beautiful and clean and Hindle P: Psychological and physiolog-
cut. USA Today, September 15, 1979, p 1. ical effects of physical conditioning on the
148. Rodin J, and Larson L: Social factors and the elderly. J Psychosom Res 26:505, 1982.
ideal body shape. In Brownell KD, Rodin J, 163. Blumenthal JA, Emery CF, Madden DJ, et al:
and Wilmore JH (eds): Eating, Body Weight Cardiovascular and behavioral effects of
and Performance in Athletes. Lea and Febi- aerobic exercise training in healthy older
ger, Philadelphia, 1992, p 146. men and women. J Gerontol 44:M147, 1989.
149. Blackburn GL, and Kanders BS: Medical 164. Cavanaugh DJ, and Cann CE: Brisk walking
evaluation and treatment of the obese pa- does not stop bone loss in postmenopausal
tient with cardiovascular disease. Am J Car- women. Bone 9:201,1988.
diol 60:55g, 1987. 165. Cowan MM, and Gregory LW: Responses of
150. Wassertheil-Smoller SW, Blaufox MD, pre- and post-menopausal females to aero-
Oberman A, Langford HG, and Davis BR: bic conditioning. Med Sci Sports Exerc
TAIM Study: Adequate weight loss as effec- 17:138, 1985.
tive as drug therapy for mild hypertension. 166. Franklin B, Buskirk E, Hodgson J, et al: Ef-
Paper presented at American Heart Asso- fects of physical conditioning on cardiore-
ciation Conference on Cardiovascular Dis- spiratory function, body composition and
ease Epidemiology, San Diego, 1990. serum lipids in relatively normal-weight
151. Fairburn CG, and Cooper, PJ: The clinical and obese middle-aged women. Int J Obes
features of bulimia nervosa. Br J Psychiatry 3:97, 1979.
144:238, 1984. 167. Getchell LH, and Moore JC: Physical train-
152. Garfinkel PE, and Garner DM: Anorexia ner- ing: Comparative response of middle-aged
adults. Arch Physical Med Rehab 56:250, 175. Netz Y, Tenenbaum G, and Sagir M: Patterns
1975. of psychological fitness as related to pat-
168. Haber P, Honiger B, Kilicpera M, and Nied- terns of physical fitness among older adults.
erberger M: Effects on elderly people 67-76 Percept Motor Skills 67:647, 1988.
years of age of three-month endurance 176. Seals DR, Hagberg JM, Hurley BF, Ehsani
training on bicycle ergometer. Eur Heart J AA, and Holloszy JO: Endurance training in
5:37,1984. older men and women I. Cardiovascular re-
169. Jarvie GJ, and Thompson, JK: Appropriate sponse to exercise. J Appl Physiol 57:1024,
use of stationary exercycles in the natural 1984.
environment: The failure of instructions and 177. White MK, Yeater RA, Martin RB, et al: Ef-
goal setting to appreciably modify exercise fects of aerobic dancing and walking on car-
patterns. Behav Ther 8:187,1985. diovascular function and muscular strength
170. Jette M, Sidney K, and Campbell J: Effects of in post-menopausal women. J Sports Med
a twelve-week program on maximal and 24:159, 1984.
submaximal work output indices in seden- 178. MacKeen PC, Franklin BA, Nicholas C, and
tary middle-aged men and women. J Sports Buskirk ER: Body composition, physical
Med Physical Fitness 28:59,1988. work capacity and physical activity habits at
171. Juneau M, Rogers F, DeSantos V, et al: Effec- 18-months follow-up of middle-aged women
tiveness of self-monitored, home-based, participating in an exercise intervention
moderate-intensity exercise training in mid- program. Int J Obes 7:61, 1983.
dle-aged men and women. Am J Cardiol 179. Blumenthal JA, Emery CF, Madden DJ, et al:
60:66,1987. Long-term effects of exercise on psycholog-
172. Kukkonen K, Rauramaa R, Siitonen U, and ical functioning in older men and women. J
Hanninen O: Physical training of obese mid- Gerontol, in press.
dle-aged persons. Ann Clin Res 14:80,1982.
173. Lewis S, Haskell WL, Wood PD, et al: Effects
of physical activity on weight reduction in
obese middle-aged women. Am J Clin Nutr ACKNOWLEDGMENTS
29:151,1976.
174. Morrison DA, Boyden TW, Pamenter RW, et We are grateful to Adele Jones for her as-
al: Effects of aerobic training on exercise tol- sistance with the preparation of this manu-
erance and echocardiographic dimensions script.
in untrained postmenopausal women. Am
Heart J 112:561,1986.
APPENDIX 2-1
Research Examining Physiologic Effects of Exercise in Adult Women:

Subject and Program Characteristics
Subjects Program
Session
Time Freq/ Weeks'
Authors N Age Notes (min) Week Intensity Duration Control Group
Adams and DeVries159 23 52-79 17 ex 40 3 60% MHR 13 Last six to volunteer

Badenhop et al.160 32 >60 6 control 50 3 60%-75% MHR 9 Those unable to commit time
26 F, 8 M 30%-45% MHR
14 mod ex
14 low ex
4 control
Bassey et al.161 108 55-60 53 F 20-40 5 ? 12 Randomly assigned to
55 M successive programs
Blumenthal et al.162 24 65-85 18 F 30 3 70%-85% MHR 11 None
6M
Blumenthal et al.163 101 60-83 51 F, 50 M 60 3 70% MHR 16 Random
33 aerobic
34 yoga control
34 wait list control
Cavanaugh and Cann164 17 m = 56 8 ex 25-50 3 60% MHR 52 Those unable to commit time
9 control
Cowan and Gregory165 38 35-66 20 pre-menopause 50 4 80% MHR 9 Randomly assigned to ex or
18 post-menopause control
Franklin et al.166 36 29-47 23 obese 45 4 75% Vo2max 12 None
13 normal
Foster et al.119 16 67-89 9 mod ex 17-42 5 60% MHR 10 None
9 low ex 40% MHR
Getchell and Moore167 23 28-57 11 F 30 3-4 75%-85% MHR 10 None
12 M
APPENDIX 2-1
Research Examining Physiologic Effects of Exercise in AdultWomen:

Subject and Program Characteristics (Continued)
Subjects Program
Session
Time Freq/ Weeks'
Authors N Age Notes (min) Week Intensity Duration Control Group
Haber et al.168 12 67-76 8F 20-40 3 60% MHR 12 None

4M
169
Jarvie and Thompson 16 26-52 12 F 25 7 pulse? 17 Wait list
4M
170
Jette et al. 26 35-53 12 F 30 3 60% Vo2max 12 Random 50% in no-ex gp
14 M
171
Juneau et al. 120 40-60 60 F 50 5 65%-77% MHR 24 Random 50% in no-ex gp
60 M
172
Kukkonen et al. 169 35-50 97 F 30-60 3-6 60%-70% MHR 68 None
72 M
173
Lewis et al. 22 30-52 25 and 60 2 and 2 80% MHR and low 17 None
Morrison et al.174 32 m = 51 22 ex 40 3 65%-75% MHR 32 Random
10 control
Netz et al.175 24 50-64 13 F 60 3 70% MHR 12 None
11 M
176
Seals et al. 24 60-69 14 ex 30 and 60 3 40% MHR and 48* Assignment method not
10 control 85% MHR specified
177
White et al. 72 50-63 36 walk 33 4 70% MHR 24 None
36 dance
*Subjects spent 24 weeks in low-intensity activity and then 24 weeks in higher-intensity.
MHR = age-adjusted maximal heart rate; Vo2max = maximal oxygen capacity.
Source: Adapted from Lee,87 p 134, with permission.
APPENDIX 2-2
Outcomes of Studies Listed in Appendix 2-1

% Physical Outcomes
Drop
Authors Program Type Out Improved No Change Follow-up
159
Adams and DeVries Supervised 0 PWC RSBP None
Vo2max RDBP
O2 pulse Skinfolds
RHR
Weight
Badenhop et al.160 Supervised 0 PWC, EHR None
Vo2max
Bassey et al.161 Home-based 53 EHR 12-week follow-up of 29
phys. activity Ss—some
maintenance
Blumenthal et al.162 Supervised 8 PWC RSBP, RDBP None
Endurance RHR, EHR
Weight
Blumenthaletal. 163 Supervised 4 Vo2max Bone density Blumenthal et al.179
RHR Grip strength
Endurance
Anaerobic threshold
Total cholesterol, LDL
Cavanaugh and Cann164 Supervised 0 RHR Bone density None
Phys. activity %fat
Cowan and Gregory165 Supervised? (not 0 %fat Weight None
specifically stated) V"o2max Lean mass
Endurance
Foster et al.119 Supervised 24 Vo2max Weight None
PWC Blood lactate
EHR
Total cholesterol
HDL
APPENDIX 2-2
Outcomes of Studies Listed in Appendix 2-1 (Continued)

% Physical Outcomes
Drop
Authors Program Type Out Improved No Change Follow-up
Rate-pressure prod
Franklin etal.166 Supervised 0 EHR Lean mass See MacKeen et al.178
Weight
Skinfolds
%fat
ESBP
RSBP, RDBP, EDBP
(obese only)
Getchell and Moore167 Supervised? (not EHR Weight None
specifically stated) Skinfolds
Vo2max
Lactic acid
Haber et al.168 Supervised 0 PWC EHR None
Max work load
Vo2max
Jarvie and Thompson169 Home-based 75 Vo2max None
Skinfolds
Weight
Jette et al. (1970) Supervised 0 Vo2max Blood lactate None
171
EHR
Juneau et al. Home-based 6 Vo2max RHR None
Weight (M only) EHR
%fat
Lean mass
Kukkonen et al.172 Home-based 44 Weight Total cholesterol Program continued for
BMI 17 months; tested at
Vo2max 2, 5, 11, and 17
RSBP, RDBP (M only)
Serum triglyceride (F
only)
Lewis et al.173 Supervised 9 %fat Serum triglyceride None
Weight Total cholesterol
RHR, EHR
ESBP
HDL:LDL ratio
Endurance
MacKeen et al.178 18-month follow-up of 64 Physical activity Yes
Franklin et al.166 Vo2max
%fat
Morrison et al.174 Supervised 22 Vo2max None
Endurance
Cardiac efficiency
Netz et al.175 Supervised ?high EHR
Weight
Seals et al.176 Home-based then 22 Vo2max EHR None
supervised Weight Cardiac output
RHR Blood lactate
ESBP
Blood lactate
Cardiac efficiency
White et al.177 One class/wk supervised 29 RHR
plus home-based Weight
RSBP (down)
RDBP (up)
Muscle strength
Endurance
Endurance = time spent in standard exercise task; EDBP = exercising diastolic blood pressure; HDL = high-density lipoprotein level; RDBP = resting diastolic
blood pressure; RHR = resting heart rate; Vo2max = maximal oxygen capacity; EHR = exercising heart rate; ESBP = exercising systolic blood pressure; LDL
= low-density lipoprotein level; RSBP = resting systolic blood pressure; PWC = physical work capacity.
Source: Adapted from Lee,87 pp 136-137, with permission.
CHAPTER 3 3
Training for Strength

DAVID H. CLARKE, Ph.D.
DEFINITION OF STRENGTH ISOKINETIC EXERCISE

ISOTONIC TRAINING HYPERTROPHY OF SKELETAL
ISOMETRIC TRAINING MUSCLE
ISOTONIC VERSUS ISOMETRIC AGING AND STRENGTH
TRAINING DEVELOPMENT
ECCENTRIC TRAINING
w ith proper training, women can become very strong. However, even with
the same strength-training program, their muscles will not enlarge as much as
those of men. The data-based studies regarding the adaptations resulting from
strength training have come predominantly from research conducted on male
subjects, but, aside from questions raised concerning muscle hypertrophy, it
seems tenable to conclude that principles that apply to men also apply to women.
DEFINITION OF STRENGTH
The first concept that needs to be defined is that of strength. A dictionary

definition is unacceptable, as the terms "tough," "powerful," and "muscular" do
very little to describe what is actually a functional concept. Attempts at obtaining
a true measure of muscle force show that maximum tension varies from 1.5 to 2.5
kg • cm– 2 in vertebrate nonhuman muscles and perhaps slightly higher in the nor-
mal human.1 Thus, if one assumes a value of 3 kg • cm –2 and that large muscles of
the thigh may have 100 cm2 of cross section, the resulting internal force that
could be developed would be 300 kg. Obviously, the amount of useful torque that
can be marshaled during normal activities must be expressed somewhat differ-
ently, since it is not feasible to determine true internal tensions. Thus, it is cus-
tomary to employ the concept of the maximal voluntary contraction (MVC),
which implies that the effort is not submaximal or created by some external stim-
ulus, such as a tetanic shock. Yet one does not know whether the contraction
resulted in any movement, whether it caused any muscle shortening or length-
ening, and, if movement did occur, whether it was at a fixed speed or whether
6O
Training for Strength 61
the tension on the muscle was constant or 10 RM. When an appropriate number of ad-
variable. ditional repetitions of the 10 RM could be
Mastering the terminology helps one not performed, more weight was added and the
only to understand the literature on process continued at this new 10-RM weight.
strength training but also to comprehend It is generally thought that keeping the total
the difficulty faced by investigators in quan- number of repetitions for the three sets
tifying the results of various training regi- somewhere in the range of 30 to 35 enhances
mens. There are few absolute standards the development of muscular strength.
available for the assessment of strength, so Using a program with reduced resistance
a wide variety of procedures has been em- and increased repetitions is thought to em-
ployed. Thus, there has been great difficulty phasize muscular endurance. Houtz, Par-
in making clear comparisons among various rish, and Hellebrandt3 applied the PRE prin-
studies. In the present context, isotonic ciple to female subjects, exercising the
strength (or dynamic strength) of a muscle is quadriceps and forearm muscles, and found
defined as the maximum force that can be that strength more than doubled in 4 weeks.
exerted by that muscle during contraction Thus, it seems probable that the principles
as it moves through its full range of motion. of strength development can be successfully
This can be further delineated into concen- applied to women as well as men.
tric (i.e., shortening) and eccentric (i.e., Interest in refining the procedures for PRE
lengthening) forms. Isometric strength (or for effective strength gains has been the sub-
static strength) is a single MVC performed ject of fairly intense investigation in the
by a muscle group in a static position, in subsequent years. Berger4 has provided
which no shortening or lengthening of the considerable insight into the strength
muscle occurs; isokinetic strength resembles development process, using various combi-
the isotonic contraction, since the joint nations of repetitions, sets (number of re-
moves through a range of motion, but the peated sequences the exercise is performed
speed of movement is held constant. This during a given session), and number of
latter system requires specialized equip- training sessions per week. The criterion
ment to control for a variety of movement measure of muscular strength was the 1 RM,
speeds. defined as the maximum amount of weight
that could be successfully moved through a
complete range of motion for one repetition.
ISOTONIC TRAINING In one study,4 Berger trained six groups for
12 weeks employing the bench press exer-
The usual method of training has been to cise. The groups used resistances of 2, 4, 6,
follow a routine of isotonic exercises. A sys- 8, 10, and 12 RM as their training modalities
tem described by DeLorme and Watkins2 and performed only one set of repetitions
during the period immediately following per training session. At the end of this time
World War II became known as progressive it was found that those training at four, six,
resistance exercise (PRE) and was based on and eight repetitions gained significantly
a set of 10 repetitions maximum (10 RM), greater amounts of strength than any of the
which is the heaviest weight that can be other groups, suggesting that an optimum
lifted and lowered 10 times in succession. target for training would be to perform be-
The manner in which these exercises were tween three and nine repetitions. Using one,
to be employed was first to perform a set of two, and three sets of repetitions and em-
10 repetitions of one half of the weight of the ploying 2, 6, and 10 RM as the weights and
10 RM, then to perform a second set of 10 numbers of repetitions in each set, he found
repetitions at three fourths of the weight of that no advantage was gained by exercising
the 10 RM, and finally to perform as many with heavier loads for 2 RM than with lighter
repetitions as possible at the weight of the loads at 10 RM.5 All combinations resulted in
significant strength increases, but strength each other. Thus, it appears that strength
gains were maximal when the number of gains are greatest when resistance is high.
repetitions per set was 6 RM for three sets. Since few repetitions can be done using high
To determine whether increasing the num- resistance, a smaller time expenditure is re-
ber of sets beyond three would lead to quired for this training.
greater gains in strength, Berger6 compared The question of whether an effective train-
the strength achieved by performing 2 RM ing response can be elicited for women may
for six sets, 6 RM for three sets, and 10 RM be answered in the affirmative, at least if the
for three sets. He found that all three groups intensity of the training program is high
gained significantly and similarly in enough, and if the program lasts long
strength. This suggests that there is a point enough. Staron et al.9 submitted adult
beyond which gains in muscular strength women to such a program of high-intensity,
should not be anticipated. heavy-resistance exercises of the lower ex-
Berger and Hardage7 studied an alternate, tremity for 20 weeks. A significant increase
somewhat unique modification of the 10-RM in the 1 RM was found for each exercise,
training technique. One group performed 10 even though the subjects trained only twice
repetitions for one set, but each repetition a week.
was adjusted so that it required maximum ef- A consideration for most individuals en-
fort, that is, a 1 RM. Subsequent repetitions gaging in weight training exercise has to do
were performed by gradually reducing the with how long the results of training will per-
load, so that at the 10th repetition the sub- sist if the training frequency is reduced.
jects were still exerting maximum tension. Graves et al.10 recruited both male and fe-
When compared with the regular 10-RM male subjects who trained for either 10 or 18
group, it was found that both groups im- weeks on knee extension, using a 7- to 10-
proved significantly in the 1-RM bench RM regimen. Following this 10-week period,
press after 8 weeks of training. However, the the subjects reduced their training fequency
1-RM group improved significantly more from a minimum of three times per week to
than the regular 10-RM group, indicating the less. Subjects who stopped training alto-
relative importance of intensity of effort in gether lost 68% of the previously gained
training. It should be noted that almost all strength, but those who reduced to 2 and
studies have shown the importance of at- even 1 day per week did not change signifi-
taining maximal tension of the muscles dur- cantly in strength. Thus, a maintenance rou-
ing the course of the exercise. tine would seem to be possible when train-
To compare the strength achieved by per- ing only once per week.
forming many repetitions using light weight It has generally been found that men have
with that gained by performing few repeti- greater absolute amounts of strength than
tions using heavy weight, Anderson and women under most conditions.11–14 Even un-
Kearney8 trained 43 male subjects using trained men who have not been specifically
three sets of 6 to 8 RM for one group, 30 to weight training15 exhibit greater upper and
40 RM for a second group, and 100 to 150 RM lower body strength than female athletes
for a third group, all subjects employing the trained in such sports as basketball and vol-
bench press three times per week for 9 leyball but not weight training. The ratios
weeks. Strength was assessed with the 1-RM comparing the strength of women to that of
bench press, administered before and after men are on the order of 0.46 to 0.73 when
the training. Gains in strength were compared on maximal strength of elbow
achieved by all three groups, but only the flexion, shoulder flexion, back extension,
high-resistance, low-repetition (6- to 8-RM) and hand grip.16 Even though this is the case,
group was significantly stronger than the the established principles of strength train-
other two groups, which did not differ from ing are applicable to both men and women.
ISOMETRIC TRAINING These principles were applied to postpu-

bescent young men who were trained in
The systematic use of isometric training wrist flexion employing the Hettinger and
principles can probably be traced to the Muller strategy17 of two-thirds maximum
1953 report of Hettinger and Muller,17 who tension for one 6-second period each day.
found an average strength increase of 5% This was compared with a technique in
per week when the muscle tension was held which 80% of maximum strength was em-
for 6 seconds at two thirds of maximum ployed in five 6-second periods.23 Both
strength. Even when the tension was in- groups of subjects improved significantly
creased to 100%, or when the length of time after 4 weeks of training, although no signif-
was increased, very little additional im- icant difference resulted between the two
provement was noted. Isometric exercises groups. This suggests that a single 6-second
are normally performed by establishing a bout of isometric exercise on a daily basis is
given joint angle and exerting isometric ten- about as effective for developing muscular
sion at that point in the range of motion strength as bouts practiced more frequently
(e.g., pushing against a stationary wall). As and at higher tensions. Furthermore, high
with isotonic exercises, more than one set school boys and girls training for one con-
may be performed and the length of time for traction per day at 25%, 50%, 75%, and 100%
which the tension is exerted may vary. How- of maximum isometric elbow flexion
ever, the amount of the strength gain sug- strength were compared after training.24
gested by Muller18 has not been confirmed in With the exception of the 25% resistance
subsequent experimentation. It seems more group, all groups became stronger. Thus,
likely that the amount of strength gain would the age of subjects seems to be of little con-
depend on the relative state of training of a sequence for achieving strength-training re-
given muscle group. Thus, the closer one is sults.
to a theoretic maximum, the more likely the Increasing the number of isometric con-
gains are to be small.19 tractions appears to increase the strength
Isometric exercise does increase muscu- gain over a greater range of motion.25 One
lar strength. Josenhans20 employed isomet- group of subjects held three maximum iso-
ric exercises for the grip and the flexor and metric contractions at an elbow joint angle
extensor muscles of the finger, the elbow, of 170 degrees' flexion, each for 6 seconds,
and the knee and found a 40% increase in in a program that was of 6 weeks' duration.
muscular force at the end of the training pe- Another group performed twenty 6-second
riod. When 5-second maximal isometric maximum contractions at the same joint
contractions of the quadriceps muscles angle. Maximum strength was assessed be-
were employed, it was found that strength fore and after the experiment at angles of
increases vary between 80% and 400%.21 both 90 and 170 degrees. All tests used iso-
Morehouse22 separated some trained sub- metric maximum contractions. The subjects
jects into high- and low-strength groups and who performed more contractions gained
employed either 1, 3, 5, or 10 maximum iso- strength significantly at both joint angles,
metric contractions each session. Subjects while those who performed fewer contrac-
increased significantly in strength after 5 tions became stronger only at the angle of
weeks, with similar improvements found re- 170 degrees, the training angle. Thus, the
gardless of level of initial strength. Appar- longer duration of work seems to be more
ently, most individuals can anticipate in- beneficial for strength development, but the
creases in strength regardless of how strong difference is small compared with the
they are at the outset, unless they are al- amount of effort required. The evidence for
ready in an advanced state of muscular joint-angle-specific effects of isometric
training. training is fairly strong, especially when the
muscles are placed at a relatively short ing of six maximal voluntary contractions at
length. This can be accomplished by manip- a predetermined "sticking point" in the
ulating the joint angle. This specificity of bench press. Analysis of the 1-RM bench
training response is difficult to justify if the press before and after the training program
training adaptation results in changes in revealed significant improvements for both
muscle size. An alternate explanation would groups. However, the experimental group
involve some sort of neural adaptation. was significantly stronger than the control
Thus, Kitai and Sale26 trained the ankle plan- group, providing evidence that isometric
tar flexor muscles of women at a joint angle training enhances the standard isotonic
of 90 degrees employing two sets of five training routine in the achievement of max-
maximal voluntary isometric contractions imum strength.
each held for 5 seconds. The training pro-
gram was 6 weeks in duration and result-
ed in significant increases in voluntary ISOTONIC VERSUS ISOMETRIC
strength at the training angle and the two TRAINING
adjacent angles at 5 and 10 degrees in either
direction only. Examination of peak It has been difficult to compare the im-
strength of maximum twitch of the involved provements in strength resulting from iso-
muscles would point to a neural mechanism tonic and isometric training methods, be-
as being responsible for this joint specificity cause the intensities of training in the two
in isometric training. This point has been re- methods cannot be equated. The ideal
inforced by the finding of an increase in method of comparison would employ two
maximal integrated electrical activity at the exercise regimens, both of equal workloads.
specific training angle.27 However, this has been difficult to accom-
Whereas most investigations have em- plish because isometric exercises involve
ployed either male subjects or a combina- no movement and, thus, are difficult to quan-
tion of male and female subjects, Hansen28'29 tify in physical terms.
used female subjects, employing sustained Despite the problems inherent in compar-
and repeated isometric contractions. The ing isotonic and isometric training effects,
gains in isometric strength in this study Rasch and Morehouse,31 in one of the earlier
ranged from approximately 4% to 11% over studies, compared these two methods by
a 5-week training program. having one group (isotonic) perform a 5-RM
A more recent development has been the procedure involving three sets of arm
incorporation of functional isometrics into presses and curls, taking a total of 15 sec-
an isotonic strength training program. In a onds to perform, and having the other group
given range of motion, it is common to locate (isometric) employ a 15-second exercise pe-
a given point at which the muscle is most in- riod contracting the muscles isometrically
efficient. Weight lifters refer to this as the at two-thirds maximum. Following 6 weeks
"sticking point" of exercise. It represents of training, substantial increases were found
the point at which the force available is for the isotonic exercise group in elbow flex-
equal to the resistance of the weight. To de- ion and arm elevation and for the isometric
termine whether the incorporation of maxi- exercise group in arm elevation alone. No
mum isometric contractions at this point significant gain was made in elbow flexion
would permit the development of strength for the isometric training group. Thus, sub-
beyond that provided by the isotonic exer- jects employing isotonic exercise gained a
cise alone, subjects30 in a control group greater amount of strength than did those
trained on the bench press exercise using an subjects employing isometric exercises. It
isotonic training procedure employing 6 to 8 was suggested by the investigators that
RM, while the experimental group added to some of the strength development may have
this routine an isometric program consist- come from the acquisition of skill, since sub-
jects tended to do better when performing ually increased force to maximum over ap-
familiar procedures. This may help explain proximately 4 seconds. The isotonic group
sudden early increases in strength; they lifted a load equivalent to 75% of maximum
may be attributable more to neuromuscular as far as possible, also over a duration of 4
coordination than to true muscle hypertro- seconds. The exercise involved supination
phy. of the left hand and included 12 male and 8
Isometric and isotonic training proce- female subjects. All training procedures re-
dures were applied to subjects engaging in sulted in a significant improvement in
exercise over a 12-week training period, ex- strength. However, no significant differ-
ercising three times per week and employ- ences were found between the different pro-
ing the larger muscles of the back.32 The iso- cedures. Chui36 noted similar findings. Two
metric group trained with a back pull groups trained with rapid and slow isotonic
machine, contracting the muscles for 6 sec- contractions and were compared with a
onds maximally, three sets per exercise ses- group employing isometric contractions.
sion, and the isotonic group employed back The slow isotonic contractions required a
hyperextension exercises based on an 8- to cadence of 4 seconds for movement and re-
12-RM regimen. Both groups improved sig- covery, and the isometric contractions were
nificantly in muscular strength, but the iso- held for 6 seconds. All groups employed a
metric group gained significantly more weight equal to a 10-RM resistance. No ad-
when an isometric test was employed, and vantage was found for either procedure over
the isotonic group performed better when a the other, although each group gained sig-
test of isotonic strength, such as the 1-RM nificantly in muscular strength. When iso-
procedure, was used. This finding suggests metric contractions were lengthened to 30
that training is specific, a concept that has seconds,37 the development of strength was
received additional support from some found to be less than by isotonic methods by
studies. some 14%, even though both isotonic and
This is in contrast, however, to the work of isometric methods caused increases in mus-
many other investigators who have reported cular strength.
similar gains in strength from these two dif- Thus, it would seem desirable to employ
ferent training methods. For example, isotonic procedures whenever possible.
Berger33 trained subjects for 12 weeks both Gains in strength with isometric exercise
isometrically and isotonically and used the tend to be less consistent than those with
criterion of the 1-RM test. The final strength isotonic exercise, when many training tech-
of the isometrically trained group was not niques and strength tests are employed.
significantly different from seven of the nine
groups that trained isotonically. Coleman34
employed the elbow flexor muscle in a pro- ECCENTRIC TRAINING
gram of 12 weeks' duration, using an isomet-
ric regimen consisting of two 10-second con- As pointed out earlier, isotonic movement
tractions and an isotonic training program can be divided into a concentric (shorten-
consisting of a 5-RM regimen. In this in- ing) and an eccentric (lengthening) phase.
stance, there was an attempt to equate the It is generally concluded that in isotonic
load, duration, and range of motion of the training the greatest force is exerted con-
exercise. No significant difference was found centrically, and this usually means that the
between the two methods, although both muscle is shortening and the load is being
produced significant strength gains. lifted against gravity. Thus, loads are ad-
Salter35 investigated the effect on muscu- justed so that the greatest tension is pro-
lar strength of maximum isometric and iso- vided during this phase. The eccentric
tonic contractions, performed at different phase is ordinarily employed to complete
repetition rates. The isometric group grad- the movement so that the muscle returns to
its original length. The weight is simply low- 31%. This suggests that during maximum
ered slowly with gravity assistance. It is gen- contractions in eccentric movement, the an-
erally accepted that the amount of weight tagonistic muscles are also contracted. By
that can be lowered maximally is about 20% palpation and by examination of the electro-
greater than that which can be lifted against myographic activity emanating from the an-
gravity. Logically, one would expect the tagonistic muscle, the investigators verified
added force that can be resisted with an ec- that this occurs. This finding illustrates the
centric contraction to be a greater stimulus fact that it is very difficult to isolate muscle
to strength gain. However, scientific studies activity in the human body.
have failed to show any advantage of eccen- More recently, Johnson and co-workers40
tric over concentric training. trained subjects with eccentric movements
Bonde Petersen38 studied isometric, iso- on one arm and leg and concentric move-
tonic, and eccentric contractions in female ments on the opposite arm and leg, three
and male subjects for a period lasting from times weekly for a period of 6 weeks. The
20 to 36 days. Training for each subject con- specific exercises included the arm curl, arm
sisted of one of the following protocols: 1 press, knee flexion, and knee extension.
maximum isometric contraction daily, 10 Each exercise lasted for 3 seconds. The con-
maximum isometric contractions daily, or centric movement was performed against a
10 eccentric contractions daily. It was found resistance of 80% of the subject's 1-RM
that performance of one maximum isometric strength, and the eccentric movement was
contraction daily had no effect on the iso- against 120% of 1 RM. Both exercise pro-
metric strength of the subjects; performance grams resulted in significant gains in
of 10 isometric contractions daily caused no strength in all subjects, but neither training
change in the strength of the female subjects procedure produced gains that were signifi-
but led to a significant increase (13%) for the cantly different from the other. Interest-
male subjects. Subjects who trained with the ingly, the subjects felt that the eccentric
10 daily eccentric contractions failed to training movements were easier to perform
demonstrate any significant increase in than the concentric movements.
strength. This lack of significant strength Jones and Rutherford 41 included a group
gain may have been due to training every of subjects who trained by eccentric and iso-
day rather than every other day. It is possi- metric procedures as well. In each case sub-
ble that insufficient time was allowed be- jects trained knee extensor muscles three
tween training sessions to recover com- times per week for 12 weeks. The isometric
pletely from the previous training session. group held a contraction of 80% of maximum
Singh and Karpovich39 designed a study to for 4 seconds, the concentric group trained
determine the effect of eccentric training on at an intensity of 6 RM, and the eccentric
a muscle group as well as on its antagonist subjects employed a resistance of 145% of
(the opposing muscle complex). In this in- the concentric strength. A large and signifi-
stance, the forearm extensors were given 20 cant increase in isometric force occurred,
maximum eccentric contractions four times and these gains were significantly greater
per week for 8 weeks, and the extensors as than found for both concentric and eccen-
well as the forearm flexors were tested for tric training. Even though there was no sig-
maximum strength before and after training. nificant difference between concentric and
Concentric and isometric strength of the ex- eccentric training regimens, both programs
ercised muscles increased approximately resulted in significant increases in strength,
40%, but the eccentric strength increased approximately 15% for the concentric train-
only 23%. When the antagonistic muscles ing and 11% for eccentric.
were examined, it was found that they also The perception that eccentric exercise is
increased in strength, ranging from 17% to easier to perform would seem to lead sub-
jects to greater compliance and acceptabil- studied groups that exercised isometrically,
ity of such training. However, present equip- isotonically, and isokinetically for a 4-week
ment and common training habits do not period. Significant increases in isometric
permit isolation of eccentric contractions. strength occurred for all groups, with one
Moreover, since a muscle can resist greater exception: when the isotonic group was
force in an eccentric contraction than in a tested at 90 degrees rather than 45 degrees,
concentric contraction, considerably no significant improvement was noted.
greater tension is required in the eccentric None of the groups improved significantly in
movement in order to promote strength the quadriceps muscles when tested for iso-
gains. Thus, in a regular isotonic exercise kinetic work, but all were significantly better
encompassing both concentric and eccen- when the hamstring muscles were tested.
tric contractions, the eccentric phase con- Lesmes and colleagues44 trained male sub-
tributes relatively little to strength devel- jects isokinetically on knee extensors and
opment, since the amount of force is flexors four times per week for 7 weeks, at
undoubtedly well below the training stimu- maximal intensity and at a constant velocity
lus during that phase of the exercise. of 180 degrees/sec. One leg was trained at 6-
second work bouts and the other leg at 30-
ISOKINETIC EXERCISE second work bouts, the ratio of work to rest
providing a method of keeping workloads
The newest form of exercise used for equal. Isokinetic testing was accomplished
training is isokinetic exercise. It is often re- at various intervals between 60 and 300 de-
ferred to as "accommodating resistance ex- grees/sec. Increased peak torque occurred
ercise," because, as explained earlier, it has at both 6 and 30 seconds at all intensities ex-
the unique feature of adjusting to the ability cept those between approximately 180 and
of the muscles throughout the range of mo- 300 degrees/sec. It apparently makes some
tion, so that weak spots are eliminated and difference to train isokinetically, but it de-
the muscles remain under constant tension pends upon the velocity at which one trains
throughout the movement. Actually, few ac- and the speed at which testing occurs.45 In
tivities produce and maintain isokinetic ten- general, training at slow speed (60 degrees/
sion, the arm strokes in swimming and oar sec) does not cause significant peak torque
strokes in rowing being the major excep- increases, and training at fast speed (240 de-
tions. Properly designed equipment offers grees/sec) does not enhance peak torque at
exercise at any one of a range of fixed slow speeds. This is another example of the
speeds; the subject determines the resist- specificity of strength training.
ance by the applied force. Thus, it is possi- Thus, isokinetic exercises are effective in
ble to exercise maximally throughout a full increasing muscular strength but probably
range of motion using any one of several not more so than isotonic training. The abil-
speeds. In isokinetic exercise, increased ity of isokinetic movements to create maxi-
force does not produce increased accelera- mum tension throughout the range of mo-
tion but simply increased resistance. tion is clearly desirable, but methods of
One of the earlier studies42 compared iso- measuring strength may not illustrate this
kinetic training with isotonic and isometric advantage. Perhaps future studies using
training over an 8-week period. The isoki- more refined methods to measure gains in
netic group increased in total muscular abil- strength may show increased gains in
ity by 35%, the isotonic group increased strength with isokinetic training compared
28%, and the isometric group increased ap- with isotonic and isometric training. How-
proximately 9%. Employing quadriceps and ever, the specificity of training and the bias
hamstring muscle exercises on 12 male and inherent in that situation make it difficult to
48 female subjects, Moffroid and associates43 compare results.
HYPERTROPHY OF SKELETAL ence and muscle cross-sectional area. How-

MUSCLE ever, male subjects had higher absolute val-
ues in strength and hypertrophy than did
Based on the evidence presented so far, females. No significant differences occurred
heavy resistance exercise unquestionably in thigh muscle size. Thus, even though men
results in increases in muscular strength for have larger muscles than women, and
men. While some of the experimentation has women normally have low blood concentra-
included women, the extent of strength de- tions of testosterone, which might be ex-
velopment and muscle hypertrophy for pected to limit the development of muscle
women has not been studied as extensively. size, percentage changes in muscle hyper-
One of the most striking occurrences for trophy resulting from heavy-resistance
men engaged in weight training over an ex- training are similar in men and women. It is
tended period of time is the obvious evi- also true that anabolic steroid administra-
dence of hypertrophy, as shown by changes tion during training will promote muscle hy-
in muscle size accompanying increases in pertrophy in women. However, the adverse
strength. The extent of these changes de- metabolic effects of anabolic steroid use out-
pends on a number of factors surrounding weigh their potential desirability for en-
the strengthening regimen. However, for hancing muscle size.
men, high blood levels of androgens ac- One of the major issues examined over the
count for the increased muscle size. years has been to clarify the nature of hy-
One of the reasons for the reluctance of pertrophy itself. It is clear that size in-
women to engage in serious weight training creases with strength development, and ex-
in the past has been a fear that they would amining the structural changes that take
develop the same hypertrophy that men do place within the muscle has been of interest
and would look "masculine." Wilmore12 ex- to exercise physiologists and biologists. The
amined the strength and body composition term "hypertrophy" denotes an increase in
of 47 women and 26 men before and after a the size or bulk of the muscle fibers, rather
10-week intensive weight-training program. than an increase in the number of muscle fi-
Men were found to be stronger than women bers (called hyperplasia). The question of
in most measures of strength, but women whether the latter actually occurs as a result
were stronger in leg strength per unit of lean of systematic weight training has been the
body weight. Both groups made similar rel- subject of a number of investigations. Early
ative gains in strength, but the degree of studies concentrated on laboratory animals
muscular hypertrophy for women was con- as subjects. Goldspink47 trained mice by
siderably less than that noted for men. means of an exercise requiring the pulling of
However, when hypertrophy is assessed a weight to retrieve food. He reported a 30%
in a more direct manner, such as by com- increase in cross-sectional area of the aver-
puted axial tomography (CAT) scan rather age fiber. He also reported a threefold or
than by a more indirect procedure of deter- fourfold increase in the number of myofi-
mining lean body mass, sex differences in brils per fiber. In working with guinea pigs,
muscle hypertrophy apparently disappear Helander48 found an increase of some 15% in
or become minimal.46 Male and female sub- actomyosin as a result of training. The stud-
jects participated in a 16-week training pro- ies suggest that both hypertrophy and hy-
gram in which significant strength increases perplasia take place.
in elbow flexion, elbow extension, knee flex- One of the earliest studies to report the
ion, and knee extension occurred. Percent- formation of new muscle fibers (hyperpla-
age changes in strength were not signifi- sia) was published by van Linge,49 who sur-
cantly different between males and females, gically implanted the plantaris muscle of fe-
nor was any significant sex difference found male rats into the calcaneus. He cut the
in relative increases in upper arm circumfer- nerve of the other plantar flexors so that the
plantaris muscle would provide plantar flex- occur in skeletal muscle. Many of these en-
ion. The formation of new muscle fibers was zymatic changes are important for the at-
observed at the end of a prolonged heavy tainment of muscle endurance, and many
training period. Several studies have per- occur during weight training. The biochem-
formed muscle tenotomy (severing the mus- ical changes that take place for the weight-
cle tendon at its insertion) to observe the ef- lifting individual are those that are involved
fect of training on the muscle that must take primarily in anaerobic metabolism.
over the function of the cut muscle. A very
rapid hypertrophy takes place after this pro-
cedure, and fiber splitting and branching AGING AND STRENGTH
have been reported, as well as increases in DEVELOPMENT
strength and fiber diameter.
If a muscle is examined repeatedly for sev- It is agreed that aging results in a decrease
eral months after removal of its synergists, in muscular strength. The greatest decline,
hyperplasia is noted.50 Gonyea51 subjected however, usually does not take place until
20 cats to a conditioning program involving after the age of 50. On the other hand,
lifting of weights with the right forelimb strength increases markedly during the ad-
against increasing resistance to receive a olescent years and reaches its highest value
food reward. The program lasted for 34 in the early 20s.53 Klein and colleagues54
weeks, and the flexor carpi radialis muscle compared physically active subjects of ages
was examined to determine any increase in 25 and 66 and found the maximal voluntary
fiber number as a result of low-resistance isometric contraction to be 31% greater in
and high-resistance training. The control the young subjects. Similar results are found
group experienced no difference in the num- with isokinetic torque. A study of young and
ber of fibers in either the left or right limb, old tennis players55 found that at all speeds,
and no difference in the number of fibers ranging from 30 to 240 degrees/sec, the
was found in those that lifted a "light-resist- young subjects generated significantly more
ance" weight. There was a significant in- torque than the older subjects. When com-
crease in fiber number (20.5%) for those lift- pared with inactive subjects, those who
ing the heavy load. This was attributed to were active were significantly stronger, and
muscle fiber splitting. men were stronger than women at all
Male albino rats were trained by Ho and speeds. When the data were presented as a
co-workers52 in a progressive training pro- percentage of maximum rather than as ab-
gram against high resistance for 8 weeks. solute values, women exhibited a larger rel-
The number of fibers per unit of cross-sec- ative decline in torque at high speeds than
tional area increased significantly in the men. It should also be noted that when iso-
weight-lifting animals. The authors sug- kinetic torque is adjusted for fat-free muscle
gested that the fiber splitting appeared to be mass or muscle mass itself, age-related dif-
due to some sort of "pinching off" of a small ferences between men and women are no
segment from the parent fiber or to an invag- longer significant.56
ination of the sarcolemma deep into the Strength increases for older men as a re-
muscle fiber in a plane parallel to the sar- sult of resistance training have been clearly
comeres. identified within 12 weeks.57–59 The same
Under certain conditions, fiber splitting holds true for older women. Charette and
seems to occur, but hypertrophy still re- co-workers60 trained women aged 64 to 86
mains the major mechanism for the size in- years on lower extremity exercises for 12
crease that results from intense weight weeks, exercising three times a week, per-
training. In addition to the structural forming three sets of each exercise at 6-RM
changes evident from hypertrophy and hy- intensity. All seven of the exercises resulted
perplasia, a number of enzymatic changes in significantly greater increases in strength
than control subjects who did not train. The timal regimen of exercises seems to be six to
average gain was 11.5%. When combined nine repetitions maximum undertaken for
aerobic and anaerobic training was exam- three sets at least three times a week. Most
ined over 50 weeks, Cress and associates61 individuals will be working with a system
found that the exercise subjects, aged 72 that is at the very least an isotonic one. How-
years, responded to regular exercise train- ever, because some of the equipment cur-
ing of the leg muscles some 12% more than rently available is specifically designed to
nontraining control subjects. It is significant maximize the tension throughout the full
to note that the control subjects curtailed range of motion, many people now use what
their normal independent activities by some are called variable-resistance machines (for
34% over the winter months, ostensibly be- example, Universal, Keiser, Nautilus). It
cause of a fear of falling in inclement seems reasonably clear that both isotonic
weather. and isokinetic exercises can be used suc-
Further examination of the relative distri- cessfully for developing muscle strength.
bution and size of fiber types of muscles that Less effective are isometric exercises and
have undergone such training reveals im- eccentric contractions. Gains are greater for
portant clues regarding muscle hypertro- untrained than for trained individuals. Most
phy. If one considers that human muscle is athletes, male or female, find increases in
composed of a combination of essentially strength to come more slowly near the peak
two types of fibers, it helps to understand of training.
the response to a functional overload. One Many of the changes associated with mus-
type responds rapidly to stimulation, and cle hypertrophy are cellular and thus are not
one responds more slowly. The fast type are associated with noticeable enlargement.
called fast-twitch fibers (FT) and fatigue With training, men develop greater muscle
fairly quickly. On the other hand, the slow- hypertrophy than women, because they
twitch fibers (ST) are better adapted to en- have much higher levels of androgenic hor-
durance activities, and thus fatigue less mones, but women can become very strong
quickly. Age-related changes in men reveal through weight training and still not de-
the atrophy of FT fibers,53 but during velop markedly enlarged muscles. The av-
strength training the relative area of the FT erage woman should find a number of ad-
fibers has been shown to increase signifi- vantages in being physically strong as she
cantly.57 The same phenomenon occurs carries out normal activities and engages in
with women. Charette's 12-week training other fitness exercise. This may have special
program60 caused a 20.1% increase in FT significance with increasing age.
fiber area, and Cress's 50-week program61 re- The principles outlined, not the type of
vealed an increase of 46%. No evidence in- equipment available, should form the basis
dicates any change in the percentage of the for exercise selection. Selecting appropriate
fiber types as a result of training, so the con- exercises and establishing an acceptable
clusion can be reached that not only can el- routine are more important to strength de-
derly women safely engage in a resistance velopment than the use of certain commer-
training program, but they can expect cial fitness machines. Training with free
changes to occur as a result of muscle hy- weights can accomplish the same gains in
pertrophy. strength as training with machines. How-
ever, free weights are more likely to cause
injury, since the weights are unsupported
SUMMARY and require somewhat greater skill to use.
The individual should choose the appropri-
The unmistakable conclusion to be drawn ate exercises and engage in a systematic and
is that training for strength is a goal that can progressive program. Early gains are due to
be pursued by both men and women. An op- an increase in motor coordination. Those
gains that occur after several months of parisons in untrained men and women ath-
training are due to greater muscle strength. letes, age 10 to 69. Med Sci Sports 13:194,
Expecting great gains in strength after a few 1981.
16. Yates JW, et al: Static lifting strength and
weeks of training is unrealistic, since the ac- maximal isometric voluntary contractions of
quisition of strength is a slow and progres- back, arm and shoulder muscles. Ergonomics
sive process. Such unrealistic expectations 23:37, 1980.
about improvement are a common cause of 17. Hettinger TL, and Muller EA: Muskelleistung
attrition among novices. Qualified instruc- und muskeltrainung. Arbeitsphysiol 15:111,
1953.
tion may be beneficial to many seeking gains 18. Muller EA: Physiology of muscle training.
in muscular strength. Rev Can Biol 21:303, 1962.
19. Muller EA, and Rohmert W: Die geschwindig-
keit der muskelkraft zunahme bei isome-
trischen trainung. Int Z Angew Physiol
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CHAPTER 4
Endurance Training
THOMAS D. FAHEY, Ed.D.
FACTORS THAT DETERMINE SEX DIFFERENCES IN ENDURANCE

SUCCESS IN ENDURANCE PERFORMANCE
EVENTS
Maximal Oxygen Consumption
Mitochondrial Density TRAINING FOR ENDURANCE
Performance Efficiency Components of Overload
Body Composition Principles of Training
u ntil recently, systematic studies of female endurance athletes were limited.

This is understandable because, before passage of Title IX of the Civil Rights Act
in 1972, the number of women competing in endurance sports was small.1 This
legislation mandated equal opportunity for sports participation in the schools.
The American College of Sports Medicine is perhaps the premier organiza-
tion for the study of sports medicine in the world. In 1971 it published the Ency-
clopedia of Sport Sciences and Medicine.2 This monumental work consisted of over
1700 pages, but fewer than 10 pages were devoted to women and sports medicine.
Until 1958, the longest event in women's track and field in competitions hosted
by the Amateur Athletic Union of the United States was 440 yards. In 1965, top
female runners were threatened with banishment from international competi-
tion if they ran in a race longer than 1.5 miles. In 1984, the first Olympic marathon
for women was held in Los Angeles. Now, it is common for women to compete in
endurance events such as ultramarathons, triathlons, and long-distance swim-
ming and cycling.
FACTORS THAT DETERMINE SUCCESS IN

ENDURANCE EVENTS
Important factors in endurance performance include maximal oxygen con-

sumption (Vo2max), mitochondrial density, performance efficiency, and body
composition.3 Sex differences exist in endurance performance. However, the rel-
ative changes that occur with training and the basic underlying mechanisms that
determine performance are the same in men and women.
73
Maximal Oxygen Consumption Stroke volume is affected by hemody-

Maximal oxygen consumption (Vo2max) namic and myocardial factors. It is closely
is considered to be the best measure of car- linked to venous return of blood to the heart.
The ability of the heart to contract with in-
diovascular capacity. Many sports medicine
creased force as its chambers are stretched
experts think of it as the single most impor-
(a phenomenon known as preload) is de-
tant measure of physical fitness. It is defined
as the point at which O2 consumption fails to scribed by the Frank-Starling principle.4
Many factors affect preload. These include
rise despite an increased exercise intensity
total blood volume, body position, intratho-
or power output. The greater ability of racic pressure, atrial contribution to ven-
trained people to sustain a high exercise in-
tricular filling, pumping action of skeletal
tensity is largely due to a greater Vo2max.
muscle, venous tone, and intrapericardial
Vo2max is equal to the product of maxi- pressure.4 These hemodynamic factors can
mum cardiac output and maximum arterio- have acute and chronic effects on stroke vol-
venous oxygen difference (Eq. 5-1): ume, oxygen transport capacity, and per-
Vo2max = Qmax (a — v)O2max ception of fatigue. An example is during en-
where Vo2max is the maximal rate of O2 con- durance exercise where there is a decrease
sumption (in L.min –1 ), Qmax is the maxi- in blood volume due to dehydration or a de-
mum cardiac output (L.min –1 ), and (a — crease in venous tone. There is a compen-
v)O2max is the maximum arterial-venous O2 satory increase in heart rate and an increase
difference (mL O2.100 mL – 1 ). Thus, Vo2max in perceived exertion. Increased blood vol-
is a function of the maximum rate of oxygen ume resulting from endurance training also
transport and oxygen utilization. causes an increase in stroke volume.
During the transition from rest to maximal Stroke volume is also affected by myocar-
exercise, there is a linear increase in (a — dial contractility. The contractile force of
v)O2. Arterial oxygen partial pressure (Pao2) the myocardium changes in response to cir-
is well maintained in most athletes during culating catecholamines, the force-fre-
exercise. The increase is due to the decrease quency relationship of the muscle, sympa-
in venous oxygen partial pressure (Pvo2). thetic nerve impulses, intrinsic depression,
There is only a limited capacity to increase loss of myocardium, pharmacologic depres-
oxygen extraction through endurance train- sants, and inotropic agents. Positive inotro-
ing. The venous blood draining the active pic agents include digitalis, and negative
muscles of both trained and untrained peo- inotropic agents include hypoxemia, hyper-
ple during maximal exercise contains rela- capnia, and acidosis.4 Endurance training
tively little oxygen. increases myocardial contractility by in-
To be successful in competition, athletes creasing Ca++-myosin ATPase activity.5.6
in sports that require endurance must have The combination of increased preload and
a large cardiac output capacity. Maximum contractility is responsible for the increase
cardiac output is the product of maximum in stroke volume that occurs with endurance
heart rate (HR) and maximum stroke vol- training. Both of these factors are limited by
ume (SV) (Eq. 5-2): ventricular volume, which is affected by ge-
netic and environmental factors during
Qmax = (HRmax)(SVmax) growth and development. It can be changed
Maximum heart rate is largely determined to some extent through endurance train-
by heredity and age. It is not appreciably af- ing.7,8
fected by training. Because HRmax and (a — The relative importance of genetics and
v)O2max are stable, changes in Vo2max with environment for success in endurance ex-
training are mostly due to changes in stroke ercise is not known. Roost9 examined car-
volume. diac dimensions in trained and untrained
Endurance Training 75
school children. All of the trained children ular wall thickness increases, with no in-
were classified as talented, with potential for crease in left ventricular volume.24,25
eventual success in endurance events. He Changes in Vo2max and in endurance capac-
could find no children with congenitally en- ity are not the same. Endurance perfor-
larged hearts. Thus, considering left ventric- mance can be improved by much more than
ular diameter and wall size, the importance 20%. This is possible by improving mito-
of genetic predisposition for success may chondrial density, speed, running economy,
have been overstated. and body composition.
The oxygen consumption capacity of a
muscle varies according to fiber type.10 The Factors Limiting Vo2max
ability of the mitochondria to extract oxygen
from blood is approximately three to five The limiting factor of Vo2max has been a
times greater in slow-twitch red than in fast- source of debate for many years. Proposed
twitch white fibers. Training can double the limiting factors include cardiac output, pul-
mitochondrial mass.11 It is possible for elite monary ventilation, lung diffusion, and oxy-
endurance athletes to have 10 times the gen utilization.
muscle oxygen-extracting capacity in their A basic experimental design for determin-
trained muscles as sedentary people. Sev- ing if oxygen supply or utilization is the lim-
eral studies have demonstrated a high cor- iting factor involves artificially increasing
relation (r 0.80) between Vo2max and leg the supply of oxygen to the working muscle.
muscle mitochondrial activity.12,13 Cardiac If maximal oxygen consumption does not
output and muscle mitochondrial capacities change, it implies that the ability of the tis-
are important determinants of the upper sues to utilize oxygen is the limiting factor.
limits of Vo2max. On the other hand, if Vo2max increases with
There is a strong genetic component for an artificial increase in O2 to the muscles,
Vo2max.14–17 The well-known exercise phys- cardiac output probably is the limiting fac-
iologist Per-Olaf Åstrand has stated that to tor. Considerable evidence suggests that
become an Olympic-level endurance athlete cardiac output is the limiting factor for max-
requires choosing one's parents carefully! imal aerobic capacity. Vo2max is increased if
Genetic studies typically show less variance the rate of oxygen supply to the muscle is in-
in Vo2max and muscle fiber type between creased through induced erythrocythemia
monozygous twins than between dizygous (blood doping) or breathing 100% oxygen
twins. However, these studies also show during exercise.26–28
that training is critical for success, but the Another technique for investigating this
ability to improve performance in response question is to vary the amount of active tis-
to an endurance training program depends sue requiring increased oxygen during ex-
on genetic factors. ercise.29–31 Adding active arm work during
Intense endurance training results in a maximal treadmill exercise does not in-
maximum increase in Vo2max of approxi- crease Vo2max. This type of exercise in-
mately 20%.18–21 However, greater increases creases the amount of tissue that requires
are possible if the initial physical fitness of oxygen. Several studies have found that
the subject is low.22,23 Only certain types of Vo2peak in isolated quadriceps muscle was
exercise promote the cardiac alterations much higher than when the muscle was ex-
necessary for increased Vo2max. Maximal ercised as part of a whole body maximum ef-
stroke volume can be increased in response fort. 29–31
to a volume overload induced by participa- Many exercisers use expressions such as
tion in sports such as running, cycling, and "I was winded" or "my wind gave out on
swimming. In pressure-overload sports me." There is little evidence that pulmonary
such as weight lifting, however, left ventric- function limits aerobic capacity at sea level
in healthy people. The lungs have a very The critical mitochondrial Po2 is thought
large reserve that enables them to meet to be 1 mm Hg.37 Indirect estimates of mito-
most of the body's requirements for gas ex- chondrial Po2 during maximal exercise sug-
change and acid-base balance during heavy gest that it is above the critical level.33–35
exercise. Considerable direct and indirect
evidence exists for this:
Vo2max as Predictor of Endurance
• The alveolar and capillary surface areas of Performance
the system are approximately 140 and 125
m2, respectively. The alveolar-capillary If Vo2max were the only predictor of en-
diffusion distance is no more than a few durance performance, then endurance con-
microns thick. Thus, the lung has an ex- tests could be decided in the laboratory. Re-
tremely large diffusion capacity. search scientists could administer treadmill
• Low pulmonary resistance to blood flow tests. The person with the highest Vo2max
allows pulmonary blood volume to in- would be the winner. This might be easier
crease during heavy exercise by three and more precise than conducting athletic
times the value at rest. contests on the track, road, or swimming
• During exercise, the ventilation-perfusion pool. However, Vo2max is only one factor
ratio increases four to five times above that determines success in endurance
rest. events.
• The sigmoid shape of the oxyhemoglobin In a heterogeneous sample, women with a
dissociation curve allows the mainte- high Vo2max tend to run faster in the mara-
nance of resting values of hemoglobin ox- thon.38 This relationship does not exist
ygen saturation even when Pao2 drops when the sample is homogeneous (i.e., the
slightly. runners are of the same ability level).39 For
• Pao2 changes very little during heavy ex- example, Grete Waitz and Derek Clayton had
ercise. A constant Pao2 suggests that the Vo2max values of 73 and 69 mL.kg –1 • min –1 ,
lungs do not limit Vo2max, because Pao2 is respectively. These values were measured
an important indicator of lung function.3,32 shortly after they set world records for the
women's and men's marathons. Yet, Clay-
Dempsy and Fregosi32 presented evidence
ton's time was over 15 minutes faster than
that the lungs may be limiting in some elite
Waitz's. Other factors important for success
male endurance athletes. No such evidence
include speed, the ability to continue exer-
has been presented for elite female athletes.
cising at a high percentage of Vo2max, lactic
In their subjects, Pao2 dropped as low as 65
acid clearance capacity, maximal muscle
mm Hg. There was a significant widening in
blood flow, and performance economy.
the difference between alveolar oxygen par-
A high Vo2max is a prerequisite to per-
tial pressure (PAo2) and Pao2. They hypoth-
forming at elite levels in endurance events.
esized that there was a diffusion limitation
The minimum values for elite female endur-
as well as increased airway impedance at
ance athletes are approximately 65 mL-
high levels of ventilation in these athletes.
kg–1 • min – 1 for runners and cross-country
Others have argued that oxygen supply
skiers. Appropriate values for swimmers are
does not limit either Vo2max or endur-
55 to 60 mL.kg –1 . Cyclists require approxi-
ance.33–36 Rather, the limiting factors are
mately 60 mL.kg – 1 . The evidence for a min-
biochemical. Suggested limiting factors in-
imum aerobic capacity requirement is cir-
clude decreases in the rate and force of myo-
cumstantial:
fibrillar cross-bridge cycle activity. Contrib-
uting factors may be failure of calcium • All elite endurance athletes have high aer-
transport mechanisms or decreased myofi- obic capacities. Even though Vo2max is a
brillar ATPase activity. poor predictor of performance among ath-
letes at the same level of competition, the • Changes in running performance with
variance in maximal aerobic power be- training occur without equivalent changes
tween them is small. in Vo2max.
• Oxygen consumption increases as a func-
Noakes's data suggest that a good predic-
tion of velocity in all endurance events. tor of endurance performance is peak tread-
Although athletes vary somewhat in their
mill velocity. He hypothesized that maxi-
efficiencies, the variance between them is
mum speed may be related to the muscles'
small. capacity for high cross-bridge cycling and
Even though a high Vo2max is important for respiratory adaptations. Respiratory adap-
achieving superior levels of endurance, it is tations may make it possible to prevent the
not the only requirement for success. onset of exercise-induced dyspnea.
Noakes36 has questioned the validity of
Vo2max as a predictor of endurance perfor-
mance. His reservations are based on these Mltochondrial Density
observations: Mitochondrial density is a better predic-
• Much of the evidence of an oxygen limi- tor of endurance capacity than Vo2max. En-
tation during exercise is circumstantial. durance is the ability to sustain a particular
Noakes analyzed the data of the classic submaximal level of physical effort. Davies
studies that established Vo2max as a lab- and co-workers43 showed that cytochrome
oratory benchmark for cardiovascular oxidase activity (which is directly depen-
performance.40–42 He found that most sub- dent upon mitochondrial mass) had a cor-
jects did not show that Vo2 leveled off with relation coefficient of 0.92 with running en-
increasing intensity of exercise at maxi- durance but only 0.70 with Vo2max. With
mum. training, Vo2max increases by less than 20%
• Studies have used transfusion or O2 in most people, but the ability to sustain a
breathing in an attempt to show that O2 given submaximal exercise intensity may in-
transport is limiting. None of these stud- crease by much more. Endurance perfor-
ies have demonstrated that their subjects mance by athletes in sports such as cycling,
reached a plateau in Vo2 during normal ex- running, swimming, and cross-country ski-
ercise. There was no evidence of an O2 ing requires intense effort and maintenance
transport limitation before the experi- of that intensity for a long time. Increased
mental intervention. mitochondrial density may be the key factor
• In blood doping studies, there is a disso- in endurance. It may allow some athletes to
ciation between changes in Vo2max and run, cycle, or swim at high velocities for
performance. Performance changes last longer than others, even though their maxi-
only a few days, while changes in Vo2max mal oxygen uptakes are similar to those of
last longer. slower athletes.
• Exercise at extreme altitudes is not lim- Endurance training results in an in-
ited by high blood lactate levels or by increased mitochondrial density in both fast-
dications of central limitations in cardiac twitch and slow-twitch muscle fibers.44 This
or respiratory function. probably plays a major role in improving en-
• Exhaustion during maximal exercise oc- durance. There are several possible mecha-
curs at a lower oxygen consumption dur- nisms. Increased mitochondrial mass may
ing cycling than during running in the increase fat utilization during exercise and
same subjects. thus spare muscle glycogen. It also may im-
• Blood lactate levels at exhaustion during prove muscle lactic acid clearance capacity,
progressive treadmill exercise testing are allowing exercise at a higher intensity.44,45
lowest in elite athletes. A fundamental purpose of energy metab-
olism during exercise is to generate ATP to • During sustained exercise, lactate produc-
meet the demands of the exercise intensity. tion and removal occur simultaneously
A deficit in ATP causes the athlete to fatigue within active muscle.
quickly. The rate of ATP formation is critical. • Most lactic acid produced during exercise
Fat provides the most energy per gram. Car- is oxidized.
bohydrate is the most important fuel for • During endurance exercise, the turnover
high-intensity endurance exercise, how- and oxidation rates of lactate exceed
ever, because it provides the most ATP per those of glucose.
liter of oxygen. Thus, carbohydrate pro- • Lactate production during both rest and
vides ATP more quickly than does fat.46 exercise is not necessarily associated
At least two problems are associated with with muscle anaerobiosis.
the use of carbohydrates during endurance • Training mainly affects the rate of lactate
exercise: removal rather than its production.
• The supply of carbohydrates is limited. The effects of the increased mitochon-

• The rapid use of carbohydrates during drial mass with training are complex but el-
high-intensity exercise results in a rate of egant. Glycogen is the critical fuel for endur-
lactic acid production greater than its rate ance exercise. However, its use increases
of clearance. Accumulation of lactic acid the risk of its own depletion and lactic acid
may interfere with muscle contraction accumulation due to an excess of lactic acid
and energy metabolism.47,48 production over clearance. The increased
mitochondrial mass that results from train-
Increasing muscle mitochondrial mass may ing prevents lactic acid accumulation. It
help the body to cope with both of these does this by providing the muscles with an
problems. increased capacity for lactic acid oxidation.
The glycogen content of muscle is impor- It also prevents glycogen depletion by al-
tant in endurance capacity. When glycogen lowing an increased use of fats as fuel.
is depleted, fatigue results. During sustained Nevertheless, training is probably not as
exercise, muscle glycogen is the muscle's important as genetics for obtaining a high
principal source of carbohydrate.45 In addi- mitochondrial mass in the muscles required
tion, the rate of glycogen utilization infor endurance exercise.50 Studies of success-
creases as a function of exercise intensity. It ful male endurance athletes have shown that
is very important, then, for the athlete to they often have a high percentage of slow-
conserve glycogen to maintain the intensity twitch muscle fibers. A high mitochondrial
of exercise at the desired level. Endurance density is a characteristic of these fibers.
training, which results in an increased mi- Tesch and Karlsson51 suggest, however, that
tochondrial mass, increases the capacity of the greater percentage of slow-twitch fibers
the muscle to oxidize fat.49 This slows the in the active muscles of endurance athletes
rate of glycolysis and the catabolism of glu- may be an adaptive response. As discussed,
cose and glycogen. Thus, glycogen is spared Vo2max and mitochondrial density are
and fatigue delayed. highly related. Athletes whose muscles have
The increased mitochondrial mass ac- a high mitochondrial mass also have high
companying training may also increase the Vo2max values.
muscle's ability to remove lactate through
oxidation. For more than 50 years, lactic
acid has been thought of by many as a met- Performance Efficiency
abolic pariah. However, research using ra- Although exercise intensity is the most
dioactive tracer methodology has demon- important determinant of metabolic rate, in-
strated that lactate is an important substrate dividual differences in performance effi-
during exercise:45,50 ciency can be responsible for the difference
between winning and losing. When power ulating ventilation, changing body compo-
output can be measured accurately, effi- sition, improving training status, and im-
ciency can be calculated with the following proving running style.55
equation (Eq. 5-3):52 Other than metabolic considerations,
Change in power output
Efficiency =
Change in caloric equivalent of O2 consumption (100)
Efficiency is decreased by energy lost as technique is probably the most important
heat, by wasted movement, and by mechan- factor affecting performance efficiency. In
ical factors such as wind resistance, friction, swimming, athletes should develop good
and drag. The efficiency of walking and cycle hydrodynamics, using strokes that employ
ergometry is slightly less than 30%.52,53 It is efficient propulsive force and minimize
probable that the efficiency of running, cy- drag. This may contribute almost as much to
cling, swimming, and cross-country skiing at success as improving the physiologic as-
competitive exercise intensities is less than pects of endurance. Likewise, the frequent
that. use of "skating" in cross-country skiing has
High-intensity exercise is not performed revolutionized the sport. Efficient runners
at a steady rate. Vo2 does not account for all are thought to have a lower vertical compo-
of the ATP supplied during exercise; a por- nent in their technique. Efficient cyclists
tion is supplied through anaerobic glycoly- pedal smoothly at high revolutions per min-
sis. Consequently, efficiency cannot be acute without engaging muscle groups that do
curately calculated even when power output not contribute to pedaling speed.57,58 Wind
can be measured. resistance is also a factor in running and cy-
The relative change in efficiency can be cling. It is reduced by wearing clothing that
estimated by measuring changes in oxygen enhances aerodynamics.
consumption under different conditions. Vo2
measurements can measure the effects of Body Composition
wind resistance, mechanical aids (e.g., toe
clips in cycling and wax in cross-country ski- The importance of body composition for
ing), and technique. A fundamental problem endurance varies with the sport. In distance
is determining how much of the efficiency is running, gravity places a greater load on the
due to mechanical factors (i.e., technique athlete than in swimming or cycling. Run-
and equipment) and how much to physio- ners are usually leaner than other endur-
logic factors (i.e., mitochondrial density). ance athletes, and there is less variance in
For example, if one runner seems more effi- body fat among elite performers.59–62 Typi-
cient than another, it is difficult to identify cal fat percentages for female endurance
whether the greater efficiency is due to a athletes are shown in Table 4-1. Although
more efficient running style or to a superior the data are limited, all categories of female
lactic acid clearance capacity. endurance athletes are leaner than seden-
In women, running economy (the oxygen tary women of the same age. Swimmers have
cost of running at a specific speed) has not more body fat than runners, cyclists, and
been shown to be a good predictor of per- cross-country skiers. In long-distance swim-
formance.54 However, when the subject pop- mers, a slightly higher fat percentage de-
ulation is homogeneous, running economy creases drag in the water and provides in-
aids in the prediction of running perfor- sulation against the cold.
mance.55,56 At present, the effect of running Tanaka and Matsuura60 reported that an-
economy on performance is not well under- thropometric factors accounted for 20% to
stood. The most promising methods for 40% of the variance in male distance run-
improving running economy may be manip- ners. This is comparable to the importance
Table 4-1. BODY COMPOSITION OF ELITE fects may include endocrine and reproduc-
FEMALE ENDURANCE ATHLETES tive function and bone metabolism. These
Sport Percent Fat problems are discussed elsewhere in this
volume.
Distance running65 15.2 It is possible that the higher percentage of
Distance running 62 16.9 body fat found in female swimmers com-
Distance running38 15.3
Distance running54 15.4 pared with that of other endurance athletes
Cross-country skiing66 21.8 may be an advantage. When swimming at
Cross-country skiing67 16.1 comparable velocities, women demonstrate
Cycling20 15.4 a lower body drag than men, probably due to
Swimming68 18.1 more subcutaneous fat. This makes women
Swimming69 17.8
Swimming70 13.7 more efficient at the sport. The ideal fat per-
Swimming71 15.6 centage of the female swimmer is also af-
Swimming59 16.6 fected by fitness and stroke mechanics,
Swimming72 21.7 however. Rennie and co-workers64 have hy-
pothesized that women could swim faster
than men if they could develop comparable
of maximal oxygen consumption. However, physical capacities. The difference between
remember that correlation coefficients de- the sexes in the world record in the 1500-
scribe relationships. They do not mean that meter run is 10%, but there is only a 6% dif-
one factor causes another. These investiga- ference between them in the 400-meter
tors did not study female athletes. Most swim. The lower drag among women swim-
studies have found that female distance run- mers may account for the reduced sex dif-
ners average 16% fat. Levels as low as 6% ference. Top women swimmers today are
have been reported. Christensen and swimming faster than did 1972 Olympic
Ruhling38 have found that female marathon champion Mark Spitz.
runners continue to become leaner the
longer they participate in the sport. Novice
marathon runners were found to have 18% SEX DIFFERENCES IN
fat, experienced marathoners had 16.3%, ENDURANCE PERFORMANCE
and elite marathoners had 15.3%. The aver-
age body fat percentage of a young adult Women's performance times are 6% to
woman in the United States is 25%. 15% slower than men's in most endurance
In running, cycling, and cross-country ski- sports73,74 (Table 4-2). However, there is
ing, excess fat increases the energy cost of considerable variance in performance in
exercise. The ideal lower limit of body fat is specific events. As mentioned, in the 400-
not known. There is a 40% to 60% difference meter swim, the difference between the
between men and women in Vo2max ex- men's and women's world record is slightly
pressed in liters per minute, but these sex more than 6%. The difference in the 80-km
differences are reduced to less than 10% run is almost 44%. Men rode longer dis-
when Vo2max is expressed per kilogram lean tances in the 1988 Olympic cycling road race
body mass.63 Although it appears that low competition (82 km for women and 196.8 km
levels of body fat are desirable for peak en- for men). Yet the average velocity of the win-
durance performance in women, world dis- ning man was only 5% faster than that of the
tance running records have been set by winning woman. There are slightly larger dif-
women with greater than 15% fat. Extremely ferences between the sexes in upper-body
low levels of body fat in female endurance endurance events, such as canoeing.75 Men
athletes may affect other aspects of physi- have relatively more muscle in the upper
ology. Related are the training and dietary body, which allows them to generate more
habits necessary to achieve low body fat. Ef- power.
Table 4-2. COMPARISON BETWEEN MALE same training stimuli.79,80 At elite levels, the
AND FEMALE GOLD MEDAL ENDURANCE training programs of men and women may
PERFORMANCE TIMES IN THE 1992 be closer to each other in intensity than
OLYMPICS
those of lower-level athletes. With years of
Performance Time training, men and women get closer to their
absolute potential. As they approach abso-
Event Male Female
lute potential, it becomes possible to make
Track realistic comparisons of true sex differ-
800-m run 1:43.66 1:55.54 ences.
1500-m run 3:40.12 3:55.30 Absolute maximal oxygen consumption
10,000-mrun 27:46.70 31:06.02 (L.min – 1 ) is typically more than 40%
Marathon 2:13.23 2:32.41
greater in men than in women. This differ-
Swimming ence is reduced to approximately 20% when
200-m freestyle 1:46.70 1:57.90 Vo2max is expressed per kilogram body
400-m freestyle 3:45.00 4:07.18 weight.77 It decreases further to less than
200-m butterfly stroke 1:56.26 2:08.67 10% when expressed per kilogram of lean
200-m breaststroke 2:10.16 2:26.65
200-m backstroke 1:58.47 2:07.06
body weight. Although excess fat is a hand-
icap to women endurance athletes, it does
not appear to account for all sex differences
in performance. Cureton and Sparling78
Some events, such as the 80-km run, are added extra weight to men in an attempt ex-
not contested very often by women. This perimentally to equalize fat masses. They
makes it difficult to determine true sex dif- were able to completely abolish the differ-
ferences from performance comparisons. ences between men and women in relative
Sex differences in the physiologic responses Vo2max, but the following sex differences re-
to exercise are often unclear from the liter- mained: 30% in distance run in 12 minutes,
ature, since many studies have compared 31% in maximum treadmill run time, and
physically fit male subjects with sedentary 20% in running efficiency after the experi-
female subjects. mental intervention. They estimated that fat
Organ size and body mass are probably percentage accounts for 74% of the sex dif-
the most important factors determining the ferences in running performance. The
sex differences in endurance performance. higher Vo2max of men (mL•kg LBM –1 ) ac-
Greater size provides a greater power-out- counted for 20%.
put capacity. Men have more muscle mass, The average man has a larger heart size
both in relative and absolute terms, while and heart volume than the average woman
women have more fat. Greater lean body (in both absolute and relative terms). This
mass is an asset, while more fat weight is a results in a greater stroke volume during
hindrance. Although muscle fiber composi- maximal exercise and contributes to the sex
tion is similar between the sexes, both fast- differences in Vo2max. Even though women
twitch and slow-twitch muscle fibers are have a higher relative heart rate during ex-
usually larger in men.76 ercise, it is not enough to compensate for
Sex differences in endurance performance their lower stroke volume. The resultant
increase as sport levels decrease.75 Thus, smaller cardiac output of women contrib-
there are fewer sex differences between utes to their lower aerobic capacity. The
male and female elite athletes than between amount and concentration of hemoglobin
those of lesser standing. Strength and power also are higher in men, giving male blood
differences are major reasons for sexual di- greater oxygen-carrying capacity. Women
morphism in performance. Males and fe- average about 13.7 g Hb.100 mL –1 , whereas
males make the same relative gains in men average 15.8 g Hb.100 m L – 1 . The differ-
strength when they are subjected to the ence is attributed to the stimulating effect of.
androgens on hemoglobin production and extreme fatigue that occurs late in the race
to the effects of menstrual blood loss and dif- and is probably related to glycogen deple-
ferences in dietary intake3 (see Chapter 6). tion.
There are few sex differences among the Costill and co-workers89 did not support
factors that account for individual differ- this hypothesis. They used equally trained
ences in endurance performance. In com- male and female subjects who ran for 1 hour
paratively trained men and women, the enon a treadmill and found that the capacity to
ergy cost of running is similar.8 Bosco and use fat as fuel during exercise was similar in
colleagues82 have shown that the energy men and women. Muscle succinate dehy-
cost of running is related to the percentage drogenase and carnitine palmitoyl transfer-
of fast-twitch fibers. They have hypothe- ase activities were higher in the men, sug-
sized that many women runners have a gesting that the muscle mitochondrial
higher proportion of slow-twitch fibers than density in the male subjects may have been
most men. Women thus may have a predis- greater.
position for a higher running economy dur-
ing submaximal exercise.83 As discussed,
other investigators have found no difference TRAINING FOR ENDURANCE
between men and women in the distribution
of muscle fiber types. Training is an adaptive process. Unfortu-
There are differences in running economy nately, athletes often forget this simple fact.
in different subject populations. This may They attempt overzealous training pro-
partially explain some of the variability in grams with no real thought as to how their
running performance not explained by bodies will respond to them. Consequently,
Vo2max. Most studies show no sex differ- they often become overtrained. They fail to
ences in the percentage of Vo2max sustained improve at a desirable rate, or they become
during exercise.84,85 Although there is some injured.
disagreement among researchers, there do Selye90 formulated a theory of stress ad-
not seem to be any appreciable sex differ- aptation, which has implications for condi-
ences in performance efficiency in running tioning endurance athletes. Selye called his
or cycling.86 theory the general adaptation syndrome
To date, there are no definitive studies on (GAS). He described three processes in-
sex differences in lactate production and volved in the response to a stressor: (1)
clearance rates. No large sex differences in alarm reaction, (2) resistance development,
temperature regulation capacity have been and (3) exhaustion.
found when researchers have made a seri- In the alarm reaction, the body mobilizes
ous attempt to use subjects of equal fitness. its resources. During exercise, cardiac out-
Finally, there are no sex differences in the put increases, blood is directed to active
ability to improve Vo2max through training muscle, and metabolic rate increases. Body
or in the ability to improve endurance per- balance is upset.
formance through interval and continuous The resistance development stage can
exercise programs.87 also be called the adaptive stage. It occurs
Ullyot88 hypothesized that the higher when fitness is increased. It is the goal and
body fat of women could be an advantage purpose of the endurance training program.
during marathon and ultramarathon endur- The athlete must exercise at a threshold in-
ance events, because they may have a tensity to get an adaptive response. This
greater capacity for fat metabolism. Ullyot threshold is individual and is much higher
observed that, unlike male runners, many in elite athletes than in sedentary people.
women runners do not "hit the wall" during When a stress cannot be tolerated, the
the marathon. "Hitting the wall" is sudden, athlete enters the stage of exhaustion. This
stress can be either acute or chronic. Symp- will probably have to be decreased and rest,
toms of acute exhaustion include fractures, increased. The application of each factor de-
sprains, and strains. Chronic exhaustion is pends on variables such as experience, time
characterized by stress fractures, staleness, of year, health, goals, and environment.
and emotional stress. The basic purpose of Intensity is perhaps the most critical of
the training program is to train hard enough the basic overload factors. As discussed, the
to get an adaptive response and improve fit- optimum intensity during endurance exer-
ness, but not so hard as to become injured. cise is tied to carbohydrate metabolism. If
The body adapts specifically to the stress the intensity is too high, lactic acid produc-
of exercise.91 Athletes should develop the tion exceeds clearance capacity. The athlete
type of fitness required in their sport; run- fatigues very quickly, and recovery is more
ners should run and weight lifters should lift difficult. In addition, valuable glycogen
weights. The training program should also stores are rapidly depleted. However, if the
reflect the various components of the activ- pace is too slow, then the athlete does not
ity. For example, if a runner or cyclist must perform up to potential. She will probably
go up hills in competition, then she should lose the race or will not reach the desired
include hill-running or hill-cycling in her level of physical conditioning.
program. There have been many attempts by re-
The varying force requirements encoun- searchers to identify physiologic markers of
tered during exercise are met by recruiting the ideal exercise intensity. Markers include
the number of motor units needed to per- blood lactate, heart rate, ventilation, per-
form the task. Because a motor unit is ceived exertion, and percentage of maxi-
trained in proportion to its recruitment,92 it mum effort. Esoteric physiologic measures
is critical that the motor units that will be such as lactate inflection point have not
used in competition be trained regularly. been very useful. Good measures of training
Therefore, a runner who hopes to run re- load are exercise heart rate, percentages of
peated 6-minute miles in competition must race pace, and perceived exertion. Exercise
include a portion of her training at race pace heart rate helps select a pace that is propor-
or faster. This will condition the motor units tional to oxygen consumption. Training at
that will be recruited during the race. The different speeds helps to train more motor
frequency of different types of training de- units, since different motor units are re-
pends upon the relative importance of their cruited when running fast or slow. Perceived
target motor units. So, while repeated short exertion helps the athlete to adjust the train-
sprints may be the central component for a ing program. She can better respond to in-
100-meter runner, they would be much less jury, illness, glycogen depletion, overtrain-
valuable for a distance runner. ing, and environmental stress. The most
effective programs are those that work the
athlete through a range of distances and in-
Components of Overload tensities according to the requirements of
The amount of overload (training stimu- the sport.
lus) in the training program can be varied by The program should consist of over-dis-
manipulating intensity, volume, duration, tance training and interval training. The pur-
and rest. Intensity is the speed at which the pose of over-distance training (long, slow
activity is carried out. Volume is the number distance) is to increase or maintain Vo2max.
of repetitions. Duration is the distance of It also increases tissue respiratory capacity
each repetition. Rest is the amount of time by increasing muscle mitochondrial den-
between repetitions; each factor is affected sity. As discussed, mitochondrial density is
by the others. For example, if the intensity better correlated with endurance capacity
(speed) is increased, volume and duration than is Vo2max. It is probably the major ben-
eficiary of over-distance conditioning. Be- "Listen to your body," the third principle,
cause of the principle of specificity, how- is familiar to anyone who has ever read a
ever, a segment of this distance training book or article on exercise. While the ex-
should be conducted close to race pace. pression is a bit weathered, it is true never-
Interval training involves periods of in- theless. The athlete should not adhere to
tense exercise interspersed with rest (see her planned program too dogmatically.
Chapter 1). The nature of the interval train- Sometimes her body needs rest more than
ing program varies with the distance of com- exercise. Most studies show that the abso-
petition. Athletes who run shorter races will lute intensity is perhaps the most important
run shorter, faster distances in training than factor in improving fitness. An overtrained
those who run longer, slower races. Interval athlete is typically not recovered enough to
training increases Vo2max. It does this by in- train at the optimal intensity. A few days'
creasing maximal cardiac output and speed. rest sometimes will allow her to recover
Interval training also teaches pace, builds enough to train more intensely. On the other
speed, and improves lactate removal. It also hand, she should still try to follow a struc-
increases mitochondrial density but is less tured program.
effective than over-distance training. Endurance athletes should train first for
distance and only later for speed. Soft tis-
sues need time to adjust to the rigors of
Principles of Training
training. Ligaments and tendons adjust very
Nine principles of endurance training are slowly to the stresses of exercise.93 The ath-
listed in Table 4-3. They are explicit instruc- lete must prepare her body for heavy train-
tions for applying the general adaptation ing, or injury may result.
syndrome to the training of endurance ath- The fifth training principle suggests that
letes and will result in improved perfor- athletes should cycle the volume and inten-
mance with a minimum risk of injury. sity of their workouts. The practice of alter-
The first principle is to train all year nating between hard and easy training days
round. Athletes lose much fitness through is an application of cycle training (also
deconditioning. They are much more sus- called periodization of training).3 Cycle
ceptible to injury if they try to get in shape training allows the body to recover more
rapidly during the competitive season. The fully and to train hard when hard training is
next principle is related to the first: Get in required.
shape gradually. The athlete should give her Athletes should incorporate base and
body time to adapt to the stress of exercise. peak cycles (workouts) into the competitive
Overzealous training leads to injury and strategy. These cycles are groups of work-
overtraining. outs practiced to improve fitness gradually
(base) or to increase sharpness for compe-
tition (peak). Base or load cycles are char-
Table 4-3. PRINCIPLES OF ENDURANCE acterized by high volume with varying in-
TRAINING tensity. Peak cycles employ low volume and
• Train all year round. high-intensity workouts with plenty of rest.
• Get in shape gradually. Peak cycles are designed to produce maxi-
• Listen to your body. mum performance. The base or load cycle is
• Begin with over-distance training before the foundation for peak performance. How-
progressing to interval training.
• Cycle your training: Incorporate load, peak, and ever, peak fitness can be maintained for only
recovery cycles. a short time, and every peak is gained at the
• Do not overtrain; rest the day before competition. price of deconditioning. Both cycles are
• Train systematically. thus important. The successes of the peaks
• Train the mind. make the hard work of the base period
• Put sport in its proper perspective.
worthwhile.
A difficult training principle to adhere to must also have time for her family and other
is the sixth, "do not overtrain." It contra- aspects of life that are important to her.
dicts the work ethic that is ingrained in so
many athletes. The athlete should think of
conditioning for endurance events as a mul- SUMMARY
tiyear process. Adaptations to training take
place very gradually. Excessive training The determining factors of endurance
tends to lead to overtraining and overuse in- performance include maximal oxygen con-
juries rather than to accelerated develop- sumption, mitochondrial density, perfor-
ment of fitness. Similarly, athletes should mance efficiency, and body composition.
avoid excessive competition because nu- Maximal oxygen consumption is the body's
merous studies have shown that consider- maximum ability to transport and use oxy-
able muscle damage occurs during long-dis- gen and is largely determined by the cardiac
tance races.74 Competing too frequently output capacity. It is improved by about 20%
results in an inability to recover, which de- through training. A high initial value is im-
creases the overall level of conditioning. portant for success in endurance events. Mi-
The seventh training principle tells the tochondrial density is highly related to en-
athlete to train systematically. The athlete durance capacity. It provides a high
should plan an approximate workout sched- oxidative capacity and the ability to use fats
ule for the coming year (or even the next 4 as fuel during exercise. Efficiency is deter-
years), month, and week. Of course, she mined by physiologic factors such as mito-
should not be so rigid that she cannot chondrial density. Mechanical factors, such
change the program owing to unforeseen as technique and wind resistance, are also
circumstances. She should train in a manner important. The importance of body compo-
that will produce a consistent increase in fit- sition for endurance varies with the sport. In
ness. Coaching, training partners, and a sports such as running, cycling, and cross-
training diary will help her workouts be- country skiing, additional fat increases the
come more systematic. Coaching helps the energy cost of exercise. The ideal lower limit
athlete meet her competitive goals. A good of body fat is not known. In long-distance
coach, who is knowledgeable and experi- swimmers, a slightly higher fat percentage
enced, can keep her from repeating common decreases drag in the water and provides in-
training mistakes made by others. The sulation against the cold.
coach will also help motivate the athlete. Sex differences exist in endurance perfor-
Training partners are important for motiva- mance. The relative changes that occur with
tion and competition. The training diary will training and the basic underlying mecha-
help the athlete to formulate her goals and nisms that determine performance are the
to identify effective training techniques. same in men and women. Women trail men
Training the mind is as important as train- by 6% to 15% in most endurance sports, but
ing the body. Successful athletes believe in there is considerable variance in perfor-
themselves and their potential; they have mance in specific events. It is difficult to
goals and know how to achieve them. In en- summarize and quantify physiologic sex dif-
durance training in particular, the athlete ferences reported in the literature; physi-
must be patient and be content with contin- cally fit male subjects were often compared
uous small improvements over many years. with sedentary female subjects.
Finally, sports should be put in their Training is an adaptive process. Athletes
proper perspective. Too often, athletes should not become involved in overzealous
think of themselves solely as runners, cy- training programs that often lead to injury.
clists, or swimmers rather than as human Because the body adapts specifically to the
beings who participate in those activities. stress of exercise, the training program
Although sports are important, the athlete should reflect the various components of
the activity. Training overload can be varied cytochrome oxidase activity and its relation-
by manipulating intensity, volume, duration, ship to maximal oxygen consumption in man.
and rest. Intensity is most important for Pflugers Arch 349:319,1974.
13. Ivy JL, Costill DL, and Maxwell BD: Skeletal
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15. Bouchard C, and Lortie G: Heredity and en-
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CHAPTER 5
Bone Concerns
EVERETT L. SMITH, Ph.D., and CATHERINE GILLIGAN, B.A.
INCIDENCE AND COST OF EFFECTS OF EXERCISE

OSTEOPOROSIS
EFFECTS OF CALCIUM INTAKE ATHLETIC AMENORRHEA AND
BONE
MECHANISM OF EXERCISE
BENEFITS PROBLEMS IN STUDYING EXERCISE
EFFECTS OF INACTIVITY EFFECTS
T tie skeleton is a dynamic tissue, constantly responding to conditions relative

to its two major functions: providing structural support and acting as a mineral
reservoir. Two interacting homeostatic mechanisms control plasma calcium and
skeletal mineral: hormones and mechanical stress. The structural support func-
tion of the skeleton permits movement and protects vital organs. As a reservoir,
the skeleton responds to changes in hormone levels and helps to maintain blood
calcium at about 9.8 mg/dL (Table 5-1).1 Because of the skeleton's dual role,
structural integrity is jeopardized when the demands on the reservoir to main-
tain serum homeostasis are too high. When dietary calcium is inadequate, cal-
cium is mobilized from the bone to maintain serum calcium. If the dietary inad-
equacy is chronic, calcium will be pulled continually from the bone reservoir,
resulting in a negative calcium balance and a net loss of calcium and phosphorus.
Mechanical strain through weight bearing and muscle contraction play a signif-
icant role in maintaining skeletal structural integrity, as bone mineral content
(BMC) changes in response to the mechanical stressors applied. Under balanced
conditions, the hormonal and mechanical homeostatic mechanisms maintain
both skeletal integrity and serum calcium. With aging, however, multiple factors
decline (involving diet, hormonal levels, and mechanical strain), precipitating
bone involution that results in bone more susceptible to fracture and
osteoporosis.
Hormones and mechanical strain interact in maintaining body and skeletal
functions. If stress to specific skeletal segments or to the skeleton as a whole is
significantly reduced, bone mass declines. In severe disuse, such as in bed rest
or spinal cord injury, the mobilization of calcium from bone increases serum lev-
els, decreases parathyroid levels and 1,25-(OH)2 vitamin D, and thus decreases
calcium absorption in the intestinal tract and increases calcium elimination from
89
Table 5-1. SERUM CALCIUM HOMEOSTASIS

Condition Hormonal Response Metabolic Adaptation to Condition
Low serum calcium Increased PTH Increased fractional calcium absorption
Decreased renal excretion of calcium
Increased active form of vitamin D
Increased bone resorption
High serum calcium Decreased PTH Decreased fractional calcium absorption

Increased calcitonin Increased renal excretion of calcium
Decreased active form of vitamin D
Decreased bone resorption
Decreased gonadal function Decreased gonadal hormones Decreased fractional calcium absorption
Increased sensitivity of bone to PTH
PTH = parathyroid.
Source: Adapted from Smith and Raab,1 with permission.
the kidneys. Generally, the decline in activ- causes 1.3 million fractures at a cost of 3.8
ity with age and the resultant bone and bio- billion dollars each year.2 A major cause of
chemical changes are subtle. Over a long osteoporosis is age-related bone loss. Peak
term, however, inactivity can significantly bone mass is reached at about age 35 in both
reduce bone mass and threaten the integrity men and women. After age 35, women lose
of skeletal structure. up to 1% per year, and they may lose as
much as 4% to 6% per year during the first 4
to 5 years after menopause (Fig. 5-1). Men
INCIDENCE AND COST OF maintain bone mass until about age 50, after
OSTEOPOROSIS which they lose approximately 0.4% to 0.5%
per year. Both peak bone mass and rate of
Osteoporosis is a major public health loss are involved in the likelihood of devel-
problem, affecting more than 20 million peo- oping osteoporosis. In cortical bone, loss
ple in the United States. Osteoporosis occurs primarily on the endosteal surface,
Figure 5-1. Cross-sections of long bones of women aged 30 and 70 years. Note the enlarged medul-
lary cavity and increased porosity of the cortical bone at age 70.
Bone Concerns 91
EFFECTS OF CALCIUM INTAKE
Both cross-sectional and longitudinal

studies of the effect of calcium intake on
bone density or bone loss have produced
mixed results. In a cross-sectional study,
Matkovic and colleagues3 compared bone
mass and fracture incidence in two Yugosla-
vian populations, one with high (947 mg/d)
and one with low (424 mg/d) calcium intake
based on dietary histories. The two groups
were otherwise similar in heredity and en-
vironment. The high-calcium group had a
significantly greater skeletal mass at matu-
rity and a lower fracture incidence in old
age. The loss of bone mass with age was sim-
ilar in the two groups; therefore, the greater
incidence of fractures in the low-calcium
group was attributed to lower peak bone
mass. Other cross-sectional studies have re-
ported slight or nonsignificant correlations
Figure 5-2. A longitudinal section of the proximal end of habitual calcium intake with bone mass or
of a fernur, showing the trabecular structure within the
bone that provides maximum strength in the direction fracture incidence.4,5
of greatest applied pressure. The periosteum is a highly Studies of the effects of calcium supple-
vascular layer covering the surface of the bone; the end- mentation on bone loss have not consis-
osteum lines all interbone surfaces. (Adapted from Van
De Graff, KM: Human Anatomy, ed 2. Dubuque IA, Wil- tently demonstrated a positive effect. In 3-
liam C. Brown Publishers, 1988, p 158.) and 4-year studies, we found that calcium
supplementation reduced cortical bone loss
in the arm (radius, ulna, and humerus) of el-
derly and middle-aged postmenopausal
with some loss on the periosteal surface women, but did not affect bone loss in
(Fig. 5-2). In trabecular bone, the trabeculae premenopausal women.6,7 Horsman and
are thinned and may be entirely resorbed colleagues8 also reported that calcium sup-
(see Fig. 11-2). In the spine, horizontal supplementation reduced bone loss over 2 to 3
port trabeculae are lost preferentially, years at cortical forearm sites. In a 2-year
which reduces bone strength more than in- study, Prince and associates9 found that cal-
dicated by the density alone (Fig. 5-3). In cium supplementation combined with exer-
conjunction with this decreased bone mass, cise decreased forearm bone loss signifi-
the internal structure of bone also changes. cantly compared to exercise alone. Other
Osteons are decreased in size and increased 2-year studies, however, failed to detect a
in number. Micropetrosis increases with la- significant difference in radius bone loss be-
cunae filled by calcium depositions. These tween calcium-supplemented and control
qualitative bone changes, in addition to the groups.10-12 Riis13 reported that calcium sup-
decreased BMC, contribute to a greater frac- plementation reduced cortical bone loss in
ture potential. the proximal forearm but did not retard tra-
Although bone mass plays a significant becular bone loss in the distal radius or
role in determining bone strength, it is not spine in women who were recently post-
the sole determinant. The geometric struc- menopausal. Similarly, Ettinger and co-
ture of the tissue, determined by habitual workers14 found no effect of calcium supple-
stresses, collagen orientation, ligaments, mentation for 1 year on spine bone loss in
and muscle tone, is also important. early postmenopausal women.
Figure 5-3. Varying degrees of osteoporosis in lumbar vertebrae. Upper left: Normal structure in a 63-year-old man.
Lower left: The longitudinal trabeculae are narrowed and some broken ones are seen in the center of this vertebra,
showing mild osteoporosis in a 65-year-old woman; the horizontal trabeculae are conspicuously reduced. Upper right:
Pronounced osteoporosis in a 70-year-old woman. There is clear-cut breaking off of numerous longitudinal trabeculae
on the right and the left. Lower right: High-grade osteoporosis in a 71-year-old woman. The vertebral body has almost
completely collapsed; there are several gaps in the trabecular structure, and the restraining bone is transformed, with
formation of new longitudinal trajectories. (From Remagen, W: Osteoporosis. Sandoz Ltd., Basle, Switzerland, 1989,
Fig. 31, with permission.)
Recent studies have investigated the ef- dius. In late postmenopausal women (>5
fects of calcium supplementation on bone years since menopause), however, the CCM
loss in premenopausal and early and late group did not change significantly at any site
postmenopausal women. Premenopausal measured; those taking CC declined signifi-
women who increased their dietary calcium cantly in spine BMD; and the placebo group
by an average of 610 mg/d (n = 20) did not declined significantly in spine and femur
change significantly in spine bone mineral BMD. Radius BMD declined significantly
density (BMD), while control subjects de- less in the CCM than in the placebo group.
creased significantly (n = 17). Calcium sub- When subgroups of the late postmenopausal
jects thus had significantly greater spine groups were formed on the basis of calcium
BMD after 30 and 36 months than did control intake (<400 mg or 400 to 650 mg), differ-
subjects.15 Dawson-Hughes and colleagues16 ences in change between groups were ap-
studied 301 women with self-selected diets parent only for the lower-calcium subgroup.
low in calcium (<650 mg/d), who were di- After 2 years, CCM had significantly reduced
vided into placebo, calcium citrate malate loss in spine, femur, and radius BMD com-
(CCM) supplement, and calcium carbonate pared to the placebo group, and CC had sig-
(CC) supplement groups and followed for 2 nificantly reduced loss in radius BMD com-
years. In early postmenopausal women (<5 pared to the placebo group. Elders and
years since menopause), the groups did not associates17 found that calcium supplemen-
differ in BMD loss in the spine, femur, or ra- tation retarded spine bone loss in early
Bone Concerns 93
postmenopausal women during the first ness. The degree of bone hypertrophy or at-
year, but not the second year, of their trial. rophy is proportional to the difference in
Finally, a team led by Nelson18 randomly as- magnitude and frequency of the mechanical
signed postmenopausal women (mean age stimulus from normal. The habitual stimulus
60, mean years since menopause 11) to a to weight-bearing segments (legs and spine)
high-calcium (831 mg) or placebo (41 mg is much greater than that to the non-weight-
calcium) drink over a 1-year period. Half of bearing areas (ribs, arms, and skull). For ex-
the subjects in each group participated in a ample, the impact of the heel during walking
1-year walking program. Calcium supple- (1.2 to 1.5 times body weight) is much
mentation significantly reduced loss in greater than the stress applied by muscle
femur BMD but did not affect loss in the contractions in the arm during activities of
spine, radius, or total body calcium. daily living. Therefore, the calcaneus is nor-
Some of the differences among calcium in- mally under greater stress than the radius,
tervention studies may be due to the wide so when both bones are free of stress (as in
variety of forms and doses of calcium used, the case of the astronauts in space), more
along with differences in study length, sub- bone is lost from the calcaneus than from
ject selection criteria, menopausal age, self- the radius.22,23
selected dietary intake, sites measured, and Numerous models of the mechanism by
sample sizes. It is reasonable to hypothesize which bone responds to mechanical forces
that calcium supplementation affects mainly have been proposed. Bassett24 indicated
cortical bone in the early postmenopause19 that bone functions as a piezoelectric crys-
but may affect other sites in premenopausal tal, generating an electric charge in propor-
and late postmenopausal women. Calcium tion to the forces applied to the bone.
supplementation may be most beneficial for Carter25 hypothesized that mechanical
women with a self-selected diet low in cal- forces produce microfractures, which stim-
cium and can be expected to avert only that ulate osteoclastic remodeling coupled with
portion of bone loss due to inadequate cal- osteoblastic activity. A recent study, how-
cium intake.20 ever, did not detect evidence of microfrac-
ture in rats subjected to 20,000 loading cy-
MECHANISM OF EXERCISE cles per day for 5 or 6 days.26 Other ways in
BENEFITS which exercise may stimulate osteoclastic
and osteoblastic activity include increased
While evidence is accumulating that phys- hydrostatic pressure and streaming poten-
ical activity increases bone mass, research tials.
on the mechanisms by which bone is af- Whereas dynamic loading produces hy-
fected by mechanical stress is still in its pertrophy, static loading of bone produces
early stages. little or no hypertrophy.27 For a bone to hy-
In 1892, Wolff21 hypothesized that in- pertrophy, dynamic stimuli must exceed
creased weight bearing compresses and a threshold magnitude and frequency.
bends the long bones, increases mineral Lanyon28 demonstrated that both the rate
content, and consequently strengthens and magnitude of strain influenced bone re-
bones, making them less liable to fracture modeling. He monitored BMC in the radii of
under similar loads. Weight bearing (grav- sheep under artificial stimulation. No
ity) and muscle contraction are the two change occurred with a strain magnitude
major mechanical forces applied to bone. less than that of the animal's normal walking
Both hypodynamic and hyperdynamic load. With higher strain magnitude and nor-
states affect bone balance. Bone mass in- mal strain rates, periosteal bone deposition
creases with greater weight-bearing activity increased slightly on both convex and con-
or muscle contraction or both and de- cave surfaces. When both magnitude and
creases with immobilization or weightless- rate were higher than in normal walking,
periosteal bone increased substantially. osteal surface than did untrained sows. Min-
Other studies have applied more precisely eral apposition rate was also higher, at both
quantified stress to bone. Rubin and the periosteal (76%) and intracortical oste-
Lanyon29 applied controlled mechanical onal (23%) levels. Similarly, evidence of al-
loads, using a pneumatically operated de- tered cellular activity was found in trained
vice, to rooster ulnae isolated from muscular adult rats.34 Bone density and trabecular
stress. Bone mass decreased if no load was number, thickness, and density were signif-
applied, remained fairly constant at 4 cycles icantly higher in trained animals than in
per day of normal (2000 microstrain) mag- controls after 18 and 26 weeks of exercise.
nitude, and hypertrophied at a normal mag- The mineral apposition rate and bone for-
nitude loading for 36 cycles per day (each mation rate were significantly higher in
cycle about 2 seconds). The hypertrophy trained animals, while the percentage of
from 3600 cycles per day and 36 cycles per eroded and labeled perimeter tended to be
day did not differ. In a similar study, the lower in the trained animals. This study sup-
number of loading cycles was held constant, ports the concept of Frost35 that increased
and the magnitude of the strain varied.30 activity stimulates modeling and depresses
Bone change was directly proportional to remodeling.
the strain. Bone atrophied at strains below Bone requires a specific magnitude and
1000 microstrain, and cross-sectional area rate of stimulus in order to hypertrophy.
increased with strains over 1000 micro- Within a normal range of stimulus specific to
strain. It appears that the magnitude of the the individual's activities and genotype,
strain is more important than the frequency bone neither atrophies nor hypertrophies.
of application. Beyond or below this range, bone will
Recent studies have investigated the bio- change, as shown in Figure 5-4. Increased
chemical and histologic sequelae of bone hypertrophy with increased stress will
loading. The mechanism by which strain occur only to a point, however. Severe, re-
produces an osteogenic cellular response petitive loading may result in fatigue dam-
has not been delineated. Histomorphome- age such as that seen in the metatarsals, cal-
tric data show increased osteoclastic func- caneus, tibia, and femur of some soldiers
tion with disuse and increased osteoblastic and distance runners. Fatigue damage may
function with increased activity. Neither also occur in untrained persons who in-
mature osteoclasts nor osteoblasts, how- crease their activity levels more rapidly
ever, seem to respond directly to changes in than the bone can adapt. At the other end of
skeletal strain. Osteocytes (that number up the spectrum, bone atrophies with lessened
to 20,000 per cubic millimeter), however, mechanical stress due to bed rest and
may respond to changes in skeletal strain by weightlessness.
the production of chemical transmitters act-
ing on bone precursor cells. Using an in
vitro core biopsy model in the presence of EFFECTS OF INACTIVITY
[3H]uridine, El Haj and colleagues31 ob-
served an increase in radioactive osteocyte Donaldson and associates36 observed
RNA compared to nonloaded specimens. three men for 30 to 36 weeks of bed rest, and
Pead and Lanyon32 reported that within 5 Hulley and colleagues37 observed five men
days after a single period of skeletal loading, for 24 to 30 weeks of bed rest. Calcium bal-
quiescent surface-lining cells were trans- ance was negative throughout bed rest, with
formed into active, bone-forming osteo- 0.5% to 0.7% of total body calcium lost per
blasts. month. In the weight-bearing calcaneus,
Cellular activity at the femur midshaft in- bone loss was magnified; 25% to 45% was
creased significantly in sows training on a lost after 36 weeks. After remobilization, cal-
motor-driven treadmill for 20 weeks.33 cium balance became positive within a
Trained sows had a 27% greater active peri- month, and BMC was regained at a rate sim-
Bone Concerns 95
Figure 5-4. Effect of mechanical loading on bone mineral content. (Adapted from Carter.25)
ilar to the rate of loss, reaching baseline lev- less severe than that of a patient at bed rest,
els in about 36 weeks. Krolner and Toft38 ob- but extended over 10 to 20 years, the resul-
served a 0.9% per week loss from the lumbar tant bone loss can be a major contributor to
spine in individuals at bed rest for an aver- the development of osteoporosis.
age of 27 days because of a disk protrusion. Human studies of immobilization are rare,
LeBlanc and co-workers39 recently reported but a number of animal studies have been
the effects of 17 weeks of bed rest and 6 performed. Kazarian and Von Gierke40 im-
months of recovery at various skeletal sites. mobilized 16 rhesus monkeys in full body
During bed rest, subjects lost significantly in casts for 60 days. Bone from the immobi-
BMD at the calcaneus (10%), femur trochan- lized animals had fewer and thinner trabec-
ter (5%), lumbar spine (4%), femur neck ulae, smaller trabecular plates, reduced tra-
(4%), tibia (2%), and total body (1.4%). The becular surfaces, and reduced cortical
lumbar spine, femur trochanter, and tibia thickness compared with bones of control
BMD tended to increase during the recovery animals. Remodeling occurred in the trabec-
period, but only calcaneus BMD increased ulae of the femoral neck, which "corre-
significantly. The distal and proximal radius sponded in position and curvature to the
and ulna BMD did not decrease significantly lines of maximum compressive stress," so
during bed rest or increase significantly dur- that only those trabeculae necessary for
ing recovery. Regional analysis of total body structural integrity were retained. The com-
scans showed significant decreases in lum- pressive strength of the immobilized bones
bar spine, total spine, pelvis, trunk, and legs was two to three times less than that in con-
during bed rest, with a significant increase trol animals. Cortical bone at the sites of
in head BMD during bed rest. Pelvis and muscle and tendon attachments also was
trunk BMD increased significantly in the re- significantly weaker than in control animals.
covery period. In the average woman, the Young41 and Niklowitz42 and their co-
usual decline in activity is more gradual and workers investigated changes in the tibias of
monkeys during 7 months of immobilization of the studies in which it was measured. Aer-
and up to 40 months of recovery and remo- obic weight-bearing activities increased
bilization. Remodeling was obvious within 1 spine bone density in middle-aged post-
month of immobilization. After 10 weeks, menopausal women18,52 and women with os-
they observed endosteal resorption, sub- teoporosis.53 In two of these studies,52,53 the
periosteal loss, striations in the cortex (in- total BMD of L2 to L4 was increased signifi-
dicative of resorptive cavities), surface ero- cantly compared to controls, while in the
sion in the juxta-articular areas (patella and third study,18 trabecular (LI to L3) but not
femoral condyles), and thin, irregular exter- total BMD was affected. Physical activity
nal lamellar bone. During 6 months of im- programs incorporating arm exercises in-
mobilization, BMC decreased 23% to 31% creased BMD or decreased bone loss in the
and bending stiffness, 36% to 40%. Normal radius and ulna.6,54-56 In our study56 of mid-
bending properties of the bone were re- dle-aged women, the response to exercise
stored within 8V2 months of recovery and re- appeared to be independent of menopausal
mobilization, but BMC did not return to nor- status. A few studies that used primarily aer-
mal even after 15 months. New primary obic weight-bearing training reported no ef-
haversian systems were generated during fects on radius9,57,58or spine59 bone density.
that time, and by 40 months the cortex con- The bone hypertrophy observed in
tained many secondary and tertiary osteons weightlifters, along with animal studies
and approached normal BMC. showing a linear relationship between strain
and bone hypertrophy, have led to several
studies utilizing resistance training to pro-
EFFECTS OF EXERCISE mote BMD. In studies comparing general
aerobic training with and without additional
Numerous studies indicate that bone den- resistance training, groups performing the
sity is responsive to mechanical loading. strength training tended nonsignificantly to
The effect appears to be primarily local and increase more in calcium bone index (bone
proportional to the level of strain placed on mass of the central third of the skeleton ad-
the bone. The most convincing evidence justed for body size) and radius BMD than
that bone hypertrophy is localized appears those in aerobic training alone.54,60 Resist-
in studies of both young and old tennis play- ance training alone, however, has not con-
ers, whose dominant humerus was up to 35% sistently altered BMD. In studies of pre-
higher in BMD than was the nondominant menopausal and early postmenopausal
arm.43- 45 In studies of athletes, the amount of women, exercise subjects increased in ver-
hypertrophy was related to the loading ap- tebral BMD relative to controls.61,62 Calca-
plied by the sports activity. For example, neus, femur, and distal forearm BMD, how-
weightlifters had higher bone density in the ever, were not significantly affected in these
spine and femur than aerobic athletes,46-49 studies. Postmenopausal women receiving
whereas swimmers did not have signifi- estrogen replacement therapy (ERT) and
cantly higher spine density than did seden- assigned to a resistance-training group in-
tary subjects.48-50 In one study, male swim- creased significantly in spine, total body,
mers had significantly higher vertebral BMD and radius BMD; only in the radius, how-
than sedentary subjects, but no difference ever, did the change differ significantly from
could be detected between swimming and that in the women receiving ERT alone.63 In
sedentary women.51 contrast to these positive findings, pre-
Intervention studies have confirmed the menopausal women in a resistance-training
beneficial effect of exercise at various skel- program lost significantly more vertebral
etal sites, including the spine, radius, calca- BMD than did controls.64 Postmenopausal
neus, and tibia. Femur BMD, however, was women who performed back extensions
not significantly affected by exercise in any with light weights for 2 years did not differ
Bone Concerns 97
significantly in vertebral BMD change from rheic controls; in fact, oarswomen tended to
controls.65 be higher in vertebral BMC. Regular, oligo-
menorrheic and amenorrheic oarswomen
did not differ significantly. This may have
ATHLETIC AMENORRHEA AND been the result of small sample sizes, how-
BONE ever, since a nonsignificant trend toward
lower density in groups with menstrual dis-
Whereas exercise is associated with an in- turbances was apparent. The authors spec-
crease in bone density, excessive exercise ulated that the increased muscular work of
leading to amenorrhea is associated with a the back involved in rowing and weightlift-
decrease in bone density. Investigators have ing exerted a protective effect on vertebral
found that unlike hyperprolactinemic, ano- bone. Wolman and colleagues,85 however,
rexic, and premature menopausal women, did not confirm this protective effect on ver-
amenorrheic athletes do not have signifi- tebral trabecular bone density. A two-way
cantly lower cortical (radius) BMD, 66-74 but analysis of variance incorporating men-
they are significantly lower than eumenor- strual status and sports activity showed a
rheic athletes in vertebral HMD67-69,73,75 and significant (negative) factor for amenorrhea
vertebral trabecular density.72,75-79 Men- and a significant (positive) factor for rowers
strual history is an important determinant of but no significant interactive effect.
vertebral density even among currently eu- The apparent immunity of the radius and
menorrheic athletes.68,77 Athletes with men- susceptibility of the spine to menstrual dis-
strual disorders also appear more prone to orders indicates that there may be a differ-
injury and stress fractures.68,80-82 ential responsiveness of cortical and trabec-
A few longitudinal studies have demon- ular bone. A recent study included
strated that subjects with menstrual distur- additional sites of varying trabecular com-
bances lose more vertebral bone. Prior and position.68 Ninety-seven athletes were
colleagues83 studied 66 women without overt graded for menstrual history, and BMD was
menstrual irregularities, who varied widely measured at the spine (LI to L4), femur neck
in their exercise patterns. They found that and shaft, radius (10% and 20% distal), tibia,
ovulatory disturbances accounted for 24% of and fibula. Spine and femur shaft BMD were
the variance in vertebral bone loss: spinal higher in subjects who had always been reg-
bone density tended to increase in women ular than in subjects with some history of
with normal cycles but decreased signifi- menstrual irregularity. Currently amenor-
cantly in women with two or more short lu- rheic subjects with a history of oligomenor-
teal phases and in those with anovulatory rhea or amenorrhea were significantly lower
cycles. Cann and associates84 reported that in vertebral BMD than subjects with other
loss of vertebral bone with amenorrhea was patterns of irregularity. No differences were
biphasic. In one year, women who had been detected at other sites. The authors con-
amenorrheic 3 years or less lost 4.2% in ver- cluded that deficits in bone density from
tebral trabecular mineral content, while previous menstrual irregularity appeared to
those who had been amenorrheic for longer be confined to the vertebrae. Weight was sig-
periods did not change significantly. nificantly correlated with BMD at all sites,
In most of these studies of bone density, and the association became stronger as the
the athletes were runners or involved in severity of menstrual disorder increased.
other aerobic sports that did not particu- An important question is whether bone
larly stress the back musculature. On the deficits due to amenorrhea can be corrected
other hand, Snyder and co-workers74 re- or averted. Seven subjects who regained
ported that oarswomen, regardless of men- menses following a reduction in training in-
strual status, did not differ significantly in creased significantly (6.3%) in vertebral
vertebral BMC from sedentary eumenor- BMD, while matched eumenorrheic subjects
did not change significantly over 1 year.86 tempting to delineate the exercise programs
Bone density increased more slowly the fol- most effective in stimulating bone hypertro-
lowing year, and then plateaued. After 4 phy.
years of normal menses, vertebral density
remained well below normal. Further evi-
SUMMARY
dence of the persistence of vertebral loss
was provided by a study of 208 runners. Sub- Bone is a dynamic tissue performing two
jects with past or current untreated amen- functions: providing structural support and
orrhea had significantly lower spinal den- acting as a mineral reservoir. Two homeo-
sity than subjects who had always been static mechanisms act on bone at the same
regular. Women with current or past oligo- time: hormones and mechanical stress.
menorrhea but no amenorrhea, and women Researchers have evaluated the relation-
with treated (by estrogen or oral contracep- ship of weight-bearing and non-weight-
tives) amenorrhea for less than 3 years were bearing forces on bone to bone mass and
similar in bone density to the always-regular bone strength. Bone adjusts locally to sup-
subjects. port the structural demands of weight-bear-
ing and muscular activity. Inactivity results
PROBLEMS IN STUDYING in bone involution, whereas increased activ-
EXERCISE EFFECTS ity induces bone hypertrophy. Subjects at
bed rest or in weightless conditions lose
In animal studies, exercise and mechani- bone rapidly. Conversely, athletes have
cal loading have consistently benefitted greater bone mass than their sedentary
bone density. Although the mechanisms counterparts. Exercise intervention slows or
have not been fully elucidated, loading pro- reverses bone loss in middle-aged and el-
duces increased cellular activity and bone derly women. Bone response is specific to
formation rates. In humans, athletes had the area stressed, as seen in the selective
greater bone density than sedentary sub- hypertrophy of the dominant arm in tennis
jects, but few cross-sectional studies of non- players. Very intense levels of exercise cou-
athletes have been able to detect a differ- pled with amenorrhea may reduce skeletal
ence in bone density between moderately mass, especially in the spine.
active and sedentary subjects. It could be More research is needed to understand
that many moderately active subjects do not the precise mechanisms by which exercise
exceed the threshold for stimulating bone affects bone, and the optimum type and in-
hypertrophy. Intervention studies gener- tensity of physical activity for preventing os-
ally, but not always, increased bone density teoporosis.
or reduced bone loss. A confusing aspect of
bone research is the failure of intervention
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14. Ettinger B, Genant HK, and Cann CE: Post- Joint Surg66a:397,1984.
menopausal bone loss is prevented by treat- 30. Rubin, CT and Lanyon, LE: Regulation of
ment with low-dosage estrogen with calcium. bone mass by mechanical strain magnitude,
Ann Intern Med 106:40,1987. Calcif Tissue Int 37:411,1985.
15. Baran D, Sorensen A, Grimes J, et al: Dietary 31. El Haj AJ, Minter SL, Rawlinson SCF, et al: Cel-
modification with dairy products for prevent- lular responses to mechanical loading in
ing vertebral bone loss in premenopausal vitro. J Bone Min Res 5:923,1990.
women: A three-year prospective study. J 32. Pead MJ and Lanyon LE: Indomethacin mod-
Clin Endocrinol Metab 70:264,1989. ulation of load-related stimulation of new
16. Dawson-Hughes B, Dallal GE, Krall EA, et al: bone formation in vivo. Calcif Tissue Int
A controlled trial of the effect of calcium sup- 45:44, 1989.
plementation on bone density in postmeno- 33. Raab DM, Crenshaw TD, Kimmel DB, et al: A
pausal women. N Engl J Med 3223:878, 1990. histomorphometric study of cortical bone ac-
17. Elders PJM, Netelenbos JC, Lips P, et al: Cal- tivity during increased weight-bearing exer-
cium supplementation reduces perimeno- cise. J Bone Min Res 6:741, 1991.
pausal bone loss. J Bone Min Res 34. Jee WSS and Li XJ: Adaptation of cancellous
4(Suppl):1128, 1989 (abstr). bone to overloading in the adult rat: A single
photon absorptiometry and histomorphom- 52. Dalsky GP, Stocke KS, Ehsani AA, et al:
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35. Frost, HM: A new direction for osteoporosis bone mineral content in postmenopausal
research: A review and proposal. Bone women. Ann Intern Med 108:824,1988.
12:429,1991. 53. Krolner B, Toft B, Nielson SP, et al: Physical
36. Donaldson CL, Hulley SB, Vogel JM, et al: Ef- exercise as prophylaxis against involutional
fect of prolonged bed rest on bone mineral. vertebral bone loss: A controlled trial. Clin
Metabolism 19:1071, 1970. Sci 64:541,1983.
37. Hulley SB, Vogel JM, and Donaldson CL: Ef- 54. Rikli RE, and McManis BG: Effects of exercise
fect of supplemental calcium and phospho- on bone mineral content in postmenopausal
rus on bone mineral changes in bed rest. J women. Res Q Exerc Sport 61:243, 1990.
Clin Invest 50:2506, 1971. 55. Simkin A, Ayalon J, and Leichter I: Increased
38. Krolner B, and Toft B: Vertebral bone loss: An trabecular bone density due to bone-loading
unheeded side effect of therapeutic bed rest. exercises in postmenopausal osteoporotic
Clin Sci 64:537,1983. women. Calcif Tissue Int 40:59, 1986.
39. LeBlanc AD, Schneider VS, Evans HFJ, et al: 56. Smith EL, Smith PE, Ensign CJ, et al: Bone in-
Bone mineral loss and recovery after 17 volution decrease in exercising middle-aged
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40. Kazarian LE, and Von Gierke HE: Bone loss as 57. Aloia JF, Cohn SH, Ostuni JA, et al: Preven-
a result of immobilization and chelation: Pre- tion of involutional bone loss by exercise.
liminary results in macaca mulatta. Clin Or- Ann Intern Med 89:356, 1978.
thop 65:57, 1969. 58. Sandier RB, Cauley JA, Horn DL, et al: The ef-
41. Young DR, Niklowitz WJ, and Steele CR: Tib- fects of walking on the cross-sectional di-
ial changes in experimental disuse osteopo- mensions of the radius in postmenopausal
rosis in the monkey. Calcif Tissue Int 35:304, women. Calcif Tissue Int 41:65,1987.
1983. 59. Cavanaugh DJ, and Cann CE: Brisk walking
42. Niklowitz WJ, Bunch TE, and Young DR: The does not stop bone loss in postmenopausal
effects of immobilization on cortical bone in women. Bone 9:201,1988.
monkeys (m nemestrina). Physiologist 60. Chow RK, Harrison JE, and Notarius C: Effect
26(Suppl):S115, 1983. of two randomised exercise programmes on
43. Huddleston AL, Rockwell D, Kulund DN, et al: bone mass of healthy postmenopausal
Bone mass in lifetime tennis athletes. JAMA women. Br Med J 292:607,1987.
44:1107,1980. 61. Gleeson PB, Protas EJ, LeBlanc AD, et al: Ef-
44. Jones HH, Priest JS, Hayes WC, et al: Humeral fects of weight lifting on bone mineral density
hypertrophy in response to exercise. J Bone in premenopausal women. J Bone Min Res
Joint Surg 59A.-204, 1977. 5:153, 1990.
45. Montoye HJ, Smith EL, Pardon DF, et al: Bone 62. Pruitt LA, Jackson RD, Bartels RL, et al:
mineral in senior tennis players. Scandina- Weight-training effects on bone mineral den-
vian Journal of Sports Science 2:26,1980. sity in early postmenopausal women. J Bone
46. Block J, Genant HK, Black D, et al: Greater Min Res 7:179,1992.
vertebral bone mineral in exercising young 63. Notelovitz M, Martin D, Tesar R, et al: Estro-
men. Western J Med 145:39, 1986. gen therapy and variable-resistance weight
47. Davee AM, Rosen CJ, and Adler RA: Exercise training increase bone mineral in surgically
patterns and trabecular bone density in col- menopausal women. J Bone Min Res 6:583,
lege women. J Bone Min Res 5:245, 1990. 1991.
48. Heinrich CH, Going SB, Pamenter RW, et al: 64. Rockwell JC, Sorenson AM, Baker S, et al:
Bone mineral content of cyclically menstru- Weight training decreases vertebral bone
ating female resistance and endurance density in premenopausal women: A pro-
trained athletes. Med Sci Sports Exerc 22:558, spective study. J Clin Endocrinol Metab
1990. 71:988, 1990.
49. Nilsson BE, and Westlin NE: Bone density in 65. Sinaki M, Wahner HW, Offord KP, et al: Effi-
athletes. Clin Orthop Rel Res 77:179, 1971. cacy of nonloading exercises in prevention of
50. Jacobson PC, Beaver W, Grubb SA, et al: Bone vertebral bone loss in postmenopausal
density in women: College athletes and older women: A controlled trial. Clin Proc 64:762,
athletic women. J Orthop Res 2:328,1984. 1989.
51. Orwoll ES, Ferrant J, and Owatt SK: The re- 66. Cann CE, Martin MC, Genant HK, et al: De-
lationship of swimming exercise to bone creased spinal mineral content in amenor-
mass in men and women. Arch Intern Med rheic women. JAMA 251:626,1984.
149:2197, 1989. 67. Drinkwater BL, Nilson K, Chesnut CH, et al:
Bone Concerns 101
Bone mineral content of amenorrheic and eu- 77. Cann CE, Cavanaugh DJ, Schnurpfiel K, et al:
monorrheic athletes. N Engl J Med 311:277, Menstrual history is the primary determinant
1984. of trabecular bone density in women. Med Sci
68. Drinkwater BL, Bruemner B, and Chesnut, Sports Exerc 20:S59,1988 (abstr).
CH: Menstrual history as a determinant of 78. Lloyd T, Buchanan JR, Bitzer S, et al: Inter-
current bone density in young athletes. relationships of diet, athletic activity, men-
JAM A 263:545,1990. strual status and bone density in collegiate
69. Fisher EC, Nelson ME, Frontera WR, et al: women. Am J Clin Nutr 46:681,1987.
Bone mineral content and levels of gonado- 79. Louis O, Demeirlier K, Kalender W, et al: Low
tropins and estrogens in amenorrheic run- vertebral bone density values in young non-
ning women. J Clin Endocrinol Metab elite female runners. Int J Sports Med 12:214,
62:1232, 1986. 1991.
70. Jones KP, Ravnikar VA, Tulchinsky D, et al: 80. Myburgh KH, Hutchins J, Fataar AB, et al:
Comparison of bone density in amenorrheic Low bone density is an etiologic factor for
women due to athletics, weight loss, and pre- stress fractures in athletes. Ann Intern Med
mature menopause. Obstet Gynecol 66:5, 113:754, 1990.
1985. 81. Lloyd T, Triantafyllou J, Baker ER, et al:
71. Linnell SL, Stagger JM, Blue PW, et al: Bone Women athletes with menstrual irregularity
mineral content and menstrual regularity in have increased musculoskeletal injuries.
female runners. Med Sci Sports Exerc 16:343, Med Sci Sports Exerc 18:374,1986.
1984. 82. Warren MP, Brooks-Gunn J, Hamilton LH, et
72. Marcus R, Cann C, Madvig P, et al: Menstrual al: Scoliosis and fractures in young ballet
function and bone mass in elite women dis- dancers. N Engl J Med 314:1348,1986.
tance runners. Ann Intern Med 102:156,1985. 83. Prior JC, Vigna YM, Schechter MT, et al: Spi-
73. Nelson ME, Fisher EC, Catsos PD, et al: Diet nal bone loss and ovulatory disturbances. N
and bone status in amenorrheic runners. Am Engl J Med 323:1221,1990.
J Clin Nutr 43:910, 1986. 84. Cann CE, Martin MC, and Jaffe RB: Duration
74. Snyder AC, Wenderoth MP, Johnston CC, et of amenorrhea affects rate of bone loss in
al: Bone mineral content of elite lightweight women runners: Implications for therapy.
amenorrheic oarswomen. Hum Biol 58:863, Med Sci Sports Exerc 17:214,1985 (abstr).
1986. 85. Wolman RL, Clark P, McNally E, et al: Men-
75. Cook SD, Harding AF, Thomas KA, et al: Tra- strual state and exercise as determinants of
becular bone density and menstrual function spinal trabecular bone density in female ath-
in women runners. Am J Sports Med 15:503, letes. Br Med J 301:516,1990.
1987. 86. Drinkwater BL, Nilson K, Ott S, et al: Bone
76. Buchanan JR, Myers C, Lloyd T, et al: Deter- mineral density after resumption of menses
minants of peak trabecular bone density in in amenorrheic athletes. JAMA 256:380,1986.
women: The role of androgens, estrogen and
exercise. J Bone Min Res 3:673, 1988.
CHAPTER 6
Nutrition for Sports

GABE MIRKIN, M.D.
NUTRIENTS DRINKING DURING COMPETITION

Carbohydrates Dehydration and "Heat Cramps"
Proteins Women May Need Less Fluid Than
Fats Men
When to Drink
ENERGY STORAGE
What to Drink
Comparing Women and Men
Cold or Warm?
ENDURANCE EATING AND DRINKING AFTER
"Hitting the Wall": Depletion of COMPETITION
Muscle Glycogen
"Bonking": Depletion of Liver PROTEIN REQUIREMENTS
Glycogen VITAMINS
INCREASING ENDURANCE Mechanism of Function
Training to Increase Endurance Vitamin Needs of Female Athletes
Vitamin C and Colds
UTILIZING FAT INSTEAD OF Vitamins and Birth Control Pills
GLYCOGEN Vitamins and Premenstrual
DIET AND ENDURANCE Syndrome
Food Intake during the Week before MINERALS
Competition Iron
Eating the Night before Competition Calcium
Eating the Meal before Competition Sodium
Eating before Exercising Potassium
Eating during Competition Trace Minerals
DRINKING BEFORE COMPETITION THE ATHLETE'S DIET
w, ith the exception of iron and calcium, nutrient requirements for female ath-
letes are the same as those for their male counterparts. Women suffer far more
frequently than men from deficiencies of iron and calcium. Ten percent of
healthy, white, middle-class female adolescents are iron deficient, while 5% have
iron-deficiency anemia.1 Athletes are at greater risk than nonathletes for devel-
oping iron deficiency,2 which, even in the absence of anemia, can limit athletic
endurance.
Hypoestrogenic female athletes are at increased risk of developing osteo-
porotic bone fractures.3 In addition to hormone replacement, the prevention and
1O2
Nutrition for Sports 103
treatment of this condition should include Table 6-1. ESSENTIAL NUTRIENTS

ingestion of adequate amounts of calcium.
Water
A proper diet can help female athletes to Linoleic acid
maximize performance. However, many ath- 8 or 9 amino acids
letes have nutritional misconceptions that 13 vitamins
hinder performance rather than help it. For Approximately 21 minerals
example, many athletes incorrectly believe Glucose (for energy)
that a high-protein diet improves perfor-
mance and increases muscle size and
strength, that vitamin requirements are sig- in competition by following sound scientific
nificantly greater for athletes, that fluid re- nutritional practices. A brief discussion of
quirements during exercise should be dic- basic principles of nutrition will precede the
tated by thirst, and that salt tablets should sections on the application of such princi-
be taken in hot weather.4,5 All of these myths ples to athletic competition.
will be refuted in this chapter.
In 1967, the women's world record for the
marathon was 3:15:22, set by Maureen Wil- Carbohydrates
ton of Toronto, Canada. By 1985, the world Carbohydrates are composed of sugars.
record was lowered to 2:21:06 by Ingrid They can be monosaccharides, such as glu-
Kristiansen of Norway. The fantastic im- cose and fructose in fruit; disaccharides,
provement in world records in all sporting such as lactose in milk or sucrose in candy;
events is due primarily to superior training and polysaccharides, such as starch in a po-
methods, but it is also due to improved tato or fiber in celery.
knowledge about nutrition. In the late 1960s, Before carbohydrates can be absorbed,
it was common for athletes to eat high-pro- they must first be hydrolyzed into one or
tein diets, to reduce their intake of food on more of the following four sugars: glucose,
the days before competition, to ingest no fructose, galactose, and mannose. Of these
food or liquids during competition, and to sugars, only glucose circulates beyond the
eat only a limited amount of food after com- portal system. The other three are con-
petition. Today knowledgeable athletes fol- verted to glucose by hepatocytes before
low none of these old regimens.6 they can re-enter the circulation (Fig. 6-1).
This chapter reviews some of the basic Circulating glucose can be used by all
physiologic principles that serve as the cells as a source of energy. Glucose that is
foundation for advising athletes how to use not used immediately can be stored as gly-
nutrition to improve sports performance. cogen only in the liver and muscles. When
these tissues are saturated with glycogen,
excess glucose is then converted to fat. Liver
glycogen can yield glucose to the circula-
NUTRIENTS tion, where it subsequently can be used by
other tissues. On the other hand, the glu-
Humans require approximately 46 nutri- cose from muscle glycogen can be utilized
ents to be healthy. An essential nutrient is only by that particular muscle.
one that cannot be produced by the body in
adequate amounts and, therefore, must be
supplied by the diet (Table 6-1). Lack of an Proteins
essential nutrient can impair performance, Fifteen percent of ingested protein is hy-
but taking large amounts of any specific nu- drolyzed to amino acids and polypeptides in
trient has not been shown to improve per- the stomach, while the remaining protein
formance. undergoes hydrolysis in the small intestine.
Athletes can improve their performances These metabolites are actively transported
Figure 6-1. Sugar circulation. All carbohydrates are sugars bound together. They can be single sug-
ars, as in fruit and honey; two sugars bound together, as in milk and table sugar; and hundreds and
thousands of sugars bound together, as in corn and beans.
into intestinal epithelial cells. Once there, creatic lipase into monoglycerides, free fatty
most of the polypeptides are hydrolyzed to acids, and glycerol (Table 6-2), which enter
form amino acids, which are then absorbed the epithelial cells lining the intestines.
into the general circulation. Once there, the monoglycerides are hydro-
The main functions of proteins are to lyzed to form glycerol and fatty acids. Then,
form structural components, enzymes, triglycerides are formed again, are com-
hormones, neurotransmitters, antibodies, bined with cholesterol and phospholipids,
transport molecules, and clotting factors. and are covered with a lipoprotein coating
Protein also can be a source of energy. As to form chylomicron particles, which pass
much as 10% of energy during exercise can through the lymphatic system into the gen-
come from protein, with more than half eral circulation. Short-chain fatty acids can
coming from one amino acid, leucine. Since be absorbed directly into the circulation.
leucine represents only a small fraction of Excess fat is stored primarily in fat cells and
the amino acids in ingested protein, the leu- muscles.
cine that is used for energy must come from
a source other than ingested protein. It also
does not come from muscle sources of leu- ENERGY STORAGE
cine. Most of the leucine that is used for en-
ergy is formed de novo. The nitrogen for the Only fats and carbohydrates are stored
newly formed leucine comes from other for future use as an energy source. The
branched-chain amino acids (isoleucine human body cannot store extra protein. Fat
and valine), and most of the carbon comes stores energy in the most economic way, as
from glucose and other amino acids. it provides 14 times as much energy per
Before amino acids can be used for en- given weight as stored liver glycogen, which
ergy, deamination or transamination must must be stored with other liver tissue. One
occur to remove the nitrogen. Athletic train- pound of stored fat will yield 3500 kcal,
ing can double the levels of important trans- whereas 1 Ib of liver contains only enough
aminases, such as SCOT and SGPT, and this glycogen to yield 250 kcal. This great dispar-
increases significantly the body's ability to ity in energy storage is explained by the fact
utilize leucine and other amino acids for en- that fat occupies 85% of the space in fat cells,
ergy. while liver glycogen is diluted by other cel-
lular elements and occupies less than 15% of
the space in liver cells.
Fats The body of the average athlete contains
More than 95% of the fat in foods is in the only enough stored fat to support exercise
form of triglycerides. Fat is separated from for 119 hours, enough stored muscle glyco-
other foodstuffs in the stomach, but it is not gen for11/2hours, and enough stored liver
degraded until it is emulsified (dispersed in glycogen for 6 minutes. Table 6-3 shows
water) by bile salts in the small intestine. how limited the stores of carbohydrates are
The fat globules are then hydrolyzed by pan- and how extensive the fat stores are.
Table 6-2. GLYCEROL AND FATTY ACIDS

C-C-C-C • • • C-C-COOH C-OH C-C-C • • • C-C-COOH
| |
C-C-C-C • • • C-C-COOH * C-OH + C-C-C • • • C-C-COOH
i1 i
C-C-C-C • • • C-C-COOH C-OH C-C-C • • • C-C-COOH
TRIGLYCERIDE , GLYCEROL + FATTY ACIDS
Table 6-3. MAXIMAL BODY STORAGE swimming performances. It is likely that the
CAPACITY FOR CARBOHYDRATES AND insulating properties of fat, rather than the
FATS7 glycogen-sparing effect, gave them an ad-
Weight of Available vantage. Loss of body heat is a major prob-
Storage Site Tissue (g) Energy (kcal) lem in distance swimming. Furthermore,
having extra fat raises a swimmer higher out
Muscle glycogen 125-300 500-1200
Liver glycogen 50-100 200-400
of the water and reduces drag (see Chapter
Body fat 6000-15,000 50,000-140,000 4).
ENDURANCE
Comparing Women and Men
At the same level of fitness, the average Endurance is the ability to continue exer-
woman has 7% to 10% more body fat than the cising muscles for an extended period of
average man. For example, top female mar- time. To continue exercising, muscles re-
athon runners have 12% to 20% body fat, quire energy, the major sources of which are
compared with 5% to 10% for their male triglycerides and glycogen in muscles and
counterparts. triglycerides and glucose in blood.
Muscles use primarily fats and carbohy- The main advantage of fats is that the
drates as their energy sources. At rest, mus- body can store vast amounts. The main ad-
cles use mostly fats for energy. During ex- vantage of carbohydrates is that they can be
ercise, muscles use more carbohydrates, utilized under anaerobic conditions. Fat me-
with a higher percentage of carbohydrates tabolism always requires oxygen. As exer-
and a lower percentage of fat being used as cise intensity increases, the percentage of
the intensity of the exercise is increased. In energy derived from muscle glycogen also
spite of their increased percentage of body increases. Much of the exercise during most
fat, women use the same percentage of fat as competition events is done at maximum or
men through all intensities of exercise. For near-maximum intensity. The limiting factor
example, at race pace for the marathon, top for exercising at an intensity greater than
male and female runners have been shown 70% of Vo2max is the amount of glycogen
to derive the same 50% of their energy from that muscles can store.12
fat,8 and top female athletes have not dem-
onstrated greater endurance than male ath- "Hitting the Wall": Depletion of
letes. Muscle Glycogen
In running events from 100 to 1500 meters,
world records for women are 7% to 10% Muscle endurance depends on the ade-
slower than those for men.9,10 In running quacy of muscle glycogen stores. Depletion
events from 1500 meters to the marathon, of muscle glycogen causes pain and fatigue
world records for women are 13% to 15% and causes an athlete to lose much of her
slower than those for men.11 The extra fat strength and to have difficulty coordinating
that most women carry slows them down muscle movements. Athletes refer to this as
during running. However, having extra fat is hitting the wall, a common occurrence in
an advantage during swimming. Penny Dean marathon runners after they have raced
of California set the world's record for men more than 18 miles. The more glycogen that
and women for a single crossing of the En- can be stored in a muscle, the longer it can
glish Channel in 7 hours and 40 minutes (in be exercised. Recent research has called
1978), and Cynthia Nichols of Canada set the into question this explanation. Since bicycle
record for a double crossing at 19 hours and racers run out of their muscle glycogen after
12 minutes (in 1977). Their extra fat may 2 hours of racing and do not "hit the wall,"
well be the reason for their great endurance another explanation would be more feasible.
The most likely cause is that hard running After the athlete eats, her muscles fill with
damages the fibrous connective tissue in glycogen, and this reduces production of
muscles, while the smooth rotary motion of glycogen synthetase. Therefore, the effects
pedalling does not. of depletion training are short-lived, and de-
pletion training should be repeated at fre-
"Bonking": Depletion of Liver quent intervals. However, athletes usually
do not perform depletion training more fre-
Glycogen
quently than once a week, because depletion
Brain endurance depends on circulating of muscle glycogen leads to increased utili-
glucose. More than 98% of the energy for the zation of muscle protein for energy. This
brain is derived from blood glucose, which damages the muscle, delays recovery, and
depends on hepatic glycogen stores for limits the amount of intense training the ath-
maintenance. When the blood concentra- lete can accomplish.
tion of glucose falls to low levels, the athlete Many recreational athletes do not appre-
may feel very tired and can suffer from a syn- ciate the importance of depletion training
copal episode or seizures or both. Athletes and enter marathons before they have put
refer to this as "bonking." Bicyclists who do this training technique to adequate use. As a
not eat during endurance races may experi- result, they have inadequate muscle glyco-
ence this after 4 or more hours of cycling. gen stores to enable them to run the neces-
sary distance.
INCREASING ENDURANCE
UTILIZING FAT INSTEAD OF
An athlete can improve endurance by GLYCOGEN
using training methods and dietary manip-
ulations that increase muscle glycogen stor- In addition to depletion training, other
age and decrease muscle glycogen utiliza- techniques that have been promoted to de-
tion by increasing fat utilization.13 crease glycogen utilization by muscles dur-
ing exercise include eating a high-fat diet for
Training to Increase Endurance several days prior to competition, taking nu-
tritional supplements, and taking sympatho-
To improve the ability of muscles to store mimetic agents.
increased amounts of glycogen13 and utilize At least one study showed that eating a
increased amounts of fat (and less glyco- high-fat diet for several days prior to com-
gen),14 athletes use a training technique petition will increase muscle utilization of
called depletion. They exercise until muscle fat. However, endurance was not improved
glycogen has been nearly depleted (Table by this technique.16,17 It is not unusual for
6-4). This causes muscle cells to increase blood glucose concentrations to fall as low
production of glycogen synthetase, which as 30 mg/dL during vigorous exercise. Eat-
increases glycogen synthesis and, in turn, ing a high-fat diet does not reduce muscle
glycogen storage.15 glycogen utilization or prevent the devel-
opment of hypoglycemia (with or without
symptoms) during exercise.17
There is no evidence that taking large
Table 6-4. AVERAGE TIMES FOR MUSCLE amounts of any vitamin, mineral, protein, or
GLYCOGEN DEPLETION IN ELITE.
ATHLETES carbohydrate will cause muscles to increase
l
their utilization of fat.18
Marathon runner A-2Vih Claims have been made that carnitine
Bicycle racer 4-6 h
Cross-country skier 10-12 h
supplements enhance endurance. Carnitine
is a protein that transports fat into mito-
chondria, where fat is catabolized for en- bodies process foods in the same ways. An
ergy. However, there is no evidence that any athlete can increase her endurance by eat-
supplement will increase mitochondria! fat ing the right meals 3 days before, the night
content enough to increase fat utilization. before, or several hours before competition.
Myocytes and hepatocytes synthesize large
amounts of carnitine from lysine and methi-
onine, and human myocytes contain enough
Food Intake during the Week
carnitine to support fat metabolism even
before Competition
under extreme exercise conditions.19 The In 1939, Scandinavian researchers
fact that most athletes include meat, fish, or showed that eating a high-carbohydrate diet
chicken—rich sources of carnitine—in their for several days before a competitive event
diets provides another reason why athletes increases muscle glycogen stores and en-
do not need carnitine supplements. durance, while a low-carbohydrate diet de-
Caffeine raises blood triglyceride levels creases muscle glycogen stores and endur-
by increasing catecholamine production ance.22 In the mid-1960s, other investigators
and sensitivity. Catecholamines increase proposed a method of "carbohydrate load-
triglyceride utilization by promoting free ing" that was practiced by many endurance
fatty acid release from adipocytes and up- athletes throughout the world.23,24
take by myocytes. Taking caffeine prior to
1 Seven days prior to competition, the
workouts has been shown to increase en-
athlete performs a long depletion work-
durance in training sessions by increasing
out.
muscle utilization of fat,20 but it has not been
2 For the next 3 days, she keeps the gly-
shown to increase endurance in competi-
cogen content of her exercised muscles
tion. A possible explanation for this differ-
low by eating a low-carbohydrate diet.
ence in responses is that caffeine may be ef-
3 For the next 3 days, she eats her regular
fective in prolonging endurance only when
diet plus extra carbohydrate-rich foods.
endogenous catecholamine levels are low.
In a laboratory setting, athletes may be re- Athletes should not ingest extra carbohy-
drate for more than 3 consecutive days. In
laxed and have low circulating levels of cat-
echolamines. Raising catecholamines in thisthat time, muscles and liver will be at their
situation may enhance performance. How- maximum capacity for storing glycogen, so
ever, prior to competition most athletes no additional glycogen can be stored. In ad-
have very high levels of catecholamines. dition, carbohydrate packing should not be
Raising their levels further may not help used in events lasting less than 60 minutes,
them and, indeed, may harm them. Large because it will not be helpful and may even
amounts of catecholamines can cause trem- be harmful. 25 The muscles of trained athletes
ors and irritability. are not depleted of glycogen in so short a
Seven days of supplementation of a high-time. Carbohydrate packing may reduce per-
carbohydrate diet with dihydroxyacetone formance in events requiring great speed
and pyruvate has been shown in one study over short distances, since each gram of gly-
to increase endurance.21 Further studies are
cogen is stored with almost three additional
needed before this practice can be acceptedgrams of water, making the muscles much
as an effective means of increasing endur- heavier than usual.
ance. Few top athletes practice this 7-day regi-
men today because it can hinder perfor-
mance. During the depletion phase, the ath-
DIET AND ENDURANCE lete cannot train properly and usually is
irritable and unable to perform mental tasks
Female athletes should follow the same effectively. During the high-carbohydrate
nutritional principles as men, since their phase, the ingestion of vast amounts of car-
bohydrates has been reported to cause evening prior to competition does not seem
chest pain,26 myoglobinuria, and nephritis.27 to hinder performance and may actually
However, these side effects are rare. Marked help it. However, more research is needed
overeating raises blood lipid levels, and this to resolve this question.
can lead to occlusion of the coronary arter-
ies in exercisers who already have signifi- Eating the Meal before
cant arteriosclerosis. Furthermore, this reg- Competition
imen has not been shown to be more
effective than simply reducing the workload The major function of the precompetition
and ingesting some extra carbohydrates.28 meal is to maximize hepatic glycogen (see
As a result of all of these concerns, most Table 6-5). Serum glucose is sufficient to
top athletes in endurance sports avoid the support brain function for only 3 minutes.
low-carbohydrate phase and modify the To prevent hypoglycemia, hepatocytes must
high-carbohydrate phase. The runner can release glucose constantly. However, there
maximize muscle glycogen by a combina- is enough glycogen in hepatocytes to last
tion of reducing her workload and eating a only 12 hours when the athlete is at rest.32
regular diet that contains at least 55% of its Obviously, during exercise, liver glycogen is
calories from carbohydrates.29 The 7-day depleted much faster than that.
carbohydrate-packing regimen thus is
changed to eating a high-carbohydrate diet Timing of Meal
and stopping intense exercise 4 days prior
to competition. To maximize hepatic glycogen stores, the
precompetition meal should be ingested 5
or fewer hours before competition. If the
Eating the Night before meal is eaten more than 5 hours before com-
Competition petition, the hepatocytes will be depleted of
On the night before a competitive event, a considerable amount of stored glycogen
many athletes eat a high-carbohydrate and will have less than maximal glycogen
meal. The primary purpose of this meal is to stores when the athlete starts competition.
increase muscle glycogen stores (Table 6- Several previous studies showed that eating
5). The pregame meal cannot serve this sugared food just before competition in-
function, since it takes at least 10 hours to creased an athlete's chances of developing
replenish muscle glycogen stores.30 postprandial hyperinsulinemia, which can
It is controversial whether muscle glyco- cause hypoglycemia.33 However, the vast
gen storage is promoted more by ingestion majority of recent reports conclude that pre-
of starch or monosaccharides and disaccha- event glucose consumption can cause re-
rides. One recent study showed that a high- duced blood glucose levels during exercise,
monosaccharide and high-disaccharide diet but it has no effect on endurance.34,35 The
caused more muscle glycogen to be stored brains of well-conditioned athletes can con-
than did a high-starch diet.31 Based on these tinue to function at lower blood sugar levels
findings, ingestion of simple sugars on the than those of unfit individuals.
At rest, blood glucose levels as low as 25
mg/dL usually cause a deterioration in brain
function and loss of consciousness. How-
Table 6-5. PRIMARY FUNCTION OF ever, physically fit individuals can usually
MEALS BEFORE AN AFTERNOON
COMPETITION tolerate such levels during exercise without
developing any symptoms at all,36 even
Supper (the day before): To increase muscle glycogen though they are using up their muscle gly-
stores
Breakfast: To increase hepatic glycogen stores
cogen stores at an accelerated rate37 and will
feel fatigue sooner than usual.38
Composition of Meal just prior to exercising. It is speculated that,

when pain does occur, it is due to stomach
Precompetition meals should be high in muscle spasms, which result from ischemia
carbohydrates. It does not make any differ- caused by the shunting of blood from the
ence whether the meal is also high in fat. A stomach muscles to the exercising mus-
combination of a high-carbohydrate meal 4 cles.40 During exercise, gastric motility in-
hours before exercise and around 50 g of creases,41-43 and splanchnic blood flow de-
carbohydrate 5 minutes before exercise can creases.44
increase glycogen stores and maximize en- A drug company has advertised that tak-
durance.39 The athlete can eat any foods she ing fructose before exercise, compared to
likes, as long as she suffers no discomfort glucose, results in a much lower rate of mus-
and has an empty stomach by the time she cle glycogen depletion, because fructose
starts to exercise (Table 6-6). does not cause a rapid rise in either blood
Theoretically, fat and protein are poor sugar or insulin.45 However, there is no evi-
choices for the precompetition meal. Fat de- dence that eating fructose prior to exercis-
lays stomach emptying, and the urea and ke- ing offers any advantage over eating nothing
tones released by the catabolism of protein at all, and there is evidence that eating fruc-
can promote diuresis. However, no con- tose is less advantageous than eating noth-
trolled studies have demonstrated adverse ing at all. It is true that fructose ingestion
effects from fat or protein in precompetition may cause a lower rise than glucose in blood
meals, and many athletes can tolerate high- glucose and insulin levels,46,47 but eating
fat and high-protein precompetition meals fructose does cause an increase in circulat-
without having their performances hin- ing glucose and insulin levels, whereas eat-
dered. ing nothing does not. Fructose ingestion
also causes a greater rate of muscle glycogen
Eating Before Exercising utilization, compared with eating noth-
ing.48,49 The fact that fructose costs 15 times
Provided that the exercise is not too in- as much as glucose offers an added disad-
tense and the amount of food eaten is not too vantage.
great, most exercisers will not suffer from
abdominal pain or discomfort when they eat
Eating During Competition
Table 6-6. EXAMPLES OF

It is not necessary for most conditioned
PRECOMPETITION MEALS THAT PASS athletes to eat during events that last less
RAPIDLY FROM THE STOMACH than 2 hours. However, athletes can benefit
from eating during events lasting longer
Break fast #1
than that. The abilitity of exercising muscles
Breakfast cereal with milk to utilize ingested carbohydrates in place of
A few small pieces of fruit
Toast with butter muscle glycogen is dependent on condition-
1 cup of coffee ing. The higher the level of fitness, the better
1 glass of milk able the athlete is to utilize ingested carbo-
No more than 1A glass of orange juice hydrates during exercise.50
Break fast #2 In contrast to ingestion of food before ex-
Pancakes ercising, ingestion of food during exercise
A small pat of jelly does not cause significant pancreatic output
Breakfast cereal of insulin. At rest, eating causes hypergly-
Milk or coffee cemia, which promotes insulin release.
Glass of water However, during exercise, muscles remove
1/2 glass of fruit juice or a small piece of fruit
glucose so rapidly from the circulation that
Nutrition for Sports Ill
blood levels of glucose rarely rise high the week prior to competition by doubling
enough to induce significant insulin release her daily intake of fluid for 1 week. An in-
from the pancreas.51 Insulin-induced hypo- crease from 1 L to 2 L can increase blood vol-
glycemia caused by eating during intense ume by 10%.60 The extra fluid is not lost com-
exercise does not occur.52 pletely as urine.
Almost any food can be used for energy. She can also increase her intake of fluids
When taken during exercise, glucose has not during exercise by distending her stomach
been shown to be more effective than table with a large amount of fluid just before she
food in prolonging endurance. Studies com- competes. If she drinks 600 mL of water just
paring glucose with fructose offer conflicting before competition, almost 400 mL will pass
results. One study showed that neither glu- into the intestines in 20 minutes.61 Then she
cose nor fructose is better than placebo in should try to ingest 3 oz (about 90 mL) of
reducing muscle glycogen utilization.43 An- water every 10 minutes.
other study showed that fructose has a
greater muscle-glycogen-sparing effect,53
while a third study showed that glucose has DRINKING DURING
a greater glycogen-sparing effect.54 COMPETITION
Any maneuver that causes muscles to in-
crease the rate at which they utilize fat for Although most fit athletes do not gain any
energy theoretically should help to con- advantage from eating during competition in
serve muscle glycogen and prolong endur- events lasting less than 2 hours, they can al-
ance. A high-fat diet has been shown to in- ways benefit from keeping themselves ade-
crease endurance in rats,55 but neither a fatty quately hydrated. Competitive runners and
meal nor glycerol has been shown to pro- swimmers can lose approximately \1A L of
long endurance in humans.56,57 fluid during an intense 1-hour workout. Al-
Ten years ago, maltodextrin glucose poly- though athletes exercising in warm, humid
mer solutions, Exceed (Ross Laboratories, environments can see their sweat and ap-
Columbus, Ohio) and MAX (Coca-Cola), appreciate their obvious fluid loss, those ex-
peared to enhance endurance in events last- ercising in water sports may not be able to
ing longer than 2 hours.58 The polymers in perceive that this loss has occurred.
these drinks are composed of five glucose
molecules and seemed to supply calories at
a low osmotic pressure, thereby not delay- Dehydration and "Heat
ing absorption and resultant glucose utili- Cramps"
zation. However, recent data show that they
are not superior to free glucose for maintain- As the athlete becomes progressively
ing hydration and blood glucose levels, and more dehydrated, her blood volume de-
they have not been shown to increase en- creases. There may not be an adequate vol-
durance.59 ume of circulating blood to carry heat from
exercising muscles to the skin, where the
heat can be dissipated, and, at the same
DRINKING BEFORE time, to carry oxygen to heavily exercising
COMPETITION muscles. Reduced cutaneous blood flow will
raise body temperature, and this will impair
The maximal amount of fluid that can be performance. The decreased blood volume
absorbed during exercise is 600 to 800 can also limit the amount of blood that flows
mL/h. No matter how much fluid an athlete to the most heavily exercising muscles. The
ingests during competition, she will not be resultant hypoxia can cause sustained pain-
able to absorb enough to keep up with her ful muscle contractions, known as heat
losses. She can increase hydration during cramps.62
Women May Need Less Fluid What to Drink

than Men Adequate hydration will usually prevent
Earlier studies showed that men have bet- heat cramps and hyperthermia. Water is the
ter tolerance than women for exercising in preferred drink to be taken during exercise
the heat. However, these studies did not lasting less than 1 hour. Extra calories64 and
compare men and women exercising at com- minerals65 are usually not needed. With ad-
parable percentages of their Vo2max. More equate dietary intake, the athlete will store
recent studies have shown that women are enough hepatic and muscle glycogen to last
able to tolerate exercise in the heat as well 1 hour.64,65 Athletes who exercise longer than
as men, provided that they both have the that need energy sources and minerals also.
same Vo2max.63 The rules for energy-containing fluids have
During exercise, women perspire less changed dramatically in the last few years.
than men of the same fitness level,63 but In 1968, studies showed that 2.5% was the
there is no evidence that women tolerate ex- highest concentration of sugar that could be
ercise in the heat better than men. There- contained in an exercise drink and still be
fore, female athletes should take the same absorbed.66,67 This posed a problem because
precautions as men to ensure that they are drinks taste best when they contain a 7% to
adequately hydrated during hot-weather ex- 10% concentration of sugar. Soft drinks and
ercise. fruit juices contain 7% to 10% sugar. Soon
after these studies, many exercise drinks
containing 2.5% sugar appeared on the mar-
ket. They did not taste good because the
When to Drink
concentration of sugar was too low, so some
The athlete should drink before she feels of the manufacturers added saccharin to
thirsty. By the time that she perceives thirst, sweeten the taste.
she already will have lost 1 to 2 L of fluid and Twenty years later, new studies refuted
will not be able to replace that deficit while the 1968 report. The 1968 data were col-
she exercises. During intense exercise, it is lected on resting subjects. Exercise in-
impossible to absorb fluids as fast as they creases gastric emptying for both solid
are lost. The maximum rate of gastric emp- meals and liquids.68 When the same studies
tying is about 800 mL/h. It is common for were repeated using people who were exer-
competing athletes to perspire as much as cising, 7% to 10% sugared drinks were ab-
2000 mL/h. sorbed rapidly. Based on the most recent
Thirst is a late sign of dehydration during evidence, special exercise drinks are not
exercise because osmoreceptors in the necessary, although many athletes prefer
brain will not signal a thirst sensation until them. All 10% drinks are equally effective in
the blood sodium concentration rises con- supplying energy. A basic 10% sugared drink
siderably. The primary mode of fluid loss may be prepared by dissolving 8 table-
during exercise is sweating. Sweat contains spoons of sugar in 1 L of water. Each table-
some sodium, although it is hypotonic in spoon of sugar contains 12 g of sucrose.
comparison to blood. As sodium is secreted Drinks with low levels of minerals are ab-
into sweat, the serum sodium level rises sorbed slightly more quickly than pure
more slowly than if water alone were lost. As water, but the difference is not significant.
a result, significant amounts of fluid are lost Mineral loss through sweat occurs so slowly
before hypernatremia develops enough to that conditioned athletes rarely develop hy-
cause thirst. Therefore, on a warm day, the ponatremia, hypokalemia, or hypocalcemia
athlete should drink a cup of cool water just during exercise.65 In fact, the opposite is
before she starts to exercise and every 15 more likely to occur. Serum sodium and po-
minutes during exercise. tassium levels rise during exercise and do
not fall unless the exercise is intense and Table 6-7. IMMEDIATE
prolonged. Increased serum sodium levels POSTCOMPETITION MEAL TO PREPARE
are due to the loss of sweat, which is hypo- FOR ANOTHER COMPETITION WITHIN A
FEW HOURS*
tonic in relation to blood. Increased serum
potassium levels are due to release of potas- Food Carbohydrate
sium from myocytes, preventing overheat-
1 orange 10 g
ing of muscles during exercise. Blood cal- 1 slice of bread 13 g
cium levels usually are not altered during 2 chocolate chip cookies 12 g
exercise. Magnesium levels in blood de- 1 banana 30 g
crease slightly during exercise, but this is 1 12-ounce soft drink 35 g
due primarily to cellular uptake of magne- No fluid restriction
sium and not to a significant loss of magne- *A 50-kg woman needs 75 to lOOgofCHO.
sium from the body.69,70
In events such as gymnastics, track and

Cold or Warm? field, wrestling, and swimming, athletes may
In the 1960s, studies showed that cold be scheduled to compete in several events
drinks (4°C) are absorbed faster and are less on the same day. It is very important for
likely to cause abdominal cramps than warm them to drink and eat immediately after they
ones.67 The theory was that cold water finish each event. Even if they rehydrate
causes the stomach to contract and push flu- completely (as evidenced by a return to nor-
ids rapidly into the intestines. However, mal weight), it will still take 4 to 5 hours for
more recent studies show that temperature the water to redistribute among the body
does not make much difference.71,72 Further- fluid compartments.79 Delaying carbohy-
more, carbonated drinks are absorbed as drate ingestion % hour markedly delays
rapidly as noncarbonated ones.73 muscle glycogen replenishment.80 The rec-
ommended amount of carbohydrate inges-
tion for immediate maximal rate of replen-
EATING AND DRINKING AFTER ishment is 1.5 g/kg of body weight81 (Table
COMPETITION 6-7). Doubling that amount does not in-
crease glycogen replenishment further.
Much of postcompetition tiredness is due
to depletion of muscle glycogen stores and
dehydration. Recovery from vigorous exer- PROTEIN REQUIREMENTS
cise depends on muscle glycogen replenish-
ment and rehydration.74 It makes no differ- When adjusted for weight, protein re-
ence whether such replacement is quirements are the same for men and
accomplished by eating simple sugars or women. The protein requirement of 0.8 g/kg
complex carbohydrates.75,76 Fructose offers body weight per day is based on body mass.
no advantage over other carbohydrates, as It is increased significantly by reduced ca-
glucose causes more rapid muscle glycogen loric intake, but had previously been felt to
restoration than fructose does.77 Carbohy- be increased only slightly during exer-
drate intake in athletes averages around 250 cise.82-84 However, several recent studies
g/d. This is far too little to afford maximal using leucine turnover measurements seem
glycogen replacement. It takes at least 600 to show an increase of up to 20% in protein
g/d of carbohydrate for maximum compen- turnover during aerobic exercise.85,86 The
sation. Therefore, it is important for athletes case for increased protein needs during ex-
to eat carbohydrate-rich meals after com- ercise is supported further by other studies
petition.78 showing increased excretion of 3-methyl
histidine,87 increased urea nitrogen losses,87 tein (1.3 X 100) or 160 g of lower-quality
and depression of protein synthesis.88 protein in a week. This is accomplished by
Further research is necessary before pro- eating the equivalent of only 2 cups of corn
tein can be considered a significant source and beans per day.
of energy during exercise.89 Studies show an Since the body cannot store extra protein,
increased utilization of only the branched- the excess is catabolized into ammonia and
chain amino acids, leucine, isoleucine, and organic acids, much of which is excreted in
valine. This does not make a strong case for the urine. These compounds act as diuretics
increased protein utilization during exer- and, during exercise in hot weather, can
cise. The branched-chain amino acids are cause dehydration and increase the risk of
degraded by active skeletal muscles to re- heat stroke.94 Ingesting excessive amounts
lease nitrogen, which is combined with py- of protein can also increase calcium require-
ruvate in muscles to form alanine. The liver ments by increasing urinary loss.95 While
removes nitrogen from alanine to form glu- this is probably of little significance to most
cose, as a source of energy. However, turn- women, it may accelerate bone loss in hy-
over rates for amino acids that are not poestrogenic female athletes. Taking more
branched chain, such as lysine, are unaf- than 4 g of extra protein per kilogram per
fected by exercise,90 nitrogen losses are not day can also cause loss of appetite and di-
consistently elevated during and after exer- arrhea.
cise,90 and no loss of muscle mass can be de-
tected during exercise.90 VITAMINS
Taking extra protein does not increase
protein turnover rates in exercisers,91 but Sixty million Americans, or 37% of the
when combined with a heavy resistance adult population, take vitamin supple-
program, it was shown to increase protein ments.96 More women (42%) than men
retention slightly.92 In that study, an extra 2 (31%) take vitamins, presumably because
g of protein supplements per kilogram per they are more health conscious than men.
day was added to the subjects' usual intake Three out of four Americans think that tak-
of 1.3 g. The vast majority of the extra pro- ing extra vitamins will give them more en-
tein was oxidized for energy, with only a ergy.97 One out of five believes that lack of vi-
small amount retained in lean tissue. tamins causes arthritis and cancer,98 and
The sole stimulus to make a muscle one out of 10 does not know that vitamin re-
stronger is to exercise that muscle against quirements can be met without taking sup-
resistance. This stimulus is so strong that plements.99 Although 10% may seem like a
muscles can be enlarged and strengthened small part of the population, this figure sig-
by proper resistance training, even if a sub- nifies that 25 million Americans believe that
ject is fasting or losing weight and if all of her they have to take vitamin supplements to be
other muscles are becoming smaller.93 healthy.
It does not take much extra protein to sup-
ply amino acids for enlarging muscles. An
Mechanism of Function
athlete with an excellent strength-training
program may gain 1 Ib of muscle in a week. A vitamin is an organic compound that the
Since muscle is 72% water, 1 Ib of muscle body requires in small amounts for health.
contains only about 100 g of protein. How- While the exact mechanisms of function for
ever, the loss of efficiency in high-quality several vitamins are not completely under-
protein utilization is around 30% and in stood, much is known about the function of
poorer-quality protein, around 60%. There- the B vitamins, which are parts of enzymes.
fore, to build 100 g of extra protein, the ath- Because the enzymes containing these vita-
lete must consume 130 g of high-quality pro- mins are required in only small amounts,
they catalyze reactions without being de- These four vitamins catalyze the reactions
pleted. that convert carbohydrates and protein to
The B vitamins enter the cells that are to energy.105 For example, heavy exercise can
use them. Such cells produce apoenzymes, increase riboflavin requirements by as
which combine with the vitamins to form much as 17%,105 but the total daily needs for
holoenzymes. Cells produce only limited riboflavin can be met by drinking three
amounts of apoenzymes, leaving unbound B glasses of milk. The total needs for all four
vitamins in excess. The Recommended Di- "energy" vitamins can be met by eating a
etary Allowances (RDAs) for B vitamins, de- varied diet that contains more than 2000 cal-
termined by the Food and Nutrition Board ories per day, because all four of these vita-
(FNB) of the National Research Council of mins are found in meat, fish, chicken, milk,
the National Academy of Sciences, "are the and whole grains.
levels of intake ... adequate to meet the Although the refining process removes
known nutritional needs of practically all thiamine, niacin, riboflavin, and panto-
healthy persons."100 It also represents the thenic acid from flour, most manufacturers
amount of B vitamins that will saturate the routinely add these vitamins in order to
apoenzymes of the target cells.100 Ingesting comply with interstate shipping laws. Thus,
more vitamins does not increase the rate of athletes who eat breads made from refined
reactions, because cellular apoenzymes are flour rarely need supplements containing
the limiting factor. these "energy vitamins."
To help your patients understand why ex-
cess dosages of B vitamins are not needed,
you can use the following analogy offered by Vitamin C and Colds
Herbert and Barrett.101 Consider the human Some athletes take large doses of vitamin
body to be like a traffic intersection. Many C in the hope that it will help to protect them
cars (chemical reactions) pass through the from developing upper respiratory infec-
intersection, but only one police officer (vi- tions. However, virtually all double-blind
tamin) is necessary to direct traffic. Bringing studies on the subject show that vitamin C
in many police officers (excess vitamins) does not prevent colds.106
will not cause more cars (chemical reac-
tions) to pass through the intersection.
Vitamins and Birth Control Pills
Vitamin Needs of Female Whether women who take oral contracep-
Athletes tives require vitamin supplementation re-
mains controversial.107-109A review of the lit-
The diets of athletes who take in more erature shows that, on the average, women
than 2000 calories per day usually supply vi- who take birth control pills have lower
tamins in amounts greater than their serum levels of riboflavin, pyridoxine, fola-
RDAs.102 People who try to control their cin, cyanocobalamin, and ascorbic acid and
weight usually restrict their intake of food, higher body levels of vitamin K.109 However,
and this can lead to an intake of vitamins their tissue levels110 and blood levels111 are
that is less than the RDA. However, the still within the normal range. There is no ev-
RDAs are set so far above minimum require- idence that such women are more likely to
ments that dieters rarely develop signs or develop clinical symptoms of vitamin defi-
symptoms of vitamin deficiency, even if they ciency. Since birth control pills increase the
do not meet the RDAs.103 need for these vitamins only a small per-
Prolonged exercise can increase require- centage, if at all, it seems unlikely that vita-
ments for thiamine, niacin, riboflavin, and min requirements change appreciably be-
pantothenic acid beyond their RDAs.104 cause of oral contraceptive use.
Vitamins and Premenstrual Table 6-8. Minerals

Syndrome
Major Trace
Strength, speed, endurance, and coordi-
Calcium Fluorine
nation have not been shown to vary consis- Phosphorus Silicon
tently throughout the menstrual cycle. Fe- Chlorine Vanadium
male athletes report greater perceived Potassium Chromium
exertion premenstrually. Premenstrual syn- Sulfur Manganese
drome (PMS) is discussed more thoroughly Sodium Iron
Magnesium Cobalt
in Chapter 13. Nickel
Several investigators have suggested that Copper
nutritional factors play a role in PMS and Zinc
have proposed dietary therapy for this syn- Selenium
drome. Pyridoxine has been touted as a Molybdenum
Tin
treatment for PMS, because it is claimed to Iodine
raise serotonin levels in the brain. Pyridox-
ine is a coenzyme for 5-hydroxy-tryptophan
decarboxylase, which catalyzes trypto-
phan's conversion to serotonin. High levels ments which contain iron. Most healthy
of serotonin are associated with mood ele- people can take iron supplements without
developing obvious toxicity.124 However, a
vation; low levels are associated with de-
pression. There is no evidence, however, recent study from Finland124a showed that
that PMS sufferers have low brain levels of high stored iron levels may increase a per-
serotonin or that giving extra pyridoxine son's chances of developing a myocardial
will raise brain levels. Two studies showed infarction. It is proposed that free iron cat-
alyzes free radical production which con-
that taking pyridoxine improves PMS symp-
toms,112,113 while another showed no im- verts LDL cholesterol to oxidized LDL to
provement.114 Although many women conform arteriosclerotic plaques in arteries.
Iron supplements can harm people who
sider pyridoxine, in any dosage, to be
have hereditary disorders of iron metabo-
harmless, large doses of pyridoxine have
been reported to cause neural toxicity.115,116 lism, such as hemochromatosis and por-
phyria.
As many as one out of every four female
MINERALS athletes is iron deficient.117 Men and non-
menstruating women need about 12 mg of
The major minerals are listed in Table 6- iron per day. The average man ingests ade-
8. Iron and calcium are the only supple- quate iron from dietary sources alone. The
ments that healthy female athletes may average woman ingests around 12 mg of iron
need to take. An adequate diet can provide per day, but menstruating women need 18
adequate amounts of all minerals, but many mg of iron per day, the extra 6 mg needed to
diets are deficient in these two. replace the iron that is lost through men-
strual bleeding. Birth control pills reduce
iron requirements by decreasing menstrual
Iron blood loss and increasing iron absorption.118
Because of the high prevalence of iron de- Iron deficiency, even in the absence of
ficiency among female athletes and because anemia, can impair endurance.119 Approxi-
of its detrimental effect upon performance, I mately 40% of the iron in the body is in the
recommend that female athletes who have iron reserves, such as the liver, bone mar-
ferritin levels below 25 take daily supple- row, and spleen. The rest is contained in he-
ments containing 30 to 60 mg of elemental moglobin. Iron-deficiency anemia does not
iron. All others should avoid all supple- occur until almost all of the iron reserves are
depleted. Iron deficiency reduces the con- and vitamin D all help to prevent osteopo-
centration of a-glycerophosphate oxidase in rosis. Estrogen appears to be the most im-
muscle, and this impairs glycolysis and portant. With adequate calcium intake, es-
leads to lactic acid accumulation in muscle trogen replacement, and exercise, even
and blood.120 An increase in lactate causes a osteoporotic bones can increase in den-
lowering of pH, and this reduces muscular sity.125 Low bone density of any cause in-
endurance.121 People who have iron defi- creases a woman's chances of developing
ciency, even without anemia, have a re- stress fractures during exercise.126
duced rate of lactic acid clearance from the Exercise can enlarge bones and increase
blood, and they tire earlier during exercise. bone density.127,128The bones in the racquet-
Restoring their iron reserves to normal in- holding arm of a tennis player are larger and
creases their endurance.122 denser than those in the other arm. Runners
The most accurate test for detecting iron have denser femoral shafts than rowers,
deficiency is a microscopic examination of dancers, and sedentary controls.129 How-
bone marrow for stained iron. However, ob- ever, exercise will not maintain bone den-
taining marrow is painful, invasive, and ex- sity effectively in women who lack estro-
pensive. A simple, noninvasive screening gen.130 For example, exercise-associated
test for iron deficiency is the measurement amenorrhea is associated with decreased
of serum ferritin. Caution must be used in in- bone density,131 and estrogen replacement
terpreting the results, since inflammation helps to maintain bone density in hypoes-
anywhere in the body can raise ferritin lev- trogenic women.132 Birth control pills do not
els. A person who has an inflammatory pro- affect bone density in women whose bodies
cess may have normal serum ferritin levels produce estrogen.133 Women who have
despite having iron deficiency. Further- higher-than-normal levels of androgens
more, exercise raises serum ferritin levels. have denser bones.134
Patients who have a microcytic, hypochro- Nevertheless, adequate calcium intake is
mic anemia with normal ferritin levels with- essential for maintenance of bone density.
out elevated fetal hemoglobin should have Children who do not ingest adequate
their serum ferritin levels repeated after amounts of calcium during growth have
they stop exercising for a week.123 smaller bones with reduced amounts of cal-
Up to 30% of heme iron, found in meat, cium, and develop osteoporosis at an in-
fish, and chicken, is absorbed, while less creased rate as adults.135,136 Increasing di-
than 10% is absorbed from nonheme iron etary calcium can improve calcium balance
sources. Acidity enhances iron absorption in women who lack estrogen.137 Hypoestro-
from nonheme sources but not from heme genic women require 1500 mg of calcium per
sources. Thus, eating an orange with spin- day to maintain zero calcium balance,
ach enhances iron absorption from the spin- whereas euestrogenic women require 1000
ach, but taking vitamin C with meat does not mg to do so.138 However, estrogen is far more
increase absorption of iron from meat. On effective than dietary calcium in maintaining
the other hand, alkalinity, fiber, and tannins bone density.139 Hypoestrogenic, amenor-
reduce iron absorption from both heme and rheic women who do not have a contraindi-
nonheme sources. For example, taking ant- cation to estrogen replacement therapy
acids, eating fibrous vegetables, or drinking should be treated with estrogen and, if di-
tea or coffee decreases iron absorption from etary calcium is inadequate, calcium supple-
all sources. ments.
The best dietary sources of calcium are
dairy products and soft-boned fish, such as
Calcium
canned salmon and sardines (Table 6-9).
Estrogen, androgenic hormones, exer- Dairy products provide 72% of dietary cal-
cise, dietary calcium, etidronate, calcitonin, cium for the average American.140 Those who
Table 6-9. FOODS THAT CONTAIN Sodium

APPROXIMATELY 250 MG CALCIUM
Most people do not need to consume extra
1 glass milk sodium when they exercise. The require-
1 cup yogurt ment for sodium for people at rest is 0.2 g/d.
1% cups cottage cheese
IHcups icecream With prolonged exercise in very hot
IHozhard cheese weather, the maximal requirement for so-
2 oz sardines with bones dium is approximately 3 g/d. The average
4 oz canned salmon with bones American diet contains between 6 and 18 g
of sodium chloride per day, of which 40% is
sodium (2.4 to 7.2 g). Manufacturers add so-
dium chloride to foods as a preservative,
do not meet their calcium requirements
and some people add sodium chloride to
from diet alone should take calcium supple-
foods to improve the taste. Athletes who try
ments (Table 6-10), unless they are predis-
to limit sodium intake by avoiding salty-tast-
posed to nephrolithiasis. ing foods and by adding no sodium to foods
The Food and Drug Administration has still take in about 3 g of sodium each day.
found significant amounts of lead in some Sodium chloride tablets should not be
samples of bone meal and dolomite.141 Do- given routinely to exercising athletes. Be-
lomite is most frequently harvested from the sides being unnecessary, they can cause
shells of shellfish at the bottom of harbors. gastric irritation, nausea, and, in very large
Dolomite taken from polluted harbors can doses, potassium deficiency.
contain toxic amounts of lead, mercury, ar- Sodium deficiency can occur in healthy
senic, and other heavy metals. Bone meal people because of an inadequate intake of
also may contain significant amounts of sodium or excessive use of diuretics. It can
toxic metals, since it usually comes from the also occur in people with hormonal or renal
bones of older animals.142 With aging, toxic defects. Any exerciser who feels tired and
metals accumulate in the bones of all ani- weak or develops painful muscle cramps
mals, including humans. Because dolomite should have serum levels of sodium mea-
and bone meal are usually sold as food sup- sured. If present, hyponatremia requires a
plements rather than drugs, manufacturers thorough evaluation to determine the cause
are not required by the government to list (e.g., diabetes insipidus, diabetes mellitus,
the heavy metal content of their products. water intoxication, and so on).
Therefore, labels on packages containing Many women who experience premen-
these products do not list their heavy metal strual fluid retention as part of PMS may
content. benefit from dietary sodium restriction at
the times of symptoms during each cycle.
Despite anecdotal reports of the success of
Table 6-10. CALCIUM CONTENT IN 600- this regimen, no scientific studies have as-
MG SUPPLEMENT
sessed its effectiveness.
Number of Pills
% Required to
Content of Pill Mg Calcium Ingest 1 G Potassium
Calcium 240 40 4 Potassium deficiency is an extremely rare
carbonate
Calcium lactate 78 13 12 condition in trained athletes. The kidney
Calcium 54 9 18.5 and sweat glands are highly efficient in con-
gluconate serving potassium in response to low body
Calcium 171 28 6 levels. Even with prolonged exercise in very
phosphate hot weather, potassium needs can be met by
(dibasic)
an intake of only 3 to 4 g/d.143 However, po-
tassium deficiency can occur as the result of They argue that repeated harvesting of
potassium restriction and sodium loading.144 crops depletes the soil of essential minerals.
The only way that one researcher could When the soil in a certain region is deficient
create a low-potassium diet for athletes and in a mineral, the plants and animals that
still provide enough calories for exercise grow in that region will suffer from a defi-
was to feed them candy and little else ciency of that mineral also. That may have
throughout the day. Even then, the athletes been possible in the past, but it is extremely
did not develop potassium deficiency.145 Al- unlikely to occur now. Although it is possi-
most all foods are rich in potassium. Since ble that some soils lack certain minerals, our
potassium is found primarily within cells, transportation system is so extensive and ef-
any food that contains cells also contains ficient that very few Americans eat foods
potassium. grown only in a single locality. It is impos-
Hypokalemia always requires a thorough sible for all soils to be deficient in the same
evaluation to determine the cause. Potas- single mineral.
sium deficiency can be caused by drugs, Oral contraceptive agents may reduce re-
such as diuretics and corticosteroids, and quirements for copper slightly and raise
certain foods, such as licorice. Prolonged di- those for zinc, but there is no evidence that
arrhea and vomiting also can cause potas- the latter is enough to require supplemen-
sium deficiency (Table 6-11). With diarrhea, tation. Women who take birth control pills
potassium is lost in the stool. With vomiting, have higher serum levels of copper and
loss of hydrogen ions causes a metabolic al- lower levels of zinc than those who do not
kalosis, which increases potassium loss in take such pills.146,147 Estrogen is thought to
the urine to conserve renal hydrogen ions. raise serum copper levels by increasing
Bulimia can present in athletes as weak- serum ceruloplasmin levels.148 The mecha-
ness and tiredness with laboratory evidence nism by which oral contraceptives lower
of potassium deficiency. If blood samples serum zinc levels is not known.149
show reduced potassium levels, and 24-hour
urine collections contain increased amounts
of potassium, suspect vomiting as the cause. THE ATHLETE'S DIET
Of course, your patients cannot become

Trace Minerals
great athletes just by altering their diets.
Humans require approximately 14 trace They have to choose their parents wisely
minerals in small amounts. There is no evi- and train harder than their competitors.
dence that athletes need trace mineral sup- From the foregoing discussion, it is obvious
plements, with the exception of iron, be- that they can get all the nutrients their bod-
cause trace mineral deficiencies are ies need from the foods they eat. With the
extremely rare in healthy athletes. possible exceptions of iron and calcium, a
Some lay publications for athletes claim female athlete's requirement for nutrients is
incorrectly that trace mineral deficiencies the same as it is for male athletes. The only
are common causes of fatigue in athletes. supplements that are required commonly
are iron and calcium. Taking large doses of
vitamin and mineral supplements can be
toxic. Adverse side effects have been re-
Table 6-11. MECHANISM BY WHICH ported from large doses of even the rela-
VOMITING CAUSES HYPOKALEMIA
tively harmless water-soluble vitamins,
Loss of hydrogen ions such as niacin, pyridoxine, and folic acid. To
Raised blood pH help your patients perform sports more ef-
Renal hydrogen retention fectively, you should recommend that they
Renal potassium loss
eat a varied diet that is rich is carbohydrates
and that they follow the rules for eating and meal on the night before competition, and
timing foods and drinks that are outlined in by eating an easily absorbed meal 5 or fewer
this chapter. hours prior to competition. Maintaining ad-
Several lay books claim that a high-fiber, equate hydration, even before experiencing
low-fat diet will improve athletic perfor- thirst, will also improve endurance. The rate
mance. There is no evidence to support this. of recovery following intense exercise can
In fact, one study showed that exercisers be hastened by eating extra carbohydrates
who ate a diet that contained 10% fat had the and drinking large amounts of fluids soon
same improvement in Vo2max as those who after exercising.
obtained 45% of their calories from fat.150 Vitamin supplementation is not neces-
Nevertheless, you may want to recommend sary, since requirements can be met through
restricting dietary fat, saturated fat, and diet. Healthy athletes do not need to in-
cholesterol because it may help to reduce a crease their intake of sodium, potassium, or
woman's chances of developing coronary trace minerals because the body can usually
artery disease and certain types of cancers compensate for increased loss or decreased
in the future. intake by increasing retention.
Taking into account that foods have nutri-
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ritin and serum iron changes after cross- performance. J Lab Clin Med 92:953, 1978.
country and roller ski endurance races. Eur 139. Riis B, Thomsen K, and Christiansen C: Does
J Appl Physiol 61:55, 1990. calcium supplementation prevent post-
menopausal bone loss? A double-blind, con- 146. Prasad AS, Oberleas D, Lei KY, et al: Effect of
trolled clinical study. N Engl J Med 316:173, oral contraceptive agents on nutrients: I.
1987. Minerals. Am J Clin Nutr 28:377,1975.
140. Marston RM, and Welsh SO: Nutrient con- 147. Schenker JG, Hellerstein S, Jungreis E, et al:
tent of the U.S. food supply. Nat Food Rev Serum copper and zinc levels in patients
25:7, 1984. taking oral contraceptives. Fertil Steril
141. Advice on limiting intake of bonemeal. FDA 22:229, 1971.
Drug Bull 12:5, 1982. 148. Carruthers ME, Hobbs CE, and Warren RL:
142. Roberts NJ: Potential toxicity due to dolo- Raised serum copper and caeruloplasmin
mite and bonemeal. South Med J 76:556, levels in subjects taking oral contraceptives.
1983. J Clin Pathol 19:498,1966.
143. Lane HW, Roessler GS, Nelson EW, et al: Ef- 149. Prasad AS, Moghissi KS, Lei KY, et al: Effect
fect of physical activity on human potas- of oral contraceptives on micronutrients
sium metabolism in a hot and humid envi- and changes in trace elements due to preg-
ronment. Am J Clin Nutr 31:838, 1978. nancy. In Moghissi KS, and Evans TN (eds):
144. Talbot NB, Richie RH, and Crawford JD: Nutritional Impacts on Women Throughout
Metabolic Homeostasis: A Syllabus for Life with Emphasis on Reproduction.
Those Concerned with the Care of Patients. Harper and Row, New York, 1977, p 160.
Harvard University Press, Cambridge, 1959, 150. Kosich D, Conlee R, Fisher AG, et al: The ef-
p32. fects of exercise and a low-fat diet or a mod-
145. Costill D: Muscle water and electrolytes dur- erate-fat diet on selected coronary risk fac-
ing acute and repeated bouts of dehydra- tors. In Dotson C, and Humphrey J (eds):
tion. In Panzkova J, and Rogozkin VA (eds): Exercise Physiology: Current Selected Re-
Nutrition, Physical Fitness and Health. Uni- search, Vol 2. AMS Press, New York, 1986, p
versity Park Press, Baltimore, 1978, p 106. 173.
II
Developmental
Phases
CHAPTER 7
The Prepubescent Female

ODED BAR-OR, M.D.
PHYSIOLOGIC RESPONSE TO Response to Cold Climate

SHORT-TERM EXERCISE High-Risk Groups for Heat- or Cold-
Submaximal Oxygen Uptake Related Disorders
Maximal Aerobic Power
Anaerobic Power and Muscle
GROWTH, PUBERTAL CHANGES,
Endurance
AND ATHLETIC TRAINING
Muscle Strength
TRAINABILITY
COEDUCATIONAL PARTICIPATION
THERMOREGULATORY CAPACITY IN CONTACT AND COLLISION
Response to Hot Climate SPORTS
r ReLecent years have seen an increasing interest in the physiologic response

children to exercise. Such interest reflects the greater participation and success
of prepubescents and adolescents in elite sports, as well as the recognition that
physical exercise is relevant to the health of the nonathletic child.
Although prepubescent athletes of both sexes engage in elite sports, it is pri-
marily the females who have become extremely successful at the national and
international levels. Such success is particularly apparent in gymnastics, figure
skating, and swimming, in which prepubescents have been performing at levels
that, a decade or two ago, were not considered feasible even for adults.
To achieve such excellence, many female athletes have to practice as much
as 4 to 6 hours per day and at high intensity. Such involvement and dedication
has educational, psychosocial, medical, gynecologic, orthopedic, and physio-
logic consequences. These have become a focus of research for sports scientists
of various disciplines.
Exercise-related research is oriented also toward the young nonathlete,
healthy or ill. Study of the healthy child has been of interest, for example, to kin-
anthropometrists, who are interested in growth patterns and the interrelation-
ships between morphologic and functional changes; to epidemiologists, who
assess the possible relationships between habitual activity during childhood
and the risk of chronic disease in later years; to motor behaviorists, who study
motor learning and skill acquisition; and to physiologists, who seek answers to
such maturation-related issues as strength development, energy expenditure of
locomotion, trainability, and thermoregulation.
The relevance of exercise to the ill child has also generated growing interest.
129
130 Developmental Phases
Pediatric cardiologists and respirologists, ysis of relationships between fitness and

for example, are using exercise for the as- growth in girls.
sessment of children with such diseases as
congenital heart defects, bronchial asthma,
and cystic fibrosis; an exercise prescription PHYSIOLOGIC RESPONSE TO
is incorporated into the management of the SHORT-TERM EXERCISE
child with diabetes mellitus, obesity, mus-
cular dystrophy, cerebral palsy, and cystic Differences in the response to short-term
fibrosis; and detrimental effects of exercise exercise (less than a 15-minute duration) of
are studied in such conditions as aortic ste- prepubescent and older females are sum-
nosis, dysrhythmia, primary amenorrhea, marized in Table 7-1. Table 7-2 is a sum-
and epilepsy. mary of gender-related differences in the re-
This chapter is meant to focus on the sponse of prepubescents to short-term
physiologic responses to exercise of the exercise. The following discussion will high-
healthy prepubescent girl. Emphasis will be light those characteristics of the prepubes-
given to differences among prepubescents, cent girl that have a direct relevance to her
adolescents, and young adults. Differences physical performance.
will also be pointed out between the re-
sponses to exercise of girls and boys. When-
Submaximal Oxygen Uptake
ever relevant, the implications to health of
such differences will be pointed out. Typically for young girls, oxygen uptake
It is assumed that the reader has some (calculated per body mass unit) while run-
basic knowledge of exercise physiology. Ad- ning or walking at any given speed is higher
ditional information on pediatric exercise than in adolescent or adult females.1,22-24 A
physiology can be found in monographs, 1-6 5.5-year-old girl, for example, who runs at 10
edited books,7-10 and proceedings of the Pe- km/h, consumes about 46 mL of oxygen per
diatric Work Physiology Group. 11-20 Further- kilogram of body weight per minute, com-
more, a journal (Pediatric Exercise Sciences, pared with 37 m L - k g - 1 - m i n - 1 in a 16-year-
Human Kinetics, Champaign, IL) is available old adolescent. Calculated per body surface
which is fully dedicated to the effects of ex- area, however, such differences disappear.25
ercise in children. A recent monograph21 in- The implication of such a high metabolic
cludes a comprehensive, longitudinal anal- cost is that, at any walking or running speed,
Table 7-1. SOME PHYSIOLOGIC RESPONSES TO ACUTE EXERCISE:COMPARISON

BETWEEN PREPUBESCENT GIRLS AND OLDER FEMALES
Typical for Girls
(Compared with
Physiologic Function Older Females)
O2 cost of walking/running Higher
O2 uptake max, L • m i n - 1 Lower
O2 uptake max, mL • k g - 1 • min -1 Higher
Heart rate submax Higher
Stroke volume submax Lower
Cardiac output submax Lower
Minute ventilation submax Higher
Ventilatory equivalent submax and max Higher
Peak anerobic power, watt Lower
Peak anaerobic power, watt • kg - 1 Lower
Mean anaerobic power, watt Lower
Mean anaerobic power, watt • k g - 1 Lower
The Prepubescent Female 131
Table 7-2. GENDER-RELATED however, there is little change in the Vo2max

COMPARISON OF THE RESPONSE OF of girls up to the age of 10 to 11 years. During
PREPUBESCENTS TO ACUTE EXERCISE the second decade of life, Vo2max per kilo-
Girls' Response gram decreases with age, such that it is ap-
(Compared proximately 4 to 6 mL-kg~'-min - 1 lower at
Physiologic Function with Boys) age 17 to 18 than at age 10 to n.1,2,29'30 It has
O2 cost of walking/running Similar been suggested that the lower Vo2max per
O2 uptake max, L • min~' Somewhat lower kilogram in the pubertal girl is due to the de-
O2 uptake max per kg body weight Somewhat lower crease in blood hemoglobin concentration,
O2 uptake max per kg lean mass Similar secondary to menstrual blood loss. This,
Heart rate submax Higher however, does not explain the drop in
Heart rate max Similar
Stroke volume submax and max Lower Vo 2max per kilogram of body weight even
Minute ventilation submax Similar before menarche. One reason could be the
Minute ventilation max Somewhat lower increasing adiposity of many girls who ap-
Peak anaerobic power, watt Somewhat lower proach puberty.31-33 Decreasing aerobic
Peak anaerobic power, watt • kg - 1 Lower power could also result from an age-related
Mean anaerobic power, watt Somewhat lower
Mean anaerobic power, watt • kg -1
Lower decrease in spontaneous habitual activity in
the second decade of life. 33-37
Although gender-related differences in
maximal aerobic power are apparent pri-
a young girl operates at a higher percentage marily after age 12 to 13 years, boys seem to
of her maximal aerobic power and will fa- have a somewhat 1,2, 33,38- 40
higher Vo2max even at ear-
tigue earlier than an older girl or a woman. lier ages. In a study comparing the
This may be the main reason why young maximal aerobic power of 6- to 16-year-old
girls cannot compete on a par with their girls and boys who were tested on the cycle
older counterparts in middle- and long-dis- ergometer, such gender-related differences
tance running. Such a difference is virtually were eliminated when Vo2max (L-min - 1 )
nonexistent during cycling.26-28 This sug- was plotted against lean leg volume rather
gests that the biochemical-to-mechanical than against age.39 A similar pattern was ap-
energy transfer efficiency in muscles is not parent among 8- to 16-year-old girls and
lower at a young age, but young girls have a boys when W170 (i.e., the mechanical power
more "wasteful" gait, which increases their at which they cycle when their heart rate is
mechanical output and metabolic demands 170 beats per minute) was plotted against
during the gait cycle. No data are available body cell mass.41 It should be realized, how-
on the age-related differences in the meta- ever, that when Vo2max is divided by lean
bolic cost of swimming. The success of leg volume or lean body mass, preadoles-
young girls in elite swimming would suggest, cent boys still have higher values than pre-
however, that a proficient young swimmer is adolescent girls.33 A more precise determi-
not less economical in her style than her nation of body composition is needed to tell
older counterpart. whether gender-related differences in max-
imal aerobic power of prepubescents are
Maximal Aerobic Power fully explained by the mass of their exercis-
ing muscles.
Throughout childhood and adolescence,
maximal aerobic power, as reflected by max-
imal oxygen uptake (Vo2max), increases Anaerobic Power and Muscle
with age. The Vo2max of 5-year-old pre- Endurance
schoolers is 0.80 to 0.90 L-min - 1 compared High-intensity muscle contractions that
with 1.1 to l.5L-min - 1 and 1.6 to 2.2L-min - 1 cannot be sustained for more than 20 to 30
for 10- and 16-year-old girls, respectively.1,2 seconds are dependent primarily on anaer-
Calculated per kilogram of body weight, obic energy pathways. Examples of "anaer-
obic" activities are short and long sprints in tive deficiency of anaerobic power in the
running, skating, and cycling, as well as prepubescent. Children of both sexes have
short slalom in downhill skiing. Until recent lower maximal blood lactate concentration
years, this component of fitness received lit- than do adolescents and adults. It has been
tle attention, compared with maximal aero- reported for boys, but not for girls, that cre-
bic power and muscle strength. This re- atine phosphate and glycogen concentra-
flected the paucity of reliable and valid tions in the resting muscle and, in particular,
laboratory tests for peak muscle power and the rate of glycolysis in the contracting mus-
local muscle endurance. Such tests are cur- cle are low before puberty. (For more de-
rently available, using cycle ergometers or tails, see reference 2.) Based on animal stud-
isokinetic machines. These have been ies, a relationship has been suggested
added to the Margaria step-running test,42 between muscle lactate production and cir-
which assesses peak muscle power but not culating testosterone. Whether this applies
muscle endurance. The following informa- also to humans—females or males—has yet
tion has been obtained using the Margaria to be shown. It can be assumed, however,
test and the Wingate anaerobic test.43 that a low glycolytic capacity in prepubes-
The ability of prepubertal girls and boys cents of both sexes is the main cause of their
to perform anaerobic tasks is distinctly low anaerobic performance.
lower than that of adolescents and young
adults. This was first shown for 8- to 73-year- Muscle Strength
old sedentary Italians: even when divided
by body weight, the peak muscle power of Muscle strength, defined as the maximal
the 8- to 10-year-old girls was only about force that can be exerted by a muscle or a
60% that of the 20-year-old women.42 Similar group of muscles, is similar in girls and boys
results have been shown for Nilo-Hamitic during their first decade of life.33,47 Strength
and Bantu African,44 British,39 American,45 is growth-dependent.33,47-49However, it does
and Israeli2 populations. In the last, peak not increase linearly with the growth in
muscle power and muscle endurance of the body mass or stature. In girls, the main in-
arms and the legs were both lower in the crease in strength occurs during, a few
young girls, even when corrected for differ- months following, or even just before the
ences in body weight. "growth spurt" (i.e., the year during which
The aforementioned pattern is in contrast body height velocity is at its peak). In con-
to maximal aerobic power which, when cal- trast, the increase of strength in boys
culated per kilogram body weight, is higher reaches its peak about 1 year after the
in the prepubescent girl than in the adoles- growth spurt.50,51 This difference, coupled
cent or adult female. with the earlier growth spurt in girls (about
The mechanism for the low anaerobic per- a 2-year difference), may explain why the
formance of prepubescent girls is not greater muscle strength of boys is usually
known. In a recent study performed in my not evident before age 11 or 12 years.
laboratory on adolescent girls and boys,46
lean muscle mass of the upper limb ex- TRAINABILITY
plained much of the variance in arm peak
power and muscle endurance of the boys but Does a prepubescent girl respond to train-
not of the girls. Performance of both prepu- ing in the same manner as an adolescent or
bescent girls and boys in the Margaria test, an adult female? This question is of utmost
even when corrected for fat-free mass, is relevance to the theory and practice of
lower than that of adolescents and adults.44 coaching, but should be of interest also to
It is quite likely, therefore, that qualitative the pediatric physiotherapist and the phys-
characteristics of the muscles, and possibly iatrist who wish to apply physiologic prin-
their neural control, would explain the rela- ciples to rehabilitation.
To obtain definitive answers about train- Few studies are available on the trainabil-
ability (i.e., the ability of body systems to ity of muscle strength at different ages. Niel-
adapt to repeated exercise stimuli) of differ- sen and co-workers49 trained 249 Danish
ent age groups, one must conduct a longitu- girls aged 7 to 19 years for 5 weeks. One sub-
dinal training study on these groups. Such a group did isometric knee extension, another
design must satisfy two conditions: (1) the the "vertical jump," and the third practiced
initial fitness level of all groups must be sim- acceleration in sprints. As in adults, there
ilar and (2) the training dosage must be was specificity in the responses: each sub-
equated among the groups. group improved most in the specific
Unfortunately, neither condition can be strength (but not sprinting) task at which it
adequately satisfied. First, one cannot as- had been training. While the authors did not
sume that a 6-year-old girl who, for example, report the pubertal stage of the subjects, the
sprints 50 m in 11.0 seconds has the same younger girls (less than 13.5 years) im-
sprinting ability as a 16-year-old adolescent proved more than the older ones. Likewise,
who runs at the same speed. A better ap- 8-year-old German girls improved their iso-
proach might be to use a physiologic crite- metric arm strength more than did adults
rion for equating the initial fitness level. One when given a similar training stimulus.57
cannot be sure, however, that a maximal aer- Whether trainability of strength is related to
obic power of 40 m L - k g - 1 m i n - 1 in a 6-year- the pubertal stage has yet to be shown. Most
old girl denotes the same aerobic fitness as research on muscle trainability of children
an identical value in a 20-year-old woman. It is limited to boys. There are indications,
is also fairly difficult to equate training dos- however, that trainability during prepuberty
ages. Can one assume, for example, that is similar in boys and girls.58 This is indirect
weight training at 70% of their maximal vol- evidence that training-induced strength
untary contraction represents the same gains can be achieved without the effect of
physiologic strain in a girl and a woman? androgens.
Because of such methodologic con-
straints, conclusions about the trainability
of young girls are not definitive. Some pat- THERMOREGULATORY
terns, however, seem to emerge. According CAPACITY
to several reports, when prepubescent girls
Most research on the thermoregulatory
take part in aerobic training, they respond characteristics of the exercising child is
with little or no increase in maximal oxygen
uptake, even though their athletic ability based on studies in boys. (For a review, see
may improve.52-55 This is unlike the re- reference 59.) Data are available, however,
to suggest that girls are at a disadvantage,
sponse to aerobic training of women, who
increase their maximal oxygen uptake and compared with women, when exposed to ei-
improve their athletic performance. Only a ther hot or cold climates. Very few data are
few studies have suggested that prepubes- available to compare the responses to heat
cent females do improve their maximal ox- and cold of prepubertal girls and boys.
ygen uptake in response to aerobic train-
ing.56 Response to Hot Climate
A major reason for the improvement of Table 7-3 is a summary of the morpho-
running performance in the absence of in- logic and physiologic characteristics of pre-
creased Vo2max is the training-induced im- pubescent females, as related to their ther-
provement in running economy, which is moregulatory capability. As discussed
manifested by a decrease in the O2 cost of earlier, the smaller the girl, the higher her
running. During adolescence, both aerobic Vo2 per kilogram of body weight at any given
power and running economy may improve walking or running speed. Because 75% to
with training. 80% or more of the chemical energy during
Table 7-3. MORPHOLOGIC AND PHYSIOLOGIC CHARACTERISTICS OF PREPUBESCENT GIRLS

AS RELATED TO THERMOREGULATION
Typical for Girls
Characteristic or Function (Compared with Women) Implication for Thermoregulation
O2 cost of running/walking Higher High metabolic heat
Surface-to-mass ratio Larger Greater heat exchange with environment
Onset of sweating Later Greater reliance on convective heat loss
Sweating rate Somewhat lower Lower evaporative capacity
Blood flow, peripheral vs. central Higher 1. Higher heat convection
2. Lower venous return
muscle contraction is converted into heat, low sweating capacity), it also decreases the
the metabolic heat load of the prepubescent venous return and stroke volume.60 The re-
girl is higher (by as much as 5% to 20%) than sulting decrease in maximal cardiac output
that of the adolescent or the adult, at equiv- is another explanation for the low ability of
alent walking or running tasks. Such a differ- prepubertal girls to exercise intensively in
ence imposes a greater strain on the young, hot climates. It should be added that, at any
small girl's thermodissipatory system. given exercise level, even when performed
Another size-related difference is the in neutral environments, cardiac output in
larger skin surface-area-per-mass ratio in young girls is somewhat lower than that of
the smaller individual. The rate of heat ex- women.61
change between the body and the environ- In summary, these geometric and physio-
ment depends on this surface area. There- logic characteristics suggest that a priori
fore, when the environment is warmer than young girls would tolerate exercise in hot
the skin, the smaller the girl, the greater the climates less effectively than adolescent or
heat gain (through conduction, convection, adult females. It has indeed been shown
and radiation) per unit body mass. This dif- that, during extreme climatic heat, prepu-
ference in heat gain becomes particularly bescent girls had to terminate their pre-
important in extreme climatic heat. scribed walking task earlier than did young
Evaporation of sweat is the main avenue women.60'62 In thermoneutral environments,
for heat dissipation during exercise, espe- on the other hand, there is no evidence that
cially in hot climates. When ambient tem- young age or small body size is detrimental
perature exceeds skin temperature, evapo- to thermoregulation.63
ration is the only available means of heat As recently shown,64 the sweat of prepu-
dissipation. Compared with women, prepubescent girls has a lower concentration of
bertal girls have a slow onset of sweating sodium and chloride, and a higher concen-
and a somewhat lower sweating rate while tration of potassium, than the sweat of ado-
exercising in the heat,60 which limit their ca- lescent females or of women. One possible
pacity for evaporative cooling. This differ- implication of this difference is that the op-
ence between prepubescents and adults timal electrolyte concentration of sports
seems to be even more apparent among beverages may be different for prepubes-
males. cent girls and for more mature females.
Girls were found to respond to exercise in
the heat with a marked shift of blood from
Response to Cold Climate
the central to the cutaneous vascular bed.
Although greater skin blood flow facilitates In most land-based sports, the rate of met-
greater convection of heat from the body abolic heat production exceeds heat loss,
core to the periphery (which, under certain even when the environmental temperature
climatic conditions, may compensate for a is low. Such is the case, for example, in skat-
The Pre:pubescent Female 135
ing and cross-country skiing. In other winter mented for college-age women, although the
sports, such as downhill skiing or curling, findings for prepubertal girls were inconclu-
the rate of heat production may not be high, sive.62
but clothing usually prevents excessive heat Hypohydration may often lead to heat-re-
loss. Hypothermia occurs not infrequently lated disorders. While data are not available
in such sports as mountain climbing, regarding the effects of hypohydration on
snowshoeing, and even long-distance run- the thermoregulation and health of prepu-
ning at low intensity. There is, however, no bescent girls, data on boys suggest that, for
epidemiologic evidence that prepubescent a given level of hypohydration, children
girls are more prone to hypothermia in have a greater rise in core temperature than
these events than are older females. do young adults.™ Conditions in which ex-
In contrast, small individuals are at a dis- ertion may induce heat-related disorders
tinct disadvantage during water-based ac- through hypohydration are diabetes melli-
tivities. When swimming at a speed of 30 tus, diabetes insipidus, diarrhea, and vomit-
m/rnin in 20.3°C water, 8-year-old girls (club ing. Prepubescent boys70 and girls (unpub-
swimmers) had a drop in core temperature lished data from my laboratory), like adults,
of as much as 2.5 to 3.0°C and had to be taken undergo "voluntary hypohydration" when
out of the water within 18 to 20 minutes they exercise for long periods (e.g., 1 to 2
owing to marked thermal discomfort. Their hours), even when fluids are available to
16- to 19-year-old clubmates swam for some them ad libitum. One group of young girls
30 minutes, with hardly any drop in core who are prone to hypohydration is those
temperature and with little or no thermal who compete in judo and "make weight"
discomfort.65 The reason for the cold intol- prior to competition. In some states where
erance of the younger girls was their large elementary school girls compete in wres-
surface area per mass, which facilitated con- tling, the same practice is probably fol-
ductive heat loss (water having a heat con- lowed.
ductivity at least 25 times that of air). The Lack of acclimatization to exercise in the
authors also found that the leaner girls had heat is perhaps the most important factor
a greater heat loss than those who had a that predisposes an individual to heat-re-
thicker insulative subcutaneous fat layer. lated disorders. Data suggest that 8- to 10-
year-old boys take longer than adults to ac-
climatize to the heat.71 No similar studies are
High-Risk Groups for Heat- or
available for girls, but it makes good sense to
Cold-Related Disorders
ensure that young female athletes are well
Some girls are at a potentially high risk for acclimatized to the heat before they are ex-
such heat-related disorders as heat exhaus- pected to train hard and perform well in
tion or heat stroke, while others may be warm or humid climates.
prone to hypothermia. As for hypothermia, a small, lean girl who
Evidence is available that girls with an- is immersed in water is at a greater risk than
orexia nervosa have a deficient thermoreg- a larger girl or one with thicker subcutane-
ulatory capability, both in the heat and in ous adipose tissue.
the cold.66,67 Patients with cystic fibrosis are
prone to heat-related disorders,68 possibly
because of their abnormal sweating pattern. GROWTH, PUBERTAL
Undernourished children are prone to both CHANGES, AND ATHLETIC
hypothermia and hyperthermia.69 Obese in- TRAINING
dividuals perform well and feel comfortable
in cold climates but are less tolerant to ex- Trained prepubescent and adolescent
ercise in the heat than their leaner counter- girls often have different morphologic and
parts. Such intolerance has been docu- maturational characteristics from those of
their untrained counterparts. A question short legs, and higher body adiposity—drop
often asked by coaches, physicians, and par- out because of unfavorable changes in body
ents is whether training per se affects mechanics.
growth, development, and maturation. To Based on reports from the late 1970s and
obtain a definitive answer, one would need early 1980s, delayed menarche (defined as
to launch a prospective study in which non- occurring after age 15 years) was particu-
athletic prepubescent girls are randomly as- larly common among divers, figure skaters,
signed to training and control groups and gymnasts, and volleyball players.73 Menar-
then followed until after puberty. Such a che is particularly delayed in those athletes
project has yet to be launched. Data avail- who are engaged in high-dosage training.
able at present are based on cross-sectional Delayed menarche in athletes seems also to
comparisons between athletes and nonath- correspond to delayed skeletal maturity.73
letes and among athletes of various special- Several factors, singly or in combination,
ties, or on retrospective analyses. The few have been suggested to link delayed men-
longitudinal studies lack proper controls.72 arche to physical training. Among these are
The conclusions derived from such studies a low percentage of body fat,80,81 insufficient
therefore are tentative at best and cannot calorie intake in conjunction with "energy
prove causality between training and drain,"72 onset of training prior to menar-
changes in growth, development, and mat- che,76 large sibship,82 and emotional stress of
uration. training and competition. It has also been
The following are general comments, suggested,83 but has yet to be confirmed, that
based on such studies. (For detailed re- hormonal changes which are associated
views, see Malina,73 Malina and co-work- with chronic exercise may be a cause for
ers,74 and Wells.75) Various female athletes, delayed menarche. In one study,72 low
primarily gymnasts, figure skaters, and bal- serum gonadotropins—LH, particularly—
let dancers, mature later and are shorter were found in premenarcheal ballet danc-
than the nonathletic female population. Oth- ers. Other endocrinologic studies are based
ers, notably swimmers, have little or no on postmenarcheal athletes (see reference
delay in maturation and are often taller than 84 for details).
nonathletes. 72-74,76-78 These data might sug- In a comprehensive review on menarche
gest that the above morphologic and matu- in athletes, Malina73 presented a two-part
rational differences are caused by training. hypothesis on the possible relationship be-
Such conclusions, however, ignore prese- tween physical activity and delayed menar-
lection and a possible bias in the drop-out che. First is the preselection by body char-
pattern. It is likely, for example, that those acteristics, in which the girl with a linear
girls with delayed puberty and short stature physique, long legs, and narrow hips (who is
become preferentially attracted to such often also a late maturer) is attracted to
sports as gymnastics and figure skating, sports and eventually is successful in them.
while the taller ones are more attracted to Second is the "socialization" process, in
competitive swimming. A recent retrospec- which early-maturing girls tend to interact
tive study79 has shown that 8- to 14-year-old socially in a nonsport environment with the
female gymnasts who were shorter than the appearance of pubertal changes. Con-
nonathletic population had been shorter versely, the late maturers are more likely to
even prior to having joined the gymnastics find sports participation socially gratifying.
program. Similarly, swimmers, who, as a Indeed, preselection and the bias in drop-
group, were taller than their nonathletic ping out from athletics may explain the late
counterparts, had been taller before train- menarche of athletes as found in cross-sec-
ing. It is also possible that, within a group of tional and retrospective analyses. One can-
gymnasts, those females who mature not ignore, however, the accumulating data
early—and thus attain broad hips, relatively on a more direct, possibly cause-and-effect,
relationship between intense sports partic- chronologic age around puberty, differences
ipation and secondary amenorrhea. in body size and strength of early and late
Although primary amenorrhea is a "nor- maturers within a gender group far surpass
mal" and common occurrence among ath- the intergender differences. Nor is there any
letes, one should not overlook the possibil- evidence to suggest that prepubescent girls
ity that it might reflect gynecologic or other are less capable of learning sport skills, are
hormonal abnormalities. (For details of rec- less agile, or have less stamina than boys.87,88
ommended investigations and of therapeu- While not addressing specifically the pre-
tic approach, see Shangold in reference 85, pubescent girl, a recent review on orthope-
as well as Chapter 8.) dic issues in the young female athlete89
points out the emergence of "overuse inju-
ries" during the teens. It rejects, however,
COEDUCATIONAL the notion that girls are more prone to injury
PARTICIPATION IN CONTACT than boys.
AMD COLLISION SPORTS Based on anthropometric and fitness-re-
lated considerations alone, therefore, pre-
Should prepubescent girls compete with pubescent girls can compete successfully
boys in contact (e.g., wrestling, basketball, with boys in contact and collision sports,
soccer) and collision (e.g., football, ice and with no undue risk to health. An early
hockey) sports? This issue has become maturing girl, in point of fact, may have an
highly controversial, attracting media atten- edge over boys who are average maturers. It
tion, because of its medical, educational, seems as though matching of prepubescent
and cultural implications. The following and circumpubescent opponents by body
comments are not meant to address the psy- size and maturation level has more rele-
chologic, sociologic, or ethical aspects of vance to health than the separation into gen-
this controversy but only some of the phys- der groups.
iologic and medical aspects.
A major issue is the added risk to health
that participants of either sex group may SUMMARY
incur owing to mixed participation. The
main potential cause for such added risk is a The physiologic responses to exercise in
marked difference in body mass, strength, the prepubescent girl are of a similar pattern
or skill among the participants. At age 9 to 12 to those of the more mature female. There
years, body mass of girls is similar to, or are, however, some age- or development-re-
even slightly greater than, that of boys. Body lated differences in these responses. The
height at that age range is quite similar in submaximal 02 cost during walking or run-
boys and girls, and the difference in the ning is higher in the young girl, which
strength of various muscle groups is only causes a lower "metabolic reserve" and
about 1 to 2 kg in favor of the boys.51 This is early fatigability in endurance events. Like-
to be contrasted with the increasingly wise, anaerobic muscle power and local
greater muscle strength of males—particu- muscle endurance are markedly lower in
larly in the upper body—after puberty.86 The prepubescents, who are therefore unlikely
attainment of such motor skills as throwing, to compete successfully with their older
kicking, catching, jumping, hopping, and counterparts in events such as jumping and
skipping during the first years of life is sim- sprinting. Girls are less-effective thermore-
ilar in boys and girls. Throughout the pre- gulators when exercising in the heat and in
pubertal years, these and other motor skills the cold. This has implications both to their
seem to develop and improve at a similar performance and to their health. Girls with
pace in both sex groups.87 obesity and anorexia nervosa are at special
It should be realized that, at any given risk for heat-related illness. Although more
research is needed, it appears that the train- and Exercise. Acta Paediatr Belg (Suppl
ing-induced improvement in maximal aero- 28):1, 1974.
bic power is low before puberty. 15. Borms J, and Hebbelinck M (eds): Pediatric
Work Physiology. Karger, Basel, 1978.
A causal relationship among training, 16. Ilmarinen J, and Valimaki I: Pediatric Work
growth, and maturation has yet to be estab- Physiology X. Springer Verlag, Berlin, 1983.
lished. It seems, however, that the delayed 17. Lavallee H, and Shephard RJ (eds): Frontiers
menarche in athletes may be in part a result of Activity and Child Health. Pelican, Quebec,
of intense training. 1977.
18. Rutenfranz J (ed): Pediatric Work Physiology
While coeducational participation in con- XII. Human Kinetics, Champaign, IL, 1986.
tact and collision sports may be objected to 19. Thoren C (ed): Pediatric Work Physiology.
on psychologic and societal grounds, there Acta Paediatr Scand (Suppl 213): 1, 1971.
are no physiologic or medical reasons to 20. Frenkel R, and Szmodis I (eds): Children and
ban such activities before puberty. Exercise. Pediatric Work Physiology XV. Sig-
net, Budapest, Hungary, 1991.
21. Simons J, Beunen GP, Renson R, et al (eds):
Growth and Fitness of Flemish Girls: The Leu-
ven Growth Study. Human Kinetics, Cham-
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Med Sci Sports 5:11, 1973.
CHAPTER 8
Growth, Performance, Activity,

and Training during Adolescence
ROBERT M. MALINA, Ph.D.
THE ADOLESCENT GROWTH Significance of the Adolescent

SPURT Plateau in Performance
Body Size
Body Composition INFLUENCE OF TRAINING ON THE
TEMPO OF GROWTH AND
MENARCHE
MATURATION DURING
PHYSICAL PERFORMANCE AND ADOLESCENCE
ACTIVITY DURING Stature and Body Composition
ADOLESCENCE Sexual Maturation
Strength Hormonal Responses
Motor Performance Fatness and Menarche
Maximal Aerobic Power Other Maturity Indicators
Physical Activity Habits Overtraining
AAdolescenceis a period of transition from childhood to adulthood. It includes

changes in the biologic, personal, and social domains that prepare the young girl
for adulthood in her particular culture. Thus, the biologic changes that occur
during puberty, or sexual maturation, do not occur in isolation; rather, they are
related to other developmental events so that any consideration of this period
of life must be done in a biosocial or biocultural context.
Biologically, adolescence may be viewed as beginning with an acceleration
in the rate of growth (i.e., an increase in size) prior to the attainment of sexual
maturity, then merging into a decelerative phase, and eventually terminating
with the cessation of growth. The latter is most often viewed as the attainment of
adult stature. Sexual maturity and growth are thus closely related.
The events that constitute this phase of the life cycle include changes in the
nervous and endocrine systems that initiate and coordinate the sexual, physio-
logic, and somatic changes; growth and maturation of the primary (ovaries,
vagina, and uterus) and secondary (breasts and pubic hair) sex characteristics,
leading to menarche and reproductive function; changes in size (i.e., the adoles-
cent growth spurt); changes in proportions, physique, and body composition;
and changes in the cardiorespiratory system, among others. The two most prom-
141
inent outward features of adolescence (ex- starts in some girls as early as 7 or 8 years of
cluding behavior) are accelerated growth age and in others as late as 12 or 13 years,
and appearance of secondary sex character- while the age at maximum rate of growth in
istics, which appear, on the average, during stature (PHV) occurs in some girls as early
the second decade of life. However, the neu- as 9 or 10 years of age and in others as late
roendocrine and other physiologic events as 13 to 15 years.1
underlying growth and pubertal change
have been in progress for some time prior to
the appearance of physical changes. The Body Composition
time span accommodating the growth spurt The fat-free mass (FFM) of girls, esti-
and puberty is thus wide. It can vary from 8 mated from body density, increases from
or 9 years through 17 or 18 years of age in about 25 kg at 10 years to about 45 kg at 18
girls, and in some cases may continue into years of age, whereas muscle mass, esti-
the early 20s. There is variation between in- mated from creatinine excretion, increases
dividuals in the time and rate at which the from about 12 kg at 10 years to 23 kg at 18
structural and functional changes occur; years.1 However, the major portion of
that is, the changes do not begin at the change in FFM and muscle mass between 10
same time and do not proceed at the same and 18 years occurs during the interval of
rate. maximal growth (about 11 to 13 years in
girls). This interval includes PHV, which oc-
curs, on average, at about 12 years of age in
THE ADOLESCENT GROWTH girls. The adolescent gain in FFM and mus-
SPURT cle mass during female adolescence is not,
however, as intense as that in males, so that
Body Size by late adolescence, females attain only
From birth to adulthood, both height and about two thirds of the estimated mean val-
weight follow a four-phased or double-sig- ues reported for males. Peak velocities of
moid growth pattern: rapid gain in infancy growth in arm and calf musculature occur,
and early childhood; slower, relatively con- on average, after PHV.
stant gain in middle childhood; rapid gain Fatness also increases during adoles-
during adolescence; and slow increase and cence, but estimates are highly variable.
eventual cessation of growth at the attain- Densitometric estimates increase from 18%
ment of adult size. Most dimensions of the body fat at about 10 years of age to 23% at 18
body—sitting height, leg length, shoulder years.1 These estimates are adjusted for
and hip breadths, limb circumferences, changes in the estimated chemical compo-
muscle mass, and so on—follow a similar sition of FFM (i.e., density of FFM, potas-
growth pattern. What varies is the timing, sium and water content of FFM) that occur
tempo, and intensity of the adolescent during growth and are lower than those
growth spurt in each. For example, maxi- based on adult chemical composition fig-
mum growth (peak velocity) in leg length ures. At the time of the growth spurt, how-
occurs early in the growth spurt, prior to ever, the rate of fat accumulation slows
that for sitting height or trunk length, while down in girls. This is especially apparent on
maximum growth in body weight occurs the extremities during the interval of PHV in
after peak height velocity (PHV). girls.
The timing of the growth spurt varies con-
siderably among children. Most data are
available for stature. According to data from MENARCHE
several longitudinal studies, the adolescent
growth spurt (i.e., the acceleration in rate of The age at menarche is perhaps the most
growth that marks the take-off of the spurt) commonly reported developmental mile-
Growth, Performance, Activity, and Training during Adolescence 143
stone of female adolescence. It is, however, improves more slowly.1 This pattern is in
a rather late maturational event. Menarche contrast to the marked acceleration of
occurs after maximum growth in stature; the strength development during male adoles-
average difference between menarche and cence, so that sex differences in muscular
PHV in a number of studies is about 1.2 to 1.3 strength are considerable.
years.1 The relationship between strength devel-
Menarche in American girls occurs, on av- opment and the growth spurt and sexual
erage, just before the 13th birthday. How- maturation in girls is not as clear as in boys.
ever, there is variability within the U.S. pop- Maximum strength development occurs, on
ulation. In the National Health Examination the average, after peak height and weight ve-
Survey in the 1960s, the median ages at men- locity in boys, the relationship being better
arche were 12.5 years for black girls and 12.8 with weight than with height.1,5 In girls, the
years for white girls.2 The median age at available longitudinal data vary. In the Oak-
menarche in American girls has not land (California) Growth Study, the time of
changed, on average, since the 1950s.3 Esti- maximum strength development (a compos-
mates for a number of European samples ite strength score of right and left grip and
vary between 12.5 and 13.4 years.1,4 pushing and pulling tests) does not closely
In contrast to population surveys of men- correspond to the growth spurt in stature,
arche, in which the average age for the pop- and a significant percentage of girls experi-
ulation is estimated mathematically on the ence peak strength gains prior to PHV.6 Peak
basis of the number of girls in each age strength gain precedes peak weight gain in
group who have attained menarche, many more than half of the girls, and follows peak
studies of athletes and of the influence of weight gain in only about one fourth. On the
training on the age at menarche use the ret- other hand, in the study of Dutch girls
rospective method. This approach relies on (Growth and Health of Teenagers), peak de-
the memory of the individual and thus has velopment of strength (arm pull test) oc-
the limitation of error in recall. curs, on average, one-half year after PHV
(the same time as it occurs in Dutch boys).7
The maximum gain in strength at this time is
PHYSICAL PERFORMANCE AND about 6.0 kg/y in girls, which contrasts with
ACTIVITY DURING a maximum gain of 12.0 kg/y in Dutch boys.7
ADOLESCENCE The data for Dutch girls are not expressed
relative to peak gain in body weight.
Characteristics of the adolescent growth Early-maturing girls are slightly stronger
spurt and sexual maturation, and of interre- than late-maturing girls of the same chron-
lationships among indices of sexual, skele- ologic age during early adolescence, about
tal, and somatic maturity, are reasonably 11 through 13 years.1 The differences be-
well documented. Changes in physical per- tween girls of contrasting maturity status,
formance and activity during female adoles- however, do not persist and are no longer
cence are less well documented. The data evident by 14 to 15 years of age. Further, the
are largely cross-sectional, with but few lon- differences in muscular strength between
gitudinal observations spanning the imme- girls of contrasting maturity status during
diate prepubertal and pubertal years. adolescence are not as marked as those be-
tween early- and late-maturing boys. The
strength advantage of girls advanced in ma-
Strength
turity status between 11 and 13 years re-
Muscular strength improves linearly with flects the larger body size of early maturers,
age from early childhood through about 15 since strength is positively related to body
years of age in girls, with no clear evidence mass. When strength is expressed per unit
of an adolescent spurt. After age 15, strength body weight, early maturers have less
strength per unit body weight than late-ma- of high- and low-performing girls indicated
turing girls; this difference persists through that the superior performers were about 0.5
adolescence.1 year less mature skeletally and 0.4 year later
in menarche.12 This trend is apparent in elite
female athletes (i.e., skilled performers),
Motor Performance
who tend to be later in age at menarche and
Average performances of girls in a variety delayed in skeletal maturation.13,14
of motor tasks (dash, standing long jump,
jump and reach, distance throw, and others)
improve more or less linearly from child- Maximal Aerobic Power
hood through about 13 or 14 years of age, Absolute maximal oxygen uptake (mL/
followed by a plateau in the ability to per- min) has a growth pattern in girls similar to
form some tasks and a decline in others.1,8,9 that for motor performance: it increases lin-
In most tasks, the average performances of early with age from 7 years through 13 to 14
girls fall within one standard deviation of years in untrained girls, and then declines
the boys' averages in early adolescence. slightly.15 In contrast, in untrained boys, it
After 13 to 14 years of age, however, the av- increases linearly with age through adoles-
erage performances of girls are often out- cence, so that by 16 years of age the differ-
side the limits defined by one standard de- ence between maximal oxygen uptake in un-
viation below the boys' mean performance. trained boys and girls is about 56%. When
Overhand throwing performance is an ex- expressed relative to body weight (mL-
ception; few girls approximate the throwing kg-1 • min -1 ), aerobic power declines with
performances of boys at all ages from late age from 6 through 16 years in untrained
childhood on. girls, but is more or less constant in un-
Longitudinal data relating the motor per- trained boys. The slope of the regression in
formance of girls to the timing of the adoles- girls declines from a value of 52.0 mL-kg -1
cent growth spurt are not available. Cross- min-1 at 6 years of age to 40.5 mL-kg -1
sectional analysis of longitudinal data does min -1 at 16 years. Values for untrained boys
not suggest adolescent spurts in the motor at corresponding ages are 52.8 and 53.5 mL-
performances of girls. Performances in a va- kg-1 • min - 1 , respectively, yielding a negligi-
riety of motor tasks show no tendency to ble sex difference of 1.5% at 6 years, but a
peak before, at, or after menarche (which considerable difference of 32% at 16 years.15
occurs, on average, about 1 year after PHV); The sex difference in aerobic power per
rather, performances are generally stable unit of body weight at 16 years of age is prob-
across time.5 Among boys, on the other ably related to sex differences in body com-
hand, motor performances show rather position. The aerobic power of girls per unit
clear adolescent spurts. Maximal gains in of body weight is approximately 77% of the
functional strength and power tests (flexed value for boys. This percentage is not too dif-
arm hang and vertical jump) occur, on av- ferent from estimates of lean body and mus-
erage, after PHV, whereas maximal gains in cle mass in late adolescence; that is, girls at-
speed tests (shuttle run, speed of hand tain, on the average, only about two thirds of
movement) and flexibility (sit and reach) the values for boys. The increase in relative
occur before PHV.10 fatness associated with the sexual matura-
Correlations between skeletal and sexual tion of girls probably contributes to the sex
maturity and motor performance in girls are difference in aerobic power per unit of body
low and, for many tasks, negative. The latter weight.
suggests that later maturation is more often Absolute aerobic power (mL/min) shows
associated with better motor performance a clear adolescent spurt in both girls and
in girls, whereas the opposite is more often boys, which on average occurs close to that
true in boys.1,11,12 For example, a comparison for stature.16 This reflects the growth of
heart and lung functions in proportion to through 9 (12 to 14 years), and 11.8 hours in
overall body size.1 Given the size differences grades 11 and 12 (15 to 17 years). Although
between early- and late-maturing girls, the the data suggest a trend, more specific
former have a slightly larger absolute aero- changes with age cannot be examined. In a
bic power, especially during early adoles- mixed-longitudinal sample of Dutch girls,20
cence. When expressed per unit of body the average number of hours per week spent
weight, however, relative aerobic power is in physical activity with an average energy
higher in late maturers.17 expenditure of 4 metabolic equivalents
Aerobic power responds positively to (METs) or more declined from 9.6 hours at
training, so that absolute and relative maxi- 12 to 13 years to 8.1 hours at 17 to 18 years.
mal oxygen uptakes are greater in trained The earlier adolescent years were not con-
than in untrained girls at all ages. The differ- sidered.
ences between trained and untrained girls Intensity is a critical variable when con-
are greatest during adolescence. It is also in- sidering physical activity. In the mixed-lon-
teresting to note that trained girls and boys gitudinal Dutch study, girls aged 12 to 13
differ by only 24% for absolute and 18% for participated, on the average, in only 4.0 h/
relative oxygen uptake at age 16, in contrast wk of activities of medium intensity (7 to 10
to comparable differences of 56% and 32% in METs), and 0.5/h/wk in activities of heavy
untrained boys and girls of the same age.15 intensity (10+ METs). By 17 to 18 years, the
Studies of aerobic power seldom control corresponding hours per week were 1.5 and
for the maturity status of the subjects, and O.3.20 Clearly, the majority of the activities of
the few studies that do are largely limited to these girls were of light intensity.
boys. Correlations between skeletal age and Given the type of data available, it is diffi-
aerobic power are generally low,15 but the cult to make inferences about activity habits
association between body mass and skeletal during the adolescent growth spurt and sex-
maturity confounds the relationship.1 ual maturation, as well as about possible ef-
fects of rapid growth and maturation on
activity habits. The figures do suggest, how-
Physical Activity Habits ever, that most adolescent girls are not get-
Physical activity is a major component of ting sufficient regular physical activity to
the daily energy expenditure. Energy expen- maintain a high level of aerobic fitness.
diture in free-living children and youth is dif-
ficult to measure, and the few available stud-
ies are limited to rather small samples with Significance of the Adolescent
Plateau in Performance
narrow age ranges, and largely to boys.18
Standardized questionnaires, interviews, Data relating the physical performance of
and diaries are often used to estimate phys- girls to the timing of the growth spurt and
ical activity habits in large samples of sexual maturation are not extensive. A ques-
youngsters, usually 10 years of age and tion that merits more detailed study is the
older. The data, however, are largely de- relative flatness of the performance curves
scriptive and do not consider growth and of girls during adolescence. That is, their
maturity characteristics. Results of several level of performance shows little improve-
surveys of European, Canadian, and Ameri- ment in many tasks after 13 to 14 years of
can youth indicate a slight decline in time age, and in some tasks it actually declines. Is
spent in physical activity by girls during ad- this trend related primarily to biologic
olescence.18 In the United States survey,19 for changes in female adolescence (e.g., sexual
example, the average weekly time engaged maturation, fat accumulation, physique
in physical activity outside of school physi- changes), or is it related to cultural factors
cal education was 11.5 hours in grades 5 and (e.g., changing social interests and expec-
6 (10 to 11 years), 12.5 hours in grades 7 tations, pressure from peers, lack of moti-
vation, limited opportunities to participate of this maturational event may be pro-

in performance-related physical activities)? grammed by conditions early in life and
Most likely both biologic and cultural fac- not necessarily by those conditions that
tors are reflected in the trend. Thus, the may be operating at or about the time of pu-
overall age-related pattern of physical per- berty.24-25
formance during female adolescence may A question of concern, therefore, is the
change with the recent emphasis on and op- role of intensive training for sport and per-
portunity for athletic competition for young haps of the stress of competition on the tim-
girls, and the wider acceptability of women ing and tempo of growth and sexual matu-
in the role of athlete. ration during adolescence. It should be
obvious that physical activity is only one of the
many factors that may influence growth and
maturation.
INFLUENCE OF TRAINING ON
THE TEMPO OF GROWTH AND
MATURATION DURING Stature and Body Composition
ADOLESCENCE Regular physical training has no apparent
effect on statural growth. It is, however, a
Under adequate environmental condi- significant factor in the regulation of body
tions, the timing of the adolescent growth weight and composition, specifically fat-
spurt and sexual maturation is genetically ness. Changes in response to short- or long-
determined. However, these processes can term training programs largely reflect fluc-
be influenced by environmental factors. The tuating levels of fatness, with minimal or no
delaying effects of chronic undernutrition change in FFM. The role of regular activity in
are well documented. Socioeconomic varia- the development of adipose tissue cellular-
tion in growth and maturation is evident in ity and subcutaneous fat distribution is not
some societies but not in others.1 Criteria of clearly established.26
socioeconomic status, of course, vary from Regular training is a significant factor in
country to country, but data from industri- the growth and integrity of skeletal and mus-
alized countries indicate inconsistent cle tissues. Changes in bone tissue include
trends in ages at PHV and menarche relative greater mineralization, density, and mass.
to indices of socioeconomic status. Another Training-associated changes in muscle tis-
factor related to age at menarche is the num- sue are generally specific to the type of pro-
ber of children in the family. Girls from gram followed. Strength or resistance train-
larger families tend to experience menarche ing is associated with hypertrophy, whereas
later than those from smaller families, and endurance training is associated with in-
this applies to athletes as well as nonath- creases in oxidative enzymes. The direction
letes. The estimated effect of each additional of responses to training in growing individ-
sibling on the age at menarche ranges from uals is similar to those observed in adults,
0.11 to 0.22 years in several samples of ath- but the magnitude of the responses varies.26
letes and nonathletes.21 The persistence of beneficial training ef-
Stressful life events are also significant. fects on adipose and muscular tissues de-
They are especially evident in the growth pends upon continued activity. In contrast,
and maturation of youngsters experiencing evidence is accumulating that excessive
disturbed home environments,22 and in the training associated with altered menstrual
"unusually 'fractured' curves of growth and function (see below and Chapter 9) and diet
pubertal development in girls translated to contributes to bone loss in some athletes.27,28
unfamiliar boarding schools at various Thus, there may be a threshold for some ad-
times in puberty."23 Studies of secular olescent athletes: regular training has a ben-
change in menarche suggest that the timing eficial effect on the integrity of skeletal tis-
sue up to a point, but excessive activity may between years of training before menarche
alter menstrual function and have a negative and age at menarche, a moderate correla-
influence on bone mass. tion that accounts for only about 28% of the
sample variance. Correlation does not imply
a cause-and-effect sequence, however; the
Sexual Maturation
association is more likely an artifact. The
Longitudinal data on the effects of training older a girl is at menarche, the more likely
on sexual maturation of girls (and boys too) she would have begun her training prior to
are lacking, and the available cross-sec- menarche, and conversely, the younger a
tional data do not indicate a significant effect girl is at menarche, the more likely she
of training on sexual maturation. Much of would have begun training after menarche
the discussion of training and sexual matu- or would have a shorter period of training
ration is based on comparisons of later prior to menarche.29 It could also be that
mean ages at menarche of athletes with later maturation is a factor in a girl's deci-
those of the general population, with the in- sion to take up sport, rather than the train-
ference that intensive training for sport "de- ing causing the lateness.13 Further, athletes
lays" menarche.13 The menarcheal data are as a group tend to be rather select, and other
generally consistent with observations of factors known to influence menarche are not
breast and pubic-hair development and considered in the analysis.
skeletal maturity of young athletes engaged It has also been suggested that menarche
in figure skating, ballet, gymnastics, and occurs later specifically in those disciplines
track—that is, they develop later.14 How- that emphasize low body weight, such as
ever, girls training for sport at prepubertal ballet and gymnastics.31 Emphasis on low
ages are not necessarily representative of body weight may involve dietary practices
those who are successful at later ages, who that adversely influence maturation, so that
in turn constitute the samples of athletes it would be difficult to partition dietary from
upon whom most menarcheal data are training effects. In addition, such sports
based. Also, Title IX legislation has influ- tend to have rather rigorous selection cri-
enced sport opportunity for girls and teria, which are often applied early in child-
women, so that many now continue to train hood and which favor the morphologic
and compete through the college years. In characteristics of the late-maturing girl. Fi-
the not-too-distant past, on the other hand, nally, data for elite university-level athletes
many young girls stopped training and com- indicate later mean ages at menarche in ath-
peting at 16 or 17 years of age. The oppor- letes across several sports that differ con-
tunity provided by Title IX most likely has siderably in training load and emphasis on
influenced the composition of the female body weight: diving, track and field, swim-
athlete population at the college level, par- ming, tennis, golf, basketball, and volley-
ticularly in swimming. The age at menar- ball.21
che in college-age swimmers in recent Nevertheless, two questions merit consid-
estimates21-29 is considerably older than that eration. First, are regular, intensive, prepu-
of elite swimmers about 20 years ago,13 and bertal training for sport and regular compe-
this is in contrast to the advanced pubertal tition sufficiently stressful to prolong the
status and skeletal maturity often observed prepubertal state and in turn delay the ado-
in age group swimmers.14 lescent growth spurt and sexual maturation?
Although not the first to suggest that train- Second, do intensive training for sport and
ing may delay menarche, Frisch and the stress of competition during the adoles-
colleagues30 concluded that for every year a cent growth spurt and sexual maturation
girl trains before menarche, her menarche produce conditions that are sufficiently ad-
will be delayed by up to 5 months. This con- verse to influence the progress and thus the
clusion is based on a correlation of +0.53 timing of these maturational events?
Hormonal Responses association with only "mild" growth stunt-

ing, for example, has been reported in pre-
The suggested mechanism for the associ- menarcheal ballet dancers.34 The dancers
ation between training and later menarche were delayed in breast development, men-
is hormonal. It is suggested that intensive arche, and skeletal maturation, which would
training and perhaps the associated energy suggest a prolonged prepubertal state. How-
drain influence circulating levels of gonad- ever, they were not delayed in pubic hair de-
otropic and ovarian hormones, and in turn, velopment.
menarche. Lower plasma levels of estrone, testoster-
Exercise is an effective means of stressing one, and androstenedione have been ob-
the hypothalamic-pituitary-ovarian axis, served in 11-year-old prepubertal gymnasts
producing short-term increases in serum than in swimmers of the same age and ma-
levels of all gonadotropic and sex steroid turity status, but plasma gonadotropin and
hormones.32,33 Other factors also influence dehydroepiandrosterone-sulfate (DHEAS)
hormonal levels, including diurnal varia- levels did not differ in the two samples. On
tion, state of feeding or fasting, emotional the other hand, plasma levels of the seven
states, and so on, and these need to be con- hormones assayed did not differ between
sidered. Further, virtually all hormones are early pubertal (stage 2 of breast develop-
episodically secreted, so that studies of hor- ment) gymnasts and swimmers, although
monal responses based on single serum the latter were an average of 0.5 year older.35
samples may not reflect the overall pattern. Both the prepubertal and early pubertal
What is needed are studies in which 24-hour gymnasts had been training regularly for a
levels of hormones are monitored or in longer period than the swimmers. The two
which actual pulses are sampled every 20 groups of gymnasts had been training since
minutes or so in response to exercise. Oth- 4.8 and 5.0 years of age, respectively,
erwise, the evidence from the available whereas the two groups of swimmers had
studies on the hormonal response to exer- been training since 7.2 and 8.0 years of age.
cise is inconclusive. The similar levels of DHEAS in the prepu-
It should be noted that the majority of hor- bertal gymnasts and swimmers suggests a
monal data do not deal with chronic similar stage of adrenarche, although the
changes associated with regular, intensive gymnasts had been training for a signifi-
training. Further, the data are largely de- cantly longer period. This observation thus
rived from samples of postmenarcheal does not support the suggestion that train-
women, both athletes and nonathletes, who ing delays adrenarche and prolongs the pre-
are physiologically quite different from the pubertal state.36 Moreover, recent evidence
maturing girl. What is specifically relevant does not support the view that secretion of
for the prepubertal or pubertal girl is the adrenal androgens triggers sexual matura-
possible cumulative effects of hormonal re- tion.37 Early childhood growth data for the
sponses to regular training. The hormonal two groups of athletes suggest physique dif-
responses are apparently essential to meet ferences. Since 3 years of age, the gymnasts
the stress that intensive activity imposes on had been shorter and lighter than Dutch ref-
the body. Do they have an effect on the hy- erence data, whereas the swimmers had
pothalamic center, which apparently trig- been taller and heavier. Midparental heights
gers and coordinates the changes that initi- (height of mother and height of father, di-
ate sexual maturation and eventually vided by 2) and weights were also less in the
menarche? Such data are now lacking. gymnasts than in the swimmers, and the
Hormonal data for prepubertal or puber- groups did not differ in socioeconomic sta-
tal girls involved in regular training are lim- tus.35
ited, and the results are variable and incon- Changes in basal levels of hormones in as-
clusive. Low gonadotropin secretion in sociation with training in young athletes
may be significant. Similar basal levels of occur.41 Accordingly, intensive, regular

ACTH, cortisol, prolactin, and testosterone training functions to reduce and maintain
have been reported during a 24-week train- fatness below the hypothesized minimal
ing season in small samples of premenar- level, thereby delaying menarche. The crit-
cheal and postmenarcheal competitive ical weight or fatness hypothesis has been
swimmers 13 to 18 years of age.38 During the discussed at length by many authors,21-42 and
season, ACTH levels gradually increased, the evidence does not support the specific-
prolactin levels tended to increase, and tes- ity of weight or fatness, or of a threshold
tosterone levels decreased, whereas corti- level, as the critical variable for menarche to
sol levels showed a variable pattern in the occur.
combined sample. As expected, basal estra-
diol levels differed between the premenar-
cheal and postmenarcheal swimmers, but Other Maturity Indicators
both groups experienced a decrease in basal Since indicators of sexual maturity are
levels during the first 12 weeks of training, reasonably well related to indicators of skel-
followed by a rise at 24 weeks. Basal levels etal and somatic maturity during adoles-
of estradiol at the start of training and after cence,1 it seems logical to consider the
24 weeks of training did not differ in the pre- effects of training on other maturity indica-
menarcheal swimmers, whereas the basal tors. If the hormonal responses to regular
level after 24 weeks was lower than at the training are viewed as important influences
start of training in the postmenarcheal on sexual maturation, one might expect
swimmers.38 them to influence the growth spurt, which
A role for B-endorphins in the amenor- occurs a year or so before menarche, and
rhea of runners and, in turn, in later menar- skeletal maturation around the time of men-
che in athletes has been postulated. Admin- arche. (For example, epiphyseal capping
istration of naloxone, an opiate receptor and fusion are influenced by gonadal hor-
antagonist, to amenorrheic athletes, for ex- mones, among others.)
ample, results in a marked increase in lu- Regular physical activity, including train-
teinizing hormone (LH).39 Responses of nor- ing for sport, has no apparent effect on other
mal prepubertal girls and boys to naloxone indices of biologic maturation used in
under basal conditions are different from growth studies. Age at PHV is not affected by
those of adults, however.40 Naloxone appar- training, while skeletal maturation is neither
ently does not have an effect on LH secretion accelerated nor delayed by regular training
in children. A study of the effects of nalox- for sport during childhood and adoles-
one during exercise conditions in children cence.1,2,26
might be enlightening, but ethical concerns
make collection of such data difficult.
Overtraining
Fatness and Menarche The issue of overtraining—that is, exces-
sive training without adequate time for re-
A corollary of the suggestion that training covery—must be considered, since a signif-
delays menarche is that changes in weight icant number of adolescent girls (and boys)
or body composition associated with inten- are involved in intensive training for sport.
sive training may function to delay menar- Overtraining can be short-term or chronic,
che; that is, training may delay maturation in and when it is chronic, it results in an array
young girls by keeping them lean. This idea of behavioral, emotional, and physiologic
is related to the critical weight or critical fat- symptoms.43 Data for adults indicate weight
ness hypothesis, which suggests that a cer- loss, decreased performance, and slow re-
tain level of weight (about 48 kg) or fatness covery after training. Reduction in both FFM
(about 17%) is necessary for menarche to and fat mass probably accompany weight
loss, and a reduction in efficiency and max- needed in which youngsters of both sexes
imal working capacity accompany the de- are followed from prepubescence through
crease in performance. Implications for puberty, in which several indicators of
growing girls should be obvious. The behav- growth and maturity are observed, and in
ioral, emotional, and physiologic complica- which both training and other factors known
tions of overtraining have the potential to to influence growth and maturation are
negatively influence growth and maturation. monitored.
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CHAPTER 9
Menstruation and
Menstrual Disorders
PREVALENCE OF MENSTRUAL Chronic Hormone Alterations with

DYSFUNCTION AMONG Training
ATHLETES
CONSEQUENCES OF MENSTRUAL
REVIEW OF MENSTRUAL
DYSFUNCTION
PHYSIOLOGY
Luteal Phase Deficiency
TYPES OF MENSTRUAL Anovulatory Oligomenorrhea
DYSFUNCTION Hypoestrogenic Amenorrhea
MENSTRUAL CYCLE CHANGES
DIAGNOSTIC EVALUATION OF
WITH EXERCISE AND TRAINING
MENSTRUAL DYSFUNCTION IN
Weight Loss and Thinness
ATHLETES
Physical and Emotional Stress
Dietary Factors
TREATMENT OF MENSTRUAL
HORMONAL CHANGES WITH DYSFUNCTION IN ATHLETES
EXERCISE AND TRAINING
Acute Hormone Alterations with EVALUATION AND TREATMENT
Exercise OF PRIMARY AMENORRHEA
I ncreased participation of women in sports has led to greater awareness of the

menstrual cycle alterations that frequently accompany exercise and training.
This raised consciousness has inspired more scientists to investigate the etio-
logic mechanisms responsible for such changes and has led many athletes to
seek medical attention. Unfortunately, many other athletes still avoid physician
consultation, usually because they fear they will be told to stop exercising. It is
the responsibility of all physicians and other health professionals to advise exer-
cising women about what is known regarding reproductive effects of exercise and
to assist them in formulating therapeutic plans.
PREVALENCE OF MENSTRUAL DYSFUNCTION

AMONG ATHLETES
Oligomenorrhea (infrequent menses) and amenorrhea (absent menses) are

more prevalent among athletes (10% to 20%)1,2 than among the general popula-
tion (5%) and are found more often in runners than in swimmers or cyclists3 (Fig.
152
Menstruation and Menstrual Disorders 153
or number of years of training.2, 4 Bachmann

and Kemmann5 have reported that the prev-
alences of oligomenorrhea and amenorrhea
among college students are 11% and 3%, re-
spectively. However, this population in-
cludes some athletes, for whom exercise
and training contribute to the problem. The
prevalence of menstrual dysfunction among
college students is higher than that among
the rest of the population because college
students tend to experience more emotional
stress than the general population and be-
Figure 9-1. The prevalence of amenorrhea in runners, cause many college students have not un-
swimmers, and cyclists, relative to training mileage.
(From Sanborn,3 with permission.) dergone full maturation of the hypotha-
lamic-pituitary-ovarian axis, making them
more susceptible to menstrual disorders. It
9-1), Among competitive athletes, the prev- is worth mentioning that the general popu-
alence of amenorrhea has been reported to lation has previously been considered to be
be as high as 50%.3 However, the prevalence sedentary, but the rising numbers of exer-
of menstrual dysfunction does not correlate cising women will undoubtedly increase the
with average weekly mileage, running pace, percentage of exercising women in the gen-
Figure 9-2. Percent menstrual change during training for women with regular menses before train-
ing, irregular menses before training, and amenorrhea before training. Of those women who had reg-
ular menses before training, 93% continued to have regular menses during training. (From Shangold,2
with permission.)
eral population and may raise the preva- result from variations in the length of the fol-
lence of menstrual dysfunction in this licular phase, or the time required for a fol-
group. licle to enlarge and mature enough to un-
Although it is tempting to presume that dergo ovulation.
exercise itself is responsible for the higher Throughout the menstrual cycle, the hy-
prevalence of amenorrhea associated with pothalamus secretes gonadotropin-releas-
it, many factors change simultaneously during hormone (GnRH), which is also re-
ing the course of an athletic training pro- ferred to as luteinizing hormone-releasing
gram, making it difficult to isolate causal fac- hormone (LH-RH) or luteinizing hormone-
tors. The fact that amenorrheic runners releasing factor (LRF). This decapeptide is
have a higher incidence of prior menstrual produced by cells in the arcuate nucleus of
irregularity1'2 suggests that exercise alone the hypothalamus; it promotes synthesis,
may not be responsible for menstrual dys- storage, releasability, and secretion of both
function in many cases (Fig. 9-2). pituitary gonadotropins: follicle-stimulat-
ing hormone (FSH) and luteinizing hor-
mone (LH). FSH promotes growth of the
ovarian follicle and synthesis of estrogen
REVIEW OF MENSTRUAL from androgen precursors. LH stimulates
PHYSIOLOGY ovarian androgen production, maintaining a
supply of androgens available for conver-
A brief review of menstrual physiology sion to estrogens.
follows, to facilitate the understanding of In a normal menstrual cycle, a woman pro-
readers from diverse backgrounds. It is nec- duces estrogen all the time and produces
essary to be familiar with the basic hor- significant progesterone only after ovula-
monal events of the menstrual cycle, in tion. Blood estrogen levels vary greatly
order to appreciate both the hormonal and throughout the cycle, being quite low during
menstrual alterations that accompany exer- the early follicular phase and quite high dur-
cise and training. For more comprehensive ing the late follicular phase. It is the high es-
reviews, the reader is referred to other pub- trogen level in the late follicular phase that
lications. 6-8 triggers ovulation. During the luteal phase,
A normal menstrual cycle (counting from levels of both estrogen and progesterone
the beginning of one period to the beginning are high.
of the next period) lasts from 23 to 35 days. Estrogen stimulates the endometrium
An ovarian follicle is the structure that con- (the inner lining of the uterus) to proliferate;
tains an egg; a corpus luteum is what devel- progesterone promotes maturation and sta-
ops from a follicle after the egg has been ex- bilization of an estrogen-stimulated endo-
pelled. The follicular phase is the portion of metrium. It is the decline in the concentra-
the ovarian cycle that extends from the first tions of estrogen and progesterone near the
day of menstruation until ovulation; this end of the menstrual cycle that results in
corresponds temporally with the prolifera- menstruation, which is the desquamation of
tive phase of the endometrial cycle. The lu- the endometrium (Fig. 9-3).
teal phase of the ovarian cycle extends from
ovulation until the onset of the next men-
strual period; this corresponds temporally
with the secretory phase of the endometrial TYPES OF MENSTRUAL
cycle. A normal luteal phase should ap- DYSFUNCTION
proach 14 days, while a normal follicular
phase may vary considerably in length. With any insult to a woman's reproductive
Thus, fluctuations in the length of the men- system, menstrual disturbance probably fol-
strual cycle of a woman who ovulates usually lows an orderly sequence of increasing
Figure 9-3. Hormonal events of the menstrual cycle, phases of the ovarian and endometrial cycles,
and endometrial height throughout the menstrual cycle.
severity: (1) luteal phase deficiency, (2) amenorrhea is likely to ensue. Many women
euestrogenic anovulation, and (3) hypo- do not seek attention when menstrual dys-
estrogenic amenorrhea. Thus, any condition function is mild or of recent onset and may
that disturbs the delicate balance of care- have hypoestrogenic amenorrhea by the
fully timed hormonal events needed for reg- time they first seek attention. Although pro-
ular ovulation and menstruation usually gression of this sequence has not been doc-
produces luteal phase deficiency first. If the umented in prospective studies, it is likely,
condition continues, euestrogenic anovula- nevertheless, and provides a useful model
tion will probably follow. If the condition for understanding menstrual dysfunction.
continues even longer, hypoestrogenic
MENSTRUAL CYCLE CHANGES Table 9-1. FACTORS TO WHICH AN

WITH EXERCISE AND TRAINING ATHLETE IS OFTEN SUBJECTED DURING
TRAINING
The data collected from the surveys re- 1. Weight loss
ported are derived from records of women 2. Low weight
who recorded only their menstrual patterns. 3. Low body fat
Most, but not all, women who bleed at reg- 4. Dietary alterations
5. Nutritional inadequacy
ular intervals have normal ovulatory and lu- 6. Physical stress
teal function. More accurate information 7. Emotional stress
about menstrual cyclicity can be derived 8. Acute hormone alterations
from basal body temperature records and 9. Chronic hormone alterations
hormonal measurements. By having 14 sub-
jects record their basal body temperatures
to indicate that and when ovulation had oc- have demonstrated that amenorrheic run-
curred, Prior and co-workers9 have shown in ners were thinner and had lost more weight
48 menstrual cycles that even among ath- after initiating regular running.
letic women with apparently regular men- Despite claims that women need a mini-
ses, approximately one third have anovula- mum amount of body fat in order to maintain
tion, one third have luteal phase deficiency, regular menstrual cyclicity, this hypothesis
and one third have normal luteal function. remains unproven and suspect. If such a
This suggests that menstrual disturbance minimum amount of fat must be exceeded,
among exercising women may be more per- the mechanism by which this functions also
vasive than has been appreciated. remains unproven. Adipose tissue produces
In addition to the epidemiologic studies and retains estrogen, but the amount of es-
that demonstrate a higher prevalence of oli- trogen contributed by adipose tissue is neg-
gomenorrhea/amenorrhea among athletes ligible compared with the very large quan-
than among sedentary women, several pro- tity produced by normal ovaries. Since
spective investigations have demonstrated muscle tissue contains aromatizing enzymes
changes in menstrual cyclicity in individual too, and since athletic women tend to have
women who trained. Each of these has stud- more muscle and less fat than sedentary
ied a number of factors that vary during women, aromatizing capability should be
training, any of which may contribute to comparable in both groups. Thus, the mech-
menstrual cycle alteration. It is usually very anism by which thinness promotes men-
difficult to separate the many contributory strual dysfunction remains to be shown.
variables that change simultaneously during Following the original suggestion by
training, including body composition, phys- Frisch and McArthur10 that thinness caused
ical and emotional stress, diet, and certain amenorrhea, many investigators have
hormone levels (Table 9-1). probed the relationships between thinness
and hormone production and metabolism.
Previously it was shown that thin women
Weight Loss and Thinness
metabolize most of their estradiol by 2-hy-
Many women lose both weight and body droxylation, while obese women excrete
fat when they begin to exercise regularly. most estradiol after 16-hydroxylation.11 Re-
Some attain and maintain very low levels of cently, Snow and her associates12 have
weight and fat. Simple weight loss and thin- shown that elite oarswomen who develop
ness may lead to amenorrhea, even in the menstrual dysfunction during training me-
absence of exercise. Shangold and Levine2 tabolize a greater fraction of administered
have reported that amenorrheic runners are [2-3H]estradiol by 2-hydroxylation than do
lighter than eumenorrheic (regularly men- sedentary controls or elite oarswomen who
struating) runners. Schwartz and associates1 remain eumenorrheic during training. How
the resultant catecholestrogens affect men- percentage of the total caloric intake of
strual function remains to be shown. amenorrheic runners compared with that of
eumenorrheic runners and eumenorrheic
nonrunners. These amenorrheic runners
Physical and Emotional Stress consumed more total calories than the other
Schwartz and colleagues1 have shown that groups, however, so that equal quantities of
amenorrheic runners associate more stress protein were consumed by all three groups.
with their exercise than do eumenorrheic Calabrese and colleagues14 have demon-
runners. This supports the concept that the strated that professional and student ballet
physical and emotional stress of both train- dancers consume fewer calories (1358 calo-
ing and competition may be substantially ries) than the recommended dietary allow-
greater than appreciated. Although regular ance (RDA) (2030 calories) established by
exercise tends to relieve stress and anxiety, the National Research Council,15 a figure in-
this action may be outweighed in busy tended for an "average" woman, weighing
women who are determined to incorporate 58 kg and exercising very little or not at all.
a specific quantity of exercise into their Although the mean daily protein intake by
daily schedules. these dancers (47.4 g) fell slightly below the
Warren13 has demonstrated the complex- RDA for "average-sized women" (50 g), this
ity and interrelationship of the factors con- protein intake was adequate when based on
tributing to the development of menstrual the RDA of 0.8 g/kg15 and the subjects' mean
dysfunction in two ballet dancers (Fig. 9-4). weight of 53.1 kg. Frisch and associates16
The dancer in the upper graph experienced have reported that a group of collegiate
no change in weight or body composition women who began athletic training prior to
throughout the year in which she had three menarche consumed less fat (65 g) and pro-
menstrual periods, each during an interval tein (71 g) than a group who began training
of inactivity. The dancer in the lower graph after menarche (95 g of fat and 92 g of pro-
developed regular menses when she gained tein), and that the former group also had
both weight and body fat, although she higher incidences of oligomenorrhea and
maintained her customary level of activity. amenorrhea. Very low levels of fat intake are
She continued menstruating regularly, de- difficult to attain, and such diets have been
spite a loss of both weight and body fat that associated with insidious negative calcium
occurred during an inactive vacation inter- balance.17 Deficiencies of the fat-soluble vi-
val. With no further loss of weight, she tamins, which require fat for absorption,
ceased menstruating altogether when she have never been reported in people con-
resumed her customary level of activity. It is suming low-fat diets, but such deficiencies
likely that stress levels are higher during in- remain a theoretical hazard. Deuster and
tervals of intensive dancing, compared with her co-workers18 have described differences
vacation intervals. Thus, activity, fat, between the dietary intakes of eumenor-
weight, and stress must be considered vari- rheic and amenorrheic runners, and they
ables in the changes observed. have reported that many amenorrheic run-
ners consume less than the recommended
Dietary Factors dietary allowances of some nutrients. Pirke
and associates19 have described menstrual
Many women who begin to exercise regu- dysfunction that developed in association
larly alter their dietary patterns because with caloric restriction, especially in asso-
they become more concerned about health- ciation with a vegetarian diet. These inves-
ful living. Those who have been exercising tigators have demonstrated impairment of
regularly for a long time often eat differently episodic LH secretion during dieting.20
from nonathletes. Schwartz and co-workers1 Despite the suggestion that amenorrheic
reported that protein constituted a smaller runners may consume inadequate choles-
Figure 9-4. Relationships among menses, exercise, weights, and calculated body fat values in two
young ballet dancers. (From Warren,13 with permission.)
terol to produce sufficient estrogen, there progesterone during a normal luteal phase,
remains no evidence that dietary choles- but the rest of the body can provide enough
terol is necessary for hormone synthesis. cholesterol to serve as precursor for ade-
The corpus luteum cannot make enough quate luteal progesterone production.
cholesterol de novo to synthesize adequate Although there is little to prove that estro-
gen production is affected by these dietary tradiol,24 progesterone,24 and testosterone23

differences, there is evidence that estrogen rise during exercise and return to normal
metabolism is altered. Longcope and co- within an hour or two after cessation of ex-
workers21 have shown that the ingestion of a ercise. Exercise-associated increments in
low-fat diet promotes the same pattern of es- ACTH, opioid peptides, melatonin, and cor-
trogen metabolism observed in thin women: tisol are facilitated by training.25,26 Since
increased production of catecholestrogens testosterone27 and cortisol28 increase also in
(the result of 2-hydroxylation) and reduced anticipation of exercise, it is probable that
production of estriol (the result of 16-hy- psychologic factors contribute to the re-
droxylation). ported changes as well. Rebar and co-
Myerson and her associates22 have shown workers29 have shown that dexamethasone
that the resting metabolic rate (RMR) of suppression abolishes all effects of exercise
amenorrheic runners is significantly less on adrenal and gonadal hormones, includ-
than that of eumenorrheic runners, which is ing those in anticipation of exercise. De-
significantly less than that of eumenorrheic tailed review of the many studies of hor-
sedentary controls. The RMR of the amen- monal changes during exercise sessions,
orrheic runners remained lower than that of ranging in duration from a few minutes to
each of the other two groups after adjust- the time required to complete a marathon, is
ment for body weight or for fat-free mass. Al- beyond the scope of this chapter. For a more
though the absolute caloric intake of the comprehensive review, readers are referred
amenorrheic runners was less than that of elsewhere.30-32
the eumenorrheic runners and was similar
to that of the sedentary controls, the differ-
Factors Influencing Hormone Levels
ences were not significant, probably due to
large intragroup variability and small sam- Plasma hormone levels represent a bal-
ple size. The amenorrheic runners also had ance among production, metabolism, utili-
higher scores on the eating attitudes test zation, clearance, and plasma volume, all of
(EAT-26, modified), including two subscales which may change simultaneously during
and total score; this reflected a higher level exercise. Levels of many hormones also are
of aberrant dietary patterns in the amenor- affected by episodic secretion, diurnal vari-
rheic group. Thus, a growing body of infor- ation, state of sleep or wakefulness, state of
mation has brought our attention to the role feeding or fasting, dietary composition and
of dietary intake as a contributing cause of caloric adequacy, temperature, body weight
menstrual dysfunction among athletes. and composition, emotional factors, and
body position. The hormonal response to
exercise in any person is often influenced by
HORMONAL CHANGES WITH the person's fitness, which affects the rela-
EXERCISE AND TRAINING tive workload of any given activity and, in
some cases, alters hormonal responsive-
Acute Hormone Alterations ness during exercise. Difficulty in control-
with Exercise ling these many variables during any spe-
cific investigation makes it even harder to
Blood levels of several protein and steroid interpret the observed exercise-induced
hormones increase transiently during con- changes in hormone levels.
tinuous, aerobic exercise. The long-term ef-
fects of such repetitive, but brief, alterations
remains unknown. Reported exercise-in- Chronic Hormone Alterations
duced changes in gonadotropin levels are with Training
inconsistent and have been confused by the Shangold and associates33 have observed
pulsatile nature of gonadotropin release. one runner during 18 menstrual cycles in
Circulating concentrations of prolactin,23 es- which she varied her weekly mileage. This
woman had shortening of the luteal phase

and lower progesterone levels in cycles of
greater mileage (Figs. 9-5 and 9-6). Prior
and colleagues34 have also reported luteal
phase deficiency in two runners during sev-
eral menstrual cycles of varying mileage.
One of these two runners had a normal preg-
nancy when she stopped running, suggest-
ing that exercise-induced luteal phase defi-
ciency is a reversible phenomenon.
Similarly, Frisch and associates35 ob-
served a long-distance swimmer prior to,
during, and after intensive training, with
monitoring of basal body temperature rec- Figure 9-6. Midluteal phase plasma progesterone con-
ords, as well as blood and urine hormone centrations obtained 3 to 7 days after change in cervical
mucus (presumptive evidence of ovulation), comparing
measurements. She developed a luteal seven samples from three control cycles and seven
phase defect, followed by an anovulatory samples from three training cycles. Bars indicate
cycle, during intensive training. Three means plus or minus standard errors (p < 0.001).
(From Shangold,33 reproduced with permission of The
months after completion of a long-distance American Fertility Society.)
swim (the English Channel), she regained a
normal, biphasic basal body temperature
pattern. This confirms that the menstrual alence of menstrual dysfunction was high in
cycle alterations associated with intensive both groups during intensive training, but
training occur in swimming as well as in run- was much higher in the weight-loss group;
ning. 94% of them experienced menstrual distur-
Menstrual and hormonal changes in two bances, compared with 75% of the weight-
groups of untrained women have been stud- maintenance group. Of those who lost
ied prospectively.36 One group lost weight weight, 63% experienced abnormal luteal
during a running program of increasing function, as did 66% of the weight-mainte-
mileage, and the other group maintained nance group. All subjects regained normal
weight during the same program. The prev- menstrual cyclicity within 6 months of ter-
mination of the study (and presumably of
training). As has been shown by Warren,13
weight loss and exercise act synergistically
in promoting menstrual dysfunction. How-
ever, these data36 suggest that a compensa-
tory increase in caloric intake cannot
prevent exercise-induced menstrual dys-
function in most cases.
In the same investigation of training-in-
duced menstrual dysfunction,37 two types of
luteal dysfunction were described: a short
luteal phase and an inadequate luteal phase.
The short luteal phase was marked by de-
Figure 9-5. Relationship between mileage run during creased luteal phase length, while the inad-
the first 6 days of the follicular phase and the length of
the luteal phase, defined as the interval between the equate luteal phase was characterized by in-
day of change in cervical mucus and onset of the next sufficient progesterone secretion, measured
menses, in 18 cycles, (y = 13.3 - 0.1 Ix; r = -0.81; p by the concentration in overnight urine
< 0.001). Point (1,13) represents three values. (From
Shangold,33 reproduced with permission of The Ameri- collections. The significance of these
can Fertility Society.) differences remains to be shown, but these
investigators have shown that menstrual serum cortisol to bolus administration of

dysfunction can be induced in normal human corticotropin-releasing hormone
women with intense training. It remains to (CRH), and to meals, among both eumenor-
be shown, however, whether a critical level rheic and amenorrheic athletes compared
of exertion must be exceeded, and why some to eumenorrheic sedentary controls. These
women are predisposed to this type of dys- data suggest that the hypothalamic-pitu-
function in response to training. If a critical itary-adrenal axes of athletic women are
level exists, the level undoubtedly differs characterized by increased CRH stimula-
among various women. tion, increased cortisol negative feedback,
Russell and associates38,39 found similar normal ACTH secretion, normal cortico-
weights and body fat levels among athletic troph responsiveness to cortisol-induced
and inactive women, but found a correlation negative feedback, and decreased respon-
among strenuous exercise, anovulatory oli- siveness to ACTH. In an excellent review,
gomenorrhea, and elevated levels of /3-en- DeSouza and Metzger44 have suggested that
dorphins and catechol estrogens. Although the adrenal response may be blunted be-
endogenous opiates are known to modulate cause the adrenal is functioning near capac-
pulsatile luteinizing hormone release in hu- ity at rest, unable to mount a greater re-
mans,40 it is unlikely that circulating levels of sponse to stimulation.
these peptides correspond to the brain lev- Boyden and associates45 have provided an
els influencing hypothalamic secretion. important clue toward understanding the al-
The fact that a generalized increase in terations in menstrual function associated
"stress" hormones occurs with exercise and with intensive exercise. They have shown
endurance training has been confirmed by that GnRH-stimulated LH levels in eumenor-
Villanueva and colleagues,41 who demon- rheic women decrease with endurance
strated increased cortisol production in training (distance running).
both eumenorrheic and amenorrheic run- Gumming and co-workers46 further en-
ners. Although the amenorrheic runners hanced our understanding of these changes
had higher levels of both serum cortisol and when they reported that eumenorrheic run-
urinary cortisol, the differences between ners (at rest) have lower LH pulse fre-
these two groups of runners were not statis- quency, LH pulse amplitude, and area under
tically significant. the LH curve over 6 hours, compared with
Loucks and her associates42 have demon- eumenorrheic sedentary women (Figs. 9-7
strated that both eumenorrheic and amen- and 9-8). These investigators47 then found
orrheic athletes have higher morning serum that acute exercise reduces LH pulse fre-
cortisol levels than do eumenorrheic sed- quency but does not change pulse amplitude
entary women, and that the serum cortisol or area under the 6-hour curve. These im-
levels in the amenorrheic athletes remained portant findings suggest that acute exercise
higher throughout the day compared to has an inhibitory effect on LH pulsatile re-
those in the eumenorrheic sedentary lease at the hypothalamic level in eumenor-
women. However, these three groups did rheic runners, perhaps contributing to the
not differ in plasma ACTH pulse frequency, observed alterations with training.
pulse amplitude, or mean level during any Several recent studies have provided
time interval, and also did not differ in even more information about LH pulsatile
serum cortisol pulse frequency. The eume- patterns in athletes. Veldhuis and co-
norrheic athletes had reduced serum corti- workers48 demonstrated reduced LH pulse
sol pulse amplitude during the day. Other frequency and normal LH pulse am-
investigators have also described mild hy- plitude in amenorrheic or severely oligo-
percortisolism in amenorrheic runners.43 menorrheic runners compared to eu-
Loucks and co-workers42 have also shown a menorrheic sedentary controls. These
blunted response of plasma ACTH and investigators also reported normal or accen-
in the amenorrheic athletes, compared to

the eumenorrheic sedentary controls.
These data suggest that exercise-induced
menstrual dysfunction results from inhibi-
tion of hypothalamic release of GnRH at the
level of the hypothalamus or higher brain
centers influencing hypothalamic function.
CONSEQUENCES OF
MENSTRUAL DYSFUNCTION
Luteal Phase Deficiency

The major adverse condition associated
with luteal phase deficiency is infertility,
and this association remains controversial.
Preliminary findings suggesting that proges-
terone deficiency may be linked to an in-
creased breast cancer risk49 have not been
confirmed. Prior and her associates50 have
recently demonstrated that shortening the
luteal phase correlates with loss of bone
density.
Anovulatory Oligomenorrhea
Chronic anovulation is associated with
chronic, unopposed estrogen production,
which leads to continuous endometrial
Figure 9-7. Serum LH levels in samples obtained at 15- stimulation and, as a consequence, an in-
minute intervals over 6 hours in six eumenorrheic run- creased risk of endometrial hyperplasia and
ners (upper) and four sedentary controls (lower). The
studies were performed in the early follicular phase of adenocarcinoma. Although this association
the menstrual cycle (days 3 to 6). (From Cumming,46 has been documented in women with poly-
with permission.) cystic ovary syndrome, 51-54 it has never
been reported in athletes. It remains un-
known whether anovulatory athletes carry
tuated LH release and normal estradiol re- the same, increased risk of developing en-
lease in response to exogenous GnRH dometrial hyperplasia and adenocarcinoma
pulses. as nonathletes with chronic anovulation.
Loucks and co-workers42 have shown re- Perhaps inadequate reporting or history-
duced LH pulse frequency and increased LH taking, or both, has led to the absence of
pulse amplitude in eumenorrheic athletes such reports (i.e., gynecologists may not
compared to eumenorrheic sedentary con- routinely elicit athletic histories, particu-
trols; both the LH pulse frequency and am- larly when diagnosing cancer), or perhaps
plitude of the amenorrheic athletes were anovulatory athletic women do not maintain
lower than those of the eumenorrheic ath- high enough estrogen levels long enough to
letes. An exogenous GnRH bolus caused induce hyperplasia or cancer. Until this
blunted FSH release in the eumenorrheic question is answered, it seems reasonable to
athletes and augmented FSH and LH release assume that the endometrium of the athlete
Figure 9-8. LH pulse frequency,

pulse amplitude, and the area
under the LH curve in eumenor-
rheic runners and sedentary con-
trols in the early follicular phase
of the menstrual cycle. (*p <
0.05, **p < 0.01 on Mann-Whitney
U test.) (From Cumming, 46 with
permission.)
responds the same as that of the nonathlete production may be iron-deficient or anemic.
to estrogen stimulation. Thus, an increased Either of these conditions can impair ath-
risk of endometrial hyperplasia and adeno- letic performance, as can heavy bleeding
carcinoma should be presumed until it is during training or competition. The preva-
disproved. lence of heavy bleeding among athletes re-
Recent studies have suggested that an- mains to be shown. As suggested earlier, it
ovulatory women may also be at increased is possible that anovulatory athletic women
risk of developing breast cancer.55 This pre- do not maintain high enough estrogen levels
liminary report requires further confirma- long enough to induce sufficient thickening
tion. This suggestion, too, has not described of the endometrial lining and consequent
the athletic habits of subjects. Thus, if profuse bleeding. However, heavy, infre-
chronic anovulation leads to an increased quent bleeding episodes are common
risk of breast carcinoma, it remains to be among adolescents, even those who are ath-
shown whether this increased risk includes letes; it is probable that more mature ath-
anovulatory athletes. letes are subject to the same risk.
Although Frisch and associates56 have re-
ported a lower prevalence of breast cancer
among former college athletes compared Hypoestrogenic Amenorrhea
with former college nonathletes, this report Estrogen promotes beneficial effects on
did not relate breast cancer prevalence to calcium metabolism, lipid metabolism, and
recent athletic participation. Thus, it re- urogenital epithelial maturation. Hypoestro-
mains to be demonstrated whether regular genic women lack these favorable effects.
exercise has any effect on breast cancer risk. Many reports have demonstrated that ath-
Prior and her colleagues50 have shown that letes with hypoestrogenic amenorrhea have
anovulatory cycles are also associated with reduced bone density and increased risk of
loss of bone density. musculoskeletal injury, compared with eu-
Chronic anovulation usually leads to in- menorrheic athletes.57-63
frequent, heavy bleeding at unpredictable Cann and co-workers57 were the first to
times. At best, this is an inconvenience, par- bring this finding to our attention. They re-
ticularly to competitive athletes, and at ported that women with hypothalamic
worst, it may require hospitalization to con- amenorrhea, in many cases associated with
trol blood loss. Between these extremes, exercise, had lower vertebral bone density
women with chronic, unopposed estrogen than several other groups of eumenorrheic
and amenorrheic women, including those entary women. This suggested that exercise
with hyperprolactinemia and premature is beneficial in increasing bone density, but
ovarian failure. This surprising, incidental not as beneficial as a normal estrogen level.
finding led several other investigators to the Unfortunately, differences in calcium intake
same issue. It had been shown by others that between some of these groups introduced
exercise has a beneficial effect on bone den- another variable, as occurred in the Drink-
sity, as discussed in Chapter 5. In view of the water study.59 It remains difficult to separate
higher prevalence of hypoestrogenic amen- estrogen, exercise, and calcium intake as
orrhea among athletes, it became important variables in pinpointing causality in such
to resolve whether exercise is beneficial studies.
enough to compensate for an estrogen defi- It was demonstrated by Jones and
ciency. associates61 that radial bone density re-
Rigotti and colleagues58 reported that gresses in a linear fashion with increasing
amenorrheic women with anorexia nervosa duration of amenorrhea, regardless of etiol-
had lower radial bone density than eume- ogy, confirming that hypoestrogenic young
norrheic controls and that those anorectics women lose bone density in the same pat-
who reported a high physical activity level tern as that observed for postmenopausal
had a greater bone density than those who women.65
were less active. This suggested that physi- Warren and co-workers62 have reported
cal activity offers some protection against that ballet dancers have a higher prevalence
bone loss induced by estrogen deficiency. of scoliosis and a greater incidence of frac-
In a study by Drinkwater and co-work- tures with increasing menarcheal age. They
ers,59 lower vertebral bone density was also found a higher incidence and longer du-
found in amenorrheic athletes than in eu- ration of secondary amenorrhea among
menorrheic athletes. However, these groups dancers with stress fractures. These find-
differed not only in their estrogen status but ings suggest that menarcheal delay and pro-
also in their calcium intake. Although the longed intervals of hypoestrogenic amen-
absolute values of calcium ingested by orrhea may predispose ballerinas to
the groups were not significantly different, scoliosis and stress fractures.
the amenorrheic group, but not the eume- The suggestion of increased susceptibility
norrheic group, consumed much less cal- to musculoskeletal injuries among amenor-
cium than the amount recommended for rheic athletes has been supported by the
hypoestrogenic women. Since estrogen en- work of Lloyd and colleagues.63 These au-
hances calcium absorption, hypoestrogenic thors reported that women who were in-
women require an additional 500 mg of cal- jured during their running program were
cium daily, compared with that required by more likely to have had absent or irregular
euestrogenic women. (It is recommended menses, were less likely to have used oral
that euestrogenic women consume 1000 mg contraceptives, and had been running for
of calcium daily and that hypoestrogenic more years than those running women who
women consume 1500 mg daily.64) Thus, it is were not injured.
unclear whether the lower bone density of The increased risk of cardiovascular dis-
these amenorrheic athletes was caused by ease that occurs after menopause results
estrogen deficiency, calcium deficiency, or mostly from adverse changes in lipids, in-
both. duced by estrogen deficiency. Most of the
Marcus and colleagues60 also reported adverse effects of the hypoestrogenic state
that eumenorrheic runners had greater ver- on low-density lipoprotein cholesterol con-
tebral bone density than eumenorrheic sed- centrations tend to be offset by endurance
entary women, who had greater bone den- training. In addition, most athletes have a
sity than amenorrheic runners, who had reduced risk of cardiovascular disease, com-
greater bone density than amenorrheic sed- pared with the general population. On the
other hand, exercise-induced hypoestro- population. However, because these tests

genic amenorrhea can reverse the beneficial have not proved cost-effective for patients
effects of strenuous exercise on plasma apo- in my practice who have only menstrual dys-
lipoprotein concentrations.66 function, I no longer perform these tests
Because estrogen leads to maturation of routinely.
the urogenital epithelium, a deficiency Menstrual disturbances may be caused by
causes thinning of the vaginal epithelium hyperprolactinemia, hypothyroidism, ovar-
and increased susceptibility to atrophic ure- ian failure, hyperandrogenism, and preg-
thritis and vaginitis. These uncomfortable nancy. To detect these conditions, it is nec-
conditions are most common after meno- essary to measure the following: serum
pause, probably because development of prolactin, thyrotropin (TSH), free thyrox-
urogenital atrophy requires several years ine, follicle-stimulating hormone (FSH), lu-
in the hypoestrogenic state. Since few ath- teinizing hormone (LH), dehydroepian-
letes remain severely hypoestrogenic long drosterone sulfate (DHEAS), testosterone,
enough to develop atrophic vaginitis, this and B-human chorionic gonadotropin (B-
condition is relatively uncommon among HCG). I also measure serum estradiol, in
athletes and can usually be treated easily order to determine whether the patient is
when it occurs. hypoestrogenic. Hyperprolactinemia may
result from a pituitary adenoma or micro-
adenoma; it requires further evaluation and
DIAGNOSTIC EVALUATION OF specific treatment. If both FSH and LH are
MENSTRUAL DYSFUNCTION IN very low, the sella turcica should be as-
ATHLETES sessed (probably by a lateral cone-down
film), to detect a large hypothalamic or pi-
I believe that all oligomenorrheic and tuitary lesion. An elevated TSH level or a low
amenorrheic athletes deserve the following: free-thyroxine level indicates hypothyroid-
(1) a thorough history, including detailed ism, which also requires further evaluation
dietary intake; (2) a physical examination, and specific treatment. Hyperandrogenism
including a pelvic examination; and (3) may result from any of several etiologies,
some blood tests (Table 9-2). The dietary including polycystic ovarian syndrome, ad-
record should be reviewed by a trained nu- renal hyperplasia, an ovarian tumor, an
tritionist. Although most athletes with men- adrenal tumor, or drug abuse; hyperandro-
strual disturbances will be found to have no genism requires further evaluation and
serious conditions, it is impossible to deter- treatment. Although many women with hy-
mine, without this assessment, whether the perandrogenism will also have peripheral
menstrual dysfunction is related to exercise signs of androgen excess, not all women do.
or to some serious pathologic condition. A Some hyperandrogenic women develop
complete blood count, measurement of elec- menstrual dysfunction before acne, hirsut-
trolytes and liver enzymes, and urinalysis ism, or other symptoms of androgen excess.
are useful screening tests for the general Therefore, I believe it is worthwhile to mea-
sure DHEAS and testosterone in all women
with menstrual dysfunction, regardless of
Table 9-2. INITIAL DIAGNOSTIC whether other symptoms are present. Preg-
EVALUATION OF OLIGOMENORRHEA OR nancy, of course, requires further care.
AMENORRHEA Ovarian failure requires at least counseling
1. History, including dietary intake and possibly also further evaluation and
2. Physical examination, including pelvic examination treatment. In a patient younger than age 30,
3. Prolactin, free thyroxine, TSH, FSH, LH, DHEAS, ovarian failure warrants a blood karyotype
testosterone, B-HCG, estradiol to detect the presence of a Y chromosome,
4. Progestin challenge test
which confers an increased risk of gonadal
malignancy. In a patient older than age 30, tion to protect the endometrium adequately.
no further evaluation is required. At the time This can be effected by one of the following
of the initial evaluation, and after blood has regimens: (1) medroxyprogesterone acetate
been drawn for the above determinations, 5 to 10 mg daily for 10 to 14 consecutive days
the patient may be given a prescription for a of every month; (2) oral contraceptive pills,
5- or 10-day course of medroxyprogesterone each containing 30 to 35 mg of ethinyl estra-
acetate, to assess whether her endometrium diol and 0.15 to 1.0 mg of progestin; or (3)
has been stimulated by endogenous estro- clomiphene citrate to induce ovulation
gen. If she has no withdrawal bleeding, her (Table 9-3). Ovulation induction should be
endometrium had not been stimulated and reserved for those women desiring preg-
the rest of her body probably also lacks suf- nancy at the time of evaluation. The first two
ficient estrogen. Direct measurement of choices are acceptable for women who do
serum estradiol gives more accurate infor- not seek pregnancy now, regardless of
mation, however, and is more useful in plan- whether they are sexually active. Although
ning treatment. oral contraceptive pills obviously provide
After evaluating an athlete with oligomen- contraception, medroxyprogesterone ace-
orrhea or amenorrhea in this manner, and tate does not, and this regimen requires in-
upon finding that all of these tests except the dividuals to use barrier contraceptive meth-
estradiol concentration are within normal ods if they are sexually active.
limits, the athlete can be reassured that se- Hypoestrogenic amenorrheic women re-
rious causes of menstrual dysfunction have quire hormone replacement, primarily for
been ruled out. She should be counseled skeletal protection, but also for urogenital
about potential risks that may result from protection. Such athletes should be treated
the condition. Her serum estradiol concen- with one of the following treatment proto-
tration may be helpful in planning treat- cols: (1) conjugated estrogens 0.625 to 0.9
ment. mg daily and medroxyprogesterone acetate
5 to 10 mg daily on days 1 to 12 of every cal-
endar month; (2) transdermal estradiol 0.05
TREATMENT OF MENSTRUAL to 0.10 mg daily and medroxyprogesterone
DYSFUNCTION IN ATHLETES acetate 5 to 10 mg daily on days 1 to 12 of
every calendar month; (3) oral contracep-
Even if no serious causative pathology is tive pills, each containing 30 to 35 g of ethi-
detected during the hormonal evaluation for nyl estradiol and 0.15 to 1.0 mg of progestin;
menstrual dysfunction, treatment usually is or (4) clomiphene citrate or human meno-
indicated to prevent serious resultant pa- pausal gonadotropins to induce ovulation
thology. (Table 9-4). Ovulation induction should be
The association between luteal phase de- reserved for women desiring pregnancy at
ficiency and infertility is generally accepted, the time of evaluation.
but the links between luteal phase inade- Oral contraceptive pills may be recom-
quacy and breast cancer and bone loss seem mended to any hypoestrogenic amenor-
preliminary at the present time. Until con- rheic athlete who does not desire pregnancy
firming studies for the latter two conditions
are available, treatment for only infertility is
recommended. Thus, at the present time, lu- Table 9-3. TREATMENT OF
teal phase deficiency requires no treatment EUESTROGENIC OLIGOMENORRHEA
unless and until pregnancy is desired. 1. If not sexually active or using barrier contraception:
As discussed, euestrogenic anovulatory monthly progestin therapy
women are at increased risk of developing 2. If contraception needed or preferred: oral
endometrial hyperplasia and should be contraceptives
3. If fertility desired: clomiphene citrate
treated with monthly progestin administra-
Table 9-4. TREATMENT OF Table 9-5. ABSOLUTE

HYPOESTROGENIC AMENORRHEA CONTRAINDICATIONS TO ESTROGEN
THERAPY
1. If fertility desired: clomiphene citrate
2. If contraception needed or preferred: oral 1. Abnormal liver function
contraceptives 2. History of thromboembolic or vascular disease
3. If contraception and fertility not of concern: cyclic 3. Breast or endometrial carcinoma
estrogen and progestin therapy 4. Undiagnosed vaginal bleeding
4. If diet inadequate: correct deficiencies
5. If very thin: weight gain?
6. If exercising very heavily: less exercise?
fluctuations in their observed responses,
and many experience psychologic benefit
from the regularity and predictability of oral
at the time of evaluation, regardless of
contraceptive therapy.
whether she is sexually active; no additional
The major advantages of taking either
contraceptive method is needed by athletes
progestin alone or estrogen and progestin as
selecting this form of hormone replacement
separate pills are the ingestion of more
therapy. Those who select the more physi-
physiologic doses of medication and the
ologic regimen of conjugated estrogens or
likelihood of having predictable bleeding.
transdermal estradiol and medroxyproges-
Although the risks of exogenous hormone
terone acetate, separately, should be ad-
administration are much less than the risks
vised to use mechanical methods of contra-
of hormone deficiency, in my view, certain
ception if they are sexually active. The major
women should probably avoid estrogen and
advantages of taking oral contraceptive
others should definitely avoid it. Absolute
agents are convenience and contraception;
contraindications to estrogen therapy are
the major disadvantages are their two most
listed in Table 9-5; relative contraindica-
common side effects: breakthrough bleed-
tions are listed in Table 9-6.
ing (bleeding on the days of pill ingestion)
Many athletes have an aversion to exoge-
and amenorrhea (lack of withdrawal bleed-
nous hormone ingestion and do not compre-
ing at the end of the hormone-containing
hend the difference between physiologic re-
pills in each package). These side effects are
placement and pharmacologic therapy. It
inconvenient but not serious; both can be al-
requires careful and concerned counseling
leviated by hormone manipulation. The low-
to convince many of these women that hor-
dose oral contraceptive pills recommended
mone replacement therapy is advisable.
are associated with much lesser side effects
If the dietary intake record reveals caloric
and complications than the higher doses
or other nutritional inadequacy, the athlete
prescribed commonly more than a decade
should be evaluated and counseled by a nu-
ago; the low-dose preparations are also as-
tritionist and possibly a psychologist or psy-
sociated with a reduction in many disease
chiatrist, if an eating disorder is suspected
risks, compared with the risk to the general
population.
Another advantage of oral contraceptives Table 9-6. RELATIVE
for athletes with menstrual dysfunction is CONTRAINDICATIONS TO ESTROGEN
predictable bleeding and continued endo- THERAPY
metrial and skeletal protection. Many ath-
1. Hypertension
letes may produce enough endogenous 2. Diabetes mellitus
estrogen to have withdrawal bleeding fol- 3. Fibrocystic disease of the breast
lowing progestin administration for several 4. Uterine leiomyomata
months and then produce too little estrogen 5. Familial hyperlipidemia
to do so during the next few months. It is dis- 6. Migraine headaches
7. Gallbladder disease
turbing to many athletes to experience such
(see Chapter 17). Many athletes will be will- Table 9-7. RECOMMENDATIONS FOR
ing to increase their food intake when they FOLLOW-UP OF ATHLETES WITH
understand that dietary inadequacy may be OLIGOMENORRHEA OR AMENORRHEA
contributing to the problem. Those who are 1. Annual history and physical examination
unwilling to change their diets should be re- 2. Annual prolactin, TSH, free thyroxine, FSH, LH,
ferred for such counseling by a specialist. DHEAS, testosterone, B-HCG, estradiol
Although some of them may prefer to gain 3. Annual progestin challenge test
4. Hormone replacement therapy
weight or to reduce training intensity or
quantity, to see if menses return without
hormone therapy, it is not recommended
that these measures postpone for longer ate on the day of an important competitive
than 6 months the initiation of hormone re- event and neverwantingto menstruate at all.
placement. A shorter trial is reasonable, It is likely that most would prefer to have
particularly if the athlete herself makes this normal reproductive function, rather than
suggestion. I believe that the benefits of reg- amenorrhea, even if many are unwilling to
ular exercise far outweigh these potential re- admit this to themselves.
productive hazards, which can and should
be evaluated and treated if they develop.
Despite the demonstration by several in- EVALUATION AND
vestigators that exercise-associated men- TREATMENT OF PRIMARY
strual dysfunction is often a reversible phe- AMENORRHEA
nomenon, there is no evidence that it is
reversible in all cases, nor is there any Primary amenorrhea refers to the condi-
method of predicting when normal function tion in which menstruation has never oc-
will return, if ever. It seems unlikely that curred. Secondary amenorrhea, to which we
chronic, unopposed estrogen stimulation of have referred until now, refers to the con-
the uterus will cause hyperplasia or adeno- dition in which menstruation had occurred
carcinoma in an athlete in less than one in the past but subsequently has ceased. Be-
year. However, endometrial hyperplasia can cause menarche is often delayed in athletic
develop within 6 months in postmenopausal girls, as discussed thoroughly in Chapters 7
women being treated with unopposed estro- and 8, it is tempting to assume that menar-
gen.67,68 This raises my concerns about cheal delay is related to exercise. However,
permitting any women with euestrogenic, this assumption is as dangerous as that for
anovulatory oligomenorrhea to remain un- secondary amenorrhea. Serious pathologic
treated. Similarly, bone loss takes place at conditions can easily be missed if they are
an accelerated rate as soon as a woman be- not sought.
comes hypoestrogenic, and a significant Any girl who has not developed any sec-
amount of bone will be lost within the first 3 ondary sexual characteristics by the age of
years of hypoestrogenism. I believe that it is 13 should be examined and possibly evalu-
best to initiate hormone replacement ther- ated further. The same should be done for
apy by the time 6 months have passed, for any girl who has not begun to menstruate by
both oligomenorrheic and amenorrheic ath- age 16. Physical findings will direct appro-
letes. I also believe that pelvic examination priate testing for these problems. As shown
and blood evaluation should be repeated an- in Table 9-8, the diagnostic evaluation of
nually in all athletes with menstrual dys- primary amenorrhea is similar to that for
function, regardless of whether they are re- secondary amenorrhea, except for the
ceiving hormone replacement (Table 9-7). greater emphasis in primary amenorrhea
Many athletes claim that they prefer to be upon detection of a uterus.
amenorrheic. However, there is an obvious Müllerian agenesis (which includes the
difference between not wanting to menstru- absence of the uterus) is the second most
Table 9-8. DIAGNOSTIC EVALUATION OF loss, and exercise act synergistically to pro-
ATHLETES WITH PRIMARY AMENORRHEA mote hormone alterations in both women
1. History, including dietary intake with regular menses and those without.
2. Physical examination, including pelvic examination Athletes are more likely than sedentary
3. Prolactin, free thyroxine, TSH, FSH, LH, DHEAS, women and girls to experience menstrual
testosterone, B-HCG, estradiol dysfunction and menarcheal delay. How-
4. Progestin challenge test ever, this greater susceptibility should not
5. If uterus not palpable on pelvic examination:
sonogram discourage any athletes from exercising in-
6. If uterus absent: testosterone, karyotype tensely or frequently. The benefits of regular
7. If FSH high: karyotype exercise far outweigh this potential hazard.
The increased susceptibility of athletes to
menstrual dysfunction also should not lead
common pathologic cause of primary amen- to the presumptive diagnosis of "exercise-
orrhea, second only to gonadal dysgenesis. induced" until completion of a comprehen-
If the presence of a uterus cannot be deter- sive hormonal evaluation to rule out all
mined with certainty by pelvic examination, other pathologic causes. It must be empha-
a pelvic sonogram should be performed. sized that the diagnosis of "exercise-related
The third most common pathologic cause of menstrual dysfunction" can be made only
primary amenorrhea is androgen insensitiv- by excluding all other etiologies. Any
ity syndrome (testicular feminization). woman or girl experiencing one of these
Thus, the absence of a uterus requires fur- problems should be evaluated and treated.
ther testing to distinguish between these
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Chronic anovulation syndrome and associ- year study of estrogen and progestin in post-
ated neoplasia. Obstet Gynecol 61:403, 1983. menopausal women: Effects on the endome-
54. Dennefors BL, Knutson F, Janson PO, et al: trium. Obstet Gynecol 74:398,1989.
Ovarian steroid production in a woman with
CHAPTER 10
Pregnancy
MARSHALL W. CARPENTER, M.D.
PHYSIOLOGIC CHANGES OF ACUTE METABOLIC RESPONSE

PREGNANCY TO EXERTION
ACUTE PHYSIOLOGIC RESPONSE MATERNAL THERMOREGULATION
TO EXERTION IN THE DURING EXERCISE
NONPREGNANT STATE
ACUTE EFFECTS OF MATERNAL
ACUTE METABOLIC RESPONSE TO EXERTION ON THE FETUS
EXERTION
MATERNAL EXERCISE TRAINING
EFFECT OF PREGNANCY ON THE EFFECTS ON FETAL GROWTH
ACUTE PHYSIOLOGIC AND PERINATAL OUTCOME
RESPONSE TO EXERTION
RECOMMENDATIONS ABOUT
EFFECT OF PREGNANCY ON THE RECREATIONAL EXERCISE
Exertion and pregnancy are the two most profound normal alterations in
mammalian physiology. Exertion causes acute changes in cardiac output, blood
flow distribution, oxygen uptake, fuel mobilization, and the endocrine responses
that facilitate these changes. Chronic exercise stress (exertional training) alters
resting cardiovascular and metabolic homeostasis, the circulatory response to
exertion, and aerobic capacity. Pregnancy appears to induce a primary vasodi-
latation with associated increases in cardiac output, oxygen carrying capacity,
oxygen uptake, and pulmonary changes. Whereas many of the cardiovascular
changes that characterize pregnancy at rest are similar to those seen in acute
exertion, the endocrine and metabolic changes of pregnancy differ considerably
from those seen with acute exertion. Acute maternal adaptation to exertion and
to exercise training has recently received increased investigational attention.
The effect of maternal acute and chronic exercise stress on fetal homeostasis and
growth and the role of maternal nutrition remain only superficially understood
in humans, based primarily on animal investigation. The limited physiologic and
epidemiologic investigation available, however, form the foundation for the
guidelines and counsel that can be offered to pregnant women.
This chapter examines the effects of pregnancy on resting physiology, and
its interaction with the effects of acute exertion. The impact of acute exertion on
172
Pregnancy 173
fetal homeostasis and the effect of exercise in a 17% increase in minute ventilation rel-
training on pregnancy outcome are also ex- ative to oxygen uptake (the ventilatory
plored. These observations will be related equivalent).14 This results in a fall in arterial
to recommendations which may be offered Pco2 from 39 to 31 torr, which produces a
to pregnant women in clinical circum- mild respiratory alkalosis, increasing pH to
stances. 7.44. Increased total lung capacity and in-
creased tidal volume account for most of the
increase in minute ventilation, rather than
PHYSIOLOGIC CHANGES OF changes in respiratory frequency. The in-
PREGNANCY creased resting oxygen uptake observed in
pregnancy is an early phenomenon, half of
Cardiovascular changes begin early in which occurs by 8 weeks and three quarters
pregnancy and are well established by the by 15 weeks' gestation. However, resting ox-
midtrimester, thereby anticipating later ygen uptake remains proportional to body
fetal/placental requirements for oxygen and weight, not changing from the antepartum to
nutrition. Plasma volume increases 45% by postpartum state.15'16
30 to 34 weeks,1,2 with measurable changes
by 8 weeks. Despite a dilutional anemia, red
cell volume increases by 20% to 30% by mid- ACUTE PHYSIOLOGIC
pregnancy.2 RESPONSE TO EXERTION IN
Cardiac output may increase secondary to THE NONPREGNANCY STATE
a primary increase in circulating plasma vol-
ume or decreased systemic vascular resist- The cardiovascular and respiratory sys-
ance,3 though the relationship of these fac- tems act in concert during acute exertion to
tors remains speculative.4 By 8 weeks, ensure adequate oxygen delivery to exercis-
cardiac output increases by 23% and stroke ing muscle while maintaining function in
volume by 20%.5-7 The maximal increment other tissues. Oxygen consumption is the
in cardiac output (34%) exceeds the 13% in- product of oxygen delivery (heart rate,
crease in body weight during pregnancy. stroke volume) and oxygen extraction (ar-
This is due, partly, to the 13% to 30% in- teriovenous 02 difference), as expressed in
crease in resting oxygen uptake observed in the modified Fick equation:17
pregnancy8-10 and also to the decreased ar-
teriovenous oxygen difference in preg- Vo2 = HR-SV-avD 02
nancy. During incremental exercise to maximal
End diastolic volume6,7 and stroke intensity, Vo2 increases linearly to values
volume11 appear to increase through mid- typically 10 to 20 times that at rest. Near the
pregnancy. Venous compliance increases by peak intensity of exertion, a plateau of oxy-
the second trimester and is greater in gen uptake (Vo2) occurs, which persists de-
the lower extremities.12,13 These vascular spite greater exercise intensity. This upper
changes and the expanding uterus may im- limit of oxygen uptake (Vo2max) occurs as
pede vena caval blood flow, so that maternal maximal aerobic power is reached and is the
position increasingly alters measurements most important indicator of cardiovascular
of hemodynamic function as pregnancy pro- fitness. The percentage of Vo2max may be
gresses. The further increase in resting car- used, therefore, to describe relative inten-
diac output later in pregnancy seems to be sity of exertion among individuals with dif-
heart- rate dependent butvariable, due to different aerobic capacities when comparing
ferences in maternal stature and position. physiologic responses that are related to ex-
Respiratory changes in pregnancy involve ertional intensity. Vo2max is usually limited
respiratory control and pulmonary function. by cardiac output. (See Chapters 1 and 4.)
Changes in respiratory control are reflected Cardiac output typically increases four-to-
fivefold from rest to maximum exertion. Car- oxygen uptake, approaching a ratio of 40 L of
diac output increases with Vo2 in normal in- air per liter of O2 uptake. This change in ven-
dividuals in a ratio ranging from 5:1 to 6:1. tilatory pattern has been referred to as the
Heart rate increases linearly with Vo2. Ini- "ventilatory threshold"21,22 but has uncer-
tial increases during mild exertion result tain physiologic significance. It is loosely as-
from release from vagal tone, and increases sociated with elevated levels of plasma lac-
at higher exercise intensities are caused by tate, found at high exertional intensity.
increases in sympathetic tone. Up to 40% Exercise training results in a greater in-
Vo2 max, stroke volume increases with increase in Vo2 at ventilatory threshold than in
creased venous return to 1.5 to 2.0 times that Vo2max. Maximal voluntary ventilation does
at rest. Above a heart rate of 100, however, not limit Vo2max in normal individuals.
further increases in cardiac output are
pulse-dependent.18
Peripheral as well as central hemody- ACUTE METABOLIC RESPONSE
namic changes are necessary to effectively TO EXERTION
deliver required oxygen and fuel to exercis-
ing muscle. Blood flow is redistributed by The profound increase in the energy re-
sympathetic nerve activity, which is requirements of muscle during exercise neces-
flected in increased plasma norepinephrine sitates the mobilization and distribution of
concentrations.19 Norepinephrine concen- fuel from other tissues to sustain exertion
tration is closely related to intensity of ex- beyond the first seconds of movement. En-
ertion and to heart rate above 100.17 This ergy consumption may increase over 10-fold
redistribution results in an early and sus- above resting values during intense exer-
tained linear reduction in splanchnic and tion.21,23,24 Muscle can oxidize glucose, free
renal blood flow and, at high exertional in- fatty acids, glycerol and ketones to produce
tensity, causes decreased cutaneous perfu- energy. The proportion of fuel types avail-
sion. able to muscle is a function of exercise inten-
The proportion of total cardiac output sity, duration, nutritional state, and the
perfusing exercising muscle increases with physical fitness of the individual, and is de-
the relative intensity of exertion regardless termined largely by the acute hormonal re-
of individual aerobic fitness. However, this sponse to exertion.
proportion is higher at maximal aerobic Carbohydrate stores in the body are
power among individuals with high levels of found in muscle glycogen (300 to 400 g, 5 • 103
aerobic fitness. Therefore, the increment in kJ), hepatic glycogen (80 to 90 g, 1.5 • 103 kJ),
Vo2max obtained with exercise training is at- and blood glucose (20 g, 30 kJ). This is
tributable to increased oxygen uptake of ex- dwarfed by the energy stored as fat (about
ercising muscle, while nonexercising vas- 15 kg, 6-10 5 kJ). Protein is not significantly
cular beds receive the same low absolute available as fuel during acute exercise. At
blood flow. rest, free fatty acids provide the primary fuel
Oxygen uptake during exertion is also en- for muscle in the fasting state.
hanced by increased oxygen extraction from As exertional intensity increases beyond
each volume of blood perfusing exercising 60% Vo2max, carbohydrate is oxidized in
muscle. This is reflected in a three- or four- higher proportions, so that at Vo2max, all the
fold increase in arteriovenous oxygen differ- energy expended by muscle is derived from
ence at maximal exertion compared to carbohydrate oxidation. At this intense level
rest.17'20 of exertion, adenosine triphosphate (ATP)
Ventilation increases linearly with oxygen is provided increasingly by anaerobic gly-
uptake (at 20 to 25 L per liter of O2 uptake) colysis, which is reflected in rising plasma
to about 50% Vo2max, above which the in- lactate concentrations above 60% Vo2max.
crease in ventilation is greater, relative to Elevated plasma lactate may act to suppress
Pregnancy 175
lipolysis,25 thereby increasing demands on stimulate glucagon release, which, in turn,

carbohydrate as fuel. Consequently, exer- augment hepatic glycogenolysis and periph-
cise at Vo2max can only be sustained for a eral lipolysis.28,29 Both norepinephrine and
short duration, being limited by the modest epinephrine increase with percent Vo2max
stores of carbohydrate available to sustain and pulmonary artery oxygen saturation.
exertion at this intensity. Most investigators Epinephrine concentration is increased
employ some criterion for a "plateau" of ox- with intense exertion, is produced by the ad-
ygen uptake with increasing workload to es- renal medulla, and correlates positively
tablish that Vo2max has been achieved. The with norepinephrine and negatively with
uncertainty about criteria to establish a glucose concentrations.30,31 Therefore, the
maximum Vo2 plateau and the subject's dif- net effect of these changes is to augment and
ficulty in maintenance of this level of exer- sustain the release of glucose.
tion make observations under this condition Exertion also alters the metabolic effects
problematic, especially in pregnancy. Data of insulin. The drop in insulin concentration
from such studies thereby require some during acute exertion does not impede the
judgment in their interpretation. marked rise in peripheral glucose uptake
Exercise duration also influences fuel me- during exercise.32 Under these conditions,
tabolism. The immediate, local sources of only an absolute lack of insulin causes a re-
energy (ATP and phosphocreatine) provide duction in glucose uptake (in the pancre-
energy for the first 6 to 8 seconds of muscle atectomized dog), suggesting that insulin
contraction. Glycogenolysis and local lac- may only have a permissive role in periph-
tate production provide carbohydrate for 1 eral uptake during intense exertion.32 Iso-
to 3 minutes of exertion at maximal aerobic lated exertion increases insulin-mediated
exertion. Exercise beyond 5 to 10 minutes glucose uptake (insulin sensitivity) and glu-
becomes increasingly dependent on free cose uptake at maximal effective insulin con-
fatty acids. Moderate-intensity exertion for centration (insulin responsiveness) up to 48
40 minutes results in a fourfold rise in glu- hours after exercise.33
cose production by glycogenolysis and glu- Intense or prolonged moderate exertion is
coneogenesis to maintain plasma glucose required to produce a rise in circulating lev-
concentration for tissue with obligate glu- els of glucagon,29,34 growth hormone,35 and
cose needs. This response is reduced 15% to cortisol. Growth hormone response corre-
60% by glucose infusion, and 67% by glucose lates with Vo2 and plasma lactate concentra-
and insulin infusion.26 tion.35
Diet antecedent to exercise may alter ex-
ercise capacity at Vo2max. A high carbohy-
drate diet following intense exercise EFFECT OF PREGNANCY ON
increases muscle glycogen stores. Low car- THE ACUTE PHYSIOLOGIC
bohydrate diets decrease muscle and he- RESPONSE TO EXERTION
patic glycogen. Exercise capacity is in-
creased when muscle glycogen stores are The impact of pregnancy on exercise re-
augmented.21'23,2427 Carbohydrate ingestion sponse to submaximal and maximal exer-
during exertion increases exercise endur- cise differs. During pregnancy, we found that
ance.21'23,24.27 absolute oxygen consumption (L-min^ 1 )
The neuroendocrine response to exertion was 14% higher at rest, 9% higher during
facilitates the mobilization of fuels for mus- identical workloads during submaximal,
cle contraction. Norepinephrine, released weight-supported cycle ergometry, and 12%
from synaptic nerve endings, stimulates he- higher during identical submaximal tread-
patic glycogenolysis and peripheral lipoly- mill exertion16 compared to postpartum val-
sis. It also stimulates islet -adrenergic re- ues. Similar investigations by others have
ceptors to inhibit insulin release and not consistently shown an increased oxygen
uptake during submaximal cycle exercise in Likewise, peak age-specific heart rate ap-
pregnancy compared to nonpregnant con- pears to be unchanged by pregnancy at max-
trols.8-11,37,38 However, identical submaximal imal aerobic exertion. Also, we and others
treadmill exertion has been found to result have found no difference in maximal aerobic
in increased Vo2 during pregnancy.8,16 When power in pregnancy when compared with
oxygen consumption is expressed relative postpartum values.10
to body weight (mL-kg - 2 -min - 1 ), however, Recovery from exertion in the upright po-
there are no differences in submaximal ox- sition may differ in pregnancy. Stroke vol-
ygen uptake with either mode of exercise. Of ume recorded within 3 minutes of exercise
the increased oxygen uptake of submaximal cessation has been observed to fall 26% dur-
exertion, 75% can be accounted for when the ing the third trimester, compared to only
contribution of increased maternal weight is 11% postpartum.40 Cardiac output did not dif-
controlled for experimentally during preg- fer, being maintained by a compensatory
nancy. This was accomplished by compar- increase in heart rate. This change in post-
ing non-weight-bearing and weight-bearing exertional recovery may be related to in-
exercise during pregnancy and postpartum, creased venous compliance and capacity
and by using weight belts during postpar- and possible vena caval obstruction that
tum weight-bearing exertion to mimic preg- may characterize late pregnancy, though
nancy weight.16 These data suggest that this remains to be documented.
gravid women have an increased resting and
exertional percent Vo2max due, largely, to
the increased metabolic demands of the EFFECT OF PREGNANCY ON
conceptus as well as the increased work of THE ACUTE METABOLIC
moving a heavier body. RESPONSE TO EXERTION
Pregnancy may alter the relative contri-
bution of stroke volume and heart rate to in- Pregnancy produces alterations in hor-
creased cardiac output during incremental monal and metabolic homeostasis, which
workloads at high levels of exercise inten- distinguish it from the nonpregnant resting
sity. In the nonpregnant state, stroke vol- and exercising state. Pregnancy produces
ume does not increase with incremental ex- insulin resistance, which is reflected in an
ertion above 60% Vo2max; further increases elevated fasting insulin-glucose ratio. This
in cardiac output are due to increased heart may be observed more quantitatively by in-
rate. In contrast, limited data in pregnancy ducing hyperinsulinemia by intravenous
suggest that further increases in stroke vol- infusion and measuring the rate of glucose
ume are still possible above this level of ex- infusion required to maintain steady-state
ertional intensity.10 This change in the rela- euglycemia. This euglycemia, hyperinsulin-
tive contribution of stroke volume to emic clamp technique demonstrates a
incremental cardiac output with increased reduced requirement for infused glucose
workload alters the regression equation of during pregnancy in order to maintain eu-
Vo2 on heart rate during pregnancy. Conse- glycemia compared to that required in the
quently, the mathematic model for predict- nonpregnant state under the same hyperin-
ing Vo2max from submaximal Vo2/heart-rate sulinemic conditions.41 Insulin binding on
data in pregnant women is altered.39 red cells is unaffected by pregnancy, but
In contrast to submaximal exertion, the binding is reduced on adipocytes during
limited studies performed on pregnant pregnancy.42 Pregnancy is characterized by
women at maximal aerobic exertion show postprandial hyperglycemia and by fasting
little, if any, change in maternal cardiovas- hypoglycemia. Free fatty acid and triglycer-
cular response under this condition. Preg- ide concentrations are increased in preg-
nancy is not associated with any change in nancy.
the usual coupling of Vo2 to cardiac output.10 Acute hormonal responses to exercise
Pregnancy 177
stress support internal homeostasis in two on glucagon, growth hormone, and cortisol
ways. First, release of catecholamines by pe- response to moderate or intense exertion
ripheral nerves serves to increase and redi- has not been examined.
rect cardiac output to exercising muscle Consequently, the nature and degree of
while maintaining "adequate" perfusion to pregnancy-induced alterations of acute hor-
nonexercising vascular beds. Second, the monal response to exertion are largely
medullary release of catecholamines, and unexamined. Possible direct or indirect ef-
the release of glucagon, cortisol, and growth fects of these changes on fetal homeostasis
hormone result in providing the peripheral during maternal exertion are likewise un-
circulation with fuel to maintain both in- known.
tense and sustained exertion.
Little has been published about altera-
tions in the hormonal response to exertion MATERNAL
induced by pregnancy. Resting plasma nor- THERMOREGULATION DURING
epinephrine and epinephrine levels are un- EXERCISE
changed in pregnancy, though standing is
associated with a reduced rise in norepi- Published studies of maternal thermoreg-
nephrine concentration in pregnancy.43 Ex- ulation have examined gravidae only, during
ertion appears to produce a similar norepi- submaximal exertion lasting 20 to 30 min-
nephrine response in pregnancy as in the utes in a controlled laboratory environment
nonpregnant state.44,45 Insulin concentration of 19 to 21 °C with a relative humidity of 30%
does not appear to fall during mild exertion to 55%. Two studies examined stationary
during pregnancy46 but has not been exam- cycle exercise at approximately 60%
ined at more vigorous exercise. Glucagon, Vo2max,47,48 and one49 had subjects perform
which is increased in pregnancy, has been treadmill exercise at a maternal heart rate of
observed to rise twofold with materal exer- approximately 158 beats per minute (bpm)
tion to a pulse of only 104,46 but this was not (approximately 60% Vo2max). Under these
confirmed in later studies.44 In the nonpreg- conditions, the range of mean rectal temper-
nant state, increased glucagon concentra- ature rise was 0.3 to 0.8°C during exercise,
tions are observed after only intense or pro- inversely related to gestational age (Fig. 10-
longed exertion.29 The effect of pregnancy 1). Pregnant women appear to maintain
Figure 10-1. Resting and maximal rectal temperatures (at the bottom and top of each column, re-
spectively) during, and 10 minutes48after, a 20-minute cycle exercise period at 61%-64% maximal ox-
ygen uptake. (Adapted from Clapp ).
their core temperature within narrow limits, Early studies in human pregnancy exam-
though maternal thermoregulatory capacity ined fetal heart-rate response to maternal
during exertion under more stressful ambi- exertion using the same Doppler fetal mon-
ent conditions has not been examined. As- itors used clinically on quiet, recumbent
sociated fetal effects also have not been ex- women during labor. These reports de-
amined. scribed frequent fetal bradycardia with only
brief and mild maternal exertion,57,58 but the
findings may have been confounded by mo-
ACUTE EFFECTS OF MATERAL tion artifact during maternal activity.
EXERTION ON THE FETUS Subsequent investigation has employed
two-dimensional sonographic fetal heart-
Splanchnic perfusion falls linearly with rate documentation. In one such study, 85
the percentage of Vo2max, as blood flow is submaximal and 79 maximal exercise
redistributed to exercising muscle. A similar bouts59 produced no unexplained fetal bra-
reduction in uterine blood flow with mod- dycardia (< 110 bpm) during exertion. How-
erate and extreme maternal exertion during ever, postexertional fetal bradycardia was
pregnancy has been demonstrated in noted within 3 minutes of cessation of max-
sheep50-52 and goats53 and suggested in hu- imal aerobic effort in 19% (15 out of 79) of
mans (Fig. 10-2).54-56 In sheep, this exer- cases (Fig. 10-3). This bradycardia was not
cise-induced reduction of uterine perfusion associated with the duration of maximal aer-
was found to be associated with a fall in fetal obic exertion, changes in maternal blood
Po2 of 11% with moderate maternal exertion, pressure during and after exertion, or with
and 30% with exhausting exertion.51 How- gestational age. It was more likely to occur
ever, no measurable net lactate production in women with higher Vo2max values, sug-
by the conceptus has been observed under gesting that maternal cardiovascular fitness
these conditions. This suggests that oxygen does not protect against this event. All fe-
delivery is, in most fetal tissues, adequate tuses had normal fetal heart-rate patterns
for aerobic metabolism during these short- and fetal activity within 30 minutes of mater-
term experiments. nal exercise, and the birth outcome in the
pregnancies with fetal bradycardia was un-
complicated.
These data suggest that fetal homeostatic
reserve is not compromised by even ex-
treme levels of maternal exertion in the
human. The possible adverse impact of ma-
ternal upright posture on fetal homeostasis
during maternal recovery remains to be ex-
plored. The observed postexertional fall in
stroke volume in exercising gravid women
may indicate that visceral perfusion may be
compromised in pregnancy under these
conditions.
Observations of baseline fetal heart rate
before, during, and after maternal exertion
has generally shown a 10 to 15 bpm increase
Figure 10-2. Relationship between heart rate and uter- in fetal heart rate with moderate exertion
ine blood flow as percent of control in near-terra preg- lasting 30 minutes or more. Generally mater-
nant sheep: o = rest, a = 10-minute exercise at 70% nal exertion at 60% Vo2max which lasts less
Vo2max; • = 10-minute exercise at 100% Vo2max; A =
40-minute exercise at 70% Vo2max. (From Lotgering,51 than 20 minutes will not produce fetal tachy-
with permission). cardia. Exertion at this level which lasts 20
Pregnancy 179
to 30 minutes will produce a rise in fetal

heart rate which correlates with gestational
age over 20 to 36 weeks. This response does
not correlate with the minor changes in ma-
ternal core temperature (0.3°C) observed in
these subjects, however.47
MATERNAL EXERCISE
TRAINING EFFECTS ON FETAL
GROWTH AND PERINATAL
OUTCOME
The epidemiology of the workplace envi-

ronment and activity and maternal and peri-
natal outcome occupies a large body of lit-
erature. Discussion here will be limited to
studies examining the association of recre-
ational exercise with maternal and perinatal
outcome. Prospective studies of recrea-
tional exertion can be divided into nonran-
domized and randomized, controlled com-
parisons of exercising and sedentary
pregnant women. Nonrandomized studies
have shown both no effect on maternal
weight gain60 and significantly reduced ma-
teral weight gain caused by chronic mater-
nal exercise.61 Likewise, nonrandomized ob-
servations have documented either no effect
of chronic maternal exercise on birth weight
and duration of pregnancy60,62 or a significant
reduction in birth weight, percentile birth
weight, percentage body fat,63 and earlier
gestational age at birth.61,64 Exercising moth-
ers were found to have either a lower rate of
labor complications60,64 or no significant dif-
ference from their nonrandomized con-
trols.62 It should be noted that most of these
nonrandomized studies63-65 examine the ef-
fect of the cessation of maternal recreational
exertion before or early in pregnancy among
women who are exercise enthusiasts. The
remainder are simply comparisons of
onds during the postexercise period, using videotaped

recordings of two-dimensional fetal imaging. Predece-
leration baseline fetal heart rate and nadir fetal heart
Figure 10-3. Fetal heart rate following maximal exer- rate are noted for each deceleration. Zero time is time
tion during 14 episodes of fetal bradycardia. Fetal heart of cessation of maximal effort. (From Carpenter,59 with
rate was averaged over 10 cardiac cycles every 30 sec- permission).
women who have self-selected exercise pro- Available data suggest that maternal exer-
grams or sedentary activity. tion does not predispose to preterm labor.
Two randomized, controlled trials66,67 ex-
amined the effect of instituting exercise
training during pregnancy in sedentary RECOMMENDATIONS ABOUT
pregnant women. Only one provided ob- RECREATIONAL EXERCISE
served exercise training in a laboratory en-
vironment.67 Both studies documented ob- The limited scope of applied research re-
jective signs of cardiovascular training effect garding the effects of pregnancy on acute ex-
in the groups randomized to exercise train- ercise and training and the effects of exer-
ing; however, in contrast to the nonrandom- tion on pregnancy limit the advice that can
ized investigations, neither randomized trial be confidently given to the pregnant patient.
showed any effect of maternal exercise In 1985, the American College of Obstetri-
training on maternal weight gain, length of cians and Gynecologists published two pre-
gestation, birth weight, Apgar scores, or scriptive articles,70,71 which commented on
mode of delivery. One study66 suggested that exercise during pregnancy. These recom-
primigravid trainers had a shorter second mendations preceded much of the clinical
stage of labor. research performed in this area. As such,
Differences between the results of non- they were an attempt to form a consensus
randomized and randomized prospective opinion about principles of maternal and
studies suggest that self-selected women fetal safety during maternal exertion, and
may differ in daily activity, percentage body they reflected a necessarily conservative ap-
fat, caloric intake or food type, or other fac- proach to exercise in pregnancy that could
tors that affect fetal growth, medical treat- be used, practically, in a clinical setting.
ment during labor, and maternal and peri- Some later studies have addressed some of
natal outcome. Some of the nonrandomized these issues.
studies are detraining studies rather than The principles documented in these pub-
investigations of training effects in seden- lished guidelines are listed below. In italics,
tary women, and thereby present problems the uncertainty attending these guidelines
in applying findings in atheletes to the more or modifying data available from subse-
common, inactive pregnant woman. Women quently published research are discussed.
who enter pregnancy with a history of fre-
quent vigorous exertion may differ metabol- 1 Maternal joints become more unstable
ically from those who are relatively seden- during pregnancy and may be more
tary. prone to injury during exertion. Exer-
Transabdominal pressure transducer cises should avoid "ballistic" move-
monitoring of pregnant women during ex- ment and extreme extension and flexion
ercise has shown, in one study,68 that uterine of joints. No observational or experimen-
contractions are associated with nonrecum- tal studies have quantified the risk of joint
bent types of exercise. Another investiga- injury during pregnancy. These proscrip-
tion,69 however, examined uterine contractions may reduce injury, however.
tions by the same method immediately after 2 More physically fit individuals will per-
the cessation of maternal exertion and form a given task at a relatively lower
found no increased uterine activity. These percentage of maximal aerobic capac-
studies and practical experience in the use ity. It is therefore desirable for women
of these transducers in laboring women sug- to become aerobically trained before
gest that the uterine activity detected in up pregnancy and thereby reduce fetal risk
to 50% of gravidae during exercise is likely of asphyxia and bradycardia during ma-
to represent artifact due to maternal motion. ternal exertion during pregnancy. Di-
Pregnancy 181
rect observation of fetal heart-rate re- carbohydrates during exertion if exercise

sponse during maternal exertion has is carried out at a higher percentage of
shown no fetal heart rate decelerations aerobic capacity, so it may be desirable
during exertion of any relative intensity, during pregnancy to exercise at levels that
and none following maternal exertion up elicit maternal heart rates of less than 150
to a maternal pulse of 150 bpm in the ma- bpm.
ternal age range of 21 to 37 years of age. 5 Exercise during pregnancy may result
The occasional fetal bradycardia that fol- in premature labor due to release
lows maximal maternal exertion is more of norepinephrine. Experimental data
common in the more aerobically fit show no consistent evidence of increased
mother. Maternal exertion may increase uterine contractions immediately follow-
the baseline fetal heart rate.72 However, ing exertion. Preterm labor among exer-
exercise-associated fetal tachycardia and cisers does not appear to be increased in
episodic bradycardia are unassociated either detraining or training studies.
with any measurable fetal or neonatal 6 Previously sedentary women should
morbidity.59 The usually recommended engage in activity of very low intensity
warm-up and slow cool-down periods and avoid exertional intensity known to
with exercise should probably be used increase exertional cardiovascular fit-
during pregnancy. ness. Limited human experimental data
3 Pregnant women may develop a high show no increased maternal or fetal com-
maternal core temperature during ex- promise during and after acute exertion.
ercise exceeding 15 minutes, especially Pregnant women with lower Vo2max val-
in hot and humid environments. High ues had a lower rate of fetal bradycardia
maternal core temperature may be as- after maximal exertion,59 suggesting that
sociated with teratogenesis or respira- prior sedentary lifestyle is not a contrain-
tory compromise in animals, suggesting dication to vigorous exertion during preg-
risk in the exercising mother. Human nancy.
experiments describe only a 0.3 to 0.8°C 7 Pregnant women should practice good
rise in maternal core temperature with nutritional principles (see below) and
moderate to severe maternal exertion of avoid cigarettes and alcohol. The vaso-
30 minutes' duration,47,48,73 an increase of dilatory effects of alcohol and vasocon-
little physiologic consequence. The effect strictive and hypoxemic effects of ciga-
of maternal exertion under conditions of rette smoking may compromise the
high ambient temperature and humidity homeostatic reserve of the mother and the
on fetal homeostasis and core tempera- fetoplacental unit during maternal exer-
ture has not been examined. tion. Women who smoke and drink during
4 Maternal fasting glucose levels are sig- pregnancy should probably avoid exer-
nificantly lower than in the nonpreg- tion at times when exposed to these drugs.
nant state. Since pregnant women use No human observational studies or exper-
more carbohydrate during exertion, hy- iments have been performed examining
poglycemia may occur during exertion. these interactions directly.
Little human experimental evidence is 8 Women whose pregnancies are com-
available about maternal glycemic re- promised by any maternal diseases or
sponse to exertion. Animal experiments any untoward symptoms should con-
performed in the nonpregnant state indi- tact their physician for consultation.
cate that both sympathetic and glucagon The importance of consultation of a
response to exertion must be ablated to patient with her physician should be em-
cause exertional hypoglycemia. Gravidae phasized. Though data are not available,
consume a relatively higher proportion of caution regarding exertion in many con-
ditions complicating pregnancy should be affected by maternal exercise. The sig-

counseled by physicians. nificance of these interactions is impos-
sible to estimate; thus, we remain cau-
We use several principles when counsel-
tious in our counseling of potentially
ing pregnant women regarding exercise:
affected pregnant patients.
1 We recognize the value of continued 6 Patients with a history of poor preg-
recreation during pregnancy, which for nancy outcome due to repeated abor-
many women includes vigorous exertion, abruptio placenta, preterm labor,
tion. Unless prior observational or ex- or preterm rupture of membranes are
perimental data or the individual cir- probably not compromised by exercise
cumstances of the patient's pregnancy in pregnancy, based on limited studies
appear to contradict a proposed exer- in normal women. Appropriate investi-
cise activity during pregnancy, we do gation of exercise effects on patients
not proscribe exertion for the patient. with these histories have not been per-
2 Relative exertional intensity, as de- formed, however. We counsel patients
scribed in terms of percentage of with such histories who desire to exer-
Vo2max, produces similar cardiovascu- cise about our lack of knowledge, and
lar, respiratory, and hormonal re- about their potential sense of responsi-
sponses. Likewise, fetal homeostasis is bility should another mishap occur in
similarly maintained at a given relative the present pregnancy. In this circum-
exertional intensity, regardless of the stance, however, we are nondirective in
exertional fitness of the experimental our counseling. Patients with histories
animal. We infer that this is also true for of incompetent cervix, DES exposure, or
pregnant patients and allow physical with uterocervical abnormalities are
exertion in all healthy patients up to a counseled to avoid exertion during
heart rate of 150 bpm. Since heart rate pregnancy.
is difficult to monitor during competi-
tive sports and levels of peak exertion
tend to be high, we discourage compet- NUTRITIONAL REQUIREMENTS
itive exertion for pregnant women. OF PREGNANT EXERCISERS
3 Exercise studies during pregnancy have
been limited to short bouts of exertion It seems appropriate to advise pregnant
under "comfortable" ambient condi- exercisers also about possible changes in
tions. Since exertion for prolonged pe- nutritional requirements to support the en-
riods or with high heat and humidity ergy demands of exercise and the increased
has not been examined in human preg- caloric costs of accretion of maternal and
nancy, we discourage exercise under fetal tissues. Pregnancy, but not exercise,
these conditions in pregnant patients. substantially increases dietary protein re-
4 Pregnant patients are probably more quirements. Other than fetal demands for
prone to trauma because of changes essential free fatty acids, neither exercise
in weight distribution and resulting nor pregnancy requires a net increase in di-
"clumsiness." Consequently, we cau- etary fat.
tion patients about potentially trau- Estimates of increased caloric needs of
matic sports, especially in the last half pregnancy were originally based on cross-
of pregnancy, when the uterus is more sectional data of increased maternal and
exposed to frontal trauma. fetal mass in pregnancy.73, 74 The fetal mass of
5 Fetal homeostasis during pregnancy 3.5 kg, the placental mass of 0.6 kg, the in-
compromised by uteroplacental insuf- crease in uterine and breast mass of 5 kg, of
ficiency, cardiac or respiratory disease, maternal fat of 4 kg, and the estimated in-
or significant anemia may be adversely crease in metabolic rate were used to esti-
Pregnancy 183
mate the total caloric cost of pregnancy to amounts will be provided by a balanced diet
be approximately 83,000 kcal. This estimate with sufficient increased calories. The exer-
suggests that an increase of ~250 kcal in cise-related requirements for thiamine, nia-
daily caloric intake is needed in pregnancy, cin, riboflavin, and pantothenic acid like-
consistent with the FAO/WHO/UNU,75 the wise are probably supported by a calorically
United Kingdom Department of Health and adequate diet.
Social Security,76 and the National Research Mineral needs, in the form of iron and cal-
Council.77 Longitudinal investigations of cium, are probably not increased in exercis-
pregnancy begun prior to conception pro- ing individuals. Pregnancy results in a fetal
vide different data, however. A cohort of 162 accretion of 300 mg of elemental iron and a
women from Scotland and the Netherlands maternal erythropoietic requirement of 500
underwent prospective measurements of mg. Exercise training will produce an in-
weight, body fat, dietary intake, metabolic crease in plasma volume and erythrocyte
rate at rest, and daily activity pattern.78 The mass which requires a transient increase in
estimated increased energy cost of preg- iron utilization. Recommendations for the
nancy was ~69,000 kcal. The increase in daily intake of iron (30 to 60 mg of elemental
dietary intake during pregnancy was esti- iron) and calcium (1200 to 1500 mg of ele-
mated based on fairly rigorous weighed-in- mental calcium) during pregnancy will meet
ventory 5-day measurements performed the needs of exercising as well as sedentary
every 2 to 4 weeks during pregnancy. These pregnant women.
estimates suggested that the average incre-
ment in dietary intake during pregnancy was
only ~22,000 kcal. The 47,000-kcal discrep- SUMMARY
ancy suggests either that the estimates of ca-
loric intake are in error or that there is a re- Both pregnancy and exercise produce
duction in physical activity and an increase profound adaptive cardiovascular and en-
in mechanical efficiency during pregnancy. docrine responses which affect fetal homeo-
Nevertheless, during normal pregnancy stasis. The early cardiovascular and hema-
with documented sedentary lifestyle, daily tologic changes of pregnancy include
incremental caloric intake appears to be 80 increased stroke volume, increased cardiac
to 100 kcal/d in the first half of pregnancy, output, decreased peripheral vascular re-
and approximately 150 to 200 kcal/d during sistance, increased venous compliance, in-
the second half. Since chronic exercise may creased minute respiration, and increased
increase basal metabolic rate and the char- plasma and red cell volume. These "adap-
acter, duration, frequency, and intensity of tations" occur well before the fetoplacental
exercise will otherwise affect the increased unit develops the increased gas and nutrient
caloric cost of exertion, these estimates are transport that is supported by these
complex and need to be individualized. changes.
Since maternal weight gain probably offers a Exercise in pregnancy is associated with
reproducible correlate with fetal growth in many of the same physiologic responses as-
the second half of uncomplicated, sedentary sociated with exertion in the nonpregnant
pregnancy, weekly weight gain may provide state. Vasoconstriction occurs in vascular
a practical measure of the adequacy of ca- beds, except those serving exercising mus-
loric support in exercising women. The util- cle. Mild exertion induces increases in pulse
ity of maternal weight gain as a measure of and stroke volume, which both contribute to
fetal nutritional adequacy in pregnancy in increased cardiac output. Limited data sug-
exercising women has not been adequately gest that the neuroendocrine response and
tested, however. insulin and glucagon response to exertion
Requirements for most vitamins are in- during pregnancy are similar to those found
creased during pregnancy, but adequate in the nonpregnant state. However, preg-
nancy is associated with a decreased arte- training by athletes after conception may re-
riovenous O2 difference and an increased duce fetal birth weight, though this thesis
stroke volume, which may impact on re- requires further investigation.
sponse to intense physical exertion. For ex- Clinical recommendations for patients de-
ample, during cycle exercise, increases in sirous of engaging in recreational exercise
stroke volume appear to contribute to incre- are limited by the small number of clinical
mental cardiac output at extreme exertional studies available. Consequently, current
intensity, which does not occur in nonpreg- published recommendations are conserva-
nant humans. tive, recognizing that the benefits of mater-
The increased weight in pregnancy and nal recreational exercise for the fetus are
the increase in metabolically active fetopla- probably miminal and the potential risks un-
cental tissue results in higher pulse, cardiac known.
output, and oxygen uptake at rest and at sim-
ilar external workloads during pregnancy,
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CHAPTER 11
Menopause*
MORRIS NOTELOV1TZ, M.D., Ph.D., and MONA M. SHANGOLD, M.D.
MENOPAUSE IN PERSPECTIVE MUSCLE TISSUE AND STRENGTH

Age-Related Loss of Muscle Tissue
OSTEOPOROSIS AND BONE and Strength
HEALTH Strength Training
Osteogenesis: A Brief Overview
Exercise and Osteogenesis: Clinical OTHER MENOPAUSAL PROBLEMS:
Research VASOMOTOR SYMPTOMS
OTHER AGE-RELATED CHANGES
ATHEROGENIC DISEASE AND
Exercise and Adipose Tissue
CARDIORESPIRATORY FITNESS
Exercise and Osteoarthrosis
Lipids, Lipoproteins, and Exercise
Aerobic Power EXERCISE AND WELL-BEING
MENOPAUSE IN PERSPECTIVE
Menopause is a natural phenomenon that usually lasts about 1 week—the dura-

tion of the last menstrual period. It is the biologic marker of the gradual but per-
sistent decrease in ovarian steroidogenesis that precedes the cessation of men-
struation by about 15 years and that postdates that event by a similar duration.
This period of reproductive senescence is known as the climacteric. The differ-
entiation between "menopause" and the "climacteric" involves more than
semantics, since it serves to illustrate that the midlife physical and psychologic
needs of women extend over a 30-year continuum. There are two additional fea-
tures of note: (1) the attenuation in endocrine function of the ovarian follicle
affects many systems remote from the reproductive tract; and (2) the climacteric
occurs at a time when certain age-related changes become apparent, so that one
must differentiate between biologically induced and chronologically induced
pathophysiology.
*Supported by grants from the National Insti- this chapter, the period is more properly called
tute on Aging R01 AG 00976, Nautilus Sports/ the "climacteric," "menopause" is certainly the
Medical Industries, Inc. more commonly used term.
tAlthough, as discussed at the beginning of
187
The date of menopause can be accurately terns. The late climacteric is often associ-
pinpointed, but it is a retrospective diagno- ated with conditions resulting from chronic
sis: a year of amenorrhea has to pass before estrogen deprivation—chronic atrophic
the clinical diagnosis can be confirmed. The vaginitis, the urethral syndrome, and uri-
mean age of onset of menopause in western nary incontinence.
societies is 51 years.1 The climacteric may Although the conditions just listed have
be empirically but pragmatically catego- an impact on an individual's quality of life,
rized into three decades of clinical presen- none is life-threatening. There are, however,
tation and need (Fig. 11-1): the early climac- two asymptomatic potential complications
teric (age 35 to 45), premenopausal and of the late climacteric that may have a seri-
postmenopausal periods (age 46 to 55), and ous adverse effect and that are responsible
the late climacteric (56 to 65) .2 Contrary to for much of the morbidity and mortality as-
the theory that follicular depletion is the sociated with older age in women: osteopo-
cause of menopause, primordial follicles are rosis and atherogenic disease. In the United
frequently found in the ovaries of postmeno- States, the total number of hip fractures
pausal women, but they are unable to re- among white women was 158,000 in 1986,
spond to stimulation of the pituitary gonad- and this number is expected to increase to
otropins—FSH and LH. The resultant 252,000 in the year 2020 and to 367,000 by
alteration in ovarian function brings about the year 2040.3 Of this figure, approximately
the dysfunctional uterine bleeding patterns 12% to 20% will die as a result of factors di-
that characterize this phase. As the climac- rectly attributable to their hip fracture.4
teric progresses, the decrease in estradiol Only a third of the survivors will regain nor-
production results in menopause and in a mal activity.5 Of all hip fractures, 70% to 80%
number of so-called hormone-dependent affect women. The total annual cost of hip
symptoms such as hot flushes and changes fractures was approximately $7.2 billion in
in temperament, mood, and sleeping pat- 1984, and this cost, adjusted for 5% inflation,
Figure 11-1. Diagrammatic representation of the menopause as a single event in the larger context
of the climacteric. (From Notelovitz2 with permission.)
Menopause 189
is expected to increase to $240 billion by issue is the fact that bone is a living tissue
2040.3 This cost, of course, does not take into and needs to be treated as such.
account the physical and psychologic pain
suffered by these women.
Osteogenesls: A Brief Overview
In 1989, approximately 500,000 persons
died from ischemic heart disease, the lead- Bone formation depends upon a five-stage
ing cause of death in the United States.6 An- cycle that results in "old" bone being re-
nual health-care costs for cardiovascular moved and replaced with "new" bone. Nor-
disease alone exceed $135 billion, while the mally, this process is coupled; the amount of
added costs of related injury and disability old bone removed is replaced with an equal
exceed $170 billion.7 Cardiovascular disease amount of freshly formed bone. Initiation of
has a significant influence on the well-being the cycle is dependent upon the recruitment
of the fastest-growing age group in the and activation of osteoclasts. This activity
United States: an estimated 1000 individuals usually takes place on the inner aspect of the
join the ranks of the elderly every day.8 A bone's surface—the endosteal layer—and
woman aged 65 can now expect to live an ad- results in the dissolution of bone mineral
ditional 18.8 years (14.5 years for men).9 and collagen, and the formation of a cavity.
Exercise can play an important role in en- Resorption ceases when the mean depth of
suring an appropriate quality of life in mid- the cavity reaches 60 um (trabecular bone)
dle age and later, but to be maximally effec- and 100 urn (cortical bone) from the sur-
tive, it needs to be introduced as a face.11 At this point, mononuclear cells lay
premenopausal lifestyle—hence the em- down a highly mineralized, collagen-poor
phasis on recognizing the climacteric as an bone matrix known as cement substance. It
important transitional phase in the patho- is from this surface that new bone is laid
genesis of potentially preventable disease. down by osteoblasts. These cells probably
originate from bone marrow stromal cells
(preosteoblasts), thereby sharing the abil-
ity of another cell type, the fibroblasts, to
OSTEOPOROSIS AND BONE synthesize collagen.11 The stimulus for os-
HEALTH teoblast recruitment may be mechanical
owing to humoral and/or locally produced
Osteoporosis is preventable. It is a con- substances (for example, human skeletal
dition that is relatively uncommon in men growth and other bone growth factors).12
and in black women, owing in part to their The osteoblasts are responsible for the
having a greater bone mass. Cohn and co- synthesis of collagen, which is the main
workers10 examined the skeletal and muscle component of newly formed bone matrix, or
mass of normal black women and found that osteoid. The latter matures and is later min-
their total body calcium was 16.7% higher eralized by a process that largely depends
than that of age-matched white women. on an adequate supply of calcium and phos-
More than half of this difference (9.7%) was phate and the formation of hydroxyapatite
calculated to be due to a greater muscle crystals.10 At a microstructural level, numer-
mass in the black women. Thus, despite the ous small crystallites of hydroxyapatite may
complexity of bone physiology, two practi- be seen in intimate juxtaposition and in
cal issues need to be addressed: (1) women' highly organized geometric arrangements
need to acquire as much bone as possible with collagen fibrils.11
before menopause, and (2) the rate at which The elastic and tensile strength of bone
bone is lost thereafter needs to be modu- depends in large measure on this interrela-
lated. Exercise plays a pivotal role, in that it tionship. Another very important determi-
is one of the few known means of stimulating nant of the mechanical strength of bone is
new bone formation. Central to the entire the orientation of the collagen fibrils in the
bone matrix and the three-dimensional net- rangement of vertical and horizontal trabec-
work of plates and bars found especially in ulae (Fig. 11-2). Interruption of this support
trabecular bone (such as vertebrae), and to system—for example, loss of horizontal tra-
a lesser extent in cortical bone (for example, beculae as a result of aging—can impair the
the radius), resulting in a scaffoldlike ar- structural integrity of the bone and result in
Figure 11-2. Scanning electron micrograph of an iliac crest biopsy from (A) a normal subject auu
(fi) a woman with osteoporosis. Contrast the normal contiguous vertical and horizontal trabeculae
with the thinning decreased number and loss of continuity of the trabecular plates in osteoporosis.
(From Dempster DW, et al: A simple method for correlative light and scanning electron microscopy
of human iliac crest bone biopsies: Qualitative observations in normal and osteoporotic subjects. J
Bone Min Res 1(1):15, 1986, with permission.)
Menopause 191
fracture, even in the presence of a relatively 30 years from age 50 to age 80.13 Trabecular
normal amount of bone mineral.13 This is an bone accrual reaches its maximum during
important consideration when prescribing the mid to late 20s and is followed thereafter
exercise for older women. by a linear loss of bone.15 Others maintain
that the trabecular bone loss pattern equals
that of cortical bone, with a loss of at least
Types and Rates of Bone Loss
0.19% per year before menopause and at
As mentioned above, there are two types least 1.1% thereafter. Thus an estimated
of bone: cortical and trabecular. Cortical 31.7% of trabecular bone is lost during the
(compact) bone is found primarily in the ap- 50-year span between 30 and 80 years of
pendicular skeleton (for example, in the age.13 The greater the bone mineral content
femur, tibia, and fibula of the lower limbs, at bone mass maturity (maximum), of
and in the humerus, ulna, and radius of the course, the more an individual can afford to
arms). Cortical bone constitutes 80% of the lose, so there is a need to focus on the ac-
total skeleton but is metabolically less accrual of bone during youth rather than on
tive than trabecular bone. About 10% of the the treatment of a reduced bone mass in the
cortical bone is remodeled each year. postmenopausal period.
Trabecular (cancellous) bone is found in
the axial skeleton, primarily in the vertebral
How to Acquire More Bone
bodies (70% to 95%), with lesser concentra-
tions in areas such as the neck of the femur Mechanical force plays an important role
(25% to 35%) and the distal radius (5% to in bone formation and function, but it is not
20%). The remodeling process is far more known how much exercise is needed and
active in trabecular bone, in part because whether there is an optimal form of exercise
the architectural arrangement of the bone for bone accrual. It has been postulated16
plates provides a larger exposed surface that there is a physiologic "band" of activity
area for exchange with the extracellular that is site-specific: immobilization can lead
compartment. Approximately 40% of trabec- to severe bone loss at some sites, whereas
ular bone is remodeled each year. Because repeated loading at appropriate strain mag-
of this greater activity, vertebral osteopo- nitudes can result in bone hypertrophy. The
rosis occurs more frequently than hip (cor- frequency and degree of activity is impor-
tical-related) fractures. It may also account tant: repeated and prolonged exercise
for the increased susceptibility of the ver- causes bone fatigue and microscopic frac-
tebrae to the bone mineral loss noted in fe- tures.16 Given appropriate intervals between
male long-distance runners.14 periods of exercise, however, normal bone
After longitudinal bone growth has been turnover will repair these microfractures
completed, the bone mineral content and and even strengthen the bone.16 Excessive
mass of bone further increase until about activity is known to have an adverse effect,
the age of 35 years, at which point the indi- with stress fractures a common reality in
vidual is said to have achieved her maximal long-distance runners.16
cortical bone mass. From this age until the Gravity. Bone mineral is lost with the in-
onset of menopause, it is considered normal activity of simple bed rest. The average rate
for women to lose at least 0.12% of cortical appears to be 4% per month during the early
bone per year (as measured by single- and phase of bed rest; although subjects with
dual-photon absorptiometry); after meno- higher initial bone mass lose bone more rap-
pause and until age 65, the rate of bone loss idly than those with lower values, all immo-
increases to at least 1% per year, slowing bilized patients seem to end up with a simi-
down after age 65 to 0.18% per year. This lar bone mass.17 Lack of force on bones plays
"physiologic" bone loss averages out to a a major role in bone loss, with trabecular
25% decrease in cortical bone mass over the bone being more sensitive than cortical
bone. Three hours a day of quiet standing is Age. Age is yet another significant factor:
partially effective in restoring bone mineral, bone mass accrual occurs more readily in
while 4 hours of walking prevents the bone "growing" than in "mature" bone.21 Both an-
loss associated with 20 hours of bed rest. imal experimentation and clinical experi-
Osteogenesis in long bones requires me- ence have shown that the accumulation of
chanical stress; when electrodes are placed appropriate mechanical damage can stimu-
on opposite sides of bone, bending results in late bone hypertrophy. This requires the ex-
a negative electrical potential on the con- posure of adult bone to cyclic strain levels of
cave side relative to the convex side.18 The 2000 microstrain or more.22 However, there
resulting piezoelectricity stimulates new is an optimal level beyond which increasing
bone cell growth. It is therefore not surpris- strain levels will no longer enhance bone
ing that isometric or horizontal exercise— mass and may even have a negative effect.22
which does not "bend" bone and thereby Thus, the type and intensity of exercise pre-
stimulate this piezoelectricity—is not able scribed must be tailored to the age of the in-
to restore bone loss associated with immo- dividual.
bilization. Exercise Prescription. In presenting an
Systemic versus Local Effect. It is impor- osteogenic exercise program, two additional
tant to differentiate the amount of exercise criteria should be met: (1) the activity
needed to maintain bone mass from that should be diverse and vigorous, but nonre-
needed to increase it. This difference is well petitive,23 and (2) the exercise program
illustrated by a study that compared male should be enjoyable, in order to ensure
professional tennis players with age- long-term compliance. In addition, a pro-
matched casual tennis players. The former gram that will simultaneously improve car-
group was found to have an overall greater diovascular fitness would provide an added
bone mass, but in addition, the cortical incentive and advantage. By extrapolating
thickness in the playing arm of the profes- from animal data,24 it has been suggested
sional tennis players was 34.9% greater than that aerobic exercise at an intensity associ-
in the nondominant arm. The same was ated with 65% to 80% of maximal heart rate
found in female professional tennis players; is osteogenic.
cortical thickness in the dominant arm was
28.4% greater than in the nondominant
Exercise and Osteogenesis:
arm.19 Exercise thus seems to have both a
Clinical Research
systemic and a local effect and appears to be
related to the type of exercise performed. Several investigators have studied the ef-
When combined with the effect of gravity, fects of exercise programs upon bone min-
weight-bearing activity is more osteogenic eral density in postmenopausal women,
than weight-supported exercises such as using various protocols for exercise. Some
swimming. However, both male and female of these studies have included hormone re-
swimmers have been shown to have greater placement therapy in the protocol, and
vertebral bone mineral content than do some have also quantified calcium intake.
their sedentary counterparts of the same Disparate results reflect differences in pro-
sex.20 Although the differences between tocols and populations.
male swimmers and sedentary men were When interpreting the efficacy of a given
statistically significant, the differences be- program, the method of bone strength mea-
tween female swimmers and sedentary surement needs to be considered. Most
women did not achieve significance, proba- assessments are based on radiologic tech-
bly because of the smaller numbers of niques, single- and dual-photon absorp-
women studied (58 male swimmers, 78 sed- tiometry, and/or CT scanning. A qualitative
entary men; 35 female swimmers, 20 seden- improvement in bone strength resulting
tary women). from aerobic exercise may also derive from
Menopause 193
an engineering rather than a biologic prin- entary controls (mean age 39.6 ± 1.0 years).
ciple—an increase in bone width. Radial ex- Mean values of the mineral content and the
pansion of long bones is an important deter- bone density of the marathon runners' ra-
minant of bone strength. The so-called dial midshaft and middle phalanx (repre-
cross-sectional moment of inertia (CSMI) is sentative of cortical bone) were significantly
what determines bone's resistance to bend- greater, but the mean density of the os calcis
ing. An increase in the external diameter of (trabecular bone) was higher in the physi-
the bone, brought about by increased peri- cally inactive women.28 Women with mod-
osteal (outer layer) new bone formation, can erate exercise had greater cortical but less
compensate for the inevitable loss in the trabecular bone mineral contents, indicat-
quality of bone tissue that occurs with aging. ing that the increase in cortical bone
Cavanaugh and Cann25 have demonstrated through exercise came at the "expense" of
that a moderate brisk walking program of 1 trabecular bone.
year's duration does not prevent loss of ver- Although anatomically distinct, the meta-
tebral bone density in early postmeno- bolic functions of the cortical and trabecular
pausal women. Kirk and colleagues26 re- bone compartments are shared—a gain in
ported similar vertebral bone densities for one compartment may be matched by a loss
postmenopausal runners and age-matched in another. These two studies raise the ques-
sedentary women. Although the calcium in- tion: can one exercise too much, and if so,
take of the runners was higher (1145 mg/d will this result in a compromise of the tra-
versus 707 mg/d), neither group consumed becular skeleton? Hypoestrogenic, amenor-
adequate amounts by current standards. rheic runners have been shown to have a re-
These data suggest that exercise cannot duced amount of trabecular bone in their
compensate for an estrogen deficiency in lumbar vertebrae (as measured by dual-
preventing bone loss. photon absorptiometry) but normal or min-
Relatively brief exercise programs have imally reduced cortical bone (as measured
been shown to have a positive effect on ver- by single-photon absorptiometry and radi-
tebral bone mineral. Sixteen healthy women ogrammetry).14,29-31 Lower bone density in
(mean age 61 ± 6 years) participated in an these women correlates with estrogen defi-
exercise program that involved walking, ciency, inadequate dietary calcium, and re-
running, and calisthenics for 1 hour twice duced body weight. Calcium intake obvi-
weekly. At the end of 8 months, the vertebral ously plays a very important role. When
bone mineral content (measured by dual- reported, calcium intake was inadequate in
photon absorptiometry) increased by 3% to most osteopenic groups, regardless of estro-
5%, whereas in an age-matched control gen and exercise status. The menstruating
group it decreased by 2.7%. The bone min- marathon runners referred to previously
eral content of the distal radius, however, lost trabecular bone despite an intact hypo-
showed an average decrease of 3.5%.27 The thalamic pituitary ovarian axis; another
authors concluded that physical exercise in- study has shown that physically active
hibits or reverses bone loss from the lumbar women with anorexia nervosa (all of whom
vertebrae in normal women, but that the were amenorrheic and obviously hypoes-
changes in the forearm were independent of trogenic) had significantly greater bone
these exercises. mass than a similar group of inactive ano-
These results are divergent from another rectics.32
study that examined bone mineralization by Unpublished results from a study at the
x-ray densitometry (middle phalanx of the Center for Climacteric Studies comparing dif-
fifth finger and os calcis) and photon ab- ferent forms of exercise in natural and sur-
sorptiometry (distal and midshaft) in 42 gically menopausal women reflect on some
normally menstruating marathon runners of the aforementioned issues—age, type and
(mean age 37.7 ± 0.82 years) and 38 sed- intensity of exercise, and an "intact" estro-
gen milieu. Bone mineral content in this

study was measured by dual-photon absorp-
tiometry of the total skeleton. Naturally
menopausal women participating in aerobic
(walking on a treadmill, riding a stationary
bicycle) and muscle-strengthening (Nauti-
lus) exercises, none of whom were receiving
hormonal therapy, had less bone loss over a
1-year period than did a control group that
did not exercise. The controls lost 9.9% of
their bone mineral content, compared with
3.8% in the Nautilus exercise group and 0.5%
in the bicycle-riding group. The treadmill
subjects gained 0.4%.33
Heikkinen and associates34 showed that Figure 11-3. Percentage change (mean ± SEM) in the
weight training for 40 minutes in one session bone mineral density (BMD) of surgical menopausal
women after 1 year of hormone therapy alone (H) or
per week was insufficient to enhance the hormone therapy plus Nautilus exercise (H + N). The
beneficial effect of estrogen and progesto- probability (one-tailed t-test) associated with the
gen on bone mineral density in postmeno- change in spine BMD measures within the exercising
group wasp = 0.002. The probability (one-tailed t-test)
pausal women, nor was there any improve- associated with the change in spine BMD measures
ment in bone density in a control group not within the hormone-only group was p = 0.44. Changes
treated with hormonal therapy. However, a between groups were not significant. (From Notelovitz
et al,35 p 587, with permission.)
study performed at the Center for Climac-
teric Studies demonstrated increased bone
mineral density of the spine when a group of
surgically menopausal women were treated Exercise and Calcium Intake
with both estrogen and intense Nautilus
weight training for 45 to 60 min/wk, divided The precise mechanism whereby exercise
stimulates new bone formation is not clearly
into three sessions.35 In this study, the in-
established. Mechanical load, muscular ac-
crease in vertebral bone mineral density
tivity, and gravity serve as extracellular
(measured by dual-photon absorptiometry)
stimuli that are transmitted to bone cells to
was statistically significant for the estrogen-
initiate their genetic program for growth
plus-Nautilus group, compared to baseline, and differentiation. Intermediaries include
but the increase did not reach statistical sig- events such as the generation of piezoelec-
nificance for the estrogen-only group, or for tricity, which stimulates cyclic nucleotide
the between-group comparison (Fig. 11-3).
It is likely that this lack of significance re-
sulted from the small numbers studied (n =
9 for estrogen plus Nautilus; n = 11 for es- Table 11-1. EFFECT OF EXERCISE AND
trogen only). All subjects ingested a mini- HORMONE REPLACEMENT THERAPY ON
BONE MASS IN POSTMENOPAUSAL
mum of 1400 mg of calcium daily during the WOMEN
12-month study. These studies suggest that
an estrogen-replete state might be needed Moderate Intense
for an osteogenic effect in women involved Exercise Exercise Effect on
HRT* (Aerobic) (Nautilus) Bone Mass
in intense exercise programs, and that more
moderate levels of activity can conserve and No Yes 0
maintain bone independent of the estrogen No Yes 0
milieu (Table 11-1). However, more studies Yes Yes +
are needed to delineate the frequency, in- 'Hormone replacement therapy.
tensity, and duration of exercise necessary. Source: From Notelovitz et al,33 with permission.
Menopause 195
activity, prostaglandin synthesis, and other by exercise, the bone may not improve in
matrix-derived bone growth factors. strength in response to stress because their
It has been established that exercise is di- continuity (and hence structural integrity)
rectly associated with the laying down of has been lost. Nevertheless, light to moder-
matrix on the remodeling surface of bone's ate exercise in older women has resulted in
trabeculae and cortices. The matrix is com- an improvement of the cortical bone mass.
posed primarily of collagen. Chvapil and Smith and co-workers38 designed an exer-
colleagues36 showed that the amount and cise program for older women (mean age 81
concentration of collagen in the femurs of years) that oriented activity (1.5 to 3.0 METs
adult rats increased with exercise, but there in intensity) around a chair. (One MET
was no effect on the calcium content. This equals an oxygen uptake of 3.5 mL-min" 1 -
experiment illustrates a most important kg"1, the average value of effort during chair
point: to benefit from exercise and its osteo- rest.) Over 3 years, the exercise group dem-
genic stimulus, it is necessary to ensure an onstrated a 2.9% increase in midshaft radius
adequate supply of the substrate (mainly bone mineral content, whereas a matched,
calcium) needed to mineralize and mature nonexercising control group showed a
the newly formed bone. It is well known that 3.29% decrease.
fluoride therapy without simultaneous cal- Inadequate attention is given to the pre-
cium supplementation will increase miner- scription of exercise for women with estab-
alization of the axial skeleton, but at the ex- lished osteoporosis, most of whom will
pense of the cortical bone and with an present to the physician during the late cli-
increase in hip fractures.37 A similar situa- macteric. Key is discouraging activities that
tion may be true for exercise-induced osteo- involve flexion of the back. Long-term fol-
genesis, except that in this instance it is the low-up of patients with radiologically con-
cortical bone that benefits at the expense of firmed osteoporosis revealed concurrent
the trabecular compartment. This may fractures in 16% of women practicing back
prove to be one of the reasons why the extension exercises, 89% in a flexion pro-
amenorrheic women reported by Drinkwa- gram, 53% in a combined extension and flex-
ter and associates14 had lower spinal, but not ion regimen, and 67% in a nonexercising
cortical, bone mineral content when com- control group.39 Posture is also important.
pared with the eumenorrheic controls. Al- Avoidance of flexion during sedentary activ-
though both groups met the current recom- ities, such as sewing, can prevent further
mended dietary allowance of 800 mg of stress on already weakened vertebrae.40 In-
elemental calcium per day, the amenorrheic struction should also be given to avoid back
subjects fell short of the recommended straining by twisting, lifting, and making
amount needed to maintain calcium balance sudden, forceful movements. To remove the
in low estrogen states (1500 mg), whereas strain from the lower back when lifting or
the eumenorrheic women exceeded their reaching lower objects, the large muscles of
daily requirement of 800 mg. the legs (i.e., the hamstrings and quadri-
ceps) should be used, by bending the knees
Established Osteoporosis
and keeping the back vertical during these
activities.
Exercise in women with established os- Walking is the safest form of exercise for
teoporosis has to be modulated because women with osteoporosis. Also safe and ef-
pre-existing microfractures and discontinu- fective are group activities such as square
ity between the trabecular plates, especially dancing, ballroom dancing, and folk danc-
in the axial skeleton, may be aggravated by ing, as well as other activities such as riding
weight-bearing exercise. Furthermore, even a three-wheel bike or an exercycle. Swim-
though individual fragments of the horizon- ming is an excellent exercise that allows pa-
tal trabecular plates may be hypertrophied tients to regain their confidence in being
physically active, and at the same time al- the atherogenic process.45 Exercise has a
lows them to increase the flexibility and mo- beneficial effect on the lipoprotein moiety,
bility of their joints. Osteoporotic or mark- especially regarding the HDL cholesterol.46
edly osteopenic women should be advised Physical inactivity has also been linked to
to avoid activities such as aerobic (jazz) atherogenic disease. Men who are physi-
dance classes that jar the spine and empha- cally active have fewer stigmata of coronary
size flexibility. In evaluating these women, heart disease, and when they do occur, they
care should be taken to test for balance and are less severe and appear at an older age.47
for orthostatic hypotension, and to advise The same is true for women.48 Despite some
them about practical measures such as the previous claims that physical inactivity con-
type of shoes they wear. tributed only indirectly to cardiovascular
Additional information about bone con- disease risk, there is now considerable evi-
cerns may be found in Chapter 5. dence that low physical fitness stands as an
independent risk factor, in both men and
women, for all-cause mortality, cardiovas-
ATHEROGENIC DISEASE AND cular disease mortality, and cancer mortal-
CARDIORESPIRATORY FITNESS ity.49,50 In addition to the direct role demon-
strated after controlling for other known
Premature cessation of ovarian function risk factors,50 regular physical exercise
has been shown to increase the risk of myo- probably also plays an indirect role by re-
cardial infarction. Women who had a bilat- ducing other known risk factors for coro-
eral oophorectorny before age 35 were esti- nary heart disease, such as serum lipid con-
mated to have a 7.2 times greater risk of centrations and ratios,51 hypertension,51
being hospitalized for a myocardial infarc- hyperinsulinemia,52 diabetes mellitus,51,53,54
tion than age-matched normal premeno- and abdominal fat.55,56 The type, intensity,
pausal women.41 Other studies have also ob- and duration of exercise linked to a potential
served high rates of coronary disease in decrease in coronary heart disease varies.
women who experience an early meno- There appears to be a threshold of activity
pause.7,42,43 There is a general consensus that needed to achieve a benefit. This has been
the postmenopausal period is associated estimated to be 300 kcal/d above normal ac-
with well-defined high-risk factors for ath- tivity and requires 30 to 60 minutes of mod-
erogenesis: increased total plasma choles- erately intensive exercise per day.57 Earlier
terol and increased low-density lipoprotein speculation that women,58 especially older
(LDL) levels.7 This is a biologic, not a chron- women, would not be able to achieve this
ologic, event. A Swedish study compared goal has been disproved.
women aged 50 and older, of whom some Based on the previous observations, two
were still menstruating and others had practical aspects of physical activity and
reached menopause; serum cholesterol and cardiovascular health can be objectively
triglycerides were significantly higher in the measured: (1) the response of biochemical
postmenopausal group, and these levels in- parameters such as cholesterol and HDL
creased with postmenopausal age.44 cholesterol, and (2) measures of physical
The pathogenesis of atherosclerosis is fitness and exercise quantity—maximal ox-
characterized by two factors: (1) endothe- ygen uptake (Vo2max) and total exercise
lial desquamation with later smooth muscle time.
cell proliferation, and (2) cholesterol depo-
sition within these cells. Inhibition of LDL
internalization and deposition in the Lipids, Lipoprotefns, and
smooth muscle cell by high-density lipopro- Exercise
teins (HDL) cholesterol is said to be a key The plasma lipoproteins are the means
factor in the prevention or slowing down of whereby endogenous synthesized lipids are
Menopause 197
transported in the circulation. They are clas- cussion group served as the controls. Levels
sified according to their gravitational den- of serum cholesterol, triglycerides, total
sity into four basic classes: chylomicrons, HDL, and HDL2a and HDL2b were monitored
very low density lipoproteins (VLDL), LDL, at baseline, at 6 weeks, and at 12 weeks. The
and HDL. The latter are frequently subfrac- exercise groups were instructed to walk-jog
tionated into HDL2 and the more dense for 30 minutes (after a 15-minute warm-up
HDL3. The HDL2 cholesterol component is session) and to pace their activity in order
higher in women59 and is inversely related to to maintain their heart rate at 70% to 80% of
the development of coronary heart dis- their predicted maximum heart rate. One ex-
ease.60 Exercise stimulates HDL2, which is ercise session each week was supervised by
higher in both male and female runners than a group therapy leader, and the women ex-
in sedentary controls. In one study, for exercised on their own during two other ses-
ample, male runners had HDL2 cholesterol sions per week. Cardiorespiratory function
values of 119 versus 53 mg/dL for sedentary was determined at baseline and at 12 weeks
men; in women the values for active and sed- by having subjects walk on a motorized
entary subjects were 218 versus 122 mg/dL.59 treadmill until they declared fatigue or
The HDL-elevating effect of exercise is reached their predicted maximal heart rate.
thought to be due to an increase in lipopro- The exercising group had a significantly
tein lipase, an enzyme responsible for the greater increase in Vo2max, time spent on
catabolism of triglyceride-rich lipoproteins. the treadmill, and time required to attain
Lipoprotein lipase is found in greater con- 90% of maximal oxygen consumption (p <
centrations in the skeletal muscle fibers 0.01), but did not show a statistically signif-
(slow-twitch) of endurance athletes.61 icant difference in the lipid or lipoprotein
The adverse effects of estrogen deficiency fractions at either 6 or 12 weeks.64 This dis-
on low-density lipoprotein cholesterol lev- appointing result was confirmed by Franklin
els tend to be offset by aerobic training. and associates,65 who exercised their sub-
However, the beneficial effects of strenuous jects four times a week as part of a 12-week
exercise on plasma apolipoprotein levels conditioning program. These discrepant re-
can be reversed, in premenopausal women, sults may be explained by the duration of
by exercise-induced amenorrhea and de- the exercise program and intensity of the ex-
creased serum estradiol levels.62 ercise. For example, when the weekly run-
Table 11-2 lists the serum cholesterol val- ning mileage of 22 women was increased
ues found in a cross-sectional study of from 3.5 miles to 44.9 miles (over a 7-month
women conducted at the Center for Climac- period), their mean HDL cholesterol in-
teric Studies, showing an age- and meno- creased from 53.5 to 58.5 mg/dL (p < 0.01).66
pause-related increase.63 To determine In another study, hysterectomized post-
whether this change would be improved by menopausal women who exercised thrice
exercise, a group of 50 healthy women be- weekly in 30-minute sessions of aerobic ex-
tween the ages of 40 and 65 were invited to ercise at a minimum of 70% of maximal heart
participate in a 12-week program of exer- rate had a significant reduction in total
cise, discussion sessions, or both. The dis- serum cholesterol and LDL cholesterol.
Table 11-2. SERUM CHOLESTEROL (mg/dL) OF WOMEN, RELATED TO AGE AND MENOPAUSE
Premenopausal Postmenopausal
Age range 35-45 46-55 46-55 56-65 66-75
N 30 24 23 24 10
Cholesterol (mean ± SEM) 170.5 ± 4.3 203.2 ± 7.6 233.8 ± 5.9 230.1 ± 6.9 238.8 ± 6.7
Source: From Notelovitz et al.6:
However, this effect was not greater than with age, especially after age 50. Women
that induced by oral estrogen alone.67 usually achieve maximal Vo2max values in
Like their younger counterparts, post- their 20s; by age 50 to 65 years, the values
menopausal women who engage in regular are decreased by almost 30%.74 This loss of
endurance exercise have higher HDL cho- aerobic power is not related to menopause
lesterol levels than inactive women.68-70 per se, however. In a recent study, women
Postmenopausal long-distance runners and aged 45 to 55 had their Vo2max predicted by
joggers had significantly greater levels of means of a submaximal bicycle ergometer
HDL cholesterol compared with a control test.73 They were divided into premeno-
group of relatively inactive women—79.8, pausal and postmenopausal groups, as con-
73.5, and 61.8 mg/dL, respectively. The firmed by hormonal analysis and by their
lipid-lipoprotein profiles were minimally af- menstrual pattern: postmenopausal women
fected by exercise in a simultaneously stud- were required to have been amenorrheic for
ied group of exercising premenopausal at least 1 year. As reflected in Table 11-3,
women,70 raising the issue of whether it is serum LH and FSH were significantly higher
possible to make "normal" more normal. in the postmenopausal women (p < 0.0001),
It appears that the cardioprotective HDL and the estradiol and estrone levels were
cholesterol level improves after only 3 significantly lower (p < 0.0001). The pre-
months of moderate activity (e.g., running menopausal women were slightly younger
10 to 15 miles/wk) or low-level activity (e.g., (48.7 ± 0.4 years versus 52.2 ± 0.4), but the
walking 30 miles/wk).59 As with men, exer- difference was not statistically significant.
cise training in women lowers total choles- No significant difference was found in the es-
terol slightly or not at all.65,66 timated Vo2max for the two groups (p >
0.05).73
The observed decline in Vo2max with age
Aerobic Power probably reflects a loss of functional capac-
With the advent of the "fitness craze," ity due both to a natural age-related deteri-
women have come into their own and have oration and to a decrease in physical
exploded the myth that women are "frail"; activity. The age-associated reduction in
physical fitness in young women has now cardiorespiratory efficiency at submaximal
become socially acceptable and, in many exercise, however, is due primarily to
circles, even desirable. Until fairly recently, weight gain rather than to actual systems de-
however, it was felt that exercise would not generation.75 The rate of decline is slower in
benefit middle-aged people, and that the de-
cline in cardiorespiratory function with
aging would reduce the expected benefit Table 11-3. MEAN ESTIMATED MAXIMAL
from exercise.58 Furthermore, it was postu- O 2 UPTAKE VALUES AND HORMONAL
lated that menopause per se could be re- STATUS (± SD) OF PREMENOPAUSAL
sponsible for the decrease in aerobic power AND POSTMENOPAUSAL WOMEN AGE 46-
in women over the age of 50.71,72 55 YR
As with men, cardiorespiratory fitness Premeno- Postmeno-
does decrease with age, but this decline is pausal pausal
not related to the hormonal changes of the Parameter (n = 28) (n = 30)
climacteric. Figure 11-4 shows that a dec- Estimated Vo2max 27.4 ± 6.3 26.3 ± 4.7
rement of 5.5% of Vo2max occurred with (mL-kg - 1 '-min - 1 )
each succeeding decade between ages 35 LH (mlU/mL) 23.5 ± 3.6 62.8 ± 3.5
and 75 in a study of 163 healthy sedentary FSH (mlU/mL) 12.6 ± 2.6 55.7 ± 3.5
women.73 This observation approximates Estrone (pg/mL) 107.5 ± 11.5 62.9 ± 3.9
with the generalization that sedentary indi- Estradiol (pg/mL) 146.2 ± 18.7 19.5 ± 3.5
viduals have a 1% loss of Vo2max per year Source: From Notelovitz et al,73 with permission.
Menopause 199
Figure 11 -4. Measured Vo2max (mL • kg • min) in 163 healthy climacteric women, who first were screened for cardio-
vascular normalcy by a 12-lead ECG stress test and physical examination. The Vo2max was elicited using a modified
Balke treadmill procedure, and was directly measured using a Beckman Metabolic Measurement Cart. (From No-
telovitz et al.,73 with permission.)
phrysically active men76 and women.76,77 This times a week for 12 weeks) resulted in a sig-
raises the issue of whether menopausal nificant increase in maximal oxygen con-
women can be efficiently trained. Premeno- sumption, time on the treadmill, and the
pausal women (mean age 41 years) who time to reach 90% of maximal oxygen con-
trained for 9 weeks improved their Vo2max sumption, when compared with age-
by 12.1%, while similarly trained postmeno- matched female controls who did not exer-
pausal women (mean age 57 years) im- cise.80 More recently, 63 postmenopausal
proved their Vo2max by 19%.78 This result women were evaluated over a 1-year period,
has been confirmed by others,79 including during a structured program that involved
two studies conducted at the Center for Cli- three weekly 20-minute treadmill, ergome-
macteric Studies in Gainesville, Florida. ter, or Nautilus (muscle-strengthening) ses-
Moderate exercise (walk-jogging three sions. Two nonexercising groups were
Table 11-4. RESPONSE OF CLIMACTERIC WOMEN—MEAN AGE 56 YR—TO INTENSIVE

STRUCTURED EXERCISE,81 MEAN (± SD) MAXIMAL O2 UPTAKE (mL-kg-'-mirT 1 )
% Difference
Baseline vs
Group Age n Baseline 3 Mo 6 Mo 12 Mo 12 Mo
Nautilus 59.3 ± 6.7 13 26.0 ± 5.2 26.1 ± 4.7 26.5 + 4.0 26.2 ± 3.9 0.8
Treadmill 54.9 ± 6.9 10 27.1 ± 2.7 29.5 ± 2.8 30.5 + 2.8 29.5 ± 2.4 8.9
Ergometer 55.9 ± 6.9 10 26.7 ± 4.7 28.9 ± 4.1 30.2 ± 4.1 30.0 ± 4.8 12.4
Control 62.0 ± 7.1 14 26.5 ± 4.7 26.1 ± 6.0 25.9 ± 5.9 26.2 ± 5.8 -1.1
Hormone 48.4 ± 7.2 16 26.6 ± 3.9 26.3 ± 3.7 26.4 ± 4.2 25.1 ± 3.9 -5.6
Source: From Notelovitz et al,81 with permission.
included: an age-matched nontreatment Cowan and Gregory78 noted a 29.6% increase

group and a slightly younger group on hor- in total walking time; in the Gainesville
mone replacement therapy. Aerobically study,81 the time for treadmill walkers in-
trained subjects were exercised at 70% to creased 21.5%, and for bicyclists, 17.4%. Pre-
85% of the maximal heart rate. Significant menopausal women exposed to the same ex-
improvements in both Vo2max and time on ercise regimen had an improvement rate of
the treadmill were recorded and maintained 10.9% in total exercise time.78 Since the heart
only by the bicycle and treadmill groups rate and stroke volume response to exercise
(Tables 11-4 and 11-5).81 was appropriate in postmenopausal women,
The anticipated degree of improvement in there is a possibility that the lesser percent-
aerobic power is inversely related to the age response in Vo2max compared with per-
subject's initial level of fitness, but at all ini- centage improvement in exercise time might
tial levels, the greater the intensity and fre- be accounted for by partially compromised
quency of the training program, the greater lung ventilation, lung diffusion capacity for
the improvement. For example, the post- oxygen, and/or oxygen utilization by the tis-
menopausal women in Cowan and Gregory's sues in the postmenopausal period.
study78 had a 19% improvement in Vo2max Less attention has been directed to older
(from 12.6 m L . k g - 1 . m i n - 1 to I S . m L . k g - 1 women. When 10 healthy women of mean
min -1 ). compared with a 10.7% improve- age 72.0 years exercised three times per
ment in the Gainesville study31 (from 26.9 week for 20 minutes per session, at 70% of
mL-kg - 1 -min - 1 to29.8mL-kg - 1 -min - 1 ). maximum heart rate, for 26 weeks, maxi-
An intriguing observation in both of these mum oxygen uptake increased 8.4% and
studies is the considerably greater improve- total exercise time increased 25.4%, com-
ment in total exercise time versus Vo2max. pared to a 6.1% decrease in maximum oxy-
Table 11-5. RESPONSE OF CLIMACTERIC WOMEN—MEAN AGE 56 YR—TO INTENSIVE

STRUCTURED EXERCISE,81 MEAN (±SD) TOTAL EXERCISE TIME (MIN)
% Difference
Baseline vs.
Group Age n Baseline 3 Mo 6 Mo 12 Mo 12 Mo
Nautilus 59.3 ± 6.7 13 12.1 ± 3.2 12.2 ± 2.5 12.9 ± 2.4 12.5 ± 2.4 5.3
Treadmill 54.9 ± 6.9 10 12.5 ± 1.6 14.2 ± 2.1 15.2 ± 2.0 15.3 ± 2.1 21.5
Ergometer 55.9 ± 7.9 10 13.0 ± 3.1 14.1 ± 3.0 14.5 ± 3.0 15.2 ± 3.3 17.4
Control 62.0 ± 7.1 14 12.2 ± 3.3 11.6 ± 3.6 12.2 ± 4.0 12.1 ± 3.4 -0.95
Hormones 48.4 ± 7.2 16 13.4 ± 2.4 12.6 ± 2.3 13.0 ± 2.3 12.3 ± 2.2 -7.7
Menopause 201
Table 11-6. IMPROVEMENT OF MAXIMAL O2 UPTAKE FOLLOWING AEROBIC TRAINING

PROGRAMS IN WOMEN OVER AGE 50
Duration of Duration of
Exercise Frequency Training %Gain in
per Session of Exercise Intensity Program Maximal
Author n (min) per Week of Exercise (wk) O2 Uptake
Kilbom58 13 30 2-3 70%* 7 8
Adams and 17 50 3 85% 12 20.8
DeVries133
Sidney etal.134 25 60 4 120-150 7 >30
Sidney and 28 55 3 60-80% 14 17
Shephard135
Cowan and 14 50 4 80% 9 18.9
Gregory78
Notelovitz et al81 10 (T) 20 3 70-85% 52 8.9
10 (E) 20 3 70-85% 52 12.4
Probart et al82 10 20 3 70% 24 8.4
*Vo2max.
Maximum heart rate.
Heart rate.
T = treadmill; E = ergometer.
Source: Adapted from Cowan and Gregory.78
gen uptake and a 5.4% decrease in total ex- other cross-sectional study,83 active women
ercise time in six age-matched controls who had a fitness gain of one decade when com-
did not exercise.82 These data and others pared to sedentary women. The mean
(Table 11-6) indicate that older women can Vo2max of active 40- to 49-year-old women
certainly expect to improve fitness and ex- was higher than sedentary 30- to 39-year-old
ercise capacity with aerobic training. women; active 50- to 59-year-old women had
In the studies summarized in Table 11-6, values similar to sedentary women in their
the percentage gain in aerobic power ranges 40s. One way of encouraging women to ex-
from 8% to 30%. With only one exception, ercise is to use cardiorespiratory fitness as-
the duration of these training programs was sessments as a means of demonstrating im-
less than 14 weeks. The best improvement provement in aerobic function before the
was obtained in programs whose duration of physical benefits of exercise are appreci-
exercise exceeded 30 minutes in each ses- ated. Bruce and colleagues84 reported that
sion. The study that continued for 12 63% of their patients attributed a change in
months demonstrated that most of the im- one or more adverse health habits to a
provement attained by 12 months had been graded exercise test. Persons with an abnor-
achieved by 3 months of training. These re- mal result were motivated the most.
sults, however, do not reflect the true poten- Maximal oxygen uptake tests need to be
tial of older women engaged in long-term, performed in a specially equipped labora-
intensive exercise programs, nor do they tory and are not suited to everyday clinical
consider a most important practical, real- practice. Submaximal testing, on the other
life issue of exercise: compliance. hand, is more suited to the practicing phy-
Measurements of aerobic fitness may help sician. Several studies have shown that pre-
to motivate some sedentary women. Kirk dicted maximum Vo2 values (using a bicycle
and co-workers26 reported higher levels of ergometer) correlate well with observed
fitness (maximal oxygen consumption) maximal testing when corrected for age,85,86
among postmenopausal runners compared but none of these studies have involved cli-
to age-matched sedentary women. In an- macteric women. To test this relationship in
postmenopausal women, 29 women (mean diorespiratory fitness for women (Table 11-
age 55.6 ±9.1 years) participating in an on- 7), potential exercise candidates can obtain
going exercise program had both a maximal a good index of both their current fitness
treadmill test and a submaximal ergometry status and the goals they should reach. Be-
test.73 The interval between the two tests cause postmenopausal women appear to
was less than 1 month, and the order of test- show a greater response to a given exercise
ing was randomly selected. The measured program in total exercise time than in max-
Vo2max was 28.6 ± 4.9 mL.kg - 1 -min - 1 , and imum oxygen uptake, the total exercise no-
the predicted Vo2max 32.5 ± 5.3 mL-kg~'- mogram (Fig. 11-7) may be used as the pri-
min - 1 . When the latter result was calculated mary indicator of exercise response and
using the recommended Astrand age correc- improvement.
tion factor, the mean predicted Vo2max was In view of the laziness inherent in most
23.4 ± 4.9 mL-kg -1 min - 1 . This correlated people, any program that can produce im-
closely with the directly measured result (r proved results for little effort is more likely
= 0.789; Fig. 11-5). to be successful and lead to a greater degree
Submaximal testing can thus be used both of compliance than a program that requires
as a screen to determine the cardiorespira- great effort and discipline. Schoenfeld and
tory fitness of climacteric women and as a co-workers87 examined the efficiency of
way of monitoring the response to pre- walking with a backpack load as a method
scribed exercise. Patients at high risk for for improving physical fitness of sedentary
cardiovascular disease and those classified men. They showed that it was possible to in-
as having fair to poor fitness (as measured crease Vo2max by 15% to 30% by walking for
by ergometry) require more detailed evalu- 3 to 4 miles with a 3- or 6-kg backpack. When
ation before embarking on a prescribed ex- we compared the effects of treadmill walking
ercise program. A nomogram is also very with and without extra weight in a small
useful (Figs. 11-6 and 11-7); when used to- group of postmenopausal women, we found
gether with age-adjusted tables listing car- greater improvement in the aerobic capacity
of the load-bearing group.88 However, con-
firmatory studies with larger numbers are
needed to determine whether load-bearing
enhances the efficacy of aerobic training or
modifies the perceived effort.
MUSCLE TISSUE AND

STRENGTH
Age-Related Loss of Muscle

Tissue and Strength
Muscle mass and muscle strength decline
with aging, and muscle weakness can greatly
reduce the quality of life and self-sufficiency
of many older women. The age-related de-
cline in lean body mass correlates with sev-
eral changes: a decline in endogenous
growth hormone (GH),89 a decline in pitu-
itary responsiveness to growth hormone re-
Figure 11-5. Correlation between measured and pre-
dicted Vo2max in climacteric women. (From Notelovitz et leasing hormone (GHRH),90 loss of muscle
al.,73 with permission.) fibers,91 neuromuscular alterations, inactiv-
Menopause 203
Figure 11-6. Normative Vo2max values for climacteric women. Mean ± 1 and 2 SD for each age group. (From No-
telovitz M, Fields C, et al: Unpublished data. Center for Climacteric Studies, Gainesville, FL, with permission.)
ity, and other age-related changes. Pre- Table 11-7. GUIDELINES FOR FITNESS
menopausal women have significantly ASSESSMENT BY Vo2max ( m L - k g - 1 m i n - 1 )
greater pituitary response to GHRH than do OF HEALTHY WOMEN AGE 30-70
men of the same age, but postmenopausal Age Poor Fair Average Good Excellent
women do not;90 this finding suggests that
postmenopausal estrogen deficiency accel- 30-39 <20 20-27 28-33 33-44 45 +
40-49 <17 17-23 24-30 31-41 42 +
erates the age-related decline in GH secre- 50-59 <15 15-20 21-27 28-37 38 +
tion and may also accelerate the loss of mus- 60-69 <13 13-17 18-23 24-34 35 +
cle tissue that occurs as women age.
Source: Adapted from Exercise Testing and Training in
Although Rudman and his co-workers92 re- Apparently Healthy Individuals: A Handbook for
ported that older men increased both lean Physicians, published by the Committee on Exercise,
body mass and skin thickness and de- The American Heart Association, Dallas, TX, 1972.
Figure 11-7. Normative total exercise time (.TET) to exhaustion values for climacteric women, using modified Balke
method. Mean ± 1 and 2 SD for each age group. (From Notelovitz M, Fields C, et al: Unpublished data. Center for
Climacteric Studies, Gainesville, FL, with permission.)
creased adipose tissue mass during GH in terms of milliliters per kilogram per min-
treatment, this has not been studied in older ute of muscle, as determined by 24-hour
women. Furthermore, the safety of such urine creatinine measurements. Increasing
therapy has not been demonstrated. muscle mass can thus play an important role
Several cross-sectional studies also have in determining energy expenditure: a 2-kg
shown a loss of muscle strength with age, increase in a woman's lean body mass re-
beginning after the third decade of life and sults in an additional expenditure of about
amounting to a decline of 16.5% or more.93 50 kcal/d, the equivalent of about 5 Ib of
The loss is greater in women.94 Loss of mus- body fat per year.
cle tissue is related to a number of important Muscle is also an important determinant
metabolic activities. For example, Tzanoff of carbohydrate utilization. The rate of glu-
and Morris95 maintain that the decrease in cose removal from muscle is more rapid in
muscle mass may be wholly responsible for physically active persons, and the amount of
the age-related decrease in basal metabolic insulin needed is significantly reduced.96
rate (BMR). The average Vo2max of older This effect is reputed to be due to the en-
men was 22% lower when compared with hanced sensitivity of insulin receptors in
younger men, but this difference decreased skeletal (and adipose) tissue. Obesity and
to only 8% when the values were expressed diabetes are two age-related conditions that
Menopause 205
are prevalent in the late climacteric. Van gens) will provide relief for most women. It
Dam and colleagues96a have shown improve- should be noted that medroxyprogesterone
ment in glucose tolerance among postmeno- acetate has not been approved, in the
pausal women following aerobic exercise United States, for use in women with breast
training. cancer.
Strength Training
OTHER AGE-RELATED
Weight training in women has been shown CHANGES
to improve strength with a loss of adipose
tissue and with relatively little muscle hy- Exercise and Adipose Tissue
pertrophy. These studies have involved
young women, trained athletes, or both, Most people add adipose tissue with
however.97-99 It is not known whether mus- aging. There is no evidence that accumula-
cle strengthening exercises will enhance the tion of adipose tissue is related to meno-
metabolic function of postmenopausal skel- pause, estrogen deficiency, or any other al-
etal muscle, and if so, to what degree. Ex- terations in reproductive hormones, but
trapolation from data collected in male sub- many women first notice this accumulation
jects suggests that the accumulation of around the time of menopause. Menopause
greater mass will lead to greater energy ex- also has not been shown to affect the distri-
penditure. Strength training does not im- bution of body fat,105 but there is a progres-
prove cardiorespiratory function (see Table sive age-related increase in upper and cen-
11-4), a finding confirmed by studies done tral body fat deposition, which tends to
in middle-aged men.100 Weight training accelerate in postmenopausal women.106
stresses muscles far more than do most aer- However, it remains to be shown whether
obic exercises. It is safe to start an aerobic this change is related to menopause, aging,
exercise program and then, many months or both.
later, to start lifting weights. Levels of adipose tissue lipoprotein lipase
(LPL) correlate directly with body mass
index (in kilograms per square meter of
OTHER MENOPAUSAL body surface) and affect the maintenance of
PROBLEMS: VASOMOTOR adipocyte size, body weight, and obesity.107
SYMPTOMS Adipocyte size is similar at mammary, ab-
dominal, and femoral sites and is similar
Very few studies have addressed the re- for premenopausal and postmenopausal
lationship between menopausal vasomotor women.108 It has been shown108 that femoral
symptoms ("hot flushes") and exercise. In LPL activity is much higher among pre-
one study, Hammar and co-workers101 found menopausal women than among postmeno-
vasomotor symptoms to be less common pausal women and that, among premeno-
among exercising menopausal women than pausal women, it is much higher than it is at
among inactive women. Since exercise has mammary or abdominal locations. Treat-
not been shown to relieve symptoms, how- ment of postmenopausal women with estra-
ever, this finding may reflect a self-selection diol and a progestogen leads to an increase
bias, representing differences between the in femoral LPL activity.109 When percutane-
two groups questioned. ous progesterone is applied to the femoral
Although the etiology of the menopausal region of premenopausal women during the
vasomotor flush remains enigmatic, estro- follicular phase of a natural menstrual cycle,
gen remains the most effective form of ther- LPL activity rises locally.110 These data sug-
apy available.102 When estrogen is contrain- gest that progesterone is an important de-
dicated, medroxyprogesterone acetate103 or terminant of femoral LPL activity.111
megestrol acetate104 (synthetic progesto- Regional fat distribution has achieved im-
portance since it was demonstrated that ab- subchondral bone, cyst formation, and nar-
dominal fat is a risk factor for cardiovascular rowing of the joint space.
disease and diabetes, while femoral fat is Postmenopausal women have decreased
not.55,56 Aerobic exercise facilitates the loss amounts of collagen in skin and bone,118 and
of abdominal fat more readily than fat at it is most likely that the same is true for the
other sites, and promotes fat loss more collagen content of their articular surfaces.
readily in men than in women.112-115 It is for- The collagen in the skin (and possibly also
tunate that abdominal fat is so sensitive to in the bone) of postmenopausal women is
exercise, since this facilitates reduction in responsive to estrogen replacement. Al-
disease risk. However, the relative resist- though arthralgia is a common symptom in
ance of femoral fat depots to exercise may the late climacteric, a direct linkage between
discourage many women with a preponder- menopause and joint disease has not been
ance of femoral fat. established. However, a study has demon-
Inactivity is the most common cause of strated that noncontraceptive hormonal
obesity, and it accelerates the accumulation therapy does help some women with rheu-
of body fat that occurs naturally with aging. matoid arthritis.119
Cowan and Gregory78 have reported a loss of With the increased interest in jogging, a
body fat during a 9-week training program in question arises of whether damage to the
women, confirming that exercise can cer- musculoskeletal-articular system exceeds
tainly help older women to lose fat. Control the benefit of exercise. Lane and asso-
of weight and body fat is discussed more ciates120 recently studied female long-
thoroughly in Chapter 2. distance runners over age 50 and compared
them with age-matched nonactive commu-
nity controls. The female runners did have
Exercise and Osteoarthrosls more sclerosis and spur formation in the
The articular cartilage that covers the weight-bearing areas of the spine and knees,
bone ends in joints is rich in collagen and but not in the hands. These changes were
the mucopolysaccharide proteoglycan. This not found in men studied in the same and
collagen layer acts as a barrier preventing other investigations.121
the leakage of proteoglycan from the deeper Given the asymptomatic nature of these
layers into the joint space, and at the same changes and the difficulty of extrapolating
time it inhibits potential harmful enzymes in cross-sectional data into "real-life" terms, it
the synovial fluid from perfusing into the cannot be concluded that jogging has an ad-
deeper cartilage.116 Loss or damage to the verse effect on the joints of middle-aged
cartilage layer leads to joint degeneration women. The absence of joint changes in
and the development of osteoarthritis. age-matched and hormone-replete men,
Osteoarthritis is a highly prevalent dis- however, suggests the possibility that an es-
ease: 86% of women over the age of 65 show trogen-primed articular surface (with an im-
radiologic evidence of the condition,117 al- proved collagen content) might be similarly
though only 25% to 30% of individuals with resilient to mechanical stress.
diagnosed osteoarthritis are symptomatic.
There are conflicting opinions regarding the
role of microtrauma to the joint surface in EXERCISE AND WELL-BEING
the pathogenesis of osteoarthritis. Impulse
loading causes trabecular microfracture
with subsequent healing by sclerosis, result- The administration of exogenous estro-
ing in stiffened bone that increases the gens, especially parenteral estrogen ther-
stress on the articular cartilage, with even- apy, to postmenopausal women is fre-
tual damage to the cartilage and joint degen- quently associated with a mood-elevating
eration. These changes appear on roentgen- effect. Exercise is also known to induce a
ogram as osteophytes, sclerosis of the state of well-being and, according to some
Menopause 207
studies, a reduction in symptoms such as factors that contribute to a "refreshing"

depression and anxiety. The early work of sleep period.129
Weber and Lee122 demonstrated that vigor- To evaluate the effect of exercise on psy-
ous activity in animals had a positive influ- chologic well-being, preprogram and post-
ence on psychologic measures and that this program psychosocial measures were ob-
was probably due to alterations in brain tained by questionnaire and standardized
neurotransmitter levels or activity, or tests in a group of healthy women (age 40 to
both.123 Studies in humans have been less 64 years) participating in a 12-week exercise
clear, and there is some question whether program. Methods of evaluation included a
the "runner's high" really exists.124 self-report of physical activity, a somatiza-
Part of the controversy lies in the fact that tion scale, the multidimensional health
much of the research has been conducted in locus of control inventory, the Profile of
nondepressed subjects. Greist and col- Mood States Scale, and a social support
leagues125 demonstrated that aerobic exer- questionnaire. Members of the exercised
cise performed for 12 weeks reduced de- group were required to walk-jog for 30 min-
pression (in patients complaining of mild to utes three times a week for 12 weeks, and
moderate depression) to a greater degree they were compared with matched women
than traditional psychotherapy. Additional participating in discussion groups and a
advantages noted by the authors included nonintervention control group. The only
less expense, no need to use antidepressant noted apparent benefit of exercise was a de-
medication, and the persistence of a depres- crease in intake of stimulants (e.g., coffee)
sion-free state when evaluated 12 months among exercisers, whereas there was an in-
later, whereas half the patients receiving crease in intake among the nonexercisers.80
psychotherapy returned earlier for addi- These results are similar to the report of
tional treatment. The reader is referred to an Penny and Rust,130 whose subjects partici-
excellent review by Dunn and Dishman126 of pated in a walk-jog program involving \%
the relationship between exercise and de- miles of exercise twice a week for 15 weeks.
pression. A comparison of personality scales mea-
One of the most distressing symptoms ex- sured by the MMPI showed no difference
pressed by menopausal women is anxiety. from a control nonexercising group. Despite
Vigorous physical activity reduces muscle these negative results, discussions with in-
tension and is also associated with a signif- dividuals who exercised elicited commonly
icant decrease in anxiety.127 This effect was observed responses: "feeling better, enjoy-
noted only when the exercise was intense ing social functions more, participating in
enough to provoke significant elevations in more extracurricular activities, and not
plasma epinephrine and norepinephrine, being tired at day's end."130 The operative
however,128 and did not occur if light to mod- factors appear to be the frequency, inten-
erate exercise was performed. sity, and duration of exercise, and patience.
Another common problem associated The last is most important, as the benefits of
with the menopausal syndrome—insom- exercise rarely occur before 10 weeks of
nia—may be positively influenced by exer- training, the time when most individuals
cise. Healthy subjects who engaged in static drop out of exercise programs.
exercise (e.g., contraction of a hand dyna- In summary, although the chemical basis
mometer at 40% of maximal level for 40 min- of the mood improvement induced by phys-
utes, separated by a 10-minute rest at mid- ical activity is not known, fairly strong evi-
session) 2 hours before bedtime were dence suggests that acute and chronic vig-
shown to have a significantly reduced time orous exercise is associated with an
to onset of sleep relative to nonexercise improvement in affective states, especially
nights. The improvement in sleep was as- anxiety and moderate depression.
sociated with increased slow-wave sleep Psychomotor speed is one well-recog-
and decreased movement time during sleep, nized behavior that is slowed by aging. This
is especially true for response speed that oc- generalized rather than specific exercise.
curs in reaction time, performance of tasks For example, the reactive speed of the fin-
that require the coordination of two simul- gers is improved in runners, who primarily
taneous movements, writing speed, and sim- exercise their legs.132 It is not clear whether
ple tasks such as tapping in place.131 The this exercise-induced improvement affects
quicker the response, the higher the percep- central nervous system processing time, or
tual speed score. Perceptual speed was eval- motor speed. As with the psychologic re-
uated in healthy aging women as part of a sponse to exercise, CNS function (e.g.,
large study examining age-related changes, short-term memory) that is not impaired in
and a progressive decrease was noted with a particular individual cannot be expected
both chronologic and biologic aging.63 As to be improved by exercise. With this caveat
shown in Table 11-8, the perceptual speed in mind, it is fair to conclude that "exercise
score decreased from a mean score of 64.4 seems to be one way for people to achieve
± 2.1 in 40-year-old premenopausal women maximal plasticity in aging, approximating
to 48.0 ± 2.6 in 68-year-old women (p < full vigor and consistency of performance
0.0001; r = —0.41). An interesting observa- until life's end."132
tion is the difference in the perceptual speed
score between premenopausal and post-
menopausal women aged 46 to 55. Although SUMMARY
the premenopausal women were only a few
years younger, their mean perceptual speed "Menopause," an often-misused term, is
score was significantly higher than that of actually the duration of a woman's final men-
the postmenopausal group, whose score strual period. The 15 years leading up to and
was similar to the score of women 5 or more following this event are known more prop-
years past their menopause. erly as the "climacteric."
Further analysis of these data revealed Women lose a small percentage of bone as
that, within the groups, physical fitness was a natural phenomenon in the aging process.
positively correlated with the perceptual However, the greater the bone mineral con-
speed score. The greater the degree of fit- tent at bone mass maturity, the more one
ness, the more functionally competent the can afford to lose. Thus, women should be
individual.63 This raises the issue of whether encouraged during, and even before, the
exercise may prevent premature aging of the early climacteric to accrue as much bone as
central nervous system and compensate for possible, through an appropriate calcium in-
possible alterations in the neurohormonal take and an osteogenic exercise program.
milieu of postmenopausal women. A number Likewise, such practices can be used to
of investigators have shown that people who avoid excessive bone loss during the climac-
exercise consistently have a faster reaction teric. For women who have osteoporosis, a
time, and that this difference is related to regimen of walking may be the safest type of
Table 11-8. CHANGES IN PERCEPTUAL SPEED SCORE ASSOCIATED WITH CHRONOLOGIC AND
BIOLOGIC AGING IN WOMEN
Premenopausal Postmenopausal
Age range 35-45 46-55 46-55 56-65 66-75
Mean age (± SEM) 40.9 ± 0.5 48.7 ± 0.4 52.2 ± 0.4 59.3 ± 0.5 68.5 ± 0.5
N 30 29 30 29 27
Perceptual speed score 64.4 ± 2.1 61.1 ± 1.9 56.6 ± 1.8 55.3 ± 1.3 48.0 ± 2.6
(mean ± SEM)
Menopause 209
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avoid exercises that emphasize flexion of Human Services, DHHS Pub No (PHS) 85-
the back. 1232,1984.
10. Cohn SH, Abesamis C, Yasumura S, et al:
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TCB (eds): Osteoporosis: A Multidisciplin-
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Ill
Special Issues
and Concerns
CHAPTER 12
The Breast
CHRISTINE E. HAYCOCK, M.D.
BREAST SUPPORT PREGNANCY AND LACTATION

NIPPLE INJURY PREMENSTRUAL CHANGES AND
TRAUMA FIBROCYSTIC BREASTS
BREAST AUGMENTATION AND EXERCISE FOLLOWING TRAUMA
REDUCTION OR SURGERY
w saring a bra can provide two useful functions during exercise—providing

support and limiting breast motion.1,2 This can help reduce discomfort and
impact of the breast against the anterior chest wall. Padding can be added to help
prevent traumatic injuries, such as that from a hockey stick or an elbow.
There is no evidence that free-swinging breasts are more likely to be dam-
aged during exercise. However, women in primitive cultures who never wear
bras do develop long pendulous breasts, whereas those in modern society who
frequently wear bras are less likely to develop these changes.
BREAST SUPPORT
In an effort to ascertain the injury potential for the female athlete in the early
1970s, two surveys were conducted in more than 300 physical education depart-
ments throughout the country. The first questionnaire, performed by Joan Gil-
lette, A.T.C., and published in 1975 in The Physician and Sportsmedicine,3 asked
for the numbers and types of injuries seen by coaches and trainers. I sent out a
more detailed questionnaire to cover the 1974 to 1975 season, with more empha-
sis on the types of injuries rather than on just the numbers and associated sports.
The combined results of the two surveys were published in 1976.4 The surveys
indicated that, in general, the types and numbers of injuries to these female ath-
letes were essentially the same as to their male counterparts. Of particular inter-
est to me was the fact that, of all injuries reported, those to the breast were least
common. Other studies have confirmed these findings.5-7
217
218 Special Issues and Concerns
The results of the earlier surveys Twelve female athletes with different breast
prompted me to undertake a third survey,8 sizes were fitted with special supportive
specifically asking if female athletes re- bras. They were encouraged to use these
ported tenderness or soreness in their garments during athletic competition and to
breasts or injuries such as scratches from note how they compared in comfort and
metallic parts or allergies to the materials in support with the bras they had been using
their bras. Thirty-one percent of the respon- previously. Most of the women felt that the
dents indicated sore or tender breasts after bulky test bras provided better support than
exercise. Of these, 52% reported specific their own. The women who benefited the
minor injuries to the breasts. most had size B cups or larger. Five volun-
A study was undertaken by Haycock, teers were filmed with a high-speed (100
Shierman, and Gillette9 to ascertain what frames per minute), 16-mm camera while
factors cause breast injury and discomfort. walking and running on a treadmill and
To determine if a bra is necessary to control while jumping to simulate the motion of
breast motion, a test was instituted to mea- shooting a basketball into the hoop. A
sure breast movement during exercise. marker was placed on each nipple so that
line studies made by tracing each frame
could be drawn. Each marker was placed ei-
ther on the bra or on the breast itself, since
the athletes were filmed wearing their own
bras, wearing the special bras or wearing no
bras.
The films showed that during running, the
breast moves considerably up and down,
and during jumping, the breasts roll in a spi-
ral motion (Fig. 12-1). Although the force of
breast impact upon the chest wall was not
measured, it was estimated to be between 60
and 80 foot pounds per square inch, with the
largest breasts exerting the greatest force.
Although both sets of bras limited motion,
the specially fitted ones did the best job,
corroborating the increased support and
comfort reported by the athletes them-
selves.
These findings are consistent with the
original expectations of the authors. The
natural support of the breasts is minimal.
The breast is composed mostly of adipose
tissue. It is held in place by the skin and
some deep fascial structures, which loosely
attach the glands to the underlying muscles,
blood vessels, and nerves. Cooper's liga-
ments do not support the breasts. They are
merely connective tissue strands extending
between the skin and the pectoralis fascia
Figure 12-1. The subject wore a size D cup. The solid and separating the glandular structures.8 As
line represents the range of motion with no bra; the a result of this study, the following recom-
dash-dot-dash line, the subject's own bra, which had
fairly good support; and the dash line, the specially fit- mendations regarding sports bras can be
ted bra, showing the best support. made:9
The Breast 219
1 A bra should be made of firm, mostly ples and cause soreness and sensitivity to
nonelastic material with good absorp- touch and temperature change. The use of
tive qualities (about 60% cotton plus windbreaking material over the chest area
about 40% synthetic materials for fast helps prevent this type of injury. There is no
drying and easy laundering). More elas- treatment for cold injury to nipples, except
ticity provides less support. for supportive measures. Athletes should be
2 It should be constructed to limit motion cautioned to prevent such injury by avoid-
in all directions and provide firm sup- ing cold exposure.21,22
port. There should be either no seams
over the nipples or smooth seams that
will not irritate. TRAUMA
3 Some provision should exist for inser-
tion of padding, if indicated to reduce Blows to the breasts by field hockey
the risk of traumatic injury. Obviously, sticks, pucks, elbows, kicks, and other ob-
a bra intended only for use during run- jects certainly occur but seldom result in
ning does not need these features. more than mild contusions. This superficial
4 All metal or plastic hooks or catches capillary damage may look significant but
should be well covered to protect the usually responds well to the simple appli-
wearer from skin irritation or abra- cation of cold for 10 to 20 minutes. Edema
sion.8,10,11 Various types of bras have and ecchymosis gradually resolve within
been studied.12-16 In the most recent weeks.
study, Dr. Deana Lorentzen of Utah A severe blow to the breast may cause a
State University at Logan17 compared hematoma owing to subcutaneous bleeding
eight of the most popular bras currently from deeper vessels. Hemostasis usually is
on the market. Her findings were in attained spontaneously, and most breast he-
agreement with the previous recom- matomas resolve spontaneously too. A
mendations. Dr. Lorentzen also sug- breast hematoma should be evacuated only
gested adding an underwire. Many ath- if accompanied by increasing pain, increas-
letes prefer this type of bra, as do many ing size, or possible infection. If a fibrous
larger-breasted women, regardless of nodule remains after resolution or evacua-
their exercise habits. tion of a hematoma, its removal may be nec-
essary.
There is no evidence that trauma to the
NIPPLE INJURY breast causes cancer.23-25 However, breast
injury usually leads to careful examination,
"Runners' nipples" is a condition in and previously undetected masses are more
which the nipples are irritated, abraded, likely to be appreciated as a result of more
and/or lacerated18-20 by the rubbing of cloth- careful scrutiny.
ing on the nipple during activity over a
prolonged period of time. Any type of rough-
surfaced cloth or seam can cause this prob- BREAST AUGMENTATION AND
lem. Male runners can wear Band-Aids over REDUCTION
their nipples to prevent this from happening
to them. Female runners can wear well-de- Cosmetic surgery involving either aug-
signed bras to protect their nipples. An mentation or reduction of the breast can
abrasion of the nipple can lead to infection. cause special problems. Following breast
Exposure to cold can damage the nipples, augmentation, a swimmer was unable to
too. A combination of moisture from perspi- swim at her previous freestyle speed despite
ration with evaporation and wind chill can regaining all her previous skills and
lower nipple temperature to injure the nip- strength and regaining her previous back-
stroke speed. Her larger breasts increased transient increases in the concentration of
her resistance against the water. She was lactic acid in breast milk following maximal
able to accept this loss of speed because she exercise, but it is not known whether this al-
felt an increase in her breast size from 32A teration is of any significance. Lovelady,
to 34B more than compensated psychologi- Lonnerdal, and Dewey31 demonstrated no
cally. However, a more competitive swim- differences in milk composition between ex-
mer probably would not have been content ercising and sedentary lactating women.
to sacrifice speed for the emotional benefit The exercising women in this study tended
of a more personally satisfying appear- to have greater milk energy and volume, but
ance.26 Dr. K. Barthels of California showed the differences were not statistically signifi-
that simulated augmentation of the breasts cant, possibly because of the small numbers
slowed swimmers with specific heights and of subjects studied (n = 8 in each group).
weights but did not slow others.27
Athletes in contact sports probably
should not undergo breast augmentation. PREMENSTRUAL CHANGES
Blunt chest trauma can cause rupture of the AND FIBROCYSTIC BREASTS
prosthesis, with resultant hemorrhage and
deformity of the breasts.28 Many female athletes experience breast
There are no studies to show whether a discomfort premenstrually. This may be re-
reduction in breast size improves swim duced by wearing a supportive bra and by
speed in large-breasted swimmers, but this taking bromocriptine or danazol orally, if in-
possibility has been suggested.27 Theoreti- dicated. Premenstrual mastalgia may also
cally, breast reduction might improve the occur in women who have fibrocystic
performance of large-breasted athletes, par- changes. About 50% of women have some
ticularly those in nonaquatic endurance clinical evidence of this process. No specific
sports. Several top track coaches feel that therapy has proved effective, although some
large-breasted women do not perform as investigators have advocated a reduction of
well as small-breasted women in running methylxanthine consumption or adminis-
events. This impression remains anecdotal tration of vitamin E or of danazol.32-34 (See
and unconfirmed and, if real, may relate to Chapter 13 for additional discussion.) A sup-
carrying less fat weight as well as having al- portive bra is helpful for these women, too.
tered contours and resistance factors. In addition to wearing it during exercise,
athletes with nocturnal discomfort may find
it helpful to wear it while sleeping as well.
PREGNANCY AND LACTATION Any breast masses should be evaluated
with mammography and probably also so-
Physiologic breast enlargement during nography. Diagnostic needle aspiration of
pregnancy has not been shown to hinder breast cysts may be therapeutic. If a cyst re-
athletic performance, which usually de- solves completely following aspiration, bi-
clines during pregnancy, particularly for opsy is not necessary. Persistence of a cyst
sports requiring speed. It is impossible to following attempted needle aspiration re-
isolate the effects of breast enlargement, ab- quires excisional biopsy for diagnosis.
dominal enlargement, weight gain, altered All athletes should practice monthly
center of gravity, and hormonal changes in breast self-examination. This is best per-
determining causal relationships. A good formed at the end of menses, when palpable
supporting bra is certainly useful to the physiologic changes from hormonal influ-
pregnant exerciser.29 ence are minimal. The American Cancer So-
Several studies of the effects of exercise ciety, the American College of Radiology,
upon lactation have shown no adverse ef- the American Medical Association, the Col-
fects. Wallace and Rabin30 have reported lege of American Pathologists, and the Na-
The Breast 221
tional Cancer Institute have endorsed the women's varsity athletic program. Phys
following guidelines for screening mam- Sportsmed 6(3):112,1978.
mography: 7. Zelisko JA, Noble B, and Porter M: A compar-
ison of men's and women's professional bas-
1 Onset or baseline mammography by ketball injuries. Am J Sports Med 10:297,
age 40 1982.
8. Haycock C: A need to know: Joggers' breast
2 Mammography every 1 to 2 years be- pain. Response. Phys Sportsmed 7(8):27,
tween ages 40 and 49 1979.
3 Annual mammography thereafter.35 9. Haycock C, Shierman G, and Gillette J: The fe-
male athlete—does her anatomy pose prob-
lems? Proceedings of the 19th Conference on
the Medical Aspects of Sports, AMA, 1978.
EXERCISE FOLLOWING 10. Haycock CE: Breast support and protection in
TRAUMA OR SURGERY the female athlete. AAHPER Research Con-
sortium Symposium Papers 1:50,1978.
Appendix A discusses the appropriate re- 11. Report: Female athletes need good bras, MD
turn to exercise following various types of reports. Phys Sportsmed 5(8): 15, 1977.
12. Baynes JD: Pro+ Tec Protective Bra. J Sports
breast surgery, as well as trauma. Med Phys Fitness 8:34,1968.
13. Hunter L: The bra controversy: Are sports
bras a necessity? Phys Sportsmed 10(11):75,
SUMMARY 1982.
14. Gehlsen G, and Albohm M: Evaluation of
sports bras. Phys Sportsmed 8(10):89,1980.
Breast problems in the female athlete can 15. Schuster K: Equipment update: Jogging bras
at times be of serious import to the partici- hit the streets. Phys Sportsmed 7(4): 125,
pant, but usually they fall more into the cat- 1979.
egory of a nuisance to performance, when 16. Survey: Women marathoners describe bra
size and resultant discomfort are a factor. needs. Phys Sportsmed 5(12):12, 1977.
17. Lorentzen D, and Lawson L: Selected sports
Trauma and tumors are responsible for the bras: A biomechanical analysis of breast
more disturbing conditions. motion while jogging. Phys Sportsmed
The use of good supporting bras for the 15(5):128,1987.
large-breasted athlete is certainly indicated 18. Levit F: Jogger's nipples. N Engl J Med
and can make athletic events more enjoya- 297:1127,1977.
19. Cohen HJ: Jogger's petechiae. N Engl J Med
ble for these individuals. Cosmetic surgery 279:109, 1968.
is best relegated to the postathletic phase of 20. Corrigan AB, and Fitch KD: Complications of
life. jogging. Med J Aust 2:363,1972.
21. Powell B: Bicyclist's nipples. JAMA 249:2457,
1983.
22. Adrian MJ: Proper clothing and equipment.
REFERENCES In Haycock CE (ed): Sports Medicine for the
Athletic Female. Medical Economics Book
1. Haycock C: Supportive bras for jogging. Med Div, Oradell, NJ, 1980, p 61.
Aspects Hum Sexuality. 14:6,1980. 23. Karon SE: Medical testimony in a trauma and
2. Haycock C: The female athlete and sports- breast cancer case, showing the direct and
medicine in the 70's. J Florida M A 67:411, cross-examinations of the plaintiff's internist
1980. and the defendant pathologist. Med Trial
3. Gillette J: When and where women are in- Tech Q 13:361,1967.
jured in sports. Phys Sportsmed 3(5):61, 24. Stevens M: Traumatic breast cancer. Med
1975. Trial Tech Q 25:1,1978.
4. Haycock C, and Gillette J: Susceptibility of 25. Dziob JS: Trauma and breast cancer, or the
women athletes to injury: Myths vs reality. anatomy of an insurance claim. RI Med J
JAMA 236:163, 1976. 63:37, 1980.
5. Whiteside PA: Men's and women's injuries in 26. Levine NS, and Buchanan RT: Decreased
comparable sports. Phys Sportsmed swimming speed following augmentation
8(3):130, 1980. mammoplasty. Plast Reconstr Surg 71:255,
6. Eisenberg I, and Allen WC: Injuries in a 1983.
27. Barthels KM: Discussion—decreased swim- 32. Minton JP, Abou-Isaa H, Reiches N, et al: Clin-
ming speed following augmentation mam- ical and biochemical studies on methyl-xan-
moplasty. Plast Reconstr Surg 71:257,1983. thine related fibrocystic breast disease. Sur-
28. Dellon AL: Blunt chest trauma: Evaluation of gery 90:301, 1981.
the augmented breast. J Trauma 20:982,1980. 33. Ernster VL, Mason L, Goodson WH, et al: Ef-
29. Shangold M: Gynecological and endocrine- fects of caffeine-free diet on benign breast
logical factors. In Haycock C (ed): Sports disease: A randomized trial. Surgery 91:263,
Medicine and the Athletic Female. Medical 1982.
Economics Book, Oradell, NJ, 1980. 34. London RS, Sundaram GS, Schultz M, et al:
30. Wallace JP, and Rabin J: The concentration of Endocrine parameters and alpha-tocopherol
lactic acid in breast milk following maximal therapy of patients with mammary dysplasia.
exercise. Int J Sports Med 12:328, 1991. Cancer Res 41:3811,1981.
31. Lovelady CA, Lonnerdal B, and Dewey KG: 35. Mammography screening urged: Major med-
Lactation performance of exercising women. ical groups agree on guidelines. ACR Bull
Am J C l i n N u t r 52:103,1990. 45:1, 1989.
CHAPTER 13
Gynecologic Concerns in
Exercise and Training
CONTRACEPTION PREMENSTRUAL SYNDROME

Oral Contraceptives
FERTILITY
Intrauterine Devices (lUDs)
Mechanical (Barrier) Methods STRESS URINARY INCONTINENCE
Norplant
POSTOPERATIVE TRAINING AND
Choosing a Contraceptive
RECOVERY
DYSMENORRHEA
EFFECT OF MENSTRUAL CYCLE
ENDOMETRIOSIS ON PERFORMANCE
A iletic women have many concerns about the effects of regular training upon
various gynecologic conditions, the effects of various gynecologic conditions
and their treatments upon exercise performance, and the effects of endogenous
and exogenous hormones upon exercise and health parameters. Menstrual and
hormonal changes associated with exercise and training are discussed compre-
hensively in Chapter 9. This chapter will address what is known about other
gynecologic concerns of the athlete, including contraception, dysmenorrhea,
premenstrual syndrome, fertility, stress urinary incontinence, and cyclic
changes in exercise performance.
CONTRACEPTION
Although oral contraceptives have been reported to be the most popular

form of contraception among American women,1 two surveys have found that
runners prefer diaphragm use.2,3 In a survey of the 1841 women who entered the
1979 New York City Marathon, Shangold and Levine2 reported that 37% of the 394
respondents were diaphragm users, while only 6% were oral contraceptive users.
Jarrett and Spellacy3 surveyed runners through a newspaper advertisement and
found that 44% of the 70 respondents used diaphragms, while only 13% used oral
contraceptives. Thus, based on these survey data, it seems that at the time of
these studies runners preferred the diaphragm over any other form of
contraception.
223
tent advantages over the standard (mono-

Oral Contraceptives phasic) pills containing 30 to 35 ug of estro-
Many women are concerned about side ef- gen and seem to lead to more breakthrough
fects and complications associated with oral bleeding and confusion.
contraceptive use, and such fears have un- Because of the beneficial effects of endur-
doubtedly limited the use of these agents. ance training upon some parameters af-
However, most of the reported and publi- fected adversely by oral contraceptives
cized side effects and complications were (e.g., coagulation, lipid metabolism, and
associated with higher-dose pills than are carbohydrate metabolism), several investi-
generally prescribed now. Studies have gators have studied the combined effects of
shown that the low-dose pills, each contain- exercise and oral contraceptives on these
ing 30 to 35 ug of ethinyl estradiol, are much variables.
safer than the pills containing 50 or more /ug Oral contraceptives are associated with a
of ethinyl estradiol, offering reductions in number of changes in coagulation and fibri-
cardiovascular and thromboembolic risks. nolytic factors in both sedentary and trained
Many of the adverse effects of oral contra- women. Plasma plasminogen activator,
ceptives on thrombosis, arterial disease, which converts plasminogen to plasmin, is
and lipid and carbohydrate metabolism are increased by oral contraceptive use and is
related to the progestin content of the further increased by exercise.10 Huisveld
pill. 4-8 As described in an excellent review and co-workers11 reported that oral contra-
article by Mishell,9 despite the detrimental ceptive users have increased total plasmin-
effects associated with steroid contracep- ogen and free plasminogen levels, increased
tives, women who take these agents actually factor XII and decreased Cl-inactivator and
have a reduced incidence of heavy bleeding, increased factor XH-dependent fibrinolytic
irregular bleeding, endometrial cancer, sev- activity, higher activity levels of normal eu-
eral types of benign breast disease, ovarian globulin fraction-fibrinolytic activity and ex-
carcinoma, rheumatoid arthritis, and salpin- trinsic (tissue-type) plasminogen activator,
gitis, compared with women who do not take and decreased urokinase-like fibrinolytic
oral contraceptives. activator activity. Hedlin, Milojevic, and
Low-dose oral contraceptive agents were Korey12 confirmed the increased fibrinolytic
first introduced in 1973 and have grown in activity induced by exercise or oral contra-
availability since then. They are probably ceptive use or both, and they have also
used more widely now than at the time of the shown that exercise raises antithrombin III
surveys cited. Progestin-only pills were first activity, whereas oral contraceptive use
marketed in 1973 and were intended for lowers it. In this study, the hemostatic
those women for whom estrogen is contra- change induced by oral contraceptives was
indicated; these pills have a high incidence offset by exercise. It is probable that exer-
of breakthrough bleeding, and their use is cise and training offset any net tendency to-
rarely indicated. Oral contraceptive agents ward increased coagulability induced by
containing less than 30 /ug of estrogen also oral contraceptive use.
have a high incidence of breakthrough Powell and colleagues13 demonstrated
bleeding and are poorly tolerated by most that several different oral contraceptive
women as a result. Biphasic preparations agents alter lipoprotein lipid levels ad-
were first introduced in 1982 and were fol- versely, raising total triglyceride, total cho-
lowed by the introduction of triphasic prep- lesterol, and low-density lipoprotein (LDL)
arations in 1984. In these pills, the doses of cholesterol significantly. However, the re-
progestin, and occasionally of estrogen, are port by Gray, Harding, and Dale14 showed
different on different days. These newest that runners taking oral contraceptives have
agents have not been proved to offer consis- lipid profiles similar to those of runners tak-
Gynecologic Concerns in Exercise and Training 225
ing no hormonal medication, suggesting has never had a pelvic infection, prpvided
that exercise may offset the adverse effects that menorrhagia and/or dysmenorrhea do
of oral contraceptive agents upon lipid lev- not ensue and impair the athletic perfor-
els. mance.
In view of the many beneficial effects
known about oral contraceptive use, it re- Mechanical (Barrier) Methods
mains unclear why these agents are not cho-
sen by more female athletes. It is likely that Mechanical methods of contraception are
many avoid using them because of unacceptable for all women who are motivated
founded fears based on reported side effects and reliable enough to use them. Dia-
of the higher-dose oral contraceptive agents phragms and condoms are more effective
(containing 50 ng or more of estrogen). when used in combination with contracep-
However, the weight gain, bloating, depres- tive foam or jelly. The sponge is no more ef-
sion, and mood changes associated with fective than the diaphragm and has been re-
higher dosages are uncommon with pills ported to be associated with more local
containing less than 50 ug of estrogen. The irritation and other side effects. The main
two major side effects associated with use of disadvantages of mechanical (barrier)
the lower-dose agents are breakthrough methods of contraception are their messi-
bleeding (i.e., bleeding on the days of hor- ness, inconvenience, and disruption of sex-
mone ingestion) and amenorrhea (i.e., lack ual activity. Since athletes tend to be moti-
of withdrawal bleeding at the end of each vated and disciplined, these deterrents are
hormone cycle). Each of these is a nuisance usually considered minor. However, leakage
but not of serious consequence. Break- of vaginal contraceptive jellies or foams dur-
through bleeding may resolve spontane- ing exercise may be uncomfortable. When
ously within three cycles; if it does not, it added to vaginal secretions and semen, the
may resolve with additional hormone ther- volume of such discharge may be substan-
apy, either transiently or permanently. tial and annoying during exercise. This
Amenorrhea rarely resolves spontaneously problem may be remedied by placing a sec-
but usually resolves with short-term or long- ond, smaller diaphragm distal to the first, by
term ingestion of additional estrogen or less inserting a vaginal tampon, or, preferably,
progestin. by wearing a minipad.
Diaphragm use requires vaginal retention
of the diaphragm for 6 to 8 hours following
Intrauterine Devices the last vaginal ejaculation. Some athletes
Intrauterine contraceptive devices (lUDs) may find it uncomfortable to exercise with a
were associated with an increased preva- diaphragm in the vagina; such women may
lence of menorrhagia (heavy menstrual benefit from refitting with a slightly smaller
bleeding) and dysmenorrhea (painful men- diaphragm, which will provide equal contra-
struation), each of which could impair ath- ceptive efficacy and greater comfort.
letic performance. Only two lUDs currently
are available in the United States: ParaGard,
Norplant
which contains copper, and Progestasert,
which contains progesterone. Manufacture Norplant is a subdermal implant system
of all other lUDs that previously were avail- that recently has been approved for long-
able has been discontinued for economic term contraception.15 It is made up of six
reasons, primarily expensive litigation slender capsules containing levonorgestrel,
(mostly unwarranted). An IUD is an accept- which are implanted in the upper arm. The
able contraceptive choice for the athlete levonorgestrel in each capsule is released
who is in a monogamous relationship and slowly, providing contraception for about 5
years. The primary mechanism of action is style. Women who have coitus once weekly
suppression of ovulation, and the major side or less frequently probably should use bar-
effects are irregular bleeding and head- rier methods of contraception, unless there
aches. The major advantages of this subder- is an additional reason to use oral contra-
mal implant are its long effectiveness, com- ceptives (e.g., hormone deficiency or treat-
fort, lack of requirement for attention, and ment of acne or hirsutism). It is reasonable
safety for use in women for whom estrogen for women who have coitus twice weekly or
is contraindicated. Its major disadvantages more frequently to use oral contraceptives,
are its expense, invasive insertion and re- unless there is some contraindication to
moval, and frequency of associated irregular their use (see Tables 9-5 and 9-6). Oral con-
bleeding. Although no changes in carbohy- traceptives have not been shown to alter
drate metabolism, blood coagulation, or athletic performance.
liver function have been reported, it is un- Failure rates for various contraceptive
known whether Norplant contraception af- methods are listed in Table 13-1.16
fects exercise performance or endurance.
DYSMENORRHEA
Choosing a Contraceptive
The choice of an optimal contraceptive Dysmenorrhea is caused by myometrial
agent for any athlete rarely should be af- ischemia during myometrial contractions
fected by exercise habits but should include induced by prostaglandin F2a, which is pro-
consideration of medical history and life- duced by the endometrium. Synthesis of this
chemical can be prevented by any of several
prostaglandin synthetase inhibitors (Table
Table 13-1. FIRST-YEAR FAILURE RATES 13-2).
OF BIRTH CONTROL METHODS Although many women have noticed less
Lowest dysmenorrhea during exercise or training
Reported* Typicalt or both, most of these observations remain
anecdotal and unsupported by well-con-
Female sterilization 0.0 0.4
Male sterilization 0.0 0.15 trolled scientific studies. The nature of stud-
Implant (Norplant) 0.0 0.04 ies involving exercise as the independent
Injectable progestogen 0.0 0.3
(Depo-Provera)
Birth control pill 0.0-1.1 3
Table 13-2. PROSTAGLANDIN INHIBITORS
IUD 0.5-1.9 3
Condom 4.2 12 Recommended
Diaphragm 2.1 18 Generic Name Brand Name Dose
Sponge 14-28 18-28
Cap 8 18 Aspirin 650 mg every 4
Withdrawal 6.7 18 h
Periodic abstinence 2-14 20 Naproxen Naprosyn 500 mg, then 250
Spermicides 0.0 21 mg every 6-8
Chance 43 85 h
Naproxen Anaprox, 550 mg, then 275
*In the literature on contraceptive failure, the lowest re- Anaprox-DS mg every 6-8
sodium
ported percentage who experienced an accidental
h or 550 mg
pregnancy during the first year following initiation of every 12 h
use (not necessarily for the first time) if they did not Motrin, Advil, 400 mg every
Ibuprofen
stop use for any other reason. Nuprin 4-6 h
tAmong typical couples who initiated use of a method
Mefenamic acid Ponstel 500 mg, then 250
(not necessarily for the first time), the percentage
mg every 6 h
who experienced an accidental pregnancy during the Orudis
Ketaprofen 25-50 mg every
first year if they do not stop use for any other reason.
6-8 h
Source: Modified from Hatcher et al,16 with permission.
variable and perception of pain as the de- istered by nasal spray. These agents usually
pendent variable makes double-blinding im- lead to significant pain relief. Major side ef-
possible. Theories proposed to explain the fects include hot flushes, decreased libido,
apparent reduction of pain by exercise and vaginal dryness, headaches, emotional la-
training include an exercise-induced in- bility, acne, myalgia, and reduced breast
crease in pain-preventing endorphins, an size. Synarel side effects also include nasal
exercise-induced increase in vasodilating irritation. Because these drugs produce a
prostaglandins, and exercise-induced vaso- pseudomenopausal state with low estrogen
dilatation. The truth remains to be eluci- levels, their most serious side effect is bone
dated. loss. Treatment with GnRH analogs may be
Athletes who experience dysmenorrhea continued for a maximum of 6 months, dur-
should be treated with prostaglandin inhib- ing which time significant bone loss is un-
itors. Exercise-induced relief from dysmen- likely.
orrhea should not be expected, since re- Danazol is a derivative of testosterone,
sponses are variable and unpredictable. and it has expected androgenic and anabolic
Prostaglandin inhibitors often cause re- properties. Within 6 months of danazol ther-
duced menstrual blood loss as an additional apy, women have a significant loss of adi-
benefit, due to the vasoconstriction caused pose tissue and a significant increase in lean
by the inhibition of vasodilating prostaglan- body mass.18 These changes persist longer
dins. than 6 months after discontinuing therapy.18
Other major side effects include hot flushes,
headaches, emotional lability, acne, re-
ENDOMETRIOSIS duced breast size, edema, seborrhea, and
weight gain. Danazol does not lead to bone
Endometriosis is a condition in which loss. Although the changes in body compo-
functioning endometrial tissue exists out- sition during danazol use are desirable for
side the endometrial cavity. Its most com- an athlete, muscle cramps may potentially
mon symptoms are pain and infertility, al- impair athletic training. Anecdotally, ath-
though it may produce no symptoms. In a letes treated with danazol for endometriosis
multicenter study, Cramer and associates17 have noticed improved performance, but
reported that women who had exercised this has not been investigated scientifically.
regularly since age 25 or younger and for Drug testing would detect danazol use.
more than 2 hours weekly had a decreased Although reduced distal radial bone mass
risk of developing endometriosis. Condi- has been reported in untreated women with
tioning exercises such as jogging seemed endometriosis,19 the bone mineral density of
most associated with this decreased risk. the lumbar spine has been found to be nor-
Women who have endometriosis may be mal in a population-based cross-sectional
treated medically or surgically. Surgical study of untreated women with endometri-
treatment depends on the severity of dis- osis.20
ease and may include fulguration of endo-
metriotic implants, resection of endometri-
otic tissue or cysts, or hysterectomy with PREMENSTRUAL SYNDROME
bilateral salpingo-oophorectomy.
Medical treatment is most effective with a Premenstrual syndrome (PMS) is a con-
gonadotropin-releasing hormone (GnRH) dition in which women experience emo-
analog or danazol. Several synthetic GnRH tional and/or physical symptoms during the
analogs are available today, including leu- 3 to 5 days prior to the onset of menstrua-
prolide acetate (Lupron), which is adminis- tion. In some cases, it may last even longer.
tered by daily or monthly injections, and Symptoms may include anxiety, depression,
nafarelin acetate (Synarel), which is admin- mood swings, increased appetite, head-
aches, mastalgia, and edema and may vary symptoms, only a few of these have been
in severity as well as in duration. The mul- shown to be more effective than placebo.
titude and variability of symptoms in this The high placebo response in this entity
syndrome have made it difficult to define makes it difficult to evaluate the effective-
this entity precisely, and this problem has ness of all treatments. Spironolactone has
led Magos and Studd21 to propose the follow- been shown to be more effective than
ing working definition for investigators and placebo23 and is associated with very few
clinicians: "distressing physical, psycholog- side effects. Although pharmacologic doses
ical, and behavioral symptoms, not caused of progesterone are prescribed by many cli-
by organic disease, which regularly recur nicians to treat PMS, there is no evidence
during the same phase of the menstrual/ that PMS is caused by a progesterone defi-
ovarian cycle, and which disappear or sig- ciency or that progesterone therapy in
nificantly regress during the remainder of physiologic doses is more effective than pla-
the cycle." cebo in treating it. Luteal phase deficiency is
Although the cause of PMS remains to be not associated with a more severe PMS than
elucidated, it is probably related to hor- a normal luteal phase.24 Progesterone in
mone levels and/or changes at that time of pharmacologic doses has been shown in
the menstrual cycle. No laboratory tests can only one study to be more effective than pla-
diagnose this condition, since no laboratory cebo;25 other studies have found this agent
measurements have been shown to corre- to be no more effective than placebo.26,27
late with symptomatology during any given A few studies showed bromocriptine to be
cycle or to vary between affected and unaf- more effective than placebo in relieving
fected individuals. The diagnosis of PMS is a some PMS symptoms, particularly mas-
historic one, made solely by reviewing a cal- todynia28; but other studies have failed to
endar record of when symptoms and men- confirm this.28 Danazol has been reported to
struation occur. Those women whose symp- relieve PMS symptoms,29,30 but this has been
toms occur solely premenstrually have PMS, tested in only one double-blind, controlled
and those whose symptoms occur randomly study to date.30 (The side effects associated
throughout the cycle do not. This seemingly with danazol are listed in the preceding sec-
clear picture is confused somewhat by the tion.) A GnRH agonist (Lupron) has been
fact that some women who have symptoms shown to relieve PMS symptoms while in-
throughout the cycle note a premenstrual ducing amenorrhea.31 Since this drug and
exacerbation of symptomatology. other analogs and antagonists of GnRH pro-
It has been reported that women who ex- mote bone loss as a result of the hypoestro-
ercise are less likely to experience PMS and genic state they induce,32 these agents alone
that women are less likely to experience may not be promising for long-term use in
PMS when exercising regularly. Prior, Vigna, this condition. Alprazolam has also been
and Alojado22 have shown that conditioning shown to be more effective than placebo in
exercise decreases premenstrual symp- relieving the severity of several symptoms
toms. However, it is difficult to design con- of PMS; its reported low incidence of side ef-
trolled studies in which women are blinded fects may make it a good choice for many
to the fact that they are exercising. Thus, it women unresponsive to other therapies.33 It
remains difficult to isolate exercise as a vari- remains to be shown whether any of these
able and difficult to confirm that exercise medications will affect athletic perfor-
prevents or relieves PMS symptoms. It is mance.
probable that the mood elevation and gen- Despite claims to the contrary, there is no
eral feeling of well-being associated with ex- evidence that PMS is caused by any dietary
ercise may play a role. deficiency or excess, or that dietary manip-
Optimal treatment of PMS remains to be ulation will consistently relieve symptoms.
determined. Although several drugs relieve However, salt restriction may alleviate
symptoms in some PMS sufferers and mendation. Hypothalamic-pituitary-ovarian

certainly will harm no one. Furthermore, dysfunction can resolve spontaneously, and
Wurtman and co-workers34 have shown im- ovulation can occur prior to the first subse-
provement in mood when PMS sufferers quent menstrual period. The cause of the
consumed a high carbohydrate diet. amenorrhea in such cases changes from hy-
At the present time, athletes who are in- pothalamic-pituitary-ovarian dysfunction to
convenienced by significant PMS symptoms pregnancy, but the symptom of amenorrhea
probably should be treated with spironolac- continues. Thus, the amenorrheic athlete
tone (25 to 100 mg daily). It may be reassur- may not detect an unplanned, unwanted
ing for some of them to know that 75% of all pregnancy until it is advanced enough to
women experience at least some premen- produce a significant increase in abdominal
strual symptoms, probably due to hormonal girth.
changes that reflect normal reproductive Infertile athletes and their partners
function (i.e., regular ovulation). Studies should undergo the same comprehensive
now in progress may help us to understand evaluation that would be recommended for
the etiology of PMS and lead us to optimal any infertile couple. Rarely should treat-
therapy. ment be modified because of exercise or
training.
FERTILITY
STRESS URINARY
No studies to date have shown that infer- INCONTINENCE
tility is more prevalent among athletes than
among the general population. It is true that Many women experience stress urinary
luteal phase deficiency, oligomenorrhea, incontinence during exercise.35 Involuntary
and amenorrhea are more prevalent among urine leakage results when intravesical
athletes, and infertility is more prevalent pressure is higher than intraurethral pres-
among women who have these conditions. sure.
However, the definition of infertility in- Although stress incontinence is most
cludes a desire for pregnancy. Since many likely to occur in women who have an ana-
athletes are not actively seeking pregnan- tomic defect in the posterior urethrovesical
cies at the time of intensive training, when angle, even women with normal anatomy
they are most likely to experience menstrual can experience stress urinary incontinence
dysfunction, these women technically are when intravesical pressure increases
not infertile, even though their fertility, if enough. Physical activity involving a Val-
tested, might be impaired. Many of these salva maneuver increases intra-abdominal
women resume having regular ovulatory pressure. Because changes in intra-abdom-
menses when they decrease intensive train- inal pressure are not always transmitted
ing. It is probable that transient infertility is equally to both bladder and urethra, physi-
associated with intensive training, but this cal activities like running and jumping may
has not been documented to date.2 raise intravesical pressure above intraure-
Even if temporary infertility is associated thral pressure, leading to urine leakage dur-
with training, athletes who do not desire ing exercise.36 Although stress urinary in-
pregnancy should not presume that concep- continence is more common during exercise
tion is impossible. As discussed in Chapter than during rest, exercise-induced in-
9, reliable contraception should be used by creases in intra-abdominal pressure are
even amenorrheic athletes who do not want transient and do not produce chronic pres-
a pregnancy. Many anecdotal reports of sure alterations or anatomic abnormalities.
amenorrheic athletes with unsuspected and Genital prolapse includes several ana-
unwanted pregnancies support this recom- tomic abnormalities marked by loss of sup-
port, including cystocele, urethrocele, rec- ever, athletes should aim to recover cardio-
tocele, and uterine descent. These anatomic vascular fitness as soon as possible, while
defects have been reported to be associated avoiding excessive stress on the surgical
with prior trauma during vaginal delivery site. As a general rule, postoperative avoid-
and with endogenous joint hypermobility.37 ance of pain will lead to avoidance of injury
Such joint laxity may also predispose or damage. Those who have greater strength
women to joint injury. in muscles far from the operative site can
Many women who have stress urinary in- gain mobility early by using those muscles
continence may be able to control leakage rather than the muscles near the operative
by avoiding fluid ingestion for 3 hours prior site.
to exercising and emptying their bladders A surgical wound begins to heal immedi-
immediately prior to exercising. However, ately following closure. By the 21st postop-
they must be careful to avoid dehydration erative day, the wound has gained nearly as
during prolonged exercise sessions lasting much strength as it will ultimately have (al-
more than 1 hour. Such women should re- though it will never be as strong as it was
place fluid loss immediately after cessation preoperatively). Based on the fact that it
of exercise. takes 21 days for a surgical wound to regain
Many women who experience involuntary nearly all of its ultimate strength, it is prob-
urine leakage may benefit from practicing ably reasonable for athletes to postpone
Kegel exercises. These are done by con- submaximal resistance training that in-
tracting the pubococcygeus muscle at any volves the operative site for 21 days follow-
time, or specifically during urination, ing a surgical procedure. Lighter work can
thereby stopping the urinary stream. probably be done safely prior to this time,
Women who lose urine during exercise may particularly if the wound is not stressed.
decrease their discomfort and embarrass- Avoidance of pain remains a reasonable goal
ment by wearing a minipad. No medication for the exercising patient postoperatively,
will alleviate this condition. Those who have and exercises that do not cause pain are
anatomic defects and who cannot relieve probably safe. Overzealous athletes should
their symptoms to a satisfactory degree by be cautioned to use moderation in training
practicing Kegel exercises or wearing a postoperatively and to notice subtle body
minipad should consider surgical correc- perceptions of discomfort and fatigue.
tion of the anatomic defect. Postoperatively, Although there are no studies to indicate
such women may be at increased risk of re- when exercise can be safely resumed follow-
currence due to the pressure changes during surgery, I propose the following guide-
ing exercise and to persistence of the endog- lines for earliest safe resumption of exer-
enous tissue factors that caused the original cise:
problem. No studies are available to confirm
or disprove this suspicion, but these women • Following a dilatation and curettage or a
probably should be cautious when exercis- first-trimester abortion, weighttraining
ing postoperatively. and aerobic exercise, except water sports,
may be resumed the same or the next day;
water sports should be avoided until
POSTOPERATIVE TRAINING bleeding has ceased. Tampon use also
AND RECOVERY should be avoided until bleeding has
ceased.
The traditional recovery period following • Following a vaginal delivery or a second-
abdominal or other major surgery has been trimester abortion, weighttraining may be
6 to 10 weeks. Recommendations for recov- resumed the same day; aerobic exercise,
ery should be site- and sport-specific. How- except water sports, may be resumed in 2
days; water sports may be resumed when published in peer-reviewed journals, but a
bleeding has ceased. Tampon use should recent well-designed study by DeSouza and
be avoided until bleeding has ceased. colleagues39 concluded that neither men-
• Following a diagnostic laparoscopy, aer- strual phase (follicular versus luteal) nor
obic exercise in and out of water and menstrual status (eumenorrheic versus
weighttraining may be resumed after 1 to amenorrheic) alters or limits exercise per-
2 days. Following operative laparoscopy, formance in female athletes.
aerobic exercise in and out of water and It is rarely advisable or necessary to ma-
weighttraining should be postponed at nipulate an athlete's menstrual cycle to en-
least 21 days, depending upon the com- hance her performance. However, some
plexity of the procedure. Avoidance of women do perform better during the follic-
pain may not provide sufficient limitation ular phase than at other times, and others
of activity for safety. perceive or believe that they do. If such
• Following a cesarean delivery or other ab- women are elite athletes, it may be appro-
dominal surgery (requiring an incision), priate to manipulate the menstrual cycle for
light aerobic exercise outside of water and special events of great importance; I believe
light weighttraining may be resumed in 7 that such manipulation should be reserved
days; intense aerobic exercise (speed for world-class athletes (e.g., Olympic com-
work), submaximal weighttraining, and petition).
water sports should be postponed at least The simplest and least invasive method of
21 days. manipulating an athlete's menstrual cycle
involves administering low-dose oral con-
It must be emphasized that these are the traceptives for several months prior to the
earliest times I recommend resuming exer- competitive event, continuing the hormone-
cise postoperatively. Delays may enhance containing pills until 10 days before the
healing despite potential hindrance of train- competitive event. The athlete can expect to
ing. Exercise should never be resumed if it have withdrawal bleeding within 3 days
causes pain. All situations should be indi- after cessation of the pills. She should post-
vidualized, and each patient should follow pone restarting the pills (if she plans to do
the advice of her surgeon. so) until the competitive event has passed.
This plan will give her a predictable bleed-
ing pattern during training and will leave her
EFFECT OF MENSTRUAL CYCLE with low levels of both estrogen and proges-
ON PERFORMANCE terone at the time of the important event.
For world-class athletes in their prime, this
Many investigators have studied the effect regimen can be repeated every few months
of the menstrual cycle on performance, infor the events of great importance. It also
cluding specific measurements of strength, provides hormonal protection to those ath-
speed, endurance, fatigability, and per- letes who are deficient in one or both hor-
ceived exertion and cognitive, perceptual, mones (estrogen and progesterone) during
and motor skills at different phases of the training, and it provides contraception to all
menstrual cycle, reflecting different levels athletes, regardless of menstrual status.
and ratios of estrogen and progesterone. For The only undesirable side effects associ-
a thorough review of these reports, the ated with this plan are the potential risks of
reader is referred elsewhere.38 The findings breakthrough bleeding during training and
of these studies have been inconsistent but of impaired training during oral contracep-
suggest that menstrual cycle phase does not tive use, in certain individuals. However, I
have a significant effect on any of these pa- believe these risks are small and are out-
rameters. Very few such studies have been weighed by the benefits of this plan.
An alternative method of management in- causes pain. All situations should be indi-
volves administering only a progestogen vidualized and should follow the advice of
(e.g., medroxyprogesterone acetate 5 mg) the patient's surgeon.
for 5 to 10 days, ending 10 days prior to the It is rarely advisable or necessary to ma-
important event. This is most likely to be ef- nipulate an athlete's menstrual cycle to en-
fective in women with chronic anovulation, hance her performance. If manipulation is
and it may produce undesirable bloating considered, it should be reserved for special
and a sensation of "heaviness," which may events of great importance to elite athletes.
impair training. This method provides no
contraception. As 1 have indicated, I prefer
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CHAPTER 14
Orthopedic Concerns
LETHA Y. GRIFFIN, M.D., Ph.D.
PATELLA PAIN Ankle Impingement

Anatomy of the Patella Wrist Impingement
Sources of Pain Shoulder Impingement
Evaluating Patella Pain OTHER COMMON CONDITIONS
Acute Traumatic Patella Dislocation Achilles Tendinitis
Patella Subluxation
Shin Splints
Patellofemoral Stress Syndrome
Stress Fractures
Patella Plica Low Back Pain
Patella Pain: Summary Bunions
IMPINGEMENT SYNDROMES Morton's Neuroma
w ith the growth of women's athletics, many observers predicted an increase

in the number and types of injuries occurring as women became more aggressive
and competitive in sports.1 Early injury studies of female athletes actually
reported that a greater number of injuries were sustained by female than by male
athletes.23 However, this reflected a lack of adequate conditioning in women
rather than any true physiologic weakness and predisposition to injury. As
women became more serious in their sport participation, training and condition-
ing techniques improved, and injury rates decreased.4 Recent studies surveying
injury rates in conditioned female athletes demonstrate that their injury rates are
no higher than those of their male counterparts.5–7
A review of injuries in professional and recreational athletes demonstrated
sprains and strains to be the most common injuries and the knee and ankle to be
the most frequently traumatized areas in both men and women.8 Injuries are
more sport-specific than sex-specific; that is, injury types and rates are similar
for men and women in the same sport, but they differ for female athletes partic-
ipating in different sports.9
Certain conditions, however, occur more commonly in women—in some
cases owing to anatomic differences, in others owing to greater participation in
specific sports. We have elected to focus in this chapter on those conditions more
commonly seen in women (patella pain, impingement syndromes, Achilles ten-
dinitis, shin splints, stress fractures, low back pain, bunions, and Morton's neu-
roma), and refer the reader to other more general texts on athletic injuries for a
234
Orthopedic Concerns 235
discussion of such injuries as sprains, dis- quadriceps muscles. Since the quadriceps
locations, fractures, and inflammation of muscle courses along the long axis of the
muscle origins. Table 14-1 briefly lists some femur while the patella tendon inserts into
common musculoskeletal injuries and the the tibial tubercle, patella tracking in the
women's sports in which they are com- femoral groove is also very much influenced
monly seen. by the tibial-femoral angle. This angle (the
PATELLA PAIN
Q angle) is measured by drawing a line
through the center of the quadriceps muscle
Anatomy of the Patella and noting its intersection with a line drawn
The patella or kneecap is a sesamoid through the center of the tibial tuberosity
bone, which means it is completely sur- (Fig. 14-2). Because the gynecoid pelvis of
rounded by fascial extensions (retinacu- the woman is wider than the narrow android
lum) of the four components of the quadri- pelvis of the man, this angle is generally
ceps muscle—the vastus medialis, the greater in women than in men and may ex-
vastus lateralis, the rectus femoris, and the plain the increase in patella tracking prob-
vastus intermedius (Fig. 14-1). Fascial ter- lems and patella pain in women (Fig. 14-3).
minations of these muscles arise just supe- In fact, patella pain is one of the most com-
rior to the patella, extend over it, and con- mon complaints of female athletes.
tinue inferiorly from the patella to the tibial Although the anterior surface of the pa-
tubercle as the patella tendon. The patella tella is flat, the posterior surface is com-
lies in the distal femoral groove formed posed of two facets which intersect longitu-
where the medial and lateral femoral con- dinally (Fig. 14-4). The medial facet is
dyles join at the knee. The patella is guided generally smaller than the lateral. The facets
in the femoral groove during knee flexion are lined with hyaline cartilage and articu-
and extension by the powerful group of late with the hyaline cartilage-covered su-
Table 14-1. SPECIFIC SPORTS COMMONLY ASSOCIATED WITH ORTHOPEDIC INJURIES

Injury Sport
Shoulder subluxation Swimming
Throwing sports
Sprains
Thumb Skiing
Ankle Running sports
Uneven ground (field hockey, soccer, Softball, cross-country)
Basketball, volleyball (one-foot landings)
Ice skating
Knee Basketball, volleyball
Tendinitis
First dorsal compartment Gymnastics (squeezing poles or bars)
Achilles tendon Track, basketball, skiing, ice skating, rollerskating
Biceps Tennis, other racquet sports, throwing sports
Lateral epicondylitis (tennis elbow) Tennis, other racquet sports, throwing sports
Shin splints Running
Impingements
Shoulder Swimming,* throwing sports, racquet sports
Ankle Gymnastics, ballet, diving, ice skating
Wrist Gymnastics, crew, racquet sports
Low back pain Gymnastics, diving, skating
Stress fractures (pars intra-articularis) Running, gymnastics, ice skating, diving
*In greater numbers than male counterparts.
Figure 14-1. The quadriceps muscles. Note the oblique course of the vastus medialis obliquus mus-
cle. (From Scott WN, Nisonson B, Nicholas JA, et al: Principles of Sports Medicine. Williams & Wilkins,
Baltimore, 1984, p 274, with permission.)
perior extensions of the femoral condyle, across the joint change with increasing flex-
forming the patellofemoral joint (Fig. 14-5). ion of the knee (Fig. 14-6), and as previously
discussed, are greatly influenced by the
quadriceps pull and the tibial-femoral angle.
Sources of Pain
Patella tracking in the patellofemoral
Forces across the joint have been the sub- groove may also be influenced by foot strike.
ject of much investigation, since patellofem- Pronation of the foot increases the knee val-
oral pain is a common source of discomfort gus angle and may lead to an increase or at
in many activities, especially in sports that least an alteration in lateral patellofemoral
require multiple flexion-extension maneu- forces (Fig. 14-7). If the patella does not
vers (running, kicking, climbing). Forces track anatomically in the femoral groove,
Figure 14-3. Android pelvis and gynecoid pelvis. Note

that the female (gynecoid) pelvis is wider, with a
greater varus angle of the femoral neck, resulting in a
Figure 14-2. The Q angle is an angle formed by the in- greater valgus angle at the knee when compared with
tersection of a line drawn longitudinally through the the typical male (android) pelvis.
middle of the quadriceps and a line drawn from the
middle of the patella to the center of the tibial tuber-
osity. (From O'Donoghue DH: Treatment of Injuries to
Athletes, ed 4. WB Saunders, Philadelphia, 1984, p 510,
with permission.)
forces created during quadriceps contrac-

tion may not be adequately dissipated be-
tween the two facets, causing abnormally
high forces on a small area of the articular
surfaces and resulting in patella pain (patel-
lofemoral stress syndrome).
Athletes who have sustained multiple
subluxations or dislocations of their patel-
lae may have pain secondary to traumatic
loss of the hyaline cartilage during such ep-
isodes, that is, chondromalacia. If the carti-
lage is thinned or absent or chemically un-
able to absorb the forces applied to it, these Figure 14-4. Posterior aspect of the patella, illustrating
the two patellar facets. (From Norkin CC and Levangie
forces are transferred to the bone beneath, PK: Joint Structure and Function, ed 2. FA Davis, Phila-
resulting in pain. delphia, 1992, p 367, with permission.)
location with spontaneous relocation may

not report that her "kneecap jumped out of
joint" but may perceive only severe knee
pain following her twisting injury. Similarly,
an athlete who complains of give-way or
locking of her joint may not have a mechan-
ical locking of her knee from a torn meniscus
or loose body but may have pseudolocking
or give-way on the basis of patella pain.
Observation
The first step in evaluating the patella is to
observe the knee: does the patella sit higher
in the femoral groove than usual (patella
alta), or is it lower (patella baja)? Athletes
whose patellas sit higher in the femoral
groove have a greater tendency to patella
subluxation,10 whereas those with low-lying
patellas may have increased forces across
the patellofemoral joint, especially with re-
petitive flexion-extension activities.
Does the patella lie centrally in the femo-
ral groove, or is it tipped laterally (Fig. 14-
8)? Since an increased Q angle and poorly
developed vastus medialis are associated
with an increased incidence of patella pain,
the Q angle should be measured, and the
quadriceps mechanism assessed, especially
its more medial oblique fibers, known as the
Figure 14-5. Patellofemoral joint. (1) Femoral condyle vastus medialis obliquus.
surfaces of the right knee. TL = anteroposterior length
of the lateral condyle; TM = length of the medial con-
dyle. The length of the medial condyle (LM) is greater
than the length of the lateral condyle (LL), because of Palpation and Manipulation
its curved surface. (2) Superior surface of the right
tibia. The lateral articular surface is round and the me- The retinaculum around the patella's me-
dial articular surface is oval. (3) The medial tibial artic- dial, lateral, and superior borders should be
ular surface is deeper and more concave than is the lat- palpated to check for tenderness. The ath-
eral. (4) Side view of the femur showing the flat anterior
surface and the curved posterior surface. The two artic- lete who has just sustained an acute patella
ulations are illustrated in part 1: the patellar surface, in subluxation or dislocation with spontane-
which the patella articulates with the anterior femur ous relocation will have a great deal of ten-
and the tibial surface, which then glides upon the tibia.
(From Cailliet R: Knee Pain and Disability, ed 3. FA derness at the insertion of the vastus medi-
Davis, Philadelphia, 1992, p 2, with permission.) alis on the medial border of the patella. In
addition, she may have ecchymoses along
the fibers of the muscles, from having
Evaluating Patella Pain stretched or disrupted part of the fibers at
the time of the subluxation or dislocation.
In evaluating the athlete who complains of Next, the patella should be tipped medi-
a painful knee, one must always consider the ally, and the examiner should feel under the
patella as a potential source of the pain. The medial facet (Fig. 14-9). Athletes with patel-
athlete who sustains a traumatic patella dis- lofemoral stress syndrome or chondroma-
Figure 14-6. Patellar contact areas with femoral condyles during knee flexion. (1) Knee flexed 20°:
(A) Lateral view of the patellofemoral joint. Arrows depict site of contact. (B) Area of contact of the
patella (shaded area) (L = lateral; M = medial). (C) Superior view showing patella within femoral
condyles. At 20° flexion, there is contact symmetrically of the lateral condyle. (2) Knee flexed 45:
Pressure upon the patella is in the broader central zone (C). As above, pressure on the medial and
lateral patellar facets is symmetrical. (3) Knee flexed 90°: There is broad contact with the superior
area of the medial and lateral patellar facets (B). As shown by (C), there is beginning to be more
contact of medial facets. (4) Knee flexed 135° (full flexion): The patellar facets contact both femoral
condyles, and the patella shifts (C) so that the odd facet contacts the medial condyle more firmly.
(From Cailliet R: Knee Pain and Disability, ed 2. FA Davis, Philadelphia, 1983, pp 88-89, with permis-
sion.)
lacia will experience pain with this maneu- This action mimics the give-way sensations
ver. Then the examiner should place a hand reported by women with these entities.
firmly above the patella and ask the patient Next, one should palpate the patella ten-
to contract her quadriceps (Fig. 14-10). In don to check for its intactness and to exam-
this maneuver, called an inhibition test, ath- ine for tenderness at its origin off the infe-
letes with patellofemoral stress syndrome rior surface of the patella or at its
or chondrornalacia will have give-way attachment to the tibia. In the very young
symptoms after beginning the contraction. patient (age 6 to 9 years), inflammation of
24O Special Issues and Concerns
Figure 14-9. Palpation of the medial patella facet. Pa-

tients with patellofemoral stress frequently have ten-
derness along the medial border of the patella at the
retinaculum or under the medial facet of the patella.
Figure 14-7. As the foot goes into pronation, the valgus
angle of the knee and lateral tracking of the patella are
accentuated.
Figure 14-8. Radiograph of laterally tipped patellas. Note the very short medial condylar flare and
the elongated lateral flare, corresponding to the increased width of the lateral patella facet when com-
pared with the medial one.
Figure 14-10. In the inhibition test, the examiner ap-

plies pressure above the patella as the patient contracts
the quadriceps muscle. This maneuver frequently re-
produces the pain of the athlete with patellofemoral Figure 14-11. (A) The patient with patella tendinitis
stress syndrome. will have pain at the origin of the patella tendon. (B)
The patient with Osgood-Schlatter's disease (seen in
the teenager with open growth centers) will have irri-
tation at the insertion of the patella tendon into the tib-
the patella tendon at its origin off the infe- ial apophysis. (From Andrish JT: Knee injuries in gym-
nastics. In Weiker GG (ed): Gymnastics. Clin Sports
rior surface of the patella may be associated Med 4:120, 1985, with permission.)
with irregularities of the lower patella
apophyseal pole (Fig. 14-11). Similarly, ir-
ritation of the attachment of the patella ten- joint may indicate that the knee joint has
don to the tibial apophysis when it is devel- been or is irritated. Patella abnormalities
oping (approximately age 11 to 13 years) that can result in an increase in synovial
can result in its inflammation or apophysi- fluid include patella subluxations or abnor-
tis, a condition termed Osgood-Schlatter's malities of the hyaline cartilage of the retro-
disease (Fig. 14-11). patellar surface (chondromalacia).
Aspiration of Fluid Radiographic Evaluation

If there is fluid within the knee joint, it Many different radiographic techniques
may be aspirated. A hemarthrosis, or blood have been designed to evaluate the patella
in the knee, may result from a traumatic pa- and its relationship to the femur in the pa-
tella dislocation with spontaneous reloca- tellofemoral groove. The ratio of a line
tion. (Remember that the athlete who has drawn longitudinally through the patella to
had a spontaneous relocation of her patella a line drawn from the tip of the patella to the
may not have perceived her injury as a pa- tibial tubercle measured on a lateral radio-
tella dislocation.) Other diagnoses associ- graph, with the knee in 50 degrees of flexion,
ated with a hemarthrosis include anterior can be used to estimate patella alta or baja.
cruciate ligament tear, peripheral meniscal A ratio greater than 1.2 is indicative of pa-
tear, and intra-articular fracture. tella alta (Fig. 14-12), whereas a ratio of less
Yellow synovial fluid aspirated from the than 1.0 is associated with patella baja.
thickness of the articular cartilage of the pa-

tellofemoral joint.
Another helpful study used to assess the
intactness of the patellofemoral cartilage
and the position of the patella in the femoral
groove is computerized axial tomography
done following injection of contrast material
into the knee joint. The contrast material
nicely coats the articular surface for visual-
ization (Fig. 14-14).
Acute Traumatic Patella

Dislocation
Diagnosis
If spontaneous relocation has not oc-
curred, the diagnosis of a dislocation of the
patella is obvious from observation. The pa-
tella typically lies lateral to the knee joint,
and the injured athlete usually will hold her
knee partially flexed because of pain. To
confirm the diagnosis and make certain
there are no fractures, radiographs should
be taken.
Initial Treatment
First, the intactness of the neurovascular
structures should be assessed. After medi-
cation has been given to decrease pain (giv-
ing intravenous morphine as an analgesic is
often extremely helpful), the examiner
should gently extend the patient's leg while
exerting a medial force on the patella. The
Figure 14-12. Objective confirmation of patella alta is patella will relocate with an audible sound,
obtained by using a lateral radiograph and determining resulting in rapid relief of pain. A dislocated
the length of the patella (LP) and the length of the pa-
tella tendon (LT). If the tendon length exceeds the pa- patella can sometimes be reduced on the
tella length by 20%, then patella alta is present (i.e., LP/ field or court without medication, but it is
LT 0.8). (From Scott WN, Nisonson B, Nicholas JA, et usually wiser to first radiographically docu-
al: Principles of Sports Medicine. Williams & Wilkins,
Baltimore, 1984, p 312, with permission.) ment the diagnosis and make certain there
are no associated fractures.
Following relocation, one should apply a
compressive wrap with lateral pads to hold
A view of the patella taken with the knee the patella medially. The knee is then sup-
flexed to 30 degrees and the cassette held ported in a soft knee immobilizer which
perpendicular to the radiograph tube is keeps the knee extended. The intent of the
called a skyline view of the patella (Fig. 14- lateral pad and the immobilization in exten-
13). It is used to assess the patella's position sion is to bring the patella in close approxi-
in the femoral groove, as well as to detect mation to the vastus medialis fibers so that
the presence of patella spurs and to note the they can heal securely back to the patella.
Figure 14-13. Technique for obtaining skyline view of the patella. (From Hunter LY, et al: Common
orthopedic problems of female athletes. In Frankel VH (ed): Instructional Course Lectures. American
Academy of Orthopedic Surgeons, CV Mosby, St. Louis, 1982, p 131, with permission.)
The physician should instruct the athlete comfort and to decrease stretching of the al-
to ice and elevate the extremity and should ready injured medial retinaculum.
place her on crutches, so that she bears only Some physicians recommend immediate
partial weight on the affected leg. If she de- arthroscopic examination of the joint to
velops a marked hemarthrosis over the next evacuate the hemarthrosis and to check for
several days, it can be aspirated to increase the presence of a chondral fracture off the
Figure 14-14. The patellofemoral joint as viewed

by computed axial tomography after injection of
contrast material into the knee joint.
posterior surface of the patella or the oppos- mediate arthroscopy feel that if an athlete
ing lateral femoral condyle. Cartilage frac- develops loose body symptoms following
tures are not recognized on routine radio- patella dislocation, arthroscopy can be per-
graphs unless the fracture extends into bone formed at that time. However, performed
(an osteochondral fracture). Fracture frag- acutely, such a procedure may merely in-
ments, whether cartilage alone or cartilage crease quadriceps atrophy.
and bone, need to be removed, because they
will become loose bodies that can intermit-
Rehabilitation
tently catch in the joint, causing severe pain
and locking. The knee is kept wrapped with a lateral
Physicians who do not recommend im- pad and immobilized in the extended posi-
Figure 14-15. Short arc extension exercises increase quadriceps strength following a patella dislo-
cation.
tion for approximately 3 to 6 weeks, to allow

the torn medial retinaculum to heal. Isomet-
ric exercises can be done by the athlete
while she is in the immobilizer. Some phy-
sicians will use muscle-stimulating units
during this period to help strengthen the
vastus medialis.
At the end of this time, short arc extension
exercises, as well as functional strengthen-
ing activities such as walking, bike riding, or
using a stair climber can be started. If an ex-
ercise bike is used, the seat should be set as
high as possible and tension kept on me-
dium to low. If biking outdoors, a bike that
has at least 3 gears, but preferably 5 or 10,
should be used. The athlete should be in-
structed to use low gears (rapid pedaling at
low tension) and to avoid hills. Again, seat
height should be set so the athlete's knee is
completely extended on the downstroke.
Similarly, if a stair climber is used, the ath-
lete should set the tension of the machine on
low and perform rapid small steps.
Short arc extension exercises are per- Figure 14-16. An example of a patella-stabilizing brace.
formed by placing a rolled towel beneath the Note pad encircling the patella. (From Walsh WM, et al:
knee, so that the exercise is begun at ap- Overuse injuries in girls' gymnastics. In Walsh WM
(ed): The Athletic Woman. Clin Sports Med 3:841,1984,
proximately 30 degrees of knee flexion. In a with permission.)
rhythmic fashion, the athlete performs mul-
tiple extensions from this flexed starting po-
sition (Fig. 14-15). Initially, no ankle
weights should be used; as the athlete pro- The athlete who sustains a patella dislo-
gresses in her exercise program, up to 5 Ib of cation is at greater risk for redislocation. A
weight may be added. Usually sets of 10 to quadriceps-strengthening program as well
15 repetitions are done at one time and in- as brace support may be helpful in minimiz-
corporated into a total strengthening pro- ing that risk. Athletes with recurrent patella
gram for the lower extremities. The partially dislocation may require operative proce-
flexed starting position and use of minimal dures to help stabilize the patella. (See Sur-
weights minimize the forces over the patel- gery, under Patella Subluxation.)
lofemoral joint, while the exercises increase
quadriceps strength. Patella Subluxation
As rehabilitation proceeds, a lateral pa-
tella pad or one of the many braces designed Athletes whose patellas sit laterally or
for patella stabilization can be used. The who have small, high-riding patellas (pa-
braces typically incorporate a lateral or tella alta) are more predisposed to patella
horseshoe pad to stabilize the patella me- Subluxation. During an episode of subluxa-
dially (Fig. 14-16). These same braces may tion, the patella slides laterally with twisting
be used by the athlete when she returns to movements of the knee (especially lateral
her sport. Following acute patella disloca- twists or valgus stresses) but does not
tion, however, it may be as much as 6 frankly dislocate or come completely out of
months before an athlete can fully partici- its femoral groove. In principle, the greater
pate in pivotal sports. the Q angle, the more easily the patella can
slip laterally. Medial patella subluxation In fact, the whole vastus medialis may be
theoretically can occur, but practically is poorly developed.
rarely found. Women with patella subluxation fre-
quently have an ectomorphic body type,
Symptoms
with slender, poorly muscled lower extrem-
ities. The examiner observing active and
Athletes with patella subluxation may passive knee flexion can see the patella rid-
complain merely of knee pain with kicking, ing laterally and/or sitting high in the fem-
twisting, or running maneuvers. The whip oral groove.
kick or frog kick in swimming may be pain- Palpating the medial retinaculum or the
ful. Even though both patellas are high-rid- medial facet of the patella will frequently
ing, small, and easily subluxable, frequently cause discomfort. The athlete generally will
only the dominant knee is symptomatic and be apprehensive if one moves her patella
so the athlete may not complain of pain in laterally. In fact, this sign is so characteristic
both knees. Like the athlete with patellofem- of the patient whose patella subluxes or dis-
oral stress syndrome, she may state that she locates that it is believed to be diagnostic of
has give-way episodes when going down- this condition. Frequently, the examiner
stairs (an activity that increases patellofem- may be able to completely dislocate the pa-
oral forces) or may complain of locking or tella by putting a direct lateral force on it
catching of her knee. She may not localize with the knee in extension.
her pain to the patella and may never have
experienced an episode of frank patella dis-
Treatment: Conservative
location.
The pain experienced by the athlete with Treatment of the athlete with symptom-
chronic patella subluxation may result from atic chronic patella subluxation is difficult.
inflammation of the parapatellar retinacu- Exercise to strengthen the quadriceps, es-
lum as it is stretched when the patella rides pecially the vastus medialis and particularly
laterally, or it may be secondary to abnor- its oblique fibers, so that the patella will ride
mal forces on the hyaline cartilage surface of more medially in the patellofemoral groove,
the patella. In fact, some women with may be helpful. When the athlete is acutely
chronic subluxable patellas may develop fi- symptomatic with pain, the anti-inflamma-
brillation or even fissuring of the hyaline tory agents, such as aspirin (two taken four
cartilage, eventually have erosion and loss times a day) or one of the other nonsteroidal
of the hyaline cartilage surface, and hence anti-inflammatory drugs, may be helpful.
develop patellofemoral arthritis. Intra-articular injection of steroids is not
recommended in the young athlete, as this
may cause softening of the hyaline cartilage.
Family History
The history from the athlete with sublux-
Treatment: Surgical
able patellas may reveal a sister, mother,
grandmother, or even a male relative who If all conservative measures fail—includ-
has had knee problems. The predisposition ing activity modification to avoid rapid piv-
for patella symptoms is based on anatomic otal sports—operative procedures to better
factors. centralize the patella can be performed. In-
cising (releasing) the lateral retinaculum ar-
throscopically or with a small parapatellar
Physical Examination
lateral incision may help the patella to track
As indicated previously, the patella is fre- more medially. Theoretically this weakens
quently small and high-riding. The vastus the pull of the vastus lateralis muscles on
medialis obliquus may be poorly developed. the patella. However, this procedure must
be linked with a rehabilitation program de- aminer tries to force her patella laterally.
signed to strengthen the vastus medialis Moreover, although her patella may sit lat-
muscles. erally in the patellofemoral groove, it is sta-
Other operative procedures transfer the ble in its position, and the examiner will not
bony attachment of the patella tendon more have the feeling that it could be dislocated
medially on the tibia. This decreases the Q by being pushed too firmly laterally.
angle and should better centralize the pa- The athlete with patellofemoral stress
tella, preventing subluxation. Such a proce- syndrome will have a positive patella inhi-
dure may be combined with lateral retinac- bition test; that is, she will experience pain
ular release. if the examiner puts a hand firmly above the
Care must be taken not to move the patella patella and asks the athlete to contract her
tendon attachment distally on the tibia, as quadriceps. This test increases patellofem-
this will increase patellofemoral forces and oral forces, and hence, reproduces the ath-
lead to patella cartilage softening or chon- lete's pain and give-way episodes.
dromalacia.11 The examiner should note the degree of
vastus medialis development, as frequently
athletes with patellofemoral stress syn-
Patellofemoral Stress Syndrome drome, like those with patella subluxation or
Patellofemoral stress syndrome is very dislocation, have a poorly developed vastus
common, particularly in the teenaged fe- medialis. Hamstring tightness has also
male athlete. This diagnosis is used to de- been reported to increase patellofemoral
scribe a syndrome in which there is patella forces—when the athlete fully extends the
pain with activities that load the patellofem- knee, the tight hamstrings create a "bow-
oral joint such as kneeling, kicking, running string" effect.
(especially downhill running), climbing, or Note should be made of the footstrike in
sitting for a prolonged period of time with the athlete with patella pain. Check to see if
the knee acutely flexed. The syndrome does the feet appear to have no arches, due to ex-
not include athletes with subluxable or dis- cessive inward rolling of the feet at the an-
locatable patellas. kles. Many people who have "flat feet" may
have normal arches. Their feet may appear
flat because they pronate excessively. Such
Symptoms
athletes (overpronators) may be at an in-
The athlete with patellofemoral stress creased risk of developing patella pain dur-
syndrome may have symptoms similar to ing running. During running, the foot strikes
those of the athlete with patella subluxation. the ground on the lateral part of the sole and
She may present with increasing aching dis- rolls medially prior to toeing off. If there is
comfort in the knee, with or without associ- excessive pronation associated with this
ated effusion, or she may present with an medial roll, the patella may be forced later-
acute episode of knee pain with locking or ally in the patellofemoral groove, resulting
giving way. Effusions are more typically as- in abnormal distribution of patellofemoral
sociated with patella subluxations or dislo- forces.
cations.
Treatment
Physical Examination
Alteration of patella tracking is the fun-
On physical examination, although she damental principle in all treatment pro-
may have a patella that rides laterally in the grams for patellofemoral stress syndrome.
patellofemoral groove, with an increased Q Quadriceps-strengthening exercises, de-
angle, a woman with patellofemoral stress signed to minimize patellofemoral force
syndrome is not apprehensive when the ex- while increasing quadriceps strength, are
recommended. Short arc extensions and tracking.12 In addition, there are patella
biking, as described above, are two ways of straps or bands of material that fasten about
achieving this objective. Another is straight the proximal tibia at the level of the patella
leg lifts, with minimal weights and maximal tendon. Theoretically, these bands are de-
repetitions. A stair-stepper machine can signed to alter the resting length of the
also be used, but only with small, rapid steps quadriceps-patella tendon unit, and hence,
at low tension settings. decrease the force this unit can generate at
Devices that limit pronation are often use- the patellofemoral joint, much like tennis
ful in treating patella pain. Many track shoes elbow bands are thought to alter the force
have varus wedges (thicker heels medially generated by the wrist extensor mechanism,
than laterally). Arch supports incorporated and hence, decrease the stress placed on the
into insoles or custom-ordered orthotics to lateral epicondyle.
alter foot strike may be helpful. For an or- The symptomatic athlete should be in-
thotic to limit pronation effectively, it must structed to avoid prolonged knee flexion;
be used in a shoe that has a tight counter to that is, she should not sit "Indian-style" for
grip the heel and a saddle to keep the foot long periods of time, and she should stretch
from slipping over the orthotic. her legs frequently while riding in a car or
Icing the parapatellar area following ex- sitting in the theater or at her desk. Her
ercise may help decrease inflammation, and training routines should be reviewed to
hence, pain. Oral anti-inflammatory agents, make certain they do not include activities
either aspirin, ibuprofen, or other prescrip- that maximally load the patellofemoral joint,
tion nonsteroidal drugs, may be useful in the such as stair climbing (other than discussed
patient who is acutely symptomatic. above) or deep squats. If the hamstring mus-
Braces like those previously described for cles are tight, hamstring stretching should
use in athletes with patella subluxation or be initiated. Slow stretches, as shown in Fig-
dislocation can also help to alter patella ure 14-17, are recommended.
Figure 14-17. Hamstring stretch. For stretching the left hamstring and the right side of the back,
slowly bend forward from the hips toward the foot of the left leg from a sitting position with the legs
spread. Keep the head forward and the back straight. Hold the stretch for 20 seconds. With repeti-
tions, the stretch will become easier. Repeat the stretch with the opposite leg.
Prognosis dible "pop" or snap can be felt as the knee

Although the patellofemoral stress syn- actively extends, and this sound is accom-
drome may be associated with significant panied by pain. Occasionally, the "pop" can
pain, which temporarily incapacitates the also be produced by passive knee extension.
athlete, this overuse syndrome is not typi-
cally associated with any permanent impair- Treatment
ment. Unlike chronic patella subluxation or
multiple patella dislocations, patellofemoral For the acutely symptomatic athlete, hav-
stress syndrome infrequently results in ing her rest the knee in extension in a soft
chondromalacia or frank patellofemoral ar- knee immobilizer for 5 to 10 days and pre-
thritis.9 Treating the athlete with patellofem- scribing a nonsteroidal anti-inflammatory
oral stress syndrome may be frustrating, agent such as aspirin may decrease inflam-
mation and resolve the symptoms com-
however, as symptoms may initially be quite pletely.
refractory. Treatment of the athlete with chronic pain
from a symptomatic plica is more difficult.
Patella Plica Rest and anti-inflammatory agents can be
tried. Exercises to alter patella tracking may
Patella plica (also called synovial plica or also be helpful. In rare cases, excision of the
patella shelf) is a normal developmental patella plica must be done to relieve symp-
fold of tissue that sits retropatellarly. It is toms.
the embryonic remnant of the divisions in
the knee.13
Patella Pain: Summary
Symptoms Patella pain is one of the most common
musculoskeletal complaints in female ath-
The remnant is normally thin and filmy, letes. It may result from repeated episodes
but following multiple episodes of minimal of patella dislocation, from multiple patella
trauma or one severe acute traumatic epi- subluxations, from patellofemoral stress
sode to the patellofemoral joint, this fold of syndrome, or from symptomatic patella
tissue can become thickened. When the pa- plica. Diagnosis is made on history and
tella rides over this thickened fold, it can physical examination. Altering patella track-
cause an audible "pop" and associated pain. ing while decreasing acute inflammation is
The pain may be reported by the athlete as the basis of most treatment programs.
being diffuse or as being definitely associ-
ated only with the "pop" and localized well
along the medial side of the joint. She may IMPINGEMENT SYNDROMES
feel a catching sensation as the patella tries
to slide under the thickened fold. Impingement syndromes result when soft
Pain can be gradual in onset over days and tissues are repetitively traumatized between
weeks, as this tissue slowly thickens with bony prominences. For example, shoulder
multiple low levels of trauma, or it can be impingement refers to irritation of bursa
acute, especially if the athlete has per- and rotator cuff tissue, which becomes
formed a knee-intense activity and the plica trapped between the humeral head and
has acutely been irritated and thickened. acromion with shoulder elevation if the hu-
On physical examination, the athlete may meral head is not firmly held in the glenoid
have a small effusion. She will feel tender- fossa. Impingement syndromes commonly
ness over the medial parapatellar area over occur about the ankle, the wrist, and the
the location of the plica. Moreover, an au- shoulder, and they are particularly common
in women involved in gymnastics, racquet

sports, swimming, throwing sports, ballet,
diving, ice skating, and crew (see Table 14-
1).
Ankle Impingement
Impingement of soft tissues about the
ankle may occur with either repetitive
marked dorsiflexion, such as that seen
with landings in gymnastics, or repetitive
marked plantar flexion, such as occurs in
dance, gymnastics, and diving. Athletes with
anterior capsular impingement complain of
pain in the region just lateral to the anterior
tibial tendon as it crosses the ankle. The
pain is increased with dorsiflexion activi-
ties.
Posterior capsular pain may be harder to
localize. The athlete describes her pain as
posterior in the ankle, deep to the Achilles
tendon. The pain is present when she rises
to her toes, and in fact it may prevent her
from achieving a forced plantar flexed posi-
tion. On palpation of her peroneal tendons,
Figure 14-18. Beaking of the anterior talar-tibial sur-
Achilles tendon, and posterior tibial tendon, face, secondary to multiple flexor impingements.
no tenderness is found.
Ankle radiographs of the athlete with soft
tissue ankle impingement appear normal,
Wrist Impingement
but occasionally athletes may demonstrate
bony abnormalities (beaking of the tibia and Impingement of the palmar capsule of the
talus anteriorly, and hypertrophy of the wrist is not as common as that of the dorsal
talar process posteriorly) (Fig. 14-18). capsule. Dorsal capsular impingement may
Treatment of most athletes with ankle im- develop acutely if an athlete falls on an out-
pingement syndromes is conservative. Oral stretched hand or absorbs a sharp impact
and/or local administration of anti-inflam- on the dorsiflexed hand, such as might
matory agents, ice massage, ultrasound, occur in a tumbling routine in gymnastics, in
electrical stimulation, and other physical a poor angle of contact with a volleyball, or
therapy modalities may help diminish the in improper baton handoff in track.
inflammatory response. Use of an anterior The athlete with dorsal impingement will
ankle pad, for anterior impingement, or a complain of pain diffusely along the dorsal
posterior pad to prevent hyperextension wrist structures. The pain is made worse
with posterior impingement may be helpful. with forced dorsiflexion. A fracture of the ra-
The athlete should review her fundamen- dius or navicular must be considered in the
tals, as alteration of technique may diminish differential diagnosis of any athlete present-
symptoms; for example, "landing short" in ing with a painful wrist. The pain of dorsal
gymnastics results in a hyperflexed position capsulitis will not be limited to the snuffbox,
and may precipitate anterior capsulitis. In as with navicular fractures, and the pain is
the rare athlete with excessive bony hyper- more distal (centered over the radial-carpal
trophy, surgical excision may be required. junction) than that seen with a nondisplaced
radial fracture. Moreover, with capsular im- mimicking the impingement process that
pingement, radiographs are normal. occurs dynamically during sport. This ma-
Analgesic cream applied to the area of neuver is termed the "impingement sign"
maximum tenderness and ice massage, as (Fig. 14-19).
well as other physical therapy modalities, No atrophy is generally found. The biceps
may be helpful in decreasing symptoms. tendon will be tender if it is involved in the
After the acute pain subsides, strengthening impingement process. There is often tender-
exercises for the wrist extensors and flexors ness over the acromioclavicular joint, espe-
are recommended prior to returning to the cially if arthritis of this joint is present, as in
sport. Chronic impingement pain—that is, the older patient who develops the impinge-
pain that has been present at a low level of ment syndrome. Acromioclavicular arthritis
discomfort for several months—is more dif- is less common in the younger competitive
ficult to resolve than the pain of acute im- athlete. Typically, external rotation strength
pingement. Similar treatment routines are is diminished over the opposite side, but ab-
used, however. Taping the wrist upon return duction is possible.
to activity may be beneficial in the athlete Shoulder radiographs are usually normal
with either an acute or a chronic wrist im- in the young athletic individual with shoul-
pingement. der impingement. In the impingement syn-
drome of some athletes, one occasionally
sees osteophytic spurring of the inferior sur-
Shoulder Impingement face of the acromion or sclerosis of the lat-
Shoulder impingement is commonly seen eral aspect of the humeral head from repet-
in swimmers and in athletes participating in itive trauma.14
throwing and racquet sports. It is frequently
associated with some element of anterior
shoulder subluxation in young athletes. In
the impingement syndrome, a weakened ro-
tator cuff allows upward migration of the hu-
meral head in the glenoid, causing compro-
mise of the humeral-acromial space. As this
space becomes compromised, the tissues
contained therein, those of the subacromial
bursa, and the rotator cuff itself can become
traumatized and inflamed. With greater in-
flammation, there is greater mass of tissue,
and therefore, a vicious cycle of pain, swell-
ing, more pain, and more swelling is estab-
lished. Shoulder impingement may be asso-
ciated with bicipital tendinitis, since the
biceps tendon lies in the subacromial space
and can be irritated by the impingement
process part of the syndrome.
The athlete with shoulder impingement
complains of pain at the tip of the acromion
or in the proximal arm. Frequently the pain
radiates down the external rotators of the Figure 14-19. To produce the impingement sign of the
shoulder. Tenderness can be elicited if the shoulder, the examiner holds down the acromiocla-
examiner places one hand on the patient's vicular area while elevating the extremity at the elbow
in a pronated, abducted, and forwardly flexed position.
acromion, holding it down while elevating If this maneuver reproduces the pain of impingement,
the arm in either forward or side flexion. it is called a positive impingement sign.
A treatment program for the athlete with agents. After the initial inflammatory re-
an impingement syndrome may include sponse subsides, exercises to strengthen
temporarily avoiding any activity that re- the rotator cuff muscles, to reinstitute
quires the elbow to be raised above shoul- proper mechanics of the shoulder, are ad-
der height, combined with physical therapy vised. Many different exercise routines can
modalities and oral anti-inflammatory be used to strengthen the rotator cuff. The
Figure 14-20. (A) Patient using rubber tubing to strengthen the internal rotators of the shoulder.
Note that the elbow is held tightly to the side and the forearm is rotated internally to the abdomen,
as the rubber tubing is affixed to the door. (B) Patient demonstrating use of rubber tubing to
strengthen external rotators of the shoulder. Again, the elbow is held tight to the side and the forearm
is rotated externally against the resistance of rubber tubing affixed to the door.
simple exercises using rubber tubing at- ankle or its insertion into the superior pos-
tached to a door (Fig. 14-20) were adapted terior tip of the calcaneus. In acute tendini-
from the program initiated by the Naval tis, the examiner can feel crepitation over
Academy.15 The athlete should be advised to the tendon as the athlete moves her foot
review technique with her trainer or coach, from dorsiflexion to plantar flexion. The
as frequently impingement is precipitated Achilles tendon may appear swollen when
by an alteration in form. For example, in compared with the uninjured tendon. This
swimming, an increase in internal rotation swelling may be easier to assess if the pa-
of the arm at the shoulder may cause im- tient stands facing away from the examiner
pingement of the tissues. or if she lies prone on the examining table.
Chronic impingement syndromes are
much more difficult to treat. Physical ther-
Treatment
apy modalities and oral anti-inflammatory
agents can be tried. However, the key to im- Rest is essential in the treatment of acute
provement of symptoms is to reinstitute Achilles tendinitis. The athlete can substi-
proper shoulder mechanics through a rota- tute nonimpact load activities that require
tor-cuff-strengthening exercise program. infrequent ankle motion (e.g., rowing ma-
The athlete should be advised that such a chine, swimming) to maintain fitness. If
program will take anywhere from 4 to 6 walking is painful, crutches to assist ambu-
weeks, so she should not become discour- lation, heel lifts to relax the Achilles tendon,
aged. Controversy exists as to the role of in- or in very severe cases, cast immobilization,
jected steroids to diminish symptoms. The may be needed. Rarely, the athlete will re-
decision to use these should depend on the quire surgical release of the inflamed tendon
assessment of each individual case. sheath.
Oral anti-inflammatory agents, local anti-
inflammatory creams, ice massage (rubbing
OTHER COMMON CONDITIONS
the inflamed area with an ice cube), ultra-
Achilles Tendinitis sound, iontophoresis, or electrical stimula-
tion can all be useful in decreasing acute in-
Achilles tendinitis is the result of damage flammation. Steroid injections are not
to the fibers of the Achilles tendon or to its recommended because, if injected into the
tendon sheath. It can be seen in sports re- tendon itself rather than the tendon sheath,
quiring repetitive ankle flexion and exten- they may weaken the tendon.
sion (e.g., track, basketball, soccer). It also Stretching an acutely injured tendon can
occurs in athletes who wear boots, such as delay healing, but once the acute inflamma-
skaters and skiers, from the irritation of the tion has subsided, exercises to stretch as
boot on the tendon. well as to strengthen the Achilles tendon are
Acute Achilles tendinitis is usually char- begun. Stretching can be done by standing
acterized by pain that is exacerbated when on a slant board with the heel lower than the
the patient actively plantar flexes or resists ball of the foot, by leaning against a wall
passive dorsiflexion of the foot. Chronic (facing it) with the feet flat on the floor, or
Achilles tendinitis usually results in severe by using a towel under the ball of the foot to
pain on first rising in the morning, which pull the foot gently into increasing dorsiflex-
lessens with activity. It also generally causes ion. Toe raises are an effective strengthen-
considerable pain at the start of a workout, ing exercise.
which lessens as the workout progresses, After pain has completely disappeared
unless the inflammation is severe and then with walking, stretching, and gently jogging,
the pain is persistent. the athlete can gradually resume her run-
When asked to localize her pain, the ath- ning sport. Icing following activity for sev-
lete will touch either the tendon behind the eral months is recommended, and the ath-
lete should always warm up well and stretch origin of the muscle. Radiographs usually
prior to sport. are negative, but occasionally some diffuse
periosteal reaction at the posterior tibial
Shin Splints muscle origin can be seen.
Shin splints must be differentiated from a
"Shin splints" may be used as a general stress fracture of the tibia. The pain of a
term to refer to any pain between the tibial stress fracture increases with activity and is
tubercle and the ankle that is not a stress relieved with rest. The athlete with a stress
fracture or compartment syndrome. How- fracture of the tibia will have a very discrete
ever, many physicians use the term to refer area of pain on palpation of the tibia (see
specifically to pain along the anteromedial below).
aspect of the tibia at the origin of the poste- As with other overuse syndromes, shin
rior tibial muscle (Fig. 14-21). splints can be treated with rest, local and/or
Running on hard surfaces, running in in- oral anti-inflammatory agents, physical
appropriate shoes, having weak lower leg therapy modalities (e.g., ultrasound and
muscles, and improper stretching have all electrical stimulation), and ice massage
been blamed for causing shin splints. Run- (more effective than an ice bag). Stretching
ning on hard surfaces or in noncushioned and strengthening exercises for the poste-
shoes may increase stress on the longitudi- rior tibial muscle, as well as the associated
nal arch of the foot and, hence, indirectly on toe flexor muscles, are recommended. Sup-
the posterior tibial muscle and tendon that port of the tendons by arch supports or tap-
help support this arch. ing may be beneficial.
Diagnosis of shin splints is made by his- In patients with chronic shin splints, slow
tory and physical examination. Pain may ini- return to sports may be advocated despite
tially increase with activity, usually im- the persistence of mild symptoms, as long as
proves as the activity proceeds, and may the possibility of a stress fracture has been
return following activity. The pain of shin eliminated. The athlete should be very care-
splints is localized to a 2- to 4-inch area on ful to warm up sufficiently and perform ad-
the anteromedial aspect of the tibia at the equate stretching prior to beginning activ-
Figure 14-21. Patient with shin splints demonstrating area of pain.

ity. If an activity causes severe pain, it lieved with rest. Radiographs are helpful in
should be discontinued. The athlete may be diagnosing stress fractures only if the pain
able to substitute another activity (e.g., has been present for a minimum of 2 to 3
changing from running to biking) until her weeks. Since stress fractures are really "mi-
symptoms improve sufficiently to permit re- crofractures," the fracture line itself is often
turn to her preferred sport. not visible on the x-ray film. Radiographs do
not demonstrate an abnormality until signif-
icant healing reaction of the periosteum
Stress Fractures
(healing callus) is present.
When the rate of bone breakdown from ac- To diagnose a stress fracture before a
tivity (a normal process) is greater than the healing callus is visible radiographically, a
rate of bone formation (repair), a stress frac- bone scan can be done. This study will de-
ture may result. Stress fractures have been tect increased osteoblastic activity as soon
reported to occur more often in female than as microfractures occur. Bone scans are par-
in male athletes.16 The reason for this in- ticularly valuable in diagnosing intracapsu-
creased incidence may be a lack of condi- lar stress fractures, such as those of the fem-
tioning or improper training technique, oral neck. In this location, bone has no
rather than a true predisposition to injury. A periosteum. Hence, radiographs demon-
woman who fails to condition slowly and strate no abnormality until intracortical
sensibly for her sport does not give her bone healing takes place, and this takes longer
ample time to increase in cortical thickness than periostea! healing.
to meet the mechanical demands of the ac-
tivity.
Treatment and Exercise
The most common location of stress frac-
tures in women is the tibia;17 also common In treating stress fractures, the primary
are fractures of the fibula and metatarsals. consideration is to decrease the mechanical
Fractures of the pars interarticularis are a stress on the bone to allow healing to occur.
special type of stress fracture, as noted in Neither cast immobilization nor operative
the section on low back pain. stabilization is generally required. For
Some investigators have tried to relate the stress fractures of the lower extremity, the
low estrogenic secondary amenorrhea seen athlete should use a cane or crutch until she
occasionally in competitive female athletes can bear weight on the extremity without
to osteoporosis and a higher incidence of pain.
stress fractures.18,19 However, the only area Swimming and bicycling can be started
of diminished bone content in these women early in the treatment of stress fractures.
has been in the cancellous bone of the ver- These activities will maintain cardiovascu-
tebral bodies;20 no change in the density of lar endurance and muscle tone, but are non-
cortical bone has been found. (See Chapter weight-bearing activities and therefore do
5.) Most stress fractures occur just proximal not stress bones of the lower extremities in
to the metaphysis, in the areas of cortical the same manner as running and walking.
bone. Therefore, the relationship of stress Psychologically, the athlete will fare much
fractures to low estrogenic secondary amen- better if she can participate in some sporting
orrhea is not clearly understood. More inactivity during her treatment course.
vestigation needs to be done in this area. Because stress fractures heal at variable
rates, it is better to advance activity as pain
resolves rather than to establish routine
Diagnosis
time intervals for activity adjustment. When
The pain of a stress fracture is typically re- no pain results from walking long distances
stricted to a limited anatomic area. It is unassisted by crutches or cane, running can
made worse with activity and may be re- be attempted.
Low Back Pain mal or show a lumbar list (curve) secondary

Causes of low back pain have been listed to muscle spasm.
Most mechanical low back pain runs a 2-
as mechanical, neurologic, neoplastic, infec-
tious, and metabolic. Mechanical causes, to 3-week course and is self-limited. If pain
the most frequent in athletes, include nerve lasts longer despite the institution of con-
servative therapy with bed rest, muscle re-
root impingement; repetitive microtrauma
resulting in overuse syndromes such as ten- laxants, anti-inflammatory agents, physical
dinitis, fasciitis, and stress fractures; and therapy modalities, and a graded exercise
some anatomic abnormalities. Most ana- program, the athlete's symptoms deserve
tomic abnormalities, such as asymmetric further evaluation to rule out the possibility
lumbar or sacral facets, scoliosis, increased of spondylolysis (a defect in the pars inter-
articularis, as in Fig. 14-22), spondylolisthe-
lumbar lordosis, and transitional vertebrae,
do not usually result in back pain. However, sis (forward slipping of one vertebra on an
adjacent vertebra, also in Fig. 14-22), large
unequal leg lengths (generally a difference
disk herniation, infection, neoplasm, or met-
of 1.5 cm or greater) may cause low back
abolic disease.
pain on a mechanical basis, especially in
runners.
Athletes with mechanical low back pain Spondylolysis
may present with either an acute episode of
Female gymnasts have been found to have
severe low back pain, or with pain slowly in-
a greater incidence of spondylolysis or de-
creasing over several days or months. Pain
associated with numbness or tingling of the fects in the pars interarticularis than the
general population.21 Defects in the pars in-
lower extremities, or pain radiating from the
terarticularis in the athletic population
back into the leg, implies nerve root im-
present an intriguing diagnostic problem: Is
pingement (neurologic back pain).
On physical examination, mild, moderate, this defect a stress fracture resulting from
repetitive hyperextension and flexion activ-
or severe spasm of the paravertebral mus-
ities of the area, or is it a developmental ab-
cles may be found. Palpation of the low back
normality? The youngest reported pars de-
region usually elicits pain. Reflexes, motor
fect occurred in a 31/2-month-old child. An
function, and sensation are normal in both
increased incidence of the defect is seen be-
lower extremities. Radiographs may be nor-
tween the ages of51/2and 61/2; by age 7, 5%
all white children have been found to have a
pars defect.22 A familial predisposition for
this defect has been reported.
If initial radiographs demonstrate a well-
established pars defect indicative of an
older injury, return to athletics can follow a
period of rest. A strengthening program
should be instituted prior to returning to ac-
tivity. Bent-knee sit-ups, walking, and swim-
ming all help to develop abdominal and
paravertebral muscles.
Stress Fractures
In athletes with normal radiographs and
Figure 14-22. Spondylolysis and Spondylolisthesis. persistent low back pain, the possibility of
(From Norkin CC and Levangie PK: Joint Structure and
Function, ed 2. FA Davis, Philadelphia, 1992, p 164, with stress fracture must be entertained. A bone
permission.) scan may be required to establish this diag-
nosis. If this is positive, resting from activi- level. Initial treatment of the athlete with
ties for a minimum of 3 to 4 months is rec- suspected disk herniation is similar to that
ommended, and many physicians suggest for mechanical low back pain—rest and oral
immobilization in a spica or plastic ortho- anti-inflammatory medications, followed by
sis.23 Anti-inflammatory and muscle relaxing a program for strengthening paravertebral
agents can be useful for symptomatic relief. and abdominal muscles prior to a return to
A program of abdominal and back-strength- sport. Muscle relaxing agents and physical
ening exercises should be instituted prior to therapy modalities may be helpful in dimin-
returning to athletics. ishing pain secondary to muscle spasm.
In the athlete whose pain is unresponsive
to such treatment over 2 to 3 weeks, or who
Spondylolisthesis
has increasing neurologic complaints (in-
Spondylolisthesis occurring in associa- creased weakness, muscle atrophy, de-
tion with spondylolysis is most common in creased sensation in the lower extremities,
females between the ages of 9 and 13 years. absent reflexes, etc.), further evaluation by
Unlike Spondylolisthesis in the adult, which computerized axial tomography (CAT) scan,
tends to remain stable, Spondylolisthesis in magnetic resonance imaging, or myelogram
children can increase in severity during the should be done. If a ruptured disk is con-
years of rapid growth. Children known to firmed by these studies, surgical decom-
have Spondylolisthesis who complain of pression of the ruptured disk may need to be
back pain should be examined carefully to done. However, less than 30% of myelo-
note any progression of their slip. gram-proven ruptured disks need operative
There is disagreement over whether ath- intervention.24 Most improve with conser-
letes with mild Spondylolisthesis should re- vative measures.
turn to contact sports: some authorities
have suggested that they can do so if they
Vertebral Apophysitis
are protected by a brace. Although this may
be acceptable in a football lineman, female Another cause of back pain in the skele-
gymnasts would find it difficult to compete tally immature population is vertebral
in such a restrictive device. apophysitis, that is, irritation of the growth
Rarely, the athlete with Spondylolisthesis centers of the vertebral body. Inflammation
may have persistent significant pain follow- is believed to result from traction on the
ing a treatment program consisting of rest, apophysis (the growth center) from the
anti-inflammatory agents, and using a brace. anterior longitudinal ligament, as it is
Fusions are occasionally performed in these stretched in repetitive extension maneuvers
recalcitrant cases. A few athletes have even that are a part of sports such as gymnastics,
returned to their sport following fusions for diving, and skating.
Spondylolisthesis, but contact sports are Rest often relieves symptoms, yet bony
generally not recommended in these ath- changes may persist. Prior to returning to
letes. sports, these youngsters should begin a
strengthening and flexibility program for
back and abdominal muscles. Symptoms de-
Herniated Lumbar Disk
termine when a child may resume full partic-
Athletes with nonradicular back pain un- ipation in sports.
responsive to conservative measures or
with radicular back pain should be evalu-
ated for a possible herniated lumbar disk. In Bunions
the athlete with radicular pain, careful neu- The abnormal prominence of the inner as-
rologic examination may enable localization pect of the first metatarsal head and resul-
of the pain to a particular nerve root or disk tant lateral displacement of the great toe is
Figure 14-23. Young girl with bunions on metatarsus

primus varus.
termed a bunion. Bunions appear to be more

common in women, and hence, they are
more common among female athletes than
among male athletes. Many women have in-
flammation of the bursa overlying the me-
dial prominence or flare of the great toe
metatarsal head associated with their meta-
tarsus primus varus (Fig. 14-23), but this
bursal enlargement also occurs without sig-
nificant lateral displacement of the great toe.
Shoe alteration and protective pads to re- Figure 14-24. Runner who has had stress fractures of
duce pressure over the metatarsal flare are the second and third metatarsals following her bun-
often helpful in diminishing symptoms. The ionectomy procedure. The stress fracture of the second
metatarsal is old and has a good healing reaction asso-
problem is more difficult when the athlete ciated with it, whereas the stress fracture of the third
has not only bursitis but also degenerative metatarsal is new, and no healing reaction is yet seen.
changes in the metatarsophalangeal joint, a
condition seen in athletes involved in kick-
ing sports. the middle metatarsals in a long-distance
The athlete with a bunion must be careful runner following a bunionectomy. Operative
when choosing shoes. She should look for procedures should not be done purely for
shoes with a sufficiently wide forefoot, yet a cosmetic reasons; they should be reserved
narrow enough heel to prevent her foot from for cases in which pain is unresponsive to
sliding forward in the shoe. With forward conservative care.
slippage, the first ray is forced into a valgus
position and pressure is exerted on the me- Morton's Neuroma
dial metatarsal head.
If pain persists despite all conservative Pain between the second and third meta-
treatment, bunionectomy can be performed, tarsal heads, or between the third and fourth
but great care must be taken to avoid alter- metatarsal heads, made worse by transverse
ing foot mechanics disadvantageously by compression of the forefoot, generally re-
such a surgical procedure. Figure 14-24 sults from inflammation and scarring about
demonstrates multiple stress fractures of the interdigital nerve (i.e., Morton's neu-
roma). The patient may complain of numb- 2. Anderson J: Women's sports and fitness pro-
ness in the toes supplied by the com- grams at the U.S. Military Academy. Phys
promised nerve. Swelling between the Sportsmed 7(4):72, 1979.
3. Eisenbert I, and Allen W: Injuries in a
metatarsal heads at the site of the neuroma women's varsity athletic program. Phys
may also be noted. Sportsmed 6(3):112, 1978.
The mechanism of development of this le- 4. Clarke K, and Buckley W: Women's injuries in
sion is not clearly understood, but it appears collegiate sports. Am J Sports Med 8:187,
to involve scarring of both the nerve and the 1980.
5. Whiteside P: Men's and women's injuries
vessel accompanying it.25 It has been theo- in comparable sports. Phys Sportsmed
rized that compression of the adjacent meta- 8(3):130,1980.
tarsal heads creates repetitive trauma to 6. Gillette J, and Haycock C: What kinds of in-
these structures, producing the scarring. juries occur in women's athletics? 18th Con-
In some cases, a metatarsal pad will alle- ference on the Medical Aspects of Sports,
American Medical Association, 1977, p 18.
viate symptoms. The athlete should be ad- 7. Shiveley RA, Grana WA, and Ellis D: High
vised to wear wider shoes and place antiskid school sports injuries. Phys Sportsmed
pads in her shoes to prevent forward migra- 9(8):46, 1981.
tion of her foot in the shoe, causing trans- 8. DeHaven K: Athletic injuries: Comparison by
verse compression of the metatarsal heads. age, sport, and gender. Am J Sports Med
14:218,1986.
Local injection into this area may be helpful 9. Hunter L, Andrews J, Clancy W, et al: Com-
in decreasing or resolving symptoms. mon orthopaedic problems of the female ath-
If all these measures fail, excision of the lete. American Academy of Orthopaedic Sur-
neuroma may be performed, but the athlete geons Instructional Course Lecture, Vol 31,
should be warned that postoperative swell- 1982, p 126.
10. Hunter LY: Women's athletics: The orthope-
ing of the foot can persist for 3 to 4 weeks fol- dic surgeon's viewpoint. Clin Sports Med
lowing the procedure. She should plan re- 3:809,1984.
section of the neuroma for an appropriate 11. Turba JE: Formal extensor mechanism re-
time in her competitive season to permit an construction. Clin Sports Med 8:297, 1989.
adequate recovery. 12. Palumbo PM: Dynamic patellar brace: A new
orthosis in the management of patellofemo-
ral disorder. Am J Sports Med 9:45, 1981.
13. Boland A: Soft tissue injuries of the knee. In
SUMMARY Nicholas J, and Hershman E (eds): The
Lower Extremity and Spine in Sports Medi-
Over the last several decades, there has cine. CV Mosby, St Louis, 1986, p 938.
been an increasing awareness of women's 14. Cone R, Resnick D, and Danzig L: Shoulder
sports injuries. With the advent of better impingement syndrome: Radiographic eval-
uation. Radiology 150:29,1984.
conditioning programs for women, the rate 15. Regan K, and Underwood L: Surgical tubing
of sports injuries has diminished. When an for rehabilitating the shoulder and ankle.
injury does occur, prompt diagnosis and Phys Sportsmed 9(1):144, 1981.
treatment of the injury is needed to mini- 16. Micheli L: Injuries to female athletes. Surgical
mize the time lost from sport. Rounds 2:44,1979.
17. Protzman R, and Griffis C: Stress fractures in
Guidelines for the athlete's return to ex- men and women undergoing military train-
ercise after orthopedic injury or surgery are ing. J Bone Joint Surg 59:825, 1977.
discussed in greater detail in Appendix A. 18. Caldwell F: Light-boned and lean athletes:
Does the penalty outweigh the reward? Phys
Sportsmed 12(9):139,1984.
19. Mitchell D: Case presentation. In Bulletin of
REFERENCES the Department of Gynecology and Obstet-
rics, Emory University School of Medicine,
1. Albohm M: Equal but separate—insuring 6:74, 1984.
safety in athletics. JNATA 13:131, 1978. 20. Lutter J: Mixed messages about osteoporosis
26O Special Issues and Concerns
in female athletes. Phys Sportsmed Differential diagnosis. Am J Sports Med

11(9):154,1983. 7:362,1979.
21. Jackson D, Wiltse L, and Cirincrone R: Spon- 24. Jackson D, and Wiltse L: Low back pain in
dylolysis in the female gymnast. Clin Orthop young athletes. Phys Sportsmed 2:53,1974.
117:68, 1976. 25. Bossley C, and Cairney P: The intermetatar-
22. Hoshina H: Spondylolysis in athletes. Phys sophalangeal bursa: Its significance in Mor-
Sportsmed 8(8):75,1980. ton's metatarsalgia. J Bone Joint Surg
23. Micheli L: Low back pain in the adolescent: 62B:184,1980.
CHAPTER 15
Medical Conditions Arising

during Sports
ARTHUR J. SIEGEL, M.D.
THE PHYSIOLOGY OF ATHLETES Exercise-Induced Anaphylaxis

Exercise-Induced Urticaria
CARDIAC CHANGES WITH
EXERCISE AND TRAINING: RISKS PSEUDOSYNDROMES IN
AND BENEFITS ATHLETES
Primary and Secondary Prevention Pseudoanemia ("Runner's Anemia")
of Heart Disease Through Exercise "Athletic Pseudonephritis"
EXERCISE AND CANCER RISK Serum Enzyme Abnormalities:
Muscle Injury and Pseudohepatitis
HAZARDS OF EXERCISE Pseudomyocarditis
Heat Stress
Hematologic Effects: Iron Status and SCREENING THE ATHLETE FOR
Anemia MEDICAL CLEARANCE
"Runner's Diarrhea"
Effects on the Urinary Tract CAUTION: WHEN NOT TO
Exercise-Induced Asthma EXERCISE
T he 1990s promise to be a dynamic step forward in women's health, with rec-

ognition of gender disparities in health care1 and a clear mandate from the
National Institutes of Health to close the gap through research on women's
health.2 A new NIH program is called CHOICES:
Cancer
Heart disease
Osteoporosis
Interventions and
Community
Evaluation
Studies
This program, committed to improving health outcomes in women, carries a

strong mandate to examine the gender-specific health benefits of exercise as
endorsed by the U.S. Preventive Services Task Force for the general population.3
261
The purpose of this chapter is to consider megaly without congestive heart failure. The
gender-focused medical conditions arising ECG showed a first-degree AV block with
during sports and to place these consider- voltage criteria for LVH, ST-segment
ations in the forward-looking context of the changes consistent with early repolarization
role of exercise in improving women's or acute ischemia.
health. This case illustrates the challenging dif-
ferential that may arise during the acute
evaluation of individuals—athletes or oth-
THE PHYSIOLOGY OF erwise—with abnormal clinical examina-
ATHLETES tions and laboratory data. Although this sce-
nario might well fit an individual with an
Things are not always what they appear to advanced stage of a debilitating illness
be. Athletes acquire an altered physiology (even AIDS), it is also entirely compatible
from training, and as a result of those with a nondisease state and might easily fit
changes, basic laboratory tests that are ab- the description of an elite female marathon
normal for nonathletes may be normal for runner enjoying a nap after competition! The
athletes. The medical literature is full of de- inability to arouse this patient with appro-
scriptions of medical conditions or illnesses priate stimulation, or a marked elevation of
in athletes that have subsequently been body temperature, or both, might raise the
shown to be physiologic or normal re- possibility of severe heat injury or even heat
sponses to exercise. For example, athletic stroke.
nephritis and athlete's anemia have been This sample case illustrates the impor-
appropriately reclassified as pseudosyn- tance of a working knowledge of the effects
dromes. A physician who is unfamiliar with of endurance training on exercise physiol-
laboratory data in athletes may diagnose ogy, to assess specific conditions that may
disease when none exists. arise in athletes during sport, as well as to
The following case history illustrates the differentiate true clinical problems from
complexities of medical conditions that may changes in laboratory data that may not in-
arise through intense sports activity: dicate any underlying illness or dysfunction.
A number of pseudosyndromes have been
A 21-year-old woman was brought to the recognized in athletes, from the athletic
emergency room scantily clad and coma- heart syndrome to pseudonephritis, pseu-
tose, having been found, unresponsive, by doanemia, and pseudohepatitis. These are
the roadside. Her blood pressure was 68/40,
pulse 36 bpm and regular, respirations 8 and
examples of abnormal laboratory findings
unlabored, temperature 96°F. Examination that may result from strenuous training and
showed no evidence of head injury or other not be connected to any underlying organ
trauma. The chest was clear. The heart was dysfunction.4,5
markedly enlarged with an LV lift and pan- These pseudosyndromes must be differ-
systolic murmur with an S3 gallop. Abdomi- entiated from a range of medical complica-
nal examination was unremarkable. The ex- tions that may arise in the athlete during
tremities showed the appearance of muscle prolonged strenuous exercise or competi-
wasting with scant subcutaneous tissue and tion, especially due to overexertion states.
a height/weight ratio below the fifth percen- After briefly discussing some medical bene-
tile. Laboratory data included a hematocrit fits conferred by exercise, this chapter will
value of 30%, a urinalysis positive for protein
and trace amounts of blood, and hyaline
examine both aspects of medical conditions
casts present in the sediment. Serum creat- arising during sports: true exercise-related
inine was borderline elevated at 1.7, liver illnesses, conditions, or risks; and the spec-
and cardiac enzymes were two to three trum of pseudosyndromes or apparent dis-
times normal, with a CPK 10 times normal. orders that may arise as a result of altered
Chest radiograph showed marked cardio- physiology through training.
Medical Conditions Arising during Sports 263
CARDIAC CHANGES WITH basic similarities between men and women

EXERCISE AND TRAINING: in the characteristics of disease and their re-
RISKS AND BENEFITS sponse to preventive measures. For in-
stance, atherosclerotic plaques found in
Electrocardiographic changes in trained women have similar compositions to those
individuals include a variety of rhythm and of men,7 and daily aspirin use promotes pri-
conduction disturbances, as well as depolar- mary prevention in women as well as in
ization changes, that in other clinical set- men.8,9 Nevertheless, a gender bias in access
tings would be characteristic of various to health care has been identified10,11 and
diseases.6 The heart, as studied by echocar- might be called "sex, lies, and balloon an-
diography, shows changes in both chamber gioplasty." Attention to the need for
size and myocardial mass, which vary with gender-neutral diagnosis and treatment is
type of training. Endurance-trained athletes growing.
tend to have dilated chambers with a minor While the incidence of coronary heart dis-
degree of increase in left ventricular wall ease is low in women, compared with men,
thickness, resembling the volume-overload diseases of the circulatory system account
pattern seen in valvular regurgitation. In for roughly two thirds of all deaths among
contrast, isometric or strength training in- women in the United States. The incidence
duces a greater increase in wall thickness of mild myocardial infarction or death from
and total myocardial mass without chamber coronary heart disease in premenopausal
dilatation, as is seen in valvular aortic ste- women is below 1 in 10,000 per year. A large
nosis. Work hypertrophy, as documented by number of cardiovascular deaths occur in
these studies, is associated with supernor- women after age 75, but cardiovascular
mal left ventricular performance during ex- deaths also account for one third of all
ercise, and, like the arrhythmias that may deaths from age 65 to 74. Death rates from
coexist, it is usually benign in nature. It is cardiovascular disease in women are 40%
generally felt that asymptomatic athletes lower than in men for persons between 35
with documented myocardial hypertrophy and 64 years of age, and the relative mortal-
and abnormal electrocardiograms do not re- ity rate for women falls to 25% of male levels
quire provocative or invasive cardiovascu- for ages 35 to 44.12 Nevertheless, cardiovas-
lar testing prior to training or competition. cular death rates may be increasing in
In the absence of chest pain or syncope, women, especially during the postmeno-
bradyarrhythmias or even low grades of pausal period, perhaps related to increases
heart block and ventricular irritability need in the numbers of women who have smoked
not be pursued as they would in symptom- cigarettes throughout their lives. Although
atic patients with suspected heart condi- smoking-adjusted rates for coronary heart
tions. The sole caveat concerns the rare oc- disease in women under 45 years of age have
currence of sudden cardiac death in young not increased in the United States, Framing-
athletes during sport, which is discussed in ham data from other studies indicate an in-
Chapter 16. crease in coronary disease in postmeno-
pausal women, with a risk profile similar to
that observed in men. Risk factors for coro-
Primary and Secondary
nary artery disease in women include the
Prevention of Heart Disease standard triad of hypertension, hypercho-
Through Exercise lesterolemia, and cigarette smoking. Regu-
According to the American Heart Associ- lar exercise produces a beneficial effect on
ation, nearly half of the 500,000 people who such a risk profile, reducing resting blood
die annually of heart attacks in the United pressure, increasing the "good" or HDL cho-
States are women. Four recent studies of lesterol, and creating a positive incentive to
coronary artery disease in women point to stop smoking.
As has been shown for men, cardiac risk EXERCISE AND CANCER RISK
reduction in women is closely tied to exer-
cise. Diet programs for weight reduction A great volume of literature supports the
should be augmented by exercise in order to beneficial effects of exercise in the primary
increase HDL cholesterol levels.13 The im- and secondary prevention of coronary ar-
portance of moderate exercise in a weight- tery disease, but few data exist on specific
reduction program was demonstrated using relationships between exercise and cancer.
brisk walking and light jogging designed to A recent study from the Journal of the Na-
attain 60% to 80% of the maximal heart rate tional Cancer Institute reports a relationship
for 25 minutes three times per week. Thus, between increased physical activity and de-
the new guidelines endorsed by the Ameri- creased risk of colon cancer.25 Such a rela-
can College of Sports Medicine indicate that tionship does not prove causality or a pro-
an aerobic effect linked directly to an im- tective relationship, however.
provement in cholesterol profiles may result Low-dose postmenopausal estrogen re-
from less intense exercise than had been ad- placement does not appear to increase the
vocated previously. The more conservative risk of breast cancer,26 and it does improve
CDC recommendations are similar but do the safety of exercise by preventing osteo-
not specify intensity levels. porosis and reducing coronary heart dis-
The second risk factor for coronary artery ease.
disease is hypertension, which also has
been shown to improve with the addition of
an exercise program.14 In addition, exercise HAZARDS OF EXERCISE
has been found beneficial in patients with
non-insulin-dependent diabetes mellitus, in Heat Stress
whom coronary artery disease is acceler-
ated by approximately a decade.15 Adaptation of the athlete to environmen-
Exercise training also improves quit rates tal stresses such as heat, cold, or altitude de-
in women participating in smoking cessa- pends on specific physiologic responses,
tion programs.16 The adverse effect of smok- which may be different in women. Aerobic
ing may be greater in women than in men.17 exercise involves the generation of internal
Young women now have high smoking rates, heat through performance of muscular
and a combination of smoking cessation work. As the core temperature rises, an in-
with exercise may be mutually reinforcing. creased amount of cardiac output is deliv-
Women who stop smoking may experience ered to the skin so that heat can be dissi-
minor weight gain, including increased pated in the form of sweating. Heat is lost
body fat, but lean body mass increases as a principally through evaporation of sweat
benefit of exercise.18,19 In addition, the enjoy- from the body surface, which cools off the
ment of improved exercise performance is individual at the price of losing vital circu-
an extra incentive to avoid smoking and to lating fluids. Prolonged strenuous exercise
pursue a prudent, low-fat diet. When invariably leads to dehydration, which may
needed, transdermal nicotine may improve then lead to fatigue, confusion, lethargy, and
the effectiveness of smoking cessation pro- persistent excessive body temperature. Ad-
grams.20,21 vanced states of heat exhaustion from exer-
Finally, postmenopausal estrogens have cise may lead to coma and even cardiac ar-
been shown by careful studies to pro- rhythmias and sudden death. These rare
ong life and reduce coronary artery dis- and extreme hazards can be avoided by ad-
ease mortality.22,23 On the other hand, equate knowledge of the steps that prevent
anabolic steroids are atherogenic and dehydration and hyperthermia during ex-
hazardous.24 ercise.
The capacity to dissipate body heat gen- firm a resistance to heat-stress injury from
erated during prolonged strenuous exercise physical conditioning. Nevertheless, a high
depends on both internal and environmen- level of physical fitness will not protect an
tal factors. The capacity for heat acclimati- athlete from heat exhaustion or potentially
zation depends on an increase in the rate of fatal heat stroke, which may accompany
sweat generation for the level of exertion overexertion in a given level of training.
and a lower sodium content. As judged by Considerations for women are almost iden-
such changes, heat-acclimatized men and tical to those in men for heat-intolerance
women show similar adaptive patterns. susceptibility.
After acclimatization, women's heart rates The guidelines for prevention of heat in-
and rectal temperatures in hot and humid jury as outlined by the American College of
conditions at rest and after activity are the Sports Medicine should be considered,
same of those of men.27 Lower sweat rates in whether racing or out for a recreational jog.30
women are required to maintain comparable The first tenet of prevention is adequate hy-
body temperatures, suggesting an improved dration before exercise. This is best done by
efficiency in heat-release mechanisms. Ac- consuming 8 to 10 ounces of water 10 to 20
climatization to hot weather is facilitated by minutes before beginning a strenuous work-
underlying fitness capacity, but still requires out. The warm-up phase of exercise allows
7 to 10 days for optimal adaptation. It should the muscles and tendons to adapt to the bio-
be accomplished gradually, starting at 50% mechanics of exercise while the blood flow
maximum effort and increasing 5% to 10% increases to exercising muscle. As body
daily. Competitive athletes and recreational temperature rises, the sweating mechanism
runners alike, men or women, must respect kicks into place, with the perception of "sec-
the limitations of internal (adaptive) and ex- ond wind." Prolonged exercise should in-
ternal (climatic) stresses. volve taking breaks to consume additional
An increased risk for heat exhaustion water and, when appropriate, moistening
might be hypothesized in women during the the body surface with sponging or spraying
second half of the menstrual cycle, from el- to assist in the cooling process. Such mea-
evations in basal body temperature owing to sures provide a form of "external sweating,"
progesterone effects. However, increased which helps to dissipate heat through evap-
susceptibility to heat injury during the luteal oYation without needing to use internal fluid
phase has not been demonstrated in the sci- resources as the sole source of water for
entific literature. Wells28 studied the heat re- evaporation.
sponses of women at different stages in their Sweating involves the loss of more water
menstrual cycle in hot-dry and neutral en- than sodium and chloride in comparison to
vironments. Sweat rates and evaporative their concentrations in blood. As a result,
heat loss did not vary through the menstrual serum levels of sodium rise continuously
cycle. during exercise. For this reason, salt supple-
Drinkwater and colleagues29 studied heat ments are undesirable prior to or during
adaptation in female marathon runners and strenuous exercise, and in events lasting
showed a relationship between physical less than 2 to 3 hours individuals should rely
fitness as measured by Vo2max and resis- on the use of water alone as the optimal re-
tance to heat injury. Female runners with pletion fluid in the prevention of heat injury.
high Vo2max (49 mL•kg – 1 •min – 1 vs. 39 Potassium supplements are likewise unnec-
mL•kg –1 •min –1 ) had lower heart rates, essary for participants in events lasting less
lower skin and rectal temperatures, and than 3 hours. Exclusive and excessive water
quicker onset of sweating compared with intake during prolonged events such as an
less-conditioned individuals. These findings ultramarathon, however, may lead to hypo-
are similar to patterns in men, and they con- natremia or low sodium levels.
Appropriate dress during exercise is an- cising, and saunas and hot tubs can cause
other important component to the preven- considerable additional fluid loss, even in
tion of heat stress. This involves dressing in the absence of visible sweating.
light and loose-fitting clothing during hot- Educating runners about heat acclimati-
weather exercise, especially on humid days zation, prehydration, and control of exer-
when the sweating mechanism is less effi- cise intensity during training and racing
cient. In addition, exercising in full sunlight should result in less frequent heat injury.
increases the risk, but using a hat for protec- Emergency care when such complications
tion from radiant energy in sunlight will help do arise should prevent the fatalities that
to protect the athlete from dehydration. still occur from the medical consequences of
Finally, individuals should use extreme severe exertional heat stroke. Physicians
caution when they sit in saunas or hot tubs should encourage heat-injury precautions,
after exercising. They should immediately encouraging races to be run at cooler times
leave if they feel the least bit dizzy, weak, or of the day and canceled when wet-bulb tem-
faint. All people are dehydrated after exer- peratures exceed 28.0°C. Drinking 10 to 12
Table 15-1. MEDICAL ADVICE TO RUNNERS
Training
If possible, try to acclimatize yourself to heat if the race if is to be run in hot weather. Try to run at least 36 to 50
miles a week in training runs and take occasional longer runs. If you cannot comfortably run 15 miles 1 month
before the marathon, you may have trouble running the race safely. Cut back mileage several days before the
race to avoid exhaustion on race day.
Diet
Eat what you feel comfortable with. Extreme changes, such as carbohydrate loading, may affect you adversely. A
slight increase in vitamin C and salt intake may be beneficial, especially in hot-weather races. Decreasing
protein intake and substituting carbohydrates several days before the race may increase your stores of muscle
glycogen.
Clothing
Wear light-colored clothing to protect against heat and, if possible, wear mesh clothing on a hot day. Natural
fibers such as cotton will chafe less than synthetics. On a warm day, if you are comfortably warm at the starting
line, you are probably overdressed.
Fluids
Drink early and often. Try to drink 1 pint of water 10 minutes before you run and at least half a cup of water every
15 minutes thereafter. Wetting the skin with hose sprays or sponges can bring temporary comfort but is no
substitute for drinking. You are adequately hydrated before a race if your urine is a pale straw color. Since
dehydration can actually blunt your thirst mechanism, don't let thirst be your guide for drinking. If you are not
used to electrolyte-glucose drinks, you may want to avoid them during the race.
Running the Race
Begin slowly. On humid days, when the temperature is 75°F or greater, slow your pace by 45 to 60 s/mile. If you
experience persistent localized pain, seek medical help. The signs of heat exhaustion are headache, tingling or
pins and needles in the arms, back, and extremities, fatigue, a weak pulse, cool, moist skin, profuse sweating,
and cold chills. The signs of heatstroke are headache, convulsions, altered behavior or mental state, red-hot
skin, and absence of sweating. If you feel any of those symptoms, seek medical help or at least slow down or
walk. Race officials will be instructed to remove you from the course if you appear to be at risk of injuring
yourself. If you have a pre-existing injury or medical condition that could endanger your health, do not run.
Finish Line
Get out of the sun. Drink fluids. If you don't feel well or feel faint, seek medical help. Get into dry clothes as quickly
as possible.
Source: From Editorial Staff: Marathon medicine. Emerg Med 17(16):89,1985, with permission.
ounces of cold fluids, either diluted com- durance training, which is discussed in
mercial drinks or fruit juice diluted with 2 to greater detail later in the chapter. A differ-
3 parts cold water, is recommended to re- entiation of true anemia (an absolute de-
plenish fluid and potassium losses (see crease in red cell mass) from pseudoanemia
Chapter 6). Athletes should not wait to be- (a relative or dilutional decrease in hemo-
come thirsty, since 2 to 4 Ib of fluid loss may globin value) cannot be made from mea-
occur before thirst becomes intense. Warm surement of the hemoglobin and hematocrit
fluids should not be consumed, as they are determinations alone. The clarification of
absorbed more slowly than cold fluids. Com- true iron-deficiency anemia versus "pseu-
mercial drinks are high in sugar and may doanemia" in female athletes requires the
cause abdominal cramps if not diluted. Cot- direct measurement of body iron stores.
ton socks to absorb sweat, and white or This can be done by measurement of serum
light-colored clothing to reflect the sun's iron and iron-binding capacity or serum fer-
rays are also recommended. These preven- ritin levels, which are normal in the case of
tive strategies are summarized in Table 15- the "pseudoanemia" but low in the case of
1. The best prevention, though, is an in- true iron deficiency.5 This differential is
formed runner who knows her limits. shown in Table 15-3.
The best treatment of heat injury is im- In addition to menstrual losses, women
mediate rapid cooling performed on-site face the additional possibility of ongoing
and without delay. In an Australian study,31 iron loss during endurance training through
the mean time it took to cool patients who additional body fluids such as sweat, urine,
had rectal temperatures 41.5°C was 37 and feces. A significant loss of stores may
minutes. No runners experienced the severe occur over time if not accompanied by a bal-
sequelae of heat stroke with this rapid-cool- anced intake of iron in the diet. Recent stud-
ing approach. If treatment is delayed, major ies have shown that some long-distance run-
medical complications including fulminant ners develop guaiac-positive stools during
rhabdomyolysis, acute renal failure requir- long-distance training and competition,
ing dialysis, hepatic necrosis, and dissemi- which revert to normal within 72 hours.36
nated intravascular coagulation can occur, Runners with anemia and guaiac-positive
although infrequently.32,33 Common heat in- stools deserve a systematic medical inves-
juries and their treatment are seen in Table tigation to rule out an intrinsic bowel prob-
15-2. lem unrelated to the exercise training.
The possible causes of blood loss include
intestinal ischemia, stress gastritis, drug-in-
Hematologic Effects: Iron Status duced lesions, and loss of blood from pre-
and Anemia existing lesions. Another possible cause of
Obligatory iron loss through menstrua- iron loss is hematuria, as discussed in a later
tion creates a potential risk for iron deple- section. All these disorders may add to the
tion and, if mild or subclinical, secondary burden of iron depletion in the athlete and
anemia. Studies in apparently normal, create a true iron-deficient state.
healthy college-age women document the The diagnosis of iron-deficiency anemia
depletion of total body iron stores (by ex- in women or men requires specific measure-
amination of stained bone marrow aspi- ment of the serum iron parameters as noted
rates) in up to 25% of subjects.34 Rates of iron previously. Low values for serum iron with a
deficiency among apparently healthy col- reciprocally increased serum iron binding
lege athletes may be somewhat higher, as capacity or a low serum ferritin level, or
reported in one blood study.35 both, indicate the depletion of total body
Confusion is likely to arise between true iron stores and the need for specific supple-
iron-deficiency anemia and the so-called mentation. Treatment should consist of 300
pseudoanemia, or "runner's anemia," of en- mg of ferrous sulfate given once or twice
Table 15-2. COMMON RACE INJURIES AND THEIR TREATMENT
Heat Cramps
A mild response to heat stress.
Treatment
If unaccompanied by serious complications, treat with rest, oral fluids, cooling down, stretching, ice and massage,
and muscle massage.
Heat Exhaustion
A serious situation in which hypovolemia develops as a result of excessive fluid loss. The rectal temperature may
range between 100 and 105°F or higher. The runner experiences lassitude or dizziness, nausea, headache, and
muscle weakness. Although the runner is probably volume-depleted, sweating should be evident.
Treatment
For mild cases, treat the same as for heat cramps. For serious cases, including those with hypotension, persistent
headache and vomiting, or altered mental states, initiate IV fluid resuscitation, cool vigorously (with an ice-
water bath, for example), and consider transport to an emergency facility.
Heatstroke
Often characterized by motor disturbances, such as ataxia, and severe nervous system disturbances, such as
confusion, delirium, or coma. Circulatory collapse and hypotension are possible. Rectal temperature usually
exceeds 105°F but may be lower after a period of collapse and cooling. The skin is usually warm but the victim
may not sweat, although sweating usually occurs in the initial stages.
Treatment
Cool the runner immediately with hosing or fanning and ice applied to major arteries such as the carotid, axillary,
femoral, and popliteal. If rectal temperature monitoring is possible, place the patient in an ice-water bath.
Massage her extremities, raise her legs, place her in the shade, and begin volume replacement with 1 to 2 liters
of half-normal saline, although more may be required. Transport immediately to a medical facility.
Hypothermia, Exposure
Rare and most likely to occur in underdressed runners during cold-weather runs who either don't run fast enough
to generate adequate heat or exhaust themselves early.
Treatment
Runners with a rectal temperature of 96.8°F or lower should be stripped of wet clothing, given warm clothing, and
wrapped in blankets. If the runner is not shivering, she may be hypoglycemic. Give slightly sweet drinks.
Monitor rectal temperature in those whose temperature is 91.2°F or lower.
Hypoglycemia
May present as sweating, tremor, mental confusion, and combativeness.
Treatment
Rest and sugar or electrolyte glucose drinks.
Hypovolemic Collapse
Seen most often in hot-weather races at the finish line, especially in runners who drink little or no liquid during
the race. Hypotension, caused by diminished vasoconstriction, can lead to syncope. Runner's pulse will be
weak and runner may be faint, cyanosed, or vomiting. It can occur as late as half an hour after the runner
finishes the race if fluid intake is insufficient and will be worse if she's vomiting or has diarrhea.
Treatment
Take rectal temperature; have patient rest with legs raised; hydrate intravenously initially, then orally.
Hypovolemia is usually self-limiting.
Source: Modified from Editorial Staff: Marathon medicine. Emerg Med 17(16):82, 1985, with permission.
daily for at least a year. Patients should be serve further clinical investigation for
rechecked after that time to establish the resources of iron loss (menses, renal losses,
turn of serum iron stores to the normal gastrointestinal losses) if compliance with
range. Persistent abnormalities may de- the treatment has been established.
Table 15-3. LABORATORY "Runner's Diarrhea"

DIFFERENTIATION OF TRUE ANEMIA
VERSUS PSEUDOANEMIA More common than gastrointestinal
bleeding is the rather frequent occurrence
True of runner's diarrhea, which is an expression
Pseudoanemia Anemia
of increased bowel motility akin to the irri-
Hemoglobin/ Decreased Decreased table bowel syndrome seen with emotional
hematocrit stress in a large number of individuals. Man-
Red cell mass Normal Decreased ifestations range from minor abdominal
Plasma volume Increased Normal
Total blood volume Increased Normal cramping to severe, watery diarrhea during
Iron/iron-binding Normal Decreased prolonged strenuous exercise, which can in-
capacity (IBC) terfere with performance and is intensified
Ferritin Normal Decreased by the stress of competition. This condition,
5
Source: From Siegel AJ, with permission. sometimes termed "runner's trots," is often
successfully treated with precompetition
doses of antispasmodic agents.38
It is reasonable to suggest routine iron
supplementation for female athletes under-
going intense training, just as is recom- Effects on the Urinary Tract
mended for pregnant women, because both
conditions increase iron requirements. Rou- As discussed in the subsequent section on
tine iron supplementation, however, does "athletic pseudonephritis," many apparent
not yield demonstrable benefits for the ath- urinary abnormalities in athletes are tran-
lete with adequate iron stores. sient, benign conditions, although more se-
Even in the absence of anemia, a decrease rious complications can sometimes arise. A
in body iron stores may cause a diminished positive Hemastix reaction without detect-
exercise performance or capacity, related to able blood on microscopic analysis of urine
the role of iron in the tissue cytochrome and is suggestive of myoglobinuria. This reac-
myoglobin systems. Recent reports have tion may be quite common, if not universal,
highlighted the importance of identifying in marathon runners after peak efforts, re-
borderline iron-deficiency states in athletes, sulting from transient rhabdomyolysis dur-
even in the absence of anemia, through mea- ing extended physical exertion.39 Elevations
surement of serum ferritin levels. Low of serum creatine kinase up to 30 times nor-
serum ferritin levels indicate a need for mal have been noted in marathon runners
treatment, even in the presence of normal without perceived urinary symptoms or ev-
serum iron levels. However, normal ferritin idence of injury. Other studies have shown
levels may not always exclude iron defi- transitory decrements in creatinine clear-
ciency. Acute inflammation, such as can be ance following marathon competition,
caused by infection or injury from heavy which may be prerenal or related to volume
training, can transiently raise serum ferritin depletion rather than due to tubular injury.40
levels to normal range. Therefore, when iron Whereas exertional rhabdomyolysis is
deficiency is strongly suspected, ferritin lev- common, acute renal failure is extremely
els should be assessed after the athlete has rare.33 It has been reported in patients with
recovered from any febrile illness or sickle cell trait, who are at increased risk of
stopped training for 2 or 3 days. Symptoms renal tubular necrosis following rhabdomy-
of fatigue and declining performance may be olysis, which may then proceed to other
identical in "overtraining" and in marginal complications such as disseminated intra-
iron-deficiency states. Clinical observations vascular clotting.
suggest that repletion of diminished iron Heat stress, prolonged strenuous exer-
stores may reverse these symptoms and im- cise, muscle injury, and urinary abnormali-
prove exercise performance.37 ties are interrelated. It is crucial for physi-
Table 15-4. DIFFERENTIAL DIAGNOSIS FOR ABNORMAL TEST RESULTS
Laboratory Findings Clinical Condition Exercise-Induced Findings
Low hemoglobin, low hematocrit Anemia (true iron deficiency) Pseudoanemia (see Table 15-3)
Abnormal urinalysis (hematuria, Renal disease Transient changes
proteinuria)
Positive test for GI bleeding Intrinsic gastrointestinal Transient finding due to maximal
pathology exercise
Abnormal liver enzymes: lactic Hepatic inflammation (true Transient muscle injury accompanied
acid dehydrogenase (LDH), hepatitis) by release of enzymes from
serum glutamic oxaloacetic skeletal muscle that are also
transaminase (SGOT) present in liver tissue
(pseudohepatitis)
Elevation of total creatine kinase Myocardial disease Chronic skeletal muscle injury or
and the MB isoenzyme exercise-induced rhabdomyolysis
Note: The pseudosyndromes listed above (last column) are more common in rigorously training endurance athletes
than in beginners.
Source: From Siegel AJ,5 with permission.
cians to identify runners with acute dividuals with an allergic or asthmatic back-
hypovolemia occurring in heat-stress injury ground, in whom exercise provokes or
so that they can institute the rapid rehydra- increases symptoms. Bronchospasm also
tion that will prevent attendant renal injury. occurs in subjects who do not have a clinical
Cases of acute renal failure following severe history of overt asthma, in whom symptoms
dehydration in marathon runners have been may be unappreciated or subclinical until
reported, although such injury is clinically the additional work of breathing during ex-
preventable.33 There is no evidence that per- ercise is imposed. The frequency with which
manent or progressive renal injury results such reactions are detected depends upon
from prolonged strenuous training, as done the sensitivity of measurements used, as
by long-distance runners. Reported acute well as on the type of exercise.
increases in serum creatinine levels are The typical course of symptoms is a slow
readily reversible with rest and rehydration. onset of bronchospasm as one starts exer-
Progressive renal damage from recurrent cising, reaching a peak in 6 to 8 minutes.
low-grade rhabdomyolysis and myoglobin- Symptoms often stabilize or subside if exer-
uria is a theoretical possibility but has not cise is continued, and some of these individ-
been demonstrated to date. Again, preven- uals can exercise through their attacks after
tion is the best treatment, and runners some initial difficulty. The postexercise re-
should be encouraged to take fluids liberally bound is well described, as difficulty may re-
during and immediately after strenuous turn or intensify after cessation of activity.
physical effort. The differential diagnostic Figure 15-1 shows the typical pattern of ob-
features of urinary sediment changes and served pulmonary function parameters with
other diagnostic tests are shown in Table the relationship to time in healthy subjects
15-4. Prevention and treatment are summa- and in those with EIA. The four parameters
rized in Tables 15-1 and 15-2. of lung function shown reflect the impair-
ment during and after exertion. Simple spi-
rometry with a measure of the timed or 1-
Exercise-Induced Asthma
second vital capacity is adequate to confirm
Exercise-induced asthma (EIA) is a rela- suspected clinical cases in most instances.
tively common, readily diagnosable and Exercise-induced asthma causes the same
treatable form of reversible broncho- bronchial smooth-muscle contraction that
spasm.41 It occurs with high frequency in in- results from allergen-triggered asthmatic
Figure 15-1. Comparison of spirometric measurements following exercise in healthy subjects and in
patients with exercise-induced asthma. (Adapted from Gerhard H, and Schachter FN: Exercise-in-
duced asthma. Postgrad Med 67(3):93, 1980, with permission.)
response. Recent investigations, however, fully saturated with water at body tempera-
reveal that EIA is not triggered by an allergic ture. Airway cooling from heat loss during
response, but rather by reactions of large high ventilatory work is the specific precip-
and small airways to changes in humidity itant. These findings explain why corticoste-
during cold-air breathing. McFadden and roids are ineffective in treating exercise-in-
Ingram41 have shown that the magnitude of duced asthma, whereas warming of inspired
the bronchoconstrictive response to a fixed air through a face mask can be effective.
exercise task or to a fixed level of ventilation A wide range of treatments is available for
depends on the temperature and/or water patients with EIA, including warming of in-
content of the inspired air. Lower air tem- spired air in cold weather as a preventive
peratures and lower humidity favor the ob- measure, and use of specific pharmacologic
structive response, which does not occur in agents employed in the treatment of tradi-
susceptible subjects when inspired air is tional asthma. Those treatments approved
Table 15-5. ANTIASTHMATIC eralized hives or urticaria. Such symptoms

MEDICATIONS APPROVED BY THE may occur after years or decades of being al-
INTERNATIONAL OLYMPIC COMMITTEE
FOR THE OLYMPIC GAMES*
lergy-free and may be limited to minor dis-
comfort. The reaction can, however, pro-
Medication Aerosol Oral gress to generalized angioedema, including
Theophylline NA Yes
facial swelling and laryngeal spasm, with
Cromolyn sodium Yes NA compromise of the upper airways. This re-
Albuterol Yes Yes action was reported in a group of young ath-
Terbutaline sulfate Yes Yes letes after a variety of sports and may be un-
Corticosteroid Yes Yes predictable in occurrence and severity for
*Drug Commission of IOC requires name of athlete, any individual.42 Some authors have sug-
country, drug, and dosage. gested that exposure to a specific allergen
Source: From Eisenstadt WS, Nicholas SS, Velick G, et such as shellfish, to which the individual is
al: The Physician and Sportsmedicine 12(12):100,
1984, with permission.
subclinically sensitized, may then combine
with exercise to trigger the allergic re-
sponse. Exercise causes mast cells to re-
lease vasoactive mediators similar to those
by the International Olympic Committee for in cold-induced urticaria, in which hista-
the Olympic Games are listed in Table 15-5. mine is released in the skin after cold expo-
These agents can be taken as pre-exercise sure. Susceptibility is not related to training
doses to block the onset of or to minimize or expertise, and exercise-induced anaphy-
bronchoconstriction. A warm-up period is laxis has been reported in national champi-
often useful in reducing EIA, but inhalation ons and in world record holders.43 Manage-
of a bronchodilator just prior to peak exer- ment can entail preventive measures such
cise is highly beneficial. Sympathomimetics as the administration of mild antihistamines
are disallowed in some competitive situa- or perhaps cromolyn sodium prior to exer-
tions, so that alternatives such as cromolyn cise. However, these treatments are only
sodium must be used. Cromolyn is not a partially effective at best and do not com-
bronchodilator and is most effective when pletely prevent the reaction. Such pretreat-
administered 30 minutes prior to peak ef- ment may be necessary for individuals only
fort. Physicians must be aware of these spe- at times of peak risk, since the urticarial re-
cial circumstances as well as of the range of sponse may occur only seasonally, when al-
treatments available to the recreational ath- lergic predisposition is heightened. Just as a
lete. shellfish-allergic patient avoids eating shell-
Persons susceptible to exercise-induced fish, avoiding specific foods prior to exercise
asthma should be encouraged to participate may control or eliminate the allergic re-
in sports and exercise, which may have a sponse in these individuals.
beneficial effect on general physical condi- The pathogenesis of exercise-induced
tioning and preservation of lung function. anaphylaxis is identical to immunologic-me-
The adequately informed primary care phy- diated anaphylaxis, even though the trigger
sician can enhance the capability of patients is physical rather than allergic.42 Effector
to lead full and active lives despite the need mast cells fire to release histamine, the
for specific treatment. slow-reacting substance of anaphylaxis, bra-
dykinins, and other mediators, which then
Exercise-Induced Anaphylaxis cause the angioedema. Facial swelling is an
indication for specific emergency measures,
Individuals with a history of allergic re- such as the intramuscular administration
actions such as childhood eczema, seasonal of 8 mg of dexamethasone or the subcutane-
rhinitis, or even asthma are prone to a sec- ous administration of aqueous epinephrine
ond exercise-related reaction that begins 1:1000, 0.1 to 0.3 mL, along with the inser-
with diffuse itching and may result in gen- tion of an IV tube for fluid administration.
Hypotension may develop from generalized, stores. Systematic observations have docu-
increased vascular permeability, which may mented a drop in hemoglobin, hematocrit,
require stabilization with fluids and vaso- and red blood cell count at the end of a 9-
pressive drugs. Dopamine (400 mg) and week training program in previously seden-
D5W (500 mL), given intravenously at an ap- tary college women.37 Values may fall to low-
propriate rate, may sustain blood pressure normal or within abnormal ranges during
in the face of circulatory collapse. While po- progressive training, with a return to base-
tentially life-threatening, exercise-induced line upon resumption of sedentary status.
anaphylaxis has not yet resulted in a re- "Pseudoanemia" also occurs in male ath-
ported fatality. Patients who have had this letes, owing to hemodilution from an in-
reaction, as well as individuals with known crease in plasma volume. Studies of red cell
bee-sting sensitivity (hymenoptera), should mass in athletic pseudoanemia show normal
have epinephrine available for administra- or high values, with low hemoglobin param-
tion if severe allergic manifestations de- eters resulting from an expanded plasma
velop. volume. The specific measurement of body
iron stores, or its reflection in normal values
Exercise-Induced Urticaria for serum iron and iron-binding capacity or
ferritin levels, establishes this dilutional
In the spectrum of allergic reactions to ex- cause of a low hemoglobin concentration.
ercise, some individuals may develop
blotchy red rashes, sometimes with itching,
during a workout. This is called exercise-in- "Athletic Pseudonephritis"
duced hives or urticaria, and it results from The occurrence of exercise-related uri-
histamine release in the skin owing to rapid nary abnormalities has been extensively
superficial temperature changes. Like exer- reviewed in the literature and in medical-
cise-induced asthma, exercise-induced ur- specialty books, with the term "athletic
ticaria may occur more readily with temper- pseudonephritis" applied to conditions as-
ature provocation, either cold or warm. sociated with abnormal urinary sedi-
Local symptoms of cold urticaria are red- ments.40,44 Severe volume depletion and de-
ness, itching, wheals, or edema in the skin, hydration can, indeed, lead to proteinuria
not the subcutaneous swelling seen in ana- and hematuria with the presence of formed
phylaxis, as described previously. Systemic elements such as proteinaceous casts. A
symptoms and circulatory collapse do not prospective study of 50 male physician mar-
occur. athon runners showed that microscopic he-
This condition is benign and can be han- maturia occurred in 18% in initial postrace
dled with reassurance to the athlete. Low urinalyses, but cleared within 24 to 48
doses of antihistamines may diminish hours.45
symptoms and may be prescribed if the side Exercise-related hematuria appears to be
effect of drowsiness is not more bothersome a frequent and self-limited benign condition
than the itching. that does not warrant extensive invasive
work-up. Gross hematuria occurred in only
1 out of 50 subjects and must be considered
PSEUDOSYNDROMES IN a complication of nontraumatic sports such
ATHLETES as running. A work-up of a series of patients
with so-called 10,000-meter hematuria iden-
Pseudoanemia ("Runner's tified bladder trauma as the cause of this he-
Anemia"] maturia.46 Other studies suggest that the
bleeding may come from the kidneys. Con-
As previously mentioned, athletes may comitant bladder or renal pathology cannot
show a low hemoglobin concentration with- be summarily excluded after gross hematu-
out actually suffering from depleted iron ria related to exercise; therefore, it is rea-
sonable to suggest intravenous pyelography clude chronic hepatitis, but need not lead to
and cystoscopy to exclude specific causes. invasive testing such as a liver biopsy. Many
runners have been referred to specialists for
consideration of this procedure on the basis
Serum Enzyme Abnormalities: of the muscle injury parameters, as de-
Muscle Injury and scribed earlier. Such invasive testing is usu-
Pseudohepatltis ally unnecessary and should be avoided.
Prolonged strenuous exercise may be as- With reference to the biliary tract, it
sociated with transient elevations of skeletal should be noted that some individuals have
muscle enzymes, which are also present in a genetic condition (Gilbert's disease) in
hepatocytes or liver cells. Serum levels of which bilirubin conjugation may be im-
glutamic-oxalo-acetic transaminase and lac- paired under physiologic stress such as
tic dehydrogenase are routinely used as strenuous exercise, infections, or prolonged
screening tests for hepatic dysfunction, and fasting. Such individuals may develop an in-
elevated levels of these enzymes may fre- crease primarily in unconjugated serum bil-
quently be assumed to represent hepatitis in irubin and may appear mildly jaundiced.
runners. Measurement of specific serum en- This condition is benign and asymptomatic,
zymes such as creatine kinase can resolve and can be detected by somewhat elevated
this dilemma, so that elevations of creatine levels of unconjugated bilirubin in the face
kinase and these other enzymes indicate of otherwise normal liver enzymes. This el-
transient muscle injury rather than liver dis- evation of unconjugated bilirubin is usually
ease in the endurance-trained athlete. Sev- transient, whereas liver disease usually
eral recent studies indicate that athletes leads to persistent elevations of unconju-
may have enzyme elevations two to three gated bilirubin in the face of elevated liver
times the upper limits of normal compared enzymes. These findings are in contrast to
with age-matched and sex-matched seden- those in patients with chronic hemolytic
tary individuals (see Table 15-4). These val- anemias, in whom pigment gallstones may
ues may increase tenfold after racing, be formed because of an increased biliary
because of transient exertional rhabdomy- excretion of breakdown products of hemol-
olysis.39 These findings are often accompa- ysis, leading to significant elevations of di-
nied by muscle soreness in the athlete and rect bilirubin. Pigment gallstones have been
indicate the need for rest and maintenance reported in long-distance runners and at-
of hydration. Specific clinical symptoms tributed to runner's hemolysis, although
such as persistent headache, nausea, vom- this must be a very rare and unusual occur-
iting, or flank pain should lead to the inves- rence.48
tigation of impaired renal function or other
complications, as noted in the prior sec-
Pseudomyocarditis
tions.
One avenue for excluding liver disease in In addition to the abnormalities in total
a runner with abnormal enzyme profiles is to creatine kinase that indicate transient mus-
measure liver-specific "enzymes" such as cle injury, as noted earlier, chronic endur-
alanine aminotransferase and y-glutamyl ance sports participation may lead to tran-
transpeptidase. Some transient increases in sient elevations of the MB isoenzyme or
these liver-specific proteins have been doc- heart-specific fraction of creatine kinase in
umented in marathon runners after racing, serum.49 Such elevations may at times be
indicating possible release from hepato- quantitatively similar to findings in patients
cytes due to indirect trauma or decreased with a variety of heart diseases such as car-
hepatic blood flow.47 Persistence of abnor- diomyopathy, myocarditis, or injury sec-
mal liver function tests might warrant mea- ondary to ischemic heart disease.
surement of serum hepatitis markers to ex- Large increases in the serum total cre-
atine kinase and CK-MB activities may be Appendix 15-3. This focuses on acute con-
found in both men and women after compe- ditions that should be evaluated prior to
tition. Cardiac isoenzymes are present in competitive sports participation. These
trained skeletal muscle, perhaps on the sample materials are useful for identifying
basis of chronic muscle fiber injury and repre-existing medical conditions that may in-
pair.50 Studies using heart scan techniques fluence or affect sports participation, and
fail to reveal any underlying heart injury in they help prepare the athlete for safer train-
these individuals. Abnormal elevations of ing and participation.
serum CK-MB in an otherwise asymptomatic
female athlete without cardiorespiratory
symptoms can be reasonably attributed to CAUTION: WHEN NOT TO
an exercise-induced injury to skeletal mus- EXERCISE
cle and not to a myocardial source (see
Table 15-4). While the preceding sections emphasize
the health benefits of exercise, the question
remains of how much and how soon. Chest
SCREENING THE ATHLETE FOR pain, dyspnea, or syncopal episodes should
MEDICAL CLEARANCE be contraindications to exercise until the
causes are established and relieved, and se-
With an estimated 25 to 50 million young rious medical conditions are excluded. Ill-
women engaging in sports activity, some nesses such as diabetes, ischemic heart dis-
basic concepts of medical clearance prior to ease, and arthritis may in fact be
sports participation justifiably arise. A ameliorated by appropriate low levels of ex-
sports-related questionnaire for athletes ercise. Safe limits can be established
provides an opportunity for health screen- through cardiovascular assessment, includ-
ing with the purpose of identifying predis- ing exercise testing in such cases. Cardiac,
posing medical conditions that might lead to pulmonary, and musculoskeletal diseases
complications during sports participation. A may make exercise difficult, but patients re-
sample questionnaire is included in Appen- spond positively to exercise training, with
dix 15-1, which addresses the major factors improved levels of function. Old age itself is
of sports injury as complications for young not a contraindication to regular exercise,
athletes and also screens for pre-existing which in fact facilitates balanced nutrition
medical conditions, medication allergies, and cardiovascular health.51 In addition,
and other possible complications. Such a physical activity correlates with a reduced
medical checklist is useful in preventing risk of depression in healthy adults of all
problems during training and competition, ages.52
such as exercise-induced asthma, anaphy- After musculoskeletal injury, orthopedic
laxis, and other conditions discussed in this surgery, and even general surgery, a gradu-
chapter. This gives the physician an oppor- ated return to exercise and training is nec-
tunity to screen for areas of major concern essary. The intensity and duration of work-
such as possible familial heart disease, and outs should be decreased to start, with
also to practice prevention with regard to training progressively increased at incre-
conditions such as sports-related anemia ments of no more than 10% per week. A grad-
and oligomenorrhea, which commonly ual return to exercise intensity promotes
arise. A sample physical examination form smooth recovery and reduces risk of rein-
for recording findings is given in Appendix jury or clinical setback.
15-2, and a list of medical conditions dis- Similarly, athletes must adjust to the re-
qualifying an individual for sports partici- alities of medical illness, including the im-
pation as provided through guidelines of the pact on exercise capacity of minor illnesses
American Medical Association is found in such as viral syndromes, flulike illnesses,
and especially respiratory infections. Ath- coach, who must counsel sound principles
letes must take time off from training during of moderation and consistency over time. In
febrile illness, as acute illness places stress this fashion, the physician can promote
on all organ system reserves and exercise health-enhancing levels of exercise for in-
would pose the danger of prolonging the ill- active patients, and facilitate long-range
ness and incurring additional injury. Many planning for athletes who are likely to ex-
viral illnesses are systemic; that is, all organ perience overuse injury through an imbal-
systems are subject to transient viral expo- ance of stress over rest and recovery.
sure. Exercise at such times can be hazard- Whether the goal is an improvement in car-
ous and even lead to arrhythmias and col- diorespiratory fitness from recreational ex-
lapse during workouts or competition. As a ercise or competition from structured
working guideline, 1 emphasize to athletes sports participation, moderation remains an
the importance of rest as well as stress in important preventive and rehabilitative pre-
training, and point out the necessity of al- scription.
lowing the body to recover from intercur-
rent illness in order to make future training
safe and productive. REFERENCES
Appendix A gives greater detail on exer-
cise following an infection. 1. Council on Ethical and Judicial Affairs, Amer-
ican Medical Association: Gender disparities
in clinical decision making. JAMA 226:559,
SUMMARY 1991.
2. Healy B: Women's health, public welfare.
JAMA 226:566,1991.
This chapter has addressed various med- 3. Harris SS, Caspersen CJ, DeFriese GH, et al:
ical conditions that may arise in sports-ac- Physical activity counseling for healthy
tive women and that present clinical dilem- adults as a primary preventive intervention
mas to the office practitioner. On the one in the clinical setting: Report for the US Pre-
ventive Services Task Force. JAMA 261:3588,
hand, athletes may develop abnormal clini- 1989.
cal or laboratory findings that represent 4. Bunch TW: Blood test abnormalities in run-
physiologic adjustments to training and are ners. Mayo Clin Proc 55:113,1980.
not indications of underlying illness. On the 5. Siegel AJ: Understanding abnormal lab val-
other hand, athletes do place themselves at ues in the female athlete. Contemp Obstet Gy-
necol 25:73, 1985.
risk for developing problems such as tran- 6. Huston TP, Puffer JC, and Rodney WM: The
sient hematuria, gastrointestinal bleeding, athletic heart syndrome. N Engl J Med
anemia, and heat injury, which require spe- 313:24, 1985.
cific monitoring to rule out non-exercise-re- 7. Dollar AL, Kragel AH, Fernicola DJ, et al:
Composition of atherosclerotic plaques in
lated conditions. coronary arteries in women <40 years of age
Careful assessment of the individual ath- with fatal coronary artery disease and impli-
lete, together with a background fund of cations for plaque reversibility. Am J Cardiol
information, will enable the practicing phy- 67:1223, 1991.
sician to provide reassurance when appro- 8. Manson JE, Stampfer MJ, Colditz GA, et al: A
priate and to respond to underlying clinical prospective study of aspirin use and primary
prevention of cardiovascular disease in
problems as they may arise. women. JAMA 266:521, 1991.
The knowledgeable physician can assist 9. Appel LJ, and Bush T: Preventing heart dis-
the sports-active patient in enhancing her ease in women: Another role for aspirin? (Ed-
athletic goals while reducing concern over itorial). JAMA 266:565, 1991.
10. Steingart RM, Packer M, Hamm P, et al: Sex
sports-related symptoms or conditions. differences in the management of coronary
When dealing with athletes, the physician artery disease. N Engl J Med 325:226, 1991.
should monitor and prescribe exercise as a 11. Ayanian JZ, and Epstein AM: Differences in
the use of procedures between women and cancer among college alumni. J Natl Cancer
men hospitalized for coronary heart disease. Inst 83:1324,1991.
N Engl J Med 325:221,1991. 26. Dupont WD, and Page DL: Menopausal estro-
12. Gordon T: Cardiovascular risk factors in gen replacement and breast cancer. Arch In-
women. Pract Cardiol 5:137,1974. tern Med 151:67, 1991.
13. Wood PD, Stepanick ML, Williams PT, et al: 27. Wyndham CH, Morrison JF, and Williams CG:
The effects on plasma lipoproteins of a pru- Heat reactions of male and female Cauca-
dent weight-reducing diet, with or without sians. J Appl Physiol 20:357,1965.
exercise, in overweight men and women. N 28. Wells CL: Sexual differences in heat stress re-
Engl J Med 325:461,1991. sponse. Phys Sportsmed 5(9):78,1977.
14. Somers VK, Conway J, Johnston J, et al: Ef- 29. Drinkwater BL, Kupprat JC, Denton JE, et al:
fects of endurance training on baroreflex sen- Heat tolerance of female distance runners.
sitivity and blood pressure in borderline hy- Ann NY Acad Sci 301:777,1977.
pertension. Lancet 337:1363, 1991. 30. Statement of the American College of Sports
15. Helmrich SP, Ragland DR, Leung RW, et al: Medicine: Prevention of heat injuries during
Physical activity and reduced occurrence of distance running. J Sports Med 9(7):105,
non-insulin-dependent diabetes mellitus. N 1976.
Engl J Med 325:147,1991. 31. Sutton JR: Heatstroke from running. JAMA
16. Marcus BH, Albrecht AE, Niaura RS, et al: 243:1896,1980.
Usefulness of physical exercise for maintain- 32. Koppes GM, Daly JJ, Coltman CA, et al: Exer-
ing smoking cessation in women. Am J Car- tion-induced rhabdomyolysis with acute
diol 68:406,1991. renal failure and disseminated intravascular
17. Chen Y, Home SL, Dosman JA: Increased sus- coagulation in sickle cell trait. Am J Med
ceptibility to lung dysfunction in female 63:313,1977.
smokers. Am Rev Respir Dis 143:1224,1991. 33. Stewart PJ, and Posen GA: Case report: Acute
18. Williamson DF, Madans J, Anda RF, et al: renal failure following a marathon. Phys
Smoking cessation and severity of weight Sportsmed 8(4):61, 1980.
gain in a national cohort. N Engl J Med 34. Scott DE, and Pritchard JA: Iron deficiency in
324:739, 1991. healthy young college women. JAMA 199:147,
19. Moffatt RJ, and Owens SG: Cessation from 1967.
cigarette smoking: Changes in body weight, 35. Steenkamp I, Fuller C, Graves J, et al: Mara-
body composition, resting metabolism, and thon running fails to influence RBC survival
energy consumption. Metabolism 40:465, rates in iron-repleted women. Phys
1991. Sportsmed 14(5):89, 1986.
20. Daughton DM, Heatley SA, Prendergast JJ, et 36. McMahon LJ, Ryan MJ, Larson D, et al: Occult
al: Effect of transdermal nicotine delivery as gastrointestinal blood loss in marathon run-
an adjunct to low-intervention smoking ces- ners. Ann Intern Med 100:846,1984.
sation therapy: A randomized, placebo-con- 37. Martin DE, Vroon DH, May DF, et al: Physio-
trolled, double-blind study. Arch Intern Med logical changes in elite male distance run-
151:749,1991. ners training for Olympic competition. Phys
21. Hurt RD, Lauger GG, Offord KP, et al: Nico- Sportsmed 14(1):152,1986.
tine-replacement therapy with use of a trans- 38. Priebe WM, and Priebe J: Runners' diarrhea
dermal nicotine patch: A randomized double- (RD): Prevalence and clinical symptomatol-
blind placebo-controlled trial. Mayo Clin ogy. Am J Gastroenterol 79:827, 1984.
Proc 65:1529, 1990. 39. Siegel AJ, Silverman LM, and Lopez RE: Cre-
22. Egeland GM, Kuller LH, Matthews RA, et al: atine kinase elevations in marathon runners,
Hormone replacement therapy and lipopro- relationship to training and competition.
tein changes during early menopause. Obstet Yale J Biol Med 53:275, 1980.
Gynecol 76:776, 1990. 40. Poortsmans JR: Exercise and renal function.
23. Sullivan JM, Vander Zwaag R, Hughes JP, et Sports Med 1:125,1984.
al: Estrogen replacement and coronary ar- 41. McFadden ER, and Ingram RH: Exercise-in-
tery disease: Effect on survival in postmeno- duced asthma. Seminars in Medicine of the
pausal women. Arch Intern Med 150:2557, Beth Israel Hospital, Boston 301:763,1979.
1990. 42. Sheffer AL, and Austen KF: New exercise-in-
24. Glazer G: Atherogenic effects of anabolic ste- duced anaphylactic syndrome identified.
roids on serum lipid levels—a literature re- Mod Med 1:96,1981.
view. Arch Intern Med 151:1925,1991. 43. Siegel AJ: Exercise induced anaphylaxis.
25. Lee IM, Paffenbarger RS, Hsieh C, et al: Phys- Phys Sportsmed 8(1):55, 1980.
ical activity and risk of developing colorectal 44. Gardner KD Jr: Athletic pseudonephritis al-
teration of urine sediment by athletic com- 49. Siegel AJ, Silverman LM, and Holman BL: El-
petition. JAMA 161:613,1956. evated creatine kinase MB isoenzyme levels
45. Siegel AJ, Hennekens CH, Solomon HS, et al: in marathon runners. JAMA 246:1049,1981.
Exercise-related hematuria findings in a 50. Siegel AJ, Silverman LM, and Evans WJ: Ele-
group of marathon runners. JAMA 241:391, vated skeletal muscle creatine kinase MB iso-
1979. enzyme levels in marathon runners. JAMA
46. Blacklock NS: Bladder trauma in the long dis- 250:2835,1983.
tance runner. 10,000 metres hematuria. Br J 51. Evans WJ, and Meredith CN: Exercise and nu-
Urol 49:129, 1977. trition in the elderly. In Munro HM and Dan-
47. Apple FS, and Rogers MA: Serum and muscle ford DE (eds): Nutrition, Aging, and the El-
alanine aminotransferase activities in mara- derly. Plenum, New York, p 89.
thon runners. JAMA 252:626, 1984. 52. Camacho TC, Roberts RE, Lazarus NB, et al:
48. Leslie BR, and Sanders NW: Runner's hemo- Physical activity and depression: Evidence
lysis and pigment gallstones. N Engl J Med from the Alameda County Study. Am J Epi-
313:1230,1985. demiol 134:220,1991.
APPENDIX 15-1
Sport Candidate's Questionnaire

Name Age Date of birth
School Grade Sex
Athlete's address Tel. No.
Parent's name & address Tel. No.
Regular physician Tel. No.
Medical History Yes No Past or Present Please Circle Item(s) in ( )
1. Discuss with a doctor a (health problem, injury, diet)?
2. Discuss with a doctor (emotional problem, stress
management)?
3. Any close family member with (diabetes, migraines,
asthma, heart trouble, high blood pressure)?
4. Any family member who died suddenly under age 50,
excluding accidents?
5. Any (illnesses lasting more than 1 wk, chronic or recurrent
illness)?
6. Any (hospitalizations or surgery)?
7. Any (injuries or illnesses) requiring treatment by a
doctor?
8. Any allergies (hay fever, hives, asthma, bee sting, or drug
allergies)?
9. Any medications taken regularly or within last 6 mo?
10. Any neck injury?
11. Any (concussions, skull fracture, loss of memory or
consciousness, convulsions or epilepsy, headaches)?
12. Any (eyeglasses, contact lenses, decreased vision, oir
temporary loss of vision)?
13. Any (hearing loss, perforated eardrum, recurrent ear
infections)?
14. Any (broken nose, nosebleeds, dentures, braces, bridges,
tooth caps)?
15 Have you ever fainted during exercise?
APPENDIX 15-1
Sport Candidate's Questionnaire—Continued

Medical History Yes No Past or Present Please Circle ltem(s) in ( )
16. Any (heart trouble, murmur, arrhythmias, chest pain, high
blood pressure)?
17. Do you (smoke, drink alcohol, take drugs)?
18. Any (pneumonia, tuberculosis, chronic cough)?
19. Any loss of, or serious injury to (eye, testicle, kidney,
lung)?
20. Girls, any menstrual problems? Age at first menstrual
period
21. Any (hernias, kidney problems, ulcer, heartburn, bowel
problems, hepatitis)?
22. Any (diabetes, thyroid disorders, anemia, abnormal
bleeding)?
23. Any knee injury (sprain, fracture, dislocation, surgery,
chronic pain)?
24. Any ankle injury (sprain, fracture, dislocation, surgery,
chronic pain)?
25. Any bone (fracture, infection, deformity)?
26. Any (injuries, sprains, dislocations, surgery) in (shoulder,
wrist, finger, or any other joint)?
27. Any skin disorders (recurrent rash, fungal infection, boils,
athlete's foot)?
28. Any injury not mentioned?
29. Any (heat exhaustion, heat stroke)?
30. Any reasons why you were unable to participate in the
past or should not be able to in the future?
31. Date of last tetanus booster
Explain Any Questions Answered With "Yes" Below
(please be as specific as possible: dates, treating physician, list medications, residual problems,
etc.)
Signature of student athlete Date

Signature of parent or physician Date
Source: From Gregg JR, and Spindler KP: Screening school-age athletes. Drug Therapy, September
1985, p 75, with permission.
279
Appendix 15-2
Physical Examination Form
Name Age Date of birth
School Grade
Height (in) Weight (Ib) Pulse BP (sitting, right arm)
Vision (acuity) R —/— L —/ Check one: — normal without glasses — normal with glasses
— abnormal without glasses — abnormal with glasses
Circle in ( ) if Abnormality Present or Normal
OK Condition Absent Comments Initials
1. Dental (dental prosthesis, severe caries)
2. Skin, scalp, lymphatics (active infection, acne,
rashes, adenopathy)
3. Eyes/fundi (vision-color, depth, peripheral;
pupils, extraocular movements, fundi)
4. Ears, nose, throat (hearing, tympanic
membranes, nasal septum, tonsils, throat)
5. Neck (soft tissue) (adenopathy, thyroid,
carotid pulses)
6. Cardiovascular (PMI, pulses [femoral-
branchial], rhythm, murmurs)
7. Chest and lung (breath sounds, shape,
excursion)
8. Abdomen (hepatosplenomegaly, masses,
costovertebral angle tenderness)
9. Genitalia-hernia (scrotal contents, inguinal
region)
10. Sexual maturity (Tanner staging)
11. Neurologic (sensation, deep-tendon reflexes,
mental status)
12. Orthopedic (all for active range of motion and
strength besides information in
parentheses)
a. Cervical spine/back (scoliosis)
b. Shoulders (symmetry)
c. Arm/elbow/wrist/hand
d. Hip/foot (passive range of motion hip,
foot stance with weight bearing)
e. Knee (ligamentous stability)
f. Ankle (ligamentous stability)
g. Flexibility
h. % Body fat (specify method)
13. Laboratory tests
Hg g/dl Hct %
Transferrin saturation %
Urinalysis
Other
14. Review by team physician
a. No athletic participation
b. Limited participation, e.g.,
c. Clearance withheld until:
d. Full unlimited participation
15. Comment/Advice:
16. Team physician's signature Date

Source: From Gregg JR, and Spindler KP: Screening school-age athletes. Drug Therapy, September
1985, p 77, with permission.
Appendix 15-3
Disqualifying Conditions (Indicated by an
X) for Sports Participation, by Type of
Sport
Condition Collision* Contactt Noncontact Others§
General
Acute infection (respiratory, genitourinary, X X X X
infectious mononucleosis, hepatitis,
active rheumatic fever, active
tuberculosis)
Obvious physical immaturity i n X X
comparison with other competitors in
group
Hemorrhagic disease (hemophilia, X X X
purpura, other serious bleeding
tendencies)
Diabetes, inadequately controlled X X X X
Diabetes controlled || || || ||
Jaundice X X X X
Ears
Absence or loss of function of one eye X X
Respiratory System
Tuberculosis (active o r symptomatic) X X X X
Severe pulmonary insufficiency X X X X
Cardiovascular System
Mitral stenosis, aortic stenosis, aortic X X X X
insufficiency, coarctation of aorta,
cyanotic heart disease, recent carditis of
any cause
Hypertension, organic X X X X
Previous heart surgery for congenital or ¶ ¶ ¶ ¶
acquired heart disease
Liver
Enlargement X X
*Football, rugby, hockey, lacrosse, etc.
†Baseball, soccer, basketball, wrestling, etc.
Cross-country, track, tennis, crew, swimming, etc.
§Bowling, golf, archery, field events, etc.
|| No exclusions necessary.
¶Each patient should be judged individually in conjunction with cardiologist and surgeon.
Source: From Blum RW: Preparticipation evaluation of the adolescent athlete. Postgrad Med 78:2,52-
55, 1985, with permission.
281
CHAPTER 16
Cardiovascular Issues
PAMELA S. DOUGLAS, M.D.
AEROBIC CAPACITY EXERCISE LIMITATIONS IN HEART

DISEASE
CARDIAC FUNCTION IN Mitral Valve Prolapse
RESPONSE TO EXERCISE Anorexia Nervosa
EXERCISE Sudden Death
ELECTROCARDIOGRAPHIC Other Forms of Heart Disease
TESTING
A s participation in both competitive and noncompetitive sports increases, the

numbers of female athletes, of athletes with known forms of heart disease, and
of older athletes more likely to have occult heart disease, also increases. In gen-
eral, the cardiovascular responses to exercise are similar in both sexes, both in
healthy individuals and in those with heart disease. However, physiologic and
pathologic differences do exist between the sexes and are important in the eval-
uation and treatment of the exercising woman.
Exercise of any type or intensity requires increased oxygen delivery to work-
ing tissue. This is accomplished through peripheral mechanisms, which include
the differential perfusion of vascular beds and increased oxygen extraction by
muscle, and through central or cardiac mechanisms, chiefly an increase in car-
diac output. Thus, maximal exercise, or maximal oxygen uptake, is determined
by maximal increases in the peripheral arteriovenous O2 difference, and by car-
diac output and its components, stroke volume and heart rate.
AEROBIC CAPACITY
In the average sedentary woman, maximum aerobic workload is 15% to 30%

lower than in the average sedentary man,1,2 even when corrected for body size.
This may be due to a number of factors. Women normally possess a lower total
oxygen-carrying capacity of blood, owing to lower blood volume, fewer red blood
cells, and lower hemoglobin content. Women also have smaller hearts, even
when corrected for body size, with smaller stroke volumes and therefore higher
heart rates for a given cardiac output or oxygen uptake. Finally, women generally
possess a higher percentage of adipose tissue and a lower percentage of working
282
Cardiovascular Issues 283
muscle than do men. These differences com- have been defined as those able to increase
bine to produce, on average, a lower maxi- their ejection fraction by at least five per-
mal level of work or aerobic capacity in centage points during exercise.7 Persons
women. with a lesser increase, or even a decrease,
In part, these "physiologic" differences are felt to have a component of myocardial
may also be explained by considering that, dysfunction, or at the least, impaired car-
on the average, men are more active than diac reserve. Higginbotham and associates8
women and therefore maintain a more studied healthy, sedentary adults and found
trained state, particularly as women tend to that the generally accepted "normal" in-
become relatively more sedentary after pu- crease in left ventricular ejection fraction
berty. Several factors support this hypothe- during exercise occurred only in men and
sis. Training programs produce similar in- not in women. Of the 16 women studied,
creases in aerobic capacity in both sexes, only 7 increased their ejection fraction by
even when older individuals are exam- five points or more (compared with 14 of 15
ined. 2-4 Maximal oxygen uptake in individ- men), and the average ejection fraction was
ual highly trained female athletes can ap- unchanged (63% at rest compared with 64%
proach and equal that of similarly trained at peak exercise). In contrast, the average
males.5 Finally, there is little difference in ejection fraction in men increased from 62%
exercise capacity between boys and girls to 77% (Fig. 16-1).
under the age of 12.1 In addition, the mechanisms used to in-
Regardless of cause, recognition of the crease cardiac output during exercise ap-
lower maximal aerobic capacity and higher peared different in men than in women. In
heart rates during submaximal exercise in men, end-diastolic left ventricular size did
women as compared with men is essential to not change, whereas end-systolic size de-
the accurate interpretation of exercise re- creased, leading to increases in stroke vol-
sults in women. Sex-specific standards have ume and ejection fraction. In contrast,
been developed for maximal aerobic capac- women achieved a similar increase in stroke
ity, as well as nomograms for the calcula- volume by increasing end-diastolic size
tion, in women, of maximal capacity from while end-systolic size remained un-
submaximal heart rate and oxygen uptake changed. Thus, women appeared to dilate
values. Exercise performance in women can- their left ventricles, or increase preload,
not be adequately evaluated without refer- whereas men increased ventricular short-
ence to such standards. ening. The physiologic basis for these differ-
ent mechanisms of achieving the same
end—increasing cardiac output and there-
CARDIAC FUNCTION IN fore oxygen supply to muscle—is unknown,
RESPONSE TO EXERCISE as is its significance for preserved health or
training.
In addition to differences in aerobic ca- These findings have important clinical im-
pacity, the normal cardiac response to ex- plications. If good health is defined by the
ercise in women may be different than in healthy male pattern of response, the re-
men.6 The most widely used diagnostic test mainder of the population, or women who
for the evaluation of left ventricular function normally respond differently, may be falsely
during exercise is the gated blood pool scan. diagnosed as unwell. Since exercise gated
This test involves the use of radiolabeled blood pool scanning is commonly used to
red blood cells (using technetium) to deter- measure the cardiac functional response to
mine ejection fraction, or the percentage of exercise and is recommended as a diagnos-
blood within the left ventricular chamber tic test for the evaluation of a variety of car-
that is ejected with each heart beat, at rest diac complaints, the problem is potentially
and at maximal exercise. Normal individuals a large one. At special risk for misdiagnosis
Figure 16-1. Ejection fraction responses during exercise in which the workload was increased every
3 minutes. Progressive individual data are shown for women (top left) and men (bottom left). Mean
submaximal and maximal group data are plotted on the right as mean data ± standard deviation for
normal female (F) and male (M) volunteers. Significant intergroup differences are shown for the
slope of the response, as well as for data from subjects at rest and during maximal exercise. (From
Higginbotham et al.,8 with permission.)
as having impaired cardiac function is the Blood pressure is little changed in the nor-
healthy woman, whether sedentary or ac- mal person following either isotonic or iso-
tive, undergoing evaluation of cardiac func- metric exercise training. There is some evi-
tion. In a similar manner, a woman with mild dence that both systolic and diastolic
known cardiac disease may be classified as pressures may be reduced by training in in-
having more severe impairment than is ac- dividuals with hypertension; however,
tually the case, owing to use of the male re- these effects are small and not known to dif-
sponse as a normal reference standard. fer between the sexes.9
In contrast to aerobic capacity and the The hearts of both men and women ap-
functional response to exercise, other as- pear to adapt similarly to exercise training.1,2
pects of cardiac-related exercise physiology This has been documented in studies of
appear to show few differences between women pursuing typically female-domi-
men and women. Aging affects aerobic ca- nated sports such as field hockey and
pacity of healthy individuals of both sexes dance,10,11 as well as those pursuing jogging,
similarly, causing a decline in maximal oxy- swimming, and triathlon trainings. 12-14
gen uptake. This results from a decrease in Weight training or isometric exercise ap-
both the maximal achievable heart rate and pears to produce cardiovascular effects sim-
the mechanical performance of the myocar- ilar to those of aerobic, dynamic exercise.15
dium, as well as limitations in the function- A detailed discussion of the structural car-
ing of other organ systems (Fig. 16-2). diac changes associated with dynamic and
Age (years) Age (years)

Figure 16-2. Derived values for observed and maximal cardiovascular variables in 104 normal,
healthy women. (A) Observed age- and weight-adjusted value of maximal oxygen uptake (Vo2max).
The regression line is shown and the normal range indicated by +2 standard deviations (SD). The
standard deviation for oxygen uptake is 3.59 m L - k g - 1 - m i n - 1 ) . (B) Estimated age-adjusted values of
maximal cardiac output are Qmax. The standard deviation for cardiac output is 1.35 L - m i n - 1 . (C)
Observed age-adjusted values of maximal heart rate (HRmax). The standard deviation for heart rate
is 14 beats per minute. (D) Estimated age-adjusted values of maximal stroke volume (SV). The stan-
dard deviation for stroke volume is 8 mL. (From Hossack et al.,6 with permission.)
resistive exercise training is beyond the both sexes develop cardiac arrhythmias
scope of this chapter and has been well re- with training, probably because of altera-
viewed.14 At present, no differences between tions of vagal tone and catecholamine me-
the sexes have been found in the extent or tabolism. Although sinus bradycardia is
incidence of cardiac adaptations to exercise. most common, low-grade atrioventricular
Female athletes develop clinical findings block, premature atrial or ventricular con-
of left ventricular hypertrophy, including an tractions, and repolarization abnormalities
enlarged heart on chest radiograph, in- are also seen.14 Highly trained aerobic ath-
creased left and right ventricular cavity letes also demonstrate a greater prevalence
sizes and wall thicknesses on echocardiog- of multivalvular regurgitation.17
raphy, and increased voltage on ECG, Since many of these adaptive changes
reflecting an increased myocardial mass.16 may also signify the presence of true heart
Following weight training, the cardiac disease, it is important to recognize that for
chambers tend to remain normal-sized and women, as well as men, physical training
the walls become hypertrophied. Athletes of may lead to physiologic structural and elec-
Figure 16-3. The marked differ-

ence in the incidence of false-posi-
tive test results between men and
women is statistically significant (p
< 0.001, regardless of coronary
anatomy). Hatched bars indicate
the percentage of positive exercise
test results associated with normal
coronary arteries or less than 50%
stenosis (false-positive results).
Open bars indicate the percentage
of positive tests associated with
75% or greater coronary stenosis
(true-positive results). Overall, 60
of 77 subjects (78%) had both pos-
itive exercise tests and significant
coronary disease. In men, 55 of 62
(89%) had true-positive test re-
sults, whereas only 5 of 15 women
(33%) did. This difference is statis-
tically significant (p < 0.001).
(From Sketch et al.,18 with permis-
sion.)
trical changes in a healthy heart that must ference. The most important of these is the
not be confused with similar findings in car- age-related difference in the prevalence of
diac disease states. heart disease between men and women. In
general, the effect of disease prevalence in
the population studied has a great impact
EXERCISE upon the accuracy and usefulness of any
ELECTROCARDIOGRAPHIC given diagnostic test. This is termed Bayes'
TESTING theorem and is highly applicable to the com-
parability of exercise testing results in men
The most common form of heart disease and women.20 Because coronary disease is
in the United States today is coronary ath- relatively less likely in a younger middle-
erosclerosis. Coronary stenoses limit the aged woman, any given positive test result is
delivery of adequate amounts of oxygen to more likely to be a false rather than a true
the heart, a problem often not noted until result. Thus, the diagnostic utility of exer-
oxygen demands are increased by exercise. cise testing for coronary artery disease in
Thus, monitoring of electrocardiographic women is lower than for men. To elimi-
recordings capable of detecting cardiac nate the Bayesian factor, Barolsky and co-
ischemia during a controlled exercise pro- workers21 studied the utility of exercise test-
tocol is the most widely used diagnostic pro- ing in groups of men and women with similar
cedure for the detection of coronary dis- disease prevalences. This markedly im-
ease. In men, regardless of symptoms, such proved the validity of test results, although
exercise testing is an excellent screening women still had a higher incidence of false-
test, with few false-positive results. In con- positive test results.
trast, in women, the incidence of false-posi- Another reason for the high rate of false-
tive test results (appearance of electro- positive test results is the higher incidence
cardiographic changes characteristic of in women of other characteristics that are
myocardial ischemia leading to a diagnosis associated with nondiagnostic results.22,23
of coronary disease in its absence) is quite These characteristics include atypical chest
high, perhaps as high as two thirds of all pain, resting electrocardiographic abnor-
positive tests (Fig. 16-3).18,19 malities including nonspecific ST- and T-
Several factors partially explain this dif- wave changes, and ingestion of medications
such as digoxin and anxiolytics. Since these EXERCISE LIMITATIONS IN

characteristics appear more commonly in HEART DISEASE
women than in men, test results are more
frequently confounding in women. The effects of exercise in those with heart
Several alternative strategies have been disease appear to be similar in both men and
proposed to render exercise testing more women. However, since little attention has
useful in women. These include more strin- been focused on the potential differences
gent use of probability analysis,24 alternate between men and women, it is possible that
or additional electrocardiographic lead such differences do exist but have been
placement,25 consideration of R-wave ampli- overlooked. It is known that women in gen-
tude as well as ST-segment changes,26 and eral have a worse prognosis following myo-
use of thallium-201 myocardial scintigraphy cardial infarction29 and a higher mortality
with exercise testing.19,27The addition of iso- and lower immediate success rate following
tope imaging does markedly improve the coronary artery bypass grafting30 than men
specificity of exercise testing; however, the have. Whether this dichotomy extends to
false-positive rate is still higher for women other forms of therapy, such as exercise
than for men. In part, this may be due to at- training, is unknown. A low level of physical
tenuation of tracer signal resulting from fitness, as measured by treadmill testing, is
overlying breast tissue.27,28 In addition, thal- a powerful risk factor for coronary heart dis-
lium scanning is costly, time consuming, ease and cardiac death in women, as it is in
and requires radiation exposure and the men.31 Longitudinal studies of exercise in-
availability of special equipment and trained tervention have shown some benefit in car-
personnel. diac risk factors such as lipid profiles, blood
The different sensitivity and specificity of pressure, obesity, and diabetes mellitus, al-
exercise testing in women has important though the effect is generally smaller in
clinical implications. In diagnostic exercise women than in men.32
testing performed to define and classify pre- In men, the use of exercise in the treat-
existing complaints, women with chest pain ment of known coronary heart disease, or
due to noncardiac causes are far more likely for rehabilitation following myocardial in-
to be wrongly diagnosed as having coronary farction or revascularization surgery, is of
disease than anemia. This is obviously an established value in hastening recovery and
undesirable event and, in addition to caus- improving the quality of life in the short
ing a great deal of patient anxiety, may lead term; longer-term benefits such as reduction
to taking unnecessary medications and/or of recurrence or improved long-term sur-
undergoing additional testing, which is vival are more difficult to prove. Rehabilita-
more expensive and may endanger health. tive programs for those with nonischemic
In contrast, a negative test result is a good heart disease are more controversial. How-
indication of the absence of heart disease. ever, the effectiveness of exercise regimens
Exercise testing performed to ensure that a in the primary and secondary treatment of
training program may be undertaken safely any form of heart disease has not been ex-
is at even greater risk of producing a false amined in adequate numbers of women;
suspicion of cardiac disease. The high false- their effectiveness can only be extrapolated
positive rate of exercise testing in women from studies performed in men. Possible
makes it a very poor screening test for car- sex-related differences have not been ex-
diovascular disease in women, regardless of plored.
symptoms. Unfortunately, no better alter-
native screening or diagnostic test exists for
Mitral Valve Prolapse
women, nor is the remarkably low predic-
tive accuracy of exercise testing in women In contrast to most forms of either con-
fully understood. genital or acquired heart disease, mitral
valve prolapse occurs with greater fre- be kept in mind, however, that the natural
quency in women than in men. For this rea- history of the disorder is not well known and
son, information regarding cardiac function its clinical significance remains somewhat
and exercise in this disease process may be controversial. The American College of Car-
more likely to represent the female than the diology has recommended that a small sub-
male circumstance. Mitral valve prolapse is set of patients with mitral valve prolapse
a generally benign syndrome characterized limit competitive participation to low-inten-
by a broad variety of cardiac findings, which sity sports such as bowling and golf.37 These
may include some or all of the following: patients include those with a history of syn-
midsystolic, nonejection click; late systolic cope, a family history of sudden death due to
murmur; echocardiographic or cineangio- mitral valve prolapse, chest pain worsened
graphic evidence of systolic billowing of the by exercise, repetitive ventricular ectopy or
mitral valve leaflets into the left atrium; sustained supraventricular tachycardia (es-
thickened mitral valve; atypical chest pain; pecially if worsened by exercise), moderate
palpitations; dizziness; abnormal electro- or severe mitral regurgitation, and dilata-
cardiogram; atrial or ventricular arrhyth- tion of the ascending aorta (associated with
mia; systemic emboli; mitral regurgitation; Marfan's syndrome). It was recommended
Marfan's syndrome; syncope; and sudden that no restrictions be placed on those with
death.33 any or all other manifestationsof the mitral
The question of myocardial involvement valve prolapse syndrome.
in mitral valve prolapse has been raised by
documentation of left ventricular segmental
Anorexia Nervosa
contraction abnormalities, and by its asso-
ciation with chest pain and ventricular ar- Another disorder primarily afflicting
rhythmias. This has led to the examination women and thought to affect cardiac perfor-
of global function using rest and exercise mance is anorexia nervosa, which is dis-
ejection fractions as measured by gated cussed in Chapter 17. Previous studies of
blood pool scanning.34-36 As might be ex- starvation have demonstrated decreased
pected, owing to the preponderance of heart size, blood pressure, and heart rate,
women with the disease, patients with mi- which may not be reversible with refeeding.
tral valve prolapse have an "abnormal" fail- A recent study38 has shown that cardiac
ure to increase ejection fraction in response function is preserved and that the observed
to exercise. This has been taken to be sug- changes in cardiac architecture, load, and
gestive of a "cardiomyopathic process"34 function are appropriate responses to de-
and renders difficult the accurate diagnosis creased blood pressure. These parameters,
of the etiology of chest pain (ischemic ver- as well as exercise performance, return to
sus nonischemic).3536 However, as noted normal with weight gain. Thus, the observed
previously, normal healthy females also cardiac abnormalities should not in them-
may fail to increase their ejection fraction selves represent limitations to exercise.
with exercise; therefore, it is difficult to label
the behavior of those with mitral valve pro-
lapse as indicative of myocardial pathology. Sudden Death
In the overwhelming majority of cases, The risk factors predisposing to unex-
mitral valve prolapse is a benign, isolated pected sudden death in women and the
auscultatory or echocardiographic finding prevalence of coronary artery disease in
that has no known influence on exercise per- such patients are somewhat different from
formance or the advisability of pursuing those in men.39 Data from the Framingham
competitive or recreational sports. This Heart Study showed that age and, margin-
view is supported by the rarity of complica- ally, cholesterol were risk factors in both
tions documented during exercise. It must sexes. In addition, hematocrit, vital capac-
ity, and glucose were significantly related to ferences in disease processes, other than
the incidence of sudden death in women those discussed previously, that would sug-
only. In men, additional risk factors for sud- gest different exercise limitations in men
den death were those associated with coro- and women. The reader is referred to the
nary disease, including systolic blood Task Force on Cardiovascular Abnormali-
pressure, obesity, smoking, and electrocar- ties in the Athlete and its recommendations
diographic evidence of left ventricular hy- regarding eligibility for competition.40 This
pertrophy. conference, which was sponsored by the
Although the significance of these find- American College of Cardiology and by the
ings for the exercising woman is unknown, National Heart, Lung and Blood Institute,
several other forms of heart disease are compiled an up-to-date, comprehensive
clearly associated with sudden death during summary of both resistive and dynamic ex-
exercise. As far as is known, relative risks for ercise limitations in all forms of congenital
men and women relate to the prevalence of and acquired heart disease. It must be
these cardiac illnesses; the consequences or stressed that any person with known or sus-
severity of each disease process do not dif- pected heart disease, regardless of sex,
fer in men and women, and female patients should undergo a full cardiovascular evalu-
should observe the same restrictions. ation before undertaking exercise training
Chief among cardiac diseases causing or sports competition. These recommenda-
sudden death in young people during exer- tions apply equally to male and female ath-
cise is hypertrophic cardiomyopathy. This letes.
disease is idiopathic, genetically transmit-
ted, and characterized by a thickened left
ventricle with normal chamber size. Be- SUMMARY
cause cardiac adaptation to exercise may
produce a similar picture, differentiating be- In conclusion, although many aspects of
tween physiologic and pathologic hypertro- the female cardiac response to exercise ap-
phy may be difficult and may depend on pear similar to the male response, many
identification of other pathologic features other aspects have not been fully examined
such as asymmetric septal hypertrophy and with respect to differences between the
systolic anterior motion of the mitral valve. sexes. In areas that have been studied, a
Any athlete suspected of having this disor- number of important differences exist. Be-
der should be fully evaluated by a cardio- cause many of these differences must be
vascular specialist. The American College of kept in mind for the correct interpretation of
Cardiology recommends that patients with diagnostic cardiac exercise testing per-
this disease should never participate in formed in women, an appreciation of the
high-intensity competitive sports, regard- normal female response is vital. These dif-
less of disease severity.37 Those with marked ferences are just as important to keep in
hypertrophy, significant left ventricular out- mind in examining the female athlete as they
flow tract obstruction, arrhythmias, or a are in examining the sedentary woman.
family history of sudden death or syncope Much research remains to be done before a
should not participate in any form of athletic complete examination can be made of all the
endeavors. unique aspects of cardiovascular problems
in the exercising woman.
Other Forms of Heart Disease

REFERENCES
Consideration of the exercise limitations
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yond the scope of this review. In addition, women with special reference to age. Acta
there is no evidence available to indicate dif- Physiol Scand 49:169, 1960.
2. Astrand PO: Human physical fitness with spe- Prevalence of multivalvular regurgitation in
cial reference to sex and age. Physiol Rev athletes. Am J Cardiol 64:209,1989.
36:307, 1956. 18. Sketch MH, Mohiuddin SM, Lynch JD, et al:
3. Adams GM, and de Vries HA: Physiologic ef- Significant sex differences in the correlation
fects of an exercise training regimen upon of electrocardiographic exercise testing and
women aged 52 to 79. J Gerontol 28:50, 1973. coronary arteriograms. Am J Cardiol 36:169,
4. Wessel JA, Small DA, Van Huss WD, et al: Age 1975.
and physiological responses to exercise in 19. McCarthy D: Stress electrocardiography in
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1968. 20. Patterson RE, Eng C, and Horowitz SF: Prac-
5. O'Toole ML, Hiller WDB, Douglas PS, et al: tical diagnosis of coronary artery disease: A
Cardiovascular responses to prolonged cy- Bayes' theorem nomogram to correlate clin-
cling and running. Med Sci Sports Exerc ical data with noninvasive exercise tests. Am
17:219,1985. J Cardiol 53:252, 1984.
6. Hossack KF, Kusumi F, and Bruce RA: Ap- 21. Barolsky SM, Gilbert CA, Faruqui A, et al: Dif-
proximate normal standards of maximal car- ferences in electrocardiographic response to
diac output during upright exercise in exercise in women and men: A non-Bayesian
women. Am J Cardiol 47:1080,1981. factor. Circulation 60:1021,1979.
7. Borer JS, Bacharach SL, Green MV, et al: Real- 22. Linhart JW, Laws JG, and Satinsky JD: Maxi-
time radionuclide cineangiography in the mum treadmill exercise electrocardiography
non-invasive evaluation of global and rein female patients. Circulation 50:1173,1974.
gional left ventricular function at rest and 23. Detry JMR, Kapita BM, Cosyns J, et al: Diag-
during exercise in patients with coronary ar- nostic value of history and maximal exercise
tery disease. N Engl J Med 296:839, 1977. electrocardiography in men and women sus-
8. Higginbotham MB, Morris KG, Coleman E, et pected of coronary heart disease. Circulation
al: Sex-related differences in the normal car- 56:756,1977.
diac response to upright exercise. Circula- 24. Melin JA, Wins W, Vanbutsele RJ, et al: Alter-
tion 70:357,1984. native diagnostic strategies for coronary ar-
9. Seals DR, and Hagberg JM: The effect of ex- tery disease in women: Demonstration of the
ercise training on human hypertension: A re- usefulness and efficiency of probability anal-
view. Med Sci Sports Exerc 16:207,1984. ysis. Circulation 71:535,1985.
10. Cohen JL, Gupta PK, Lichstein E, et al: The 25. Guiteras P, Chaitman BR, Waters DD, et al: Di-
heart of a dancer: Noninvasive cardiac eval- agnostic accuracy of exercise ECG lead sys-
uation of professional ballet dancers. Am J tems in clinical subsets of women. Circula-
Cardiol 45:959, 1980. tion 65:1465, 1982.
11. Zeldis SM, Morganroth J, and Rubier S: Car- 26. Ilsley C, Canepa-Anson R, Westgate C, et al:
diac hypertrophy in response to dynamic Influence of R wave analysis upon diagnostic
conditioning in female athletes. J Appl Phys- accuracy of exercise testing in women. Br
iol 44:849, 1978. Heart J 48:161, 1982.
12. Douglas PS, O'Toole ML, Hiller WDB, et al: 27. Friedman TD, Greene AC, Iskandrian AS, et al:
Left ventricular structure and function by Exercise thallium-201 myocardial scintigra-
echocardiography in ultraendurance ath- phy in women: Correlation with coronary ar-
letes. Am J Cardiol 58:805, 1986. teriography. Am J Cardiol 49:1632,1982.
13. Douglas PS, Hiller WDB, O'Toole ML, et al: 28. Stolzenberg J, and Kaminsky J: Overlying
Left ventricular structure and function in ul- breast as cause of false-positive thallium
traendurance athletes. Med Sci Sports Exerc scans. Clin Nucl Med 3:229, 1978.
17:203, 1985. 29. Puletti M, Sunseri L, Curione M, et al: Acute
14. Huston TP, Puffer JC, and Rodney WM: The myocardial infarction: Sex-related differ-
athletic heart syndrome. N Engl J Med ences in prognosis. Am Heart J 108:63, 1984.
313:24, 1985. 30. Fisher LD, Kennedy JW, Davis KB, et al: As-
15. Stone MH, and Wilson GD: Resistive training sociation of sex, physical size, and operative
and selected effects. In Goldberg L, and Elliot mortality after coronary artery bypass in the
DL (eds): The Medical Clinics of North Amer- coronary artery surgery study (CASS).
ica. WB Saunders, Philadelphia, 1985. Thorac Cardiovasc Surg 84:334, 1982.
16. Douglas PS, O'Toole ML, Hiller DB, et al: Elec- 31. Blair SN, Kohl HW, Paffenbarger RS, et al:
trocardiographic diagnosis of exercise-in- Physical fitness and all-cause mortality: A
duced left ventricular hypertrophy. Am Heart prospective study of healthy men and
J 116:784, 1988. women. JAMA 262:2395,1989.
17. Douglas PS, Berman GO, O'Toole ML, et al: 32. Lokey EA, and Tran ZV: Effects of exercise
training on serum lipid and lipoprotein con- thy, other myopericardial diseases and mi-
centrations in women: A meta-analysis. Int J tral valve prolapse. J Am Coll Cardiol 6:1215,
Sports Med 10:424, 1989. 1985.
33. Jeresaty RM: Mitral valve prolapse-click syn- 38. St. John Sutton MG, Plappert T, Crosby L, et
drome. Prog Cardiovasc Dis 15:623, 1973. al: Effects of reduced left ventricular mass on
34. Gottdiener JS, Borer JS, Bacharach SL, et al: chamber architecture, load, and function: A
Left ventricular function in mitral valve pro- study of anorexia nervosa. Circulation
lapse: Assessment with radionuclide cinean- 72(S):991,1985.
giography. Am J Cardiol 47:7,1981. 39. Schatzkin A, Cupples LA, Heeren T, et al: The
35. Newman GE, Gibbons RJ, and Jones RH: Car- epidemiology of sudden unexpected death:
diac function during rest and exercise in pa- Risk factors for men and women in the Fra-
tients with mitral valve prolapse. Am J Car- mingham Heart Study. Am Heart J 107:1300,
diol 47:14,1981. 1984.
36. Ahmad M, and Haibach H: Left ventricular 40. Mitchell JH, Maron BJ, and Epstein SE: 16th
function in patients with mitral valve pro- Bethesda Conference: Cardiovascular abnor-
lapse: A radionuclide evaluation. Clin Nucl malities in the athlete: recommendations re-
Med 7:562,1982. garding eligibility for competition. J Am Coll
37. Maron EJ, Gaffney FA, Jeresaty RM, et al: Cardiol 6:1186,1985.
Task force III: Hypertrophic cardiomyopa-
CHAPTER 17
Eating Disorders
JACK L. KATZ, M.D.
EPIDEMIOLOGY DIAGNOSIS, COURSE, AND

PROGNOSIS OF THE EATING
SETTING AND ONSET DISORDERS
Anorexia Nervosa
Bulimia Nervosa CO-MORBIDITY
CLINICAL PICTURE THEORIES OF ETIOLOGY
Anorexia Nervosa
Bulimia Nervosa TREATMENT
BIOLOGY OF EATING DISORDERS EXERCISE AND EATING
Physical Sequelae DISORDERS
Laboratory Findings
Endocrine Abnormalities.- EATING DISORDERS AND OTHER
Hypothalamic Implications SPECIAL SUBCULTURES
T wo striking developments in recent decades have made the topic of eating

disorders germane to any scientific work on women and exercise. The first is the
enormous increase in dedicated athletic participation by women. What tradi-
tionally had been almost exclusively the domain of men has now become a flour-
ishing and important aspect of living for a substantial number of women in indus-
trialized societies. The second is the dramatic rise in the incidence of eating
disorders, specifically anorexia nervosa (AN) and bulimia nervosa (BN). As
these syndromes are primarily disorders of women (90% to 95% of all cases), and
as issues related to weight, food intake, and physical activity are central both to
eating disorders and to athletics, it is not surprising that the topic of eating dis-
orders is relevant to this book's mission of examining the physiologic, medical,
and psychologic ramifications of exercise in women.
While this chapter will review in detail the nature, theories of etiology, and
approaches to treatment of the eating disorders, it will also seek to address those
concerns that are particularly related to exercise. For example,
1 Is sustained, strenuous exercising, especially by women, a risk factor for the

development of an eating disorder?
2 Are women with a vulnerability to eating disorders drawn to serious athletic
activity as a way of dealing with that vulnerability?
292
Eating Disorders 293
3 Do anorexia nervosa and intense ath- nonindustrialized societies, they have a par-
letic involvement share common ticular affinity for females growing up in in-
underlying psychologic themes and dustrialized cultures. Earlier writings sug-
conflicts? gested that white, upper-middle-class girls
4 What are the physical risks to the exer- were at particular risk, but more recent re-
cising woman with a known eating ports suggest that minority groups are now
disorder? also vulnerable.6 Rather than socioeco-
nomic background being the critical vari-
able, achievement orientation of the fami-
EPIDEMIOLOGY lies may be the more relevant common
denominator.
As indicated earlier, since the 1960s, there
has been a remarkable increase in the inci-
dence of the eating disorders that goes be- SETTING AND ONSET
1
yond heightened diagnostic acuity. Surveys
of the lifetime prevalence of AN in women Anorexia Nervosa
have generally yielded a figure of about Although there are perhaps "typical" cir-
1%,1,2 while representative figures for BN fall cumstances associated with the onset of AN,
around 4%.3 Thus, perhaps almost 5% of it must be emphasized that a substantial mi-
women in industrialized societies can be ex- nority of patients present histories that can
pected to develop an eating disorder at deviate conspicuously from the usual ste-
some time during their life. reotypic scenario.
Clearly, these are not trivial figures, and Classically, the impending anorectic indi-
they have prompted various speculations vidual is in her teens, most likely approach-
about the sources of this alarming increase ing either 14 or 18 years of age (i.e., about to
in frequency. The most common proposals make a significant transition in her school-
are that the media's emphasis on thinness ing). She has seemingly been a well-func-
as a culturally desirable physical character- tioning girl, who indeed is often described
istic has prompted more widespread dieting by her parents as having been "perfect ...
than ever before, and that the increasingly never a problem." She is highly conscien-
complex and demanding roles of women in tious about her schoolwork, appears to have
our society have created particular stress friends, and is usually well organized. But
and conflict for them around issues of iden- beneath this veneer of health, there is often
tity and control, which are being played out found a girl with low self-esteem, one who is
by excessive attention to appearance.4 How- compulsive in her style, works excessively
ever, we should also note that, perhaps be- conscientiously to maintain her grades (i.e.,
cause of better nutrition or subtle evolu- is an "overachiever"), and is overly depen-
tionary trends, female adolescents are ex- dent in her relationships. She is also, more
periencing menarche and puberty earlier often than not, slightly overweight, has a
than ever before. Thus, they are encounter- "sweet tooth," and has grown up in a family
ing biologic and psychosocial stresses at an that is weight conscious or diet conscious
earlier age than previously. If today's par- (e.g., because someone is diabetic).
ents are also more self-absorbed than were Usually, but not always, a psychosocial
those of prior generations, their children's stressor can be identified which correlates
earlier exposure to these stresses is being chronologically with the onset of con-
met by less, rather than more, nurturance sciously initiated dieting (although the con-
and support, and food may then take on par- nection between the dieting and the stressor
ticular symbolic importance.5 may not be consciously made by the individ-
Finally, although AN and BN can occur in ual). Common triggering events are a loss
males and can also occur in persons living in (e.g., parental death or divorce), a blow to
self-esteem (e.g., a failed first heterosexual The possible role of intense athletic activ-
relationship), or a separation (e.g., a vaca- ity (e.g., long-distance running) in the
tion abroad, beginning college). Of course, pathogenesis of anorexia nervosa will be
some of these circumstances are intrinsic to discussed in a later section.
adolescence and, while indeed stressful, are
hardly unique to the life histories of anorec-
tic girls. Bulimia Nervosa
Like most American female adolescents The setting, precipitating events, and
and adults who are embarking on a diet, the onset for AN have been described with
person at risk for AN makes the conscious rather impressive agreement, including the
decision to reduce or even virtually elimi- acknowledgment of exceptions to the usual
nate fats and carbohydrates. What makes pathogenetic formulations, but BN remains
her different from her peers, though, is the a somewhat more difficult disorder to eluci-
intensity of her drive to lose weight, her date.
stoic pleasure in enduring hunger pains, and However, we have come to recognize at
her increasing preoccupation with achiev- least two forms of bulimia nervosa, which
ing thinness at the expense of all other literally means "nervous ox-hunger." In
goals. one, what starts out as fairly typical AN
Initially, there is a sense of exhilaration, a evolves into BN over a course of time, typi-
"high," which may be consequent to a newly cally 1 to 2 years. Thus, after weight has
found sense of mastery or to the accolades been driven down, and in the presence of
she begins to receive from peers and adults ongoing rigid and severe dieting, the ano-
for her willpower and her improving figure. rectic individual may one day, to her shock
But it is also conceivable that this phenom- and horror, suddenly embark on an uncon-
enon is mediated by a rise in the body's en- trollable binge. Not infrequently, two cir-
dorphin level. Such a rise has been shown to cumstances coincide to facilitate the ap-
occur, at least initially, in conjunction with pearance of the binge: an upsetting
two aspects of the unfolding AN: decreased experience producing a dysphoric state (de-
food intake7 and increased physical activ- pression, anger, or anxiety) and the avail-
ity.8 It has even been speculated that an un- ability in abundance of "forbidden" foods
conscious attempt to recapture this initial, (typically carbohydrates). The vulnerability
possibly endorphin-mediated, high drives to the binge may be further enhanced if the
the anorectic into her ever-downward spi- food is available in private (e.g., in one's
ral. own apartment or after everyone else has re-
However, as indicated at the outset of this tired for the evening). After the binge, there
section, exceptions to this textbook picture is considerable disgust, shame, and guilt,
abound. Not all future sufferers of AN are followed by firm resolve not only never to
bright overachievers with compulsive permit this to happen again but also to diet
styles, and not all begin their dieting in as- even more rigorously to compensate for the
sociation with a psychosocial stressor. weight presumably gained from the binge.
Some may actually follow the lead of a girl- However, with increasing frequency, the
friend in embarking on a diet; others may binges recur, until ultimately the binging
have initially lost weight as a consequence may become a more conspicuous part of the
of a bona fide medical illness (most com- clinical picture than the dieting.
monly, perhaps, infectious mononucleosis); In the other form, the individual becomes
still others begin to lose weight because of a a binger without having ever passed through
real loss of appetite associated with a state the emaciated, officially diagnosed phase of
of depression; and not all anorectic women AN. However, the initial circumstances and
are initially overweight or come from the emotional states are probably the same
weight- or food-preoccupied families. in both forms. Although nonanorectic bu-
limic women may have never been substan- among western female adolescents has gone
tially underweight, most, if not all, have beyond the bounds of "normal." The pres-
been chronic dieters whose weights have ence of the features that follow will help an-
fluctuated frequently and substantially. swer that question, but early prediction of
Thus, chronic dieting with unstable weight which dieting adolescent will go on to de-
appears to be a risk factor for BN in non- velop an actual eating disorder is a perplex-
anorectic persons as well. ing challenge for even the most expert in the
field.
Substantial Weight Loss. With progres-
CLINICAL FEATURE sion of the dieting, this is the symptom that
typically calls attention to the illness. The
While the etiology of the eating disorders Diagnostic and Statistical Manual of Mental
remains controversial, as we shall discuss in Disorders, third edition revised (DSM-III-
a later section, the phenomenology of AN R),9 specifies a weight loss to at least 15%
and BN has been impressively delineated below expected body weight (including pro-
over the past two decades, and a rich, co- jected weight for a still-growing adolescent),
herent, and reliable clinical picture of these but the diagnosis of AN should be made with
syndromes is now available. Both eating dis- the full clinical picture in view, rather than
orders can be regarded as syndromes char- solely via mechanical .reliance on a desig-
acterized by an admixture of psychologic, nated percentage of weight loss.10
behavioral, and biologic disturbances. Morbid Concern with Losing Control
over Eating and Becoming Fat. A fear of
loss of control is central to the psychology
Anorexia Nervosa of AN. It is concretized around the dual con-
Core Features cern that food intake and weight will be-
come uncontrollable. Thus, the anorectic
Self-imposed, Rigidly Enforced Dietary woman believes that she cannot be "thin
Restriction. Classically, this is viewed as enough," much less "too thin," because
being at the heart of AN. Thus, in the face of there is always the lurking threat that some-
growing hunger and progressive weight day the floodgates will open and her insatia-
loss, the anorectic individual consciously ble appetite will spring forth to produce not
and deliberately elects to pursue a sustained only a gain in weight but a body of "humon-
course of restricted food intake. As previ- gous" dimensions.
ously noted, carbohydrates and fats are in- Obsessional Preoccupation with Food.
creasingly avoided; while protein is "per- Given the fear of loss of control over eating
mitted," many anorectics go on to become and weight, it is not surprising that the an-
exclusive vegetarians. Rituals in the prepa- orectic's central preoccupation is with food.
ration and consumption of food are also One might, however, view this repetitive,
characteristic. Obviously, such dieting must morbid dwelling on past, present, and future
be differentiated from true anorexia, that is, diet in either biologic terms (i.e., as a reflec-
real loss of appetite, which can occur with tion of starvation's physiologic effects on
certain medical illnesses or affective disor- central nervous system function and conse-
ders. However, as noted earlier, some pa- quently on appetite and related cognition)
tients actually give a history of having lost or psychodynamic terms (i.e., as a reflection
weight in conjunction with medical illness of an unconscious conflicted wish or im-
or depression, only to have the process cat- pulse that underlies the conscious preoccu-
apult them into consciously pursued dieting pation). In either case, the important fact is
with weight loss and, ultimately, full-blown that, increasingly, the anorectic individual
AN. One dilemma for parents, of course, is to devotes her time to fantasies and plans
know when the dieting that is ubiquitous about buying, cooking, and eating various
foods; this obsession progressively im- companies the excessive dieting. While
pinges on all other aspects of her existence. many anorectic women were physically ac-
Distorted Body Image. Facilitating the tive people prior to the onset of their eating
descent into AN is the impaired capacity of disorder, their exercising takes on an in-
its victims to gauge accurately their physical creasingly frenetic quality as the syndrome
dimensions. While normal female adoles- unfolds.13 Like the dieting, the physical ac-
cents generally see themselves as somewhat tivity (most commonly running, calisthen-
larger than they really are (and perhaps this ics, swimming) becomes ritualized and
is one reason for the vulnerability of females rigid. When starvation begins to be serious,
for developing eating disorders), anorectic the hyperactivity will usually give way to
patients markedly overestimate their bodily weakness and lethargy, indicating the need
dimensions—as established by objective for urgent medical care; however, the ex-
studies with distorting lenses, calipers, and treme denial characteristic of these patients
so on.11 Clinically, the 70-lb anorectic adult may permit exercising to continue, some-
will continue to talk about the need to lose times even in the face of advanced emacia-
some poundage here or there, despite her tion.
obvious emaciation. Paradoxically, this ten- Insomnia. Although often overlooked in
dency appears to intensify with progression the early literature on AN, difficulty in both
of the emaciation, thereby further confound- falling asleep and sleeping soundly is a com-
ing attempts at treatment. mon complaint.14 It is not clear whether this
Amenorrhea. Close to 100% of women symptom is a consequence of malnourish-
who meet the above criteria will experience ment, anxiety, mood disturbance, excessive
a loss of menses (or not achieve menarche if exercise, or some other aspect of the syn-
the illness begins prepubertally and goes drome, but it is sufficiently distressing so
untreated). DSM-III-R specifies that at least that many anorectic patients will find them-
three menstrual cycles (exclusive of hor- selves becoming increasingly dependent on
mone administration) should be missed for sedatives, particularly benzodiazepines, to
amenorrhea to be diagnosed in a previously attain satisfactory sleep.
regularly menstruating female. Obviously, Cold Intolerance. Conceivably as a result
there is no analogous feature in men (al- of diminished adipose tissue peripherally
though sperm count does drop signifi- and more likely as a consequence of starva-
cantly). Interestingly, not only does amen- tion's effect on hypothalamically mediated
orrhea usually occur relatively early in the thermoregulation centrally, AN commonly
course of AN, but, in approximately 25% to elicits significant cold intolerance. This
35% of anorectic women, it actually appears symptom, compounded by the psychologic
to occur prior to any significant weight loss defense of denial, accounts for the dress typ-
(although usually after dieting has begun). ical of anorectic women, namely, multiple
Furthermore, menses may take many layers of sweaters or sweatshirts, which
months to resume after weight restoration; both keep them warm and hide their ema-
AN has also developed in women after stop- ciation.
ping oral contraceptives. It is because of Use of Emetics, Cathartics, Diuretics,
aberrations such as these in hypothalamic- and Other Chemical Agents. In addition to
pituitary-ovarian axis function that endocri- their excessive restriction of food intake,
nologists have had a long-standing interest many anorectic women will employ various
in AN.12 external agents to prevent weight gain.
Thus, some will induce vomiting (particu-
Common Features
larly the bulimic subgroup) by mechanical
means (inserting a finger, toothbrush han-
High Level of Physical Activity. A dra- dle, or appliance cord into the throat to trig-
matic and highly prevalent symptom is the ger the gag reflex) or chemical means (usu-
striking level of physical activity that ac- ally with syrup of ipecac). Some will use
enemas or laxatives to "clean out" their gas- sional attention, at some point in their life
trointestinal system (leading to chronic perhaps fully half of all patients with eating
constipation eventually). And still others disorders manifest episodes of depressive
will illicitly take diuretics to minimize the symptomatology that meet the criteria for a
contribution of body fluids to their weight, formal diagnosis of affective disorder.17
thyroid hormone to increase metabolic rate, Thus, they may feel dejected, guilty, pessi-
or amphetamines to suppress appetite.15 mistic, and hopeless; sleep poorly; have dif-
Ritualistic Involvement with Food-Re- ficulty concentrating; and even entertain
lated Activities. Paradoxically, the very ob- suicidal thoughts. Whether such states are a
ject that is dreaded, namely food, is often consequence of starvation,18 reflect a genu-
central not only to the anorectic individual's ine co-morbid affective disorder, are part of
thoughts but also to her behavior. Thus, the affective lability characteristic of a bor-
those with AN appear to derive vicarious derline personality disorder, or are simply
(and probably sadistic) pleasure from reactive to the disruptions in normal living
watching others eat what they have cooked and interpersonal relations invariably pro-
or baked for them. They are often involved duced by an eating disorder remains a con-
in preparing exotic dishes and commonly troversial issue.17 Vegetative signs (e.g., ap-
display various rituals when they eat. petite loss and weight decline, insomnia,
Women with both AN and BN frequently also decreased libido, constipation) are particu-
hoard and steal food, and a substantial num- larly difficult to assess in the presence of an
ber of patients with eating disorders actu- eating disorder; moreover anhedonia, loss
ally work as waitresses. of reactivity to the environment, motor re-
Difficulty in Recognizing Satiation. De- tardation, and diurnal mood variation (i.e.,
spite its formal name, and contrary to some the classic features of melancholia) are
of the earlier writings, AN is not a "nervous characteristically not evident.
loss of appetite" and its victims do experi- Obsessional Features. Between 25% and
ence hunger pains (at least before the dis- 50% of all anorectic patients manifest behav-
ease has entered the chronic phase). How- ioral and cognitive patterns typical of obses-
ever, they are subject to real difficulty in sive-compulsive disorder.19 Thus, eating
experiencing (or, more likely, interpreting) and exercise rituals, compulsive hand wash-
sensations of satiation. They will often coming or checking, obsessive ruminations, ex-
plain of being unable to know whether they cessive perfectionism, and so forth, are
are full or still hungry after eating a meal. common. Most of these individuals give his-
Drug Abuse. About one quarter of all eat- tories of similar tendencies prior to the
ing-disorder patients (almost all of whom onset of the eating disorder, but it should
are anorectic-bulimic or just bulimic) give also be noted that starvation studies in nor-
prior or concurrent histories of drug abuse, mal volunteers have established that obses-
typically with sedatives and/or with stimu- sive-compulsive, as well as affective, distur-
lants (which, of course, may also serve as bances can be a common consequence of
anorexogenics). Cocaine use is common, starvation.18
but heroin use is rare. These patients, who
frequently also carry a diagnosis of "border-
Bulimia IMervosa
line personality," appear vulnerable to drug
abuse by virtue of their emotional lability, As described earlier, BN will evolve either
impulsive tendencies, and general anxiety, in the context of established AN or indepen-
as well as their specific panic over possibly dently of it, but typically in one who has fre-
losing control of their weight.16 quently dieted and experienced weight fluc-
Depressive Symptomatology. Although tuations. Characteristically, the binge takes
it is the symptomatology surrounding food, place in private, usually during the evening
eating, and weight that usually brings the in- hours, and involves the consumption of
dividual with an eating disorder to profes- huge quantities of food (often thousands of
calories in the same sitting). The binge BIOLOGY OF EATING

foods are commonly those that are most as- DISORDERS
siduously avoided during the rest of the bu-
limic's day, namely carbohydrate-rich While the psychologic and behavioral fea-
items, but virtually any morsel of food in the tures of the eating disorders obviously pro-
house is a potential target of the binge. Typ- duce a dramatic clinical picture, it is com-
ically, the binge terminates in self-induced monly the ensuing impaired physiology that
vomiting. Although most bulimic women brings the afflicted individual to medical at-
vomit, however, not all do, and vomiting tention. The biology of AN is essentially the
should not be considered a prerequisite for biology of starvation, whereas the biology of
the diagnosis of BN. Some individuals sim- bulimia is principally a reflection of the
ply exhaust themselves from the binge and physiologic derangements produced by
eventually settle into a troubled sleep; oth- chronic vomiting and/or laxative/diuretic
ers will try to compensate by using laxatives abuse, as well as by the violent swings in
or enemas, as well as by dieting excessively food consumption.
between binges.
The binge, which may occur anywhere Physical Sequelae
from several times per 24-hour period to
several times per month (at least twice per The physical consequences of the eating
week for at least 3 months, according to disorders are summarized in Table 17-1. It
DSM-III-R9), elicits enormous personal should be noted that the not uncommon
shame. Not only are patients disgusted with combination of AN and BN in the same in-
themselves, but they are also initially un- dividual creates the possibility of findings
willing to discuss their symptoms with any- from both disorders being present simulta-
one else. (This may account for the paucity neously in that person. Moreover, even in
of references to bulimia in the literature the normal-weight bulimic woman, the fre-
until the past two decades, when it began to quent interbinge dieting and postbinge vom-
"come out of the closet.") More importantly, iting can produce physical effects similar to
each binge triggers off an ever-greater re- those seen in the pure restricting anorectic
solve to diet, and this only intensifies the woman; for example, while osteoporosis is
fast-feast cycle. As with the anorectic pa- well known to occur in women with AN, it
tient's eating, the bulimic patient's binge has now also been documented in women
can become ritualized. Thus, the time, set-
ting, and type of food become increasingly Table 17-1. POTENTIAL PHYSICAL
FINDINGS IN EATING DISORDERS
important and fixed. However, in those bu-
limic persons who vomit, the vomiting can Anorexia Nervosa
take on its own significance, eliciting rein- Emaciation
forcement from the physical relief it pro- Dry skin
vides for the abdominal discomfort, emo- Lanugo (fine downy hair)
tional relief for the concern and guilt about Loss of scalp hair and brittle nails
Cold extremities with impaired temperature regulation
having consumed so many calories, and per- Hypotension
haps psychologic relief via symbolic reso- Bradycardia
lution of unconscious conflicts about such Cardiac rhythm disturbances
matters as sex, pregnancy, and relationship Edema
with parents. As DSM-III-R notes,9 a persis- Bulimia Nervosa
tent overconcern with body shape and Tooth decay
weight is not confined to restricting (i.e., Salivary gland enlargement
nonbulimic) anorectic women but is also Calluses on hands
characteristic of normal-weight bulimic Facial and other petechial hemorrhages
women. Cardiac rhythm disturbances
with BN,20 reflecting both decreased estro- Table 17-2. POTENTIAL RADIOLOGIC,
gen and increased cortisol production.21 ELECTROCARDIOGRAM, AND
ELECTROENCEPHALOGRAM FINDINGS IN
The degree of emaciation in AN will obvi- EATING DISORDERS
ously depend on the net caloric balance be-
tween the limited food intake and the typi- Anorexia Nervosa and Bulimia Nervosa
cally excessive exercise expenditure; in BN, Osteoporosis on x-ray
weight will reflect the balance among bing- Diminished gastric emptying on fluoroscopy
Cerebral atrophy and ventricular enlargement on CAT
ing, vomiting, possible cathartic use, possi- scan or MRI
ble substance and medication abuse, possi- Conduction, wave, and rhythm changes on
ble excessive exercising, interbinge dieting, electrocardiogram
and so on, so that the individual might be Nonspecific spike abnormalities on
below, at, or above ideal body weight. The electroencephalogram
possibility of deception about weight by pa-
tients with AN (whether by outright lying,
adding weights to one's body or clothing, or in both anorectic and bulimic women, and
filling oneself up with water) should always are discernible with special procedures
be borne in mind by the examining physi- (Table 17-2). For instance, cerebral atrophy
cian. and ventricular enlargement in the brain
The diminished sympathetic tone conse- have been reported in patients with either
quent to starvation in AN is associated with AN23 or BN,24 and presumably are conse-
bradycardia and lowered blood pressure. quent to malnutrition and reversible. De-
But what has also become evident is that layed gastric emptying can also occur in
more serious cardiac complications of star- both groups, possibly consequent to such
vation—such as rhythm disturbances, mi- gastric insults as inadequate bulk intake, re-
tral valve prolapse, and congestive heart peated vomiting, or bizarre diets. Electro-
failure—are not rare.22 The perils of contin- lyte imbalance from vomiting, particularly
ued intensive exercise as AN progresses are hypokalemia, can produce significant, even
evident in light of these potential cardiac fatal, abnormalities in cardiac function, and
problems. thus an electrocardiogram should be ob-
The salivary gland enlargement seen with tained for all vomiters; moreover, the fre-
binging and vomiting, while of a benign na- quently abused emetic, syrup of ipecac, can
ture (sialoadenosis), can combine with the produce a serious cardiomyopathy.25 Fi-
not infrequently seen edema in eating dis- nally, about 25% of all eating-disorder pa-
orders to reinforce the patient's conviction tients demonstrate nonspecific abnormali-
that she is fat and must thus further intensify ties on electroencephalography, usually
her dieting efforts. The tooth decay in BN is unilateral or bilateral spikes in the tempo-
a direct consequence of gastric juices bath- ral-occipital region; the basis for this finding
ing tooth enamel during repeated vomiting, is not known, but such EEG abnormalities
while calluses on the hands are produced by are what prompted one of the earliest phar-
the patient repeatedly sticking her fingers macotherapy trials in this field, using phe-
down her throat to elicit the gag reflex. Pe- nytoin.26
techial hemorrhages can occur in the face,
cornea, or soft palate following an extreme Laboratory Findings
episode of binging and vomiting.
The typical laboratory abnormalities in
Radiologic, ECG, and EEG
AN and BN are presented in Table 17-3. (En-
docrine abnormalities are treated sepa-
Abnormalities
rately.)
In addition to osteoporosis, several other A moderate anemia is not unusual in AN.
physical and physiologic changes can occur Hematocrit values under 35% and hemoglo-
Table 17-3. POTENTIAL LABORATORY of bulimic women, despite their adequate

FINDINGS IN EATING DISORDERS net caloric state.
Anorexia Nervosa Vomiting is particularly pernicious be-
Anemia and leukopenia cause of its possible effects on electrolyte
Partial diabetes insipidus balance. The low potassium level and meta-
Glucose tolerance abnormalities bolic alkalosis it produces can lead to car-
Abnormal liver function tests diac arrhythmias and even to cardiac arrest
Elevated serum cholesterol, carotene, and uric acid
levels
and death. Vomiting may also lead to dehy-
Depressed serum or urinary zinc, magnesium, and dration, which can then confuse the inter-
copper levels pretation of electrolyte values by producing
spuriously high figures.
Bulimia Nervosa
Other laboratory abnormalities in AN can
Evidence of dehydration (e.g., elevated BUN)
Hypokalemia, hypochloremia, and metabolic alkalosis
include an elevated level of plasma caro-
(but possible metabolic acidosis in laxative abuse) tene, in part due to the high carrot consump-
Elevated serum amylase tion characteristic of anorectic patients (be-
Glucose tolerance abnormalities cause of the low calorie value of carrots) but
possibly also related to low thyroid (partic-
ularly T3) values; hypoproteinemia and liver
enzyme abnormalities in severe and chronic
bin levels under 11.0 g/dL are common, and cases (although characteristically uncom-
a panleukopenia also is not rare. The excre- mon in earlier cases); and hypercholester-
tion of large amounts of dilute urine, reflect- olemia, perhaps also secondary to low T3
ing partial diabetes insipidus, can appear if values. The serum uric acid level may rise,
starvation becomes severe and chronic and the serum or urinary zinc, magnesium,
enough to affect hypothalamic function, and copper levels can decline.
renal function, or both. Diabetes mellitus- Moderately elevated serum amylase lev-
like changes in glucose tolerance test results els occur in at least 25% of bulimic patients
will also begin to appear with long-term consequent to excessive salivary gland ac-
avoidance of carbohydrates: fasting blood tivity in response to the frequent binging.
sugar falls to relatively low levels (less than Fractionating the serum amylase, however,
70 mg/100 mL), an excessive and sustained will prevent overlooking a pancreatitis,
rise is noted after glucose load (greater than which can also occur in BN and may be the
180 mg/100 mL), and a "rebound" hypogly- source of the elevation.29
cemia (less than 50 mg/100 mL) may appear
as a delayed but excessive insulin outpour-
ing then occurs. Patients will often claim Endocrine Abnormalities:
that their "problem" is "hypoglycemia," Hypothalamic Implications
while physicians may actually propose the Because of the consistent and often early
presence of diabetes, but these glucose ab- occurrence of amenorrhea in patients with
normalities are the consequence, not the AN, the endocrinology of AN has undergone
cause, of the chronic starvation and erratic substantial investigation. As shown in Table
carbohydrate consumption. Interestingly, 17-4, the characteristic endocrine abnor-
despite being at seemingly normal weight, malities have now been well delineated.
bulimic individuals can also have a low When taken as a group, these findings
serum glucose level27 and can show a lower- strongly suggest that hypothalamic function
than-expected rise on intravenous glucose is impaired in those with AN.30,31 This possi-
challenge (which paradoxically can set off bility is further reinforced by the previously
subjective cravings for carbohydrates).28 noted abnormalities in temperature regula-
These findings presumably reflect the tion and urine concentrating ability com-
highly chaotic, nonnutritional dietary intake monly seen with AN.
Table 17-4. POTENTIAL ENDOCRINE titive behavior, thus creating a vicious

FINDINGS IN ANOREXIA NERVOSA circle.32
Hypothalamic-Pituitary-Gonadal Axis Abnormalities While these endocrine aberrancies have
• Depressed plasma and urinary concentrations of
been well documented in most women with
gonadotropins (LH and FSH) in the face of AN, hypothalamic-pituitary-gonadal/adre-
depressed concentrations of estrogens and nal abnormalities are also not infrequently
androgens present in women with BN.33 Such findings
• Immature circadian LH secretory pattern again serve to remind us that bulimic
• Absence of monthly cycling in LH secretion
• Deficient LH "feedback" response to administered
women of totally normal weight do not eat
clomiphene citrate or ethinyl estradiol normally and are often malnourished de-
• Usually deficient LH response to administered spite their seemingly normal appearance.
releasing hormone (LHRH), although correctable by
daily "priming" with LHRH.
Hypothalamic-Pituitary-Adrenal Axis Abnormalities DIAGNOSIS, COURSE, AND
• Elevated concentrations of plasma and urinary PROGNOSIS OF THE EATING
cortisol (but usually with maintenance of normal DISORDERS
circadian rhythm)
• Diminished cortisol suppression by dexamethasone In its typical presentation, and given the
administration
• Elevated cortisol production rate (despite the
considerably enhanced sophistication in re-
elevated plasma level of cortisol) cent years of both professionals and lay per-
sons in this area, the diagnosis of AN will
Growth Hormone (GH) Abnormalities pose little problem. Although several medi-
• High-normal or slightly elevated concentrations of cal and psychiatric conditions are also as-
plasma GH
• Impaired GH response to induced hyperglycemia
sociated with weight loss (Table 17-5), the
and hypoglycemia, L-DOPA, and TRH anorectic patient's characteristic adoles-
cent age, otherwise good physical health,
Hypothalamic-Pituitary- Thyroid Axis Abnormalities and obvious pleasure in her increasingly
• Low normal concentration of plasma T4 and skeletonlike appearance should elicit little
distinctly low T3
• Low or low normal concentration of plasma TSH
diagnostic confusion. Problems can arise
(despite low T3 and possibly low T4 levels) from the following confounding sources: de-
• Normal (or delayed but correctable with priming) ception about true weight or other symp-
TSH response to administered TRH
Table 17-5. DIFFERENTIAL DIAGNOSIS

FOR ANOREXIA NERVOSA
We assume that this hypothalamic dys-
function is a consequence of the starvation Psychiatric Conditions
and extreme weight loss in patients with AN. • Depression
However, other variables conceivably play a • Mania
• Schizophrenia (paranoid)
role, such as the bizarre dietary intake (i.e.,
malnutrition as distinct from calorie insuffi- Medical Conditions
ciency), psychologic factors (such as anxi- • Malignancy
ety or depression), impaired sleep-wake • Hypothalamic tumor
patterns, and even excessive exercise. Al- • Diabetes, hyperthyroidism, other endocrinopathies
• Infectious diseases (infectious mononucleosis,
though there is no firm evidence that the hy- tuberculosis, etc.)
pothalamic dysfunction precedes AN, it is • Gastrointestinal disorders (malabsorption
conceivable that AN can adversely affect hy- syndromes, regional enteritis, ulcerative colitis,
pothalamic function and thereby second- etc.)
arily impair hypothalamic control of appe- • Chronic alcoholism or other substance abuse
toms by the patient, later age of onset (an in- family therapy,35 but most workers in the
creasing number of cases now appear to be field report less successful results.11,34,36 A
starting in the third, fourth, and even fifth consensus might be that about 40% of all
decades of life), or the simultaneous pres- treated eating-disordered patients recover,
ence of some other weight-losing condition about 30% show moderate but not definitive
to which the physician totally attributes the improvement, and about 30% run a chroni-
emaciation (e.g., substance abuse). Clearly, cally debilitating course (in which group
alertness to these possibilities is indicated will be found the 5% to 10% who die of the
when a person is suspected of having an eat- illness). Clearly, the eating disorders should
ing disorder but does not quite fit the typical not be considered benign conditions.
mold. Bulimia nervosa, of course, might be
missed because of the usually normal weight
of its sufferers, but, unlike women with AN, CO-MORBIDITY
women with BN who consult a physician
usually do so of their own accord and are One of the more important developments
thus more committed to discussing their dif- of the past decade of clinical research in the
ficulties honestly. eating disorders has been the documenta-
One of the extraordinary aspects of the tion that there is substantial psychiatric co-
eating disorders is that the outcome is so morbidity with AN and BN. Whether these
variable and unpredictable. At one end of conditions are antecedents, concomitants,
the spectrum, probably a significant number or consequences of the eating disorders, or
of teenage girls "flirt" with AN, some per- whether they share similar etiologic or pre-
haps even crossing over the border, only to disposing factors, is not clear, but it is now
respond to their parents' or physician's well established that at least four areas of
guidance or to their own good sense, and re- psychopathology occur in eating disorder
turn to more normal eating and weight. At patients with an incidence beyond what
the other end are the 5% to 10% of patients chance alone would predict. The areas are
who will die of direct complications of their depressive disorders, anxiety (including ob-
eating disorder. The causes of death are car- sessive-compulsive) disorders, substance
diovascular collapse or cardiac arrest (par- abuse, and personality (particularly border-
ticularly due to electrolyte imbalance from line) disorders. While the incidence of the
vomiting or cardiac toxicity from abuse of co-morbidity will vary with the category of
syrup of ipecac), overwhelming sepsis (due psychopathology, the type of eating disor-
to compromised immune function second- der (AN versus BN), and the setting in which
ary to starvation), or suicide. incidence is being determined (inpatient
Between these extremes, various courses versus outpatient versus community sur-
and outcomes are possible: a single full- vey), it is probably safe to say that up to 75%
blown episode, recurring discrete episides, of all eating-disorder patients will manifest
or chronic disorder. The appearance of bu- at least one of these areas of co-morbid-
limia in AN is usually regarded as a particu- ity.19,37
larly ominous prognostic sign because of its The presence of such co-morbidity has
known likelihood to become associated with several ramifications. First, it is incumbent
chronicity, although, paradoxically, it may upon the treating physician to be alert to the
somewhat alleviate the emaciation prob- presence of these other conditions. Second,
lem.34 Moreover, as we shall discuss farther it is likely that a concomitant psychiatric
on, the frequent presence of co-morbid con- disorder will have an adverse influence on
ditions can further complicate the course the course of the eating disorder. Finally,
and prognosis of both AN and BN. the diagnosed presence of a co-morbid con-
Minuchin and co-workers have claimed a dition means that the treatment plan will
better than 85% cure rate with their form of have to be comprehensive enough to in-
elude provision for both the eating disorder of mastery and effectiveness but also helps
and the co-morbid disorder(s).38 to define her as someone special; that is, her
unique appearance shores up her precari-
ous self-image and meager sense of identity.
THEORIES OF ETIOLOGY Because this scenario is played out in the
context of the adolescent's family, however,
The wide range of symptoms and signs subsequent investigators, such as Palazzoli41
found in the eating disorders has elicited an and Minuchin and co-workers,35 have em-
equally broad array of proposals to "ex- phasized the importance of understanding
plain" them. Yet, as our experience and so- and treating the family as a system. Thus,
phistication with these syndromes have in- AN not only has significance for the diag-
creased, we are becoming more cautious nosed anorectic patient, but also reflects
about accepting simple etiologic formula- pathologic roles and relationships in the
tions. family. Minuchin's group identified four spe-
Perhaps the first significant contribution cific characteristics of such families: their
historically to our understanding of eating- members are excessively enmeshed in each
disordered individuals, particularly those other's affairs, severely mutually overpro-
with restricting AN, was made by Hilde tective, rigid in their style of relating to each
Bruch,39 who moved away from a symbolic- other and to the outer world, and unable to
libidinal-conflictual framework—for exam- achieve appropriate resolution and closure
ple, seeing AN as a defense against an un- on family conflicts. In this framework, AN
derlying wish for oral impregnation— represents an attempt on one level to
toward more of an ego psychology frame- achieve at least some "space" and auton-
work. For Bruch,40 AN came to represent a omy within the family unit, while ensuring
desperate attempt by the vulnerable adoles- on another level that threats to the homeo-
cent to achieve a sense of identity and mas- stasis of the family constellation—for ex-
tery independent from that of her overbear- ample, by the designated patient's truly ma-
ing and intrusive parents (particularly turing and moving out on her own—are
mother). She speculated that the mother's thwarted.
insensitivity to physiologic and emotional Still other themes have been emphasized
cues provided by the infant resulted in the by various writers: the need to keep the
developing child's experiencing deficien- body in a state of biologic immaturity to
cies and confusion in identifying affective avoid confronting sexual impulses and het-
and visceral experiences and thus in gaining erosexual relationships;42 the response to a
a reliable sense of self. This would lead to a cultural milieu that promises women happi-
basic sense of ineffectiveness, perplexity ness and success if thinness can be at-
over bodily sensations, and disturbances in tained;4 and the symbolic attempt to rid the
body image. In the context of the develop- self of the bad mother—with whom the an-
mental transition of puberty and adoles- orectic woman identifies her body—by lit-
cence—producing such stresses as bodily erally starving it.41 (The bulimic woman, on
changes, separation, heterosexual encoun- the other hand, might be attempting to re-
ters, increased independence and respon- gain mother by excessive eating or even by
sibility, and scholastic demands—the an- regurgitating back the lost object.43)
orexia-vulnerable person, who senses a Unfortunately, all of these formulations,
family need for high achievement but who whether intrapsychic, interpersonal, famil-
has little confidence in her capacity to be ial, or sociocultural, are based on observa-
successful, presumably turns increasingly tions made after the fact. Thus, inferences
toward her own body as the one area in her are offered about premorbid characteristics
life that she might truly control. Moreover, not only after AN has been diagnosed but
her thinness not only re-establishes a sense also commonly after it has been present for
months or years. The impact of such a per- Table 17-6. RISK FACTORS FOR THE
nicious condition on self-esteem, family dy- DEVELOPMENT OF ANOREXIA NERVOSA
namics, and perception of the environment Cultural Risk Factors
cannot be readily determined; predispos- • Westernized and contemporary culture
ing, precipitating, and perpetuating ele- -Equates thinness with both beauty and happiness
ments tend to become confused. Moreover, -Emphasizes attention to self and body
many of the common conflicts described -Demands varied, and at times conflicting, roles of
(e.g., conflicts over separation, indepen- women
• Capable of readily disseminating cultural values and
dence, and sexuality) are characteristic of styles through visual media (e.g., movies, television,
normal adolescence as well, and the more magazines)
pathologic features of self and family (e.g., • Has subcultures that particularly emphasize weight
feelings of emptiness and enmeshment) are control (e.g., ballet, modeling, certain sports)
common to other pathologic, but non- • Other?
eating-disordered, conditions such as "bor- Family Risk Factors
derline" and "psychosomatic" disorders. • Achievement-oriented
For all these reasons, workers in the field • Intrusive, enmeshing, overprotective, rigid, unable
have begun to move toward a "risk-factor" to resolve conflicts
model for the eating disorders.44,45 Rather • Frugal with support, nurturance, encouragement
• Overinvested in food, diet, weight, appearance, or
than postulating a specific etiology, we have physical fitness
come to recognize that a variety of factors— • Known to have members with a formal history of
cultural, familial, and individual—increase eating disorder or affective disorder
one's vulnerability to developing an eating • Other?
disorder (Table 17-6). As the number and Individual Risk Factors
intensity of these risk factors increase, the • Female
vulnerability does as well. However, clearly • Adolescent
not all persons with eating disorders need • Slightly overweight
have exactly the same risk factors, and some • Subject to feelings of ineffectiveness and low self-
persons with some risk factors might never esteem
• Subject to conflicts and doubts about sense of
develop a manifest eating disorder; protec- personal identity and autonomy
tive individual and family characteristics, • Subject to bodily perceptual disturbances (e.g.,
individual biologic differences, and seren- distorted body image, uncertain feelings of satiation
dipity in life events could serve to modify after meals)
onset, course, and outcome. • Subject to overgeneralization and other cognitive
distortions
Moreover, the sustaining effects of star- • Subject to an obsessional style and conflicts about
vation and malnutrition in patients with AN control
should not be overlooked.32 As dieting be- • History of childhood sexual abuse
comes prolonged, its impact on digestive ca- • Other?
pacity and function, endorphin levels, hy-
pothalamic function, cognitive capacity,
affective state, body image, menstrual regu-
larity, response of peers, and so forth, may BN. While only a minority of bulimic women
actually serve to reinforce further food have a prior history of formally diagnosed
avoidance, thereby creating an increasingly AN, the overwhelming majority are chronic
self-perpetuating, treatment-resistant situa- or intermittent dieters whose weight fre-
tion. quently fluctuates substantially.3,46 On the
Finally, whereas most of the focus in the biologic side, the loss of substantial weight
eating-disorder literature has been on the (even if not to emaciated levels—e.g., an
etiology and pathogenesis of AN, we are now obese individual who diets to reach merely
also beginning to understand more ade- normal weight47), in the face of ongoing, se-
quately the nature of the vulnerability for verely restricted dietary intake, intensifies
the drive to eat. On the psychologic side, therapist must be prepared to deal with ed-
this drive will most likely be responded to in ucational issues (e.g., about food, calories,
excessive fashion (i.e., by binging) when the dieting), cognitive issues such as styles of
individual is also characterized by so-called thinking (e.g., all or none, overgeneralizing,
borderline features (impulsivity, emotional personalizing), and psychodynamic issues
instability, an all-or-nothing orientation to (e.g., ambivalence toward parents, compet-
life, feelings of inner emptiness, and so on). itiveness with siblings, fantasies about one's
Thus, it is the mesh between biologic and body). Furthermore, the therapist must be
psychologic vulnerabilities that "loads the supportive, reliable, and respectful, and
dice" for the emergence of BN. must be prepared to address concrete is-
sues concerning weight, while not permit-
ting this to become the exclusive focus of
TREATMENT therapy.
The critical place of the family as the bat-
While the number of controlled studies on tleground upon which an eating disorder
the efficacy of various treatment approaches evolves suggests that family therapy is at
to the eating disorders still remains rela- least as important as individual therapy,
tively small, there has been a significant in- particularly in younger patients living with
crease over the past two decades in such their families.35,41 Family therapy will em-
studies, as well as in empirical clinical ex- phasize the workings of the family unit as a
perience in the management of AN and system and its need to be more flexible and
BN 34,46,48 No sure.fire treatment for either less intrusive in response to perturbations
condition has been found, but certain guide- produced by any of its members. Ideally,
lines have begun to emerge. this will complement concurrent individual
Perhaps the most important principles in therapy.
the treatment of the eating disorders are (1) Group therapy for the treatment of BN has
the earlier the intervention, the greater elicited considerable interest in recent
is the likelihood of response; (2) the treat- years.46 Whereas nonbulimic anorectic
ment approach should be tailored to the women tend to say little in groups and ac-
phase, severity, and setting of the disorder, tually can become competitive with each
and also to the unique characteristics of the other over success in losing weight, bu-
individual patient; (3) multimodal treatment limic women tend to be more open about
is more likely to be effective than unimodal their feelings in a group and also to bene-
treatment; and (4) open-mindedness and fit from being confronted about their secre-
flexibility on the part of the therapist or tive gorging and purging behaviors.
treating team are crucial. Moreover, most therapy groups also
Whereas young adolescents who have just incorporate cognitive-psychoeducational-
begun to diet excessively may respond to a behavioral elements, often in the context of
good "educational" talk from a trusted pe- a time-limited course of treatment, which
diatrician, individuals with more estab- can be effective in dealing with and aborting
lished cases of AN will require, at the very eating and thinking patterns that tend to
least, individual psychotherapy with a pro- perpetuate the starve-binge cycle.
fessional who has had experience working While the aforementioned approaches are
with eating-disordered patients. The ther- germane to the patient with relatively early
apy will typically focus progressively on AN or BN, as well as to the chronic but rel-
concerns about control, self-esteem, and atively stable patient, the importance of hos-
sense of identity; on recognizing and ac- pital treatment for the acutely starving ano-
cepting bodily feelings and emotional rectic individual or the severely bulimic
states, and on facing the anxieties inherent person in electrolyte imbalance—or both,
in becoming an independent adult. The when they have lost control of their day-to-
3O6 Special Issues and Concerns
day life to the eating disorder—should not unit activities, the most potent reinforcer—
be minimized. Because restricting anorectic and one with obvious relevance to this
patients can lose weight precipitously, med- book— may well involve access to exercise.
ical involvement should be a principal part The importance of exercise in the mental
of both the initial evaluation and subsequent economy of most anorectic individuals has
outpatient treatment. Not only is the extent been demonstrated by Blinder, Freeman,
of weight loss important, but the rate must and Stunkard.49 Using a behavioral paradigm
also be considered. Some chronic patients in which access to exercise was contingent
may be able to sustain a weight at 35% below on sufficient daily weight gain, they docu-
their ideal after many years of AN, whereas mented that significant and rapid improve-
a patient who has dropped to 25% below ment in weight could be attained during hos-
ideal in just a few months may represent an pitalization.
acute medical emergency. Clearly weight, Whether on an inpatient or outpatient
electrolytes, blood chemistries, cardiac basis, medication has also begun to be part
function, pulse, and blood pressure must be of the therapeutic armamentarium. While
carefully examined to make a judgment the earlier literature mainly emphasized the
about the need for hospital admission, but use of chlorpromazine (Thorazine) in the
compulsive exercise, food-related rituals, or acutely agitated, excessively exercising an-
numerous daily binges that interfere with orectic inpatient, the more recent emphasis
the patient's functioning or interpersonal has been on the use of antidepressants, par-
relations are also indications for hospital- ticularly the monoamine oxidase inhibitors
ization. (MAOIs); the tricyclic antidepressants; and
The inpatient setting ideally would be a the serotonergic agent fluoxetine (Prozac),
unit specifically geared for eating disorders. for the treatment of BN.50 The rationale for
If necessary, however, a general medical or their use has been the seeming overlap in
psychiatric floor can provide several impor- clinical, familial, and laboratory features in
tant aspects of treatment. In addition to on- bulimia and affective disorders, but this ex-
going physiologic monitoring and support- planation remains controversial. Neverthe-
ive nursing, a hospital permits electrolyte less, while controlled studies do suggest a
correction with intravenous fluids, external statistically significant reduction in fre-
restraints on binging and vomiting, appli- quency of binges when these drugs are taken
cation of a comprehensive behavior modifi- at therapeutic doses, a positive response is
cation regimen to encourage weight gain, far from universal, and relapse both on and
use of medications as indicated, and, in rare off medication is not uncommon.51 More-
life-and-death circumstances, hyperalimen- over, side effects are poorly tolerated, and
tation (total parenteral nutrition) through bulimic patients who may binge on tyra-
an indwelling catheter in a subclavian vein. mine-containing foods are obviously not
If the patient not only is severely emaciated candidates for treatment with an MAOI. As
but also categorically refuses to eat, feed- noted earlier, the not-infrequent combina-
ings through a nasogastric tube also become tion of EEG abnormalities and eating disor-
an option. ders has spurred interest in the application
A behavior modification approach as- of anticonvulsants for binging, and both
sumes that the aberrant eating pattern, phenytoin (Dilantin) and carbamazepine
whatever its original determinants, has be- (Tegretol) have been reported as helpful;
come a "habit" by the time that hospitaliza- however, controlled studies on efficacy have
tion becomes necessary. Thus, it might best not been impressive.51 Finally, lithium has
be undone, like most habits, by the institu- also been reported to be beneficial in BN,51a
tion of an appropriate schedule of positive but again without the benefit of controlled
and negative reinforcers. Although common studies.
contingencies might include, for example, The only pharmacologic agent that has
loss of visiting privileges or access to off- been shown to produce even a slight statis-
tical advantage in treating restricting AN is these issues has increased considerably

cyproheptadine (Periactin), an antihista- over the past decade. For example, serious
mine.52 While the efficacy of this drug is long-distance running triggering the emer-
hardly profound, it is worthy of mention for gence of classic AN has been described,53
two reasons. First, its sedating effect can be but this appeared to represent the precipi-
helpful in dealing with the insomnia char- tation of an eating disorder in persons who
acteristic of AN. Second, its antiserotonergic already had a strong predisposition for its
properties seem to stimulate appetite, while development.
fluoxetine, fenfluramine, and other seroto- Indeed, with so many people running and
nergic agents appear to damp down bulimic exercising, we would be faced with an epi-
behavior.52a demic of AN or BN if such activities could ac-
It must, of course, be noted that the eating tually "cause" an eating disorder. Neverthe-
disorders become chronic conditions for less, the appearance of progressive weight
many, if not most, of those afflicted with loss, amenorrhea, and increasing preoccu-
them. The therapist must often be prepared pation with calorie intake in a female athlete
to engage in long-term treatment, to use should alert the team physician or trainer to
multiple modalities (including hospitaliza- the possibility that the ordinarily high level
tion when indicated), and to be willing to of physical activity may be evolving into a
settle for goals that emphasize minimizing manifest eating disorder. Possible biologic
morbidity rather than achieving full cure. In- and psychologic mechanisms mediating
deed, those patients and therapists who this phenomenon have been proposed.53
seek quick remedies are likely to meet only The relationship between chronic exten-
with frustration. sive exercise and anorexia nervosa remains
controversial. Eisler and Le Grange54 have
proposed four different models: (1) these
EXERCISE AND EATING are distinct phenomena which superficially
DISORDERS resemble each other because the use of ex-
cessive exercise to work off calories is char-
As indicated in the introduction to this acteristic of AN, and athletes need to control
chapter, the inclusion of substantial mate- weight to ensure maximum performance;
rial on the eating disorders in a text devoted (2) these are overlapping phenomena, with
to women and exercise was prompted by each increasing the risk for developing the
several important concerns. Can vigorous other; (3) both phenomena are related in
exercise or athletic competition "cause," in- some fashion to a third variable (e.g., obses-
crease the risk for developing, or precipitate sive-compulsive tendencies or affective dis-
an eating disorder? Do people with a predis- order), and thus occur together with more
position for an eating disorder commonly than chance frequency; (4) these are essen-
gravitate toward sports? Might physical ac- tially variants of each other, with sexual, fa-
tivity in some fashion actually protect milial, developmental, and cultural factors
against the emergence of an eating disor- accounting for why one or the other expres-
der? Why is exercise so important to most sion of the underlying basic vulnerability
persons who are anorectic? What impact becomes manifest in a given individual.
does continuing to exercise have on the an- Clearly, the last of these models is the
orectic patient's attempt to regain weight most interesting and also the most provoc-
with treatment? These and other questions ative. Impetus for it came from a report by
are being asked with increasing frequency Yates and colleagues that appeared in the
because of the growing number of women New England Journal of Medicine?55 These au-
who are active athletically and the growing thors reported that psychologic interviews
number of women who develop AN or BN. of male obligatory runners (men who ran a
While definitive answers to these ques- minimum of 50 miles per week) revealed so-
tions are not available, our understanding of cioeconomic and personality characteris-
3O8 Special Issues and Concerns
tics strikingly similar to those reported in sures and demands of the sport but should
anorectic women. They speculated that not be confused with the deep premorbid
obligatory running in men and AN in women psychopathology of those with bona fide
both represent unconscious attempts to es- AN.58
tablish a more definitive sense of identity Several more recent studies also raise
and effectiveness. Cultural values simply questions about any underlying, fundamen-
make it easier, they proposed, for men to use tal (as opposed to a preciptating or perpet-
running and women, dieting. Moreover, uating) relationship between extensive ex-
they suggested that members of either sex ercise (or competitive sports) and eating
who use running to solve problems of iden- disorders. Owens and Slade,59 for example,
tity and effectiveness will be subject to de- gave a questionnaire to 35 female marathon
pression and manifest eating disturbances runners and found that, while their scores
when they cannot run (for example, if they on the "Perfectionism" scale resembled
have been injured); this possibility is con- those of anorectic patients, their "Dissatis-
sistent with case reports.53 faction" scores were similar to those of nor-
In a recent book,56 Yates has amplified mal control women and significantly lower
these views. She proposes that at least some than those of anorectic patients. Richert and
cases of eating disorders and some cases of Hummers60 found no correlation between
compulsive exercising do not necessarily scores on the Eating Attitudes Test and
have their roots in psychopathology. hours devoted weekly to a variety of physi-
Rather, they represent a striving for excel- cal activities (e.g., swimming, bicycling), al-
lence, whether by dieting or exercising vig- though, interestingly, hours spent jogging
orously, but that, as the balance between ca- per week did show a significant correlation
loric intake and expenditure begins to with EAT scores, perhaps lending some sup-
diminish, the ensuing physiologic depriva- port to the thesis that runners represent a
tion elicits biologic mechanisms that serve unique group among exercisers. On the
to perpetuate the process. For example, other hand, Warren and co-workers,61 look-
acute exercise transiently damps down ap- ing at a variety of physical, behavioral, and
petite, while loss of weight may produce de- attitudinal measures in a group of college
creased gastric capacity and feeling full athletes versus nonathletes, found no differ-
quickly after relatively little intake; as ap- ences in varsity cross-country runners (un-
petite then progressively builds and be- like Richert and Hummers) or in a variety of
comes intense, the fear of utterly losing con- other varsity athletes, but did find signifi-
trol becomes so anxiety-provoking that the cantly more pathologic scores in varsity
exercising and dieting are further intensi- gymnasts.
fied by the performance/appearance-ori- That athletics might actually be protective
ented individual. Pathologic runners also against the emergence of an eating disorder
seem to have, in Dr. Yates' view, the same remains a possibility. For example, a study
ambivalent feeling toward their body as AN of college women engaged in intramural
patients, being prepared to inflict pain on it sports between 1977 and 1982, when the in-
in order to conform to some preconceived cidence of AN was clearly increasing, found
ideal. no evidence of low weight for height among
Nevertheless, the view that running is an the study subjects.62 While women not vul-
analogue of AN has been questioned by Blu- nerable to AN might be attracted to college
menthal and co-workers.57 Using more pre- intramural sports, or eating disorders might
cisely defined and quantitative psychologic be common among such women but be hid-
assessment scales, they could not replicate den by concomitant BN which maintains
the qualitative impressions of Yates and as- weight at a generally normal level, it is also
sociates. Moreover, it has been argued that conceivable that athletics contain physio-
the weight loss and food aversions common logic or psychologic elements that are, in
to many serious athletes reflect the pres- some manner, protective against the devel-
opment of AN. Further support for such a arrhythmias, loss of physical strength, de-
thesis might be seen in a study of both ab- hydration, and electrolyte imbalance that
normal eating attitudes and manifest AN in characterizes these syndromes.
a large number of long-distance female run- Once involved with athletic activity, some
ners.63 While 14% revealed aberrant atti- persons who are vulnerable to, but not yet
tudes on the Eating Attitudes Test and the manifesting, an eating disorder may actually
Eating Disorders Inventory, only 2.4% actu- discover a relatively healthy solution to
ally gave clinical evidence of having or pos- some of their psychologic conflicts. On the
sibly having had AN. other hand, other such individuals may find
But are persons who are prone to eating that the coincidental importance of weight
disorders perhaps strongly "pulled" toward for performance, the inevitable competitive
exercise and athletics? In addition to the defeats, the pressure to perform progres-
previously mentioned report of relatively sively more successfully, the disruption of
high percentages of female long-distance training schedules by injuries, the obstacles
runners with elevated scores on eating atti- to regular eating patterns periodically posed
tude screening tests, it is well known that an- by the demands of the sport, the common
orectic individuals are typically excessively discussions among athletes about weight
active physically during the disorder's acute and diet, and the impact of exercise on
phase. Numerous hours are devoted daily to appetite64 and on the body's endorphin
calisthenics, running, swimming, or other system8,65 only serve to intensify their pre-
athletic activities; typically the exercising disposition.
increasingly takes on a frenetic quality. This Finally, for those individuals who are se-
high level of physical activity might be seen rious athletes and have developed AN, there
as merely the expected manifestation of the are certain special considerations. Osteo-
conscious desire to work off as many calo- porosis clearly puts the vigorous exerciser
ries as possible each day as part of the ob- at risk for pathologic fractures, while the
sessional drive to attain supreme thinness. progressive emaciation will at some point
However, at least one report suggests that compromise the quality of athletic perfor-
anorectic women are more active than their mance (as must the growing preoccupation
peers prior to the overt onset of the disor- with calories and weight). Obviously, bu-
der, and that they continue to remain phys- limic athletes are faced with particular car-
ically active even after apparent recovery diovascular peril, as they add dehydration
from AN.13 Furthermore, as noted earlier, and electrolyte imbalance from perspiring
the importance of physical activity for ano- to that from vomiting. And the maintenance
rectic individuals is evident in the effective- of a high level of physical activity can sig-
ness of inpatient behavior modification pro- nificantly compromise the effectiveness
grams that use access to physical activity as of therapeutic weight-regaining regimens,
a reinforcer for weight gain.49 even in a hospital setting.66
Presumably the truth rests somewhere in
the middle of this debate. Those with con-
flicts over control and self-identity may seek EATING DISORDERS AND
solutions in exercise and sports competi- OTHER SPECIAL SUBCULTURES
tion, in dietary control, or possibly in both.
Statistically, though, this group must cer- The importance of the mesh between en-
tainly represent a very small percentage of vironmental demands and individual vul-
the vast numbers, male and female, who en- nerabilities is perhaps best demonstrated
gage in athletic activities. And among those by the high prevalence of eating disorders
who have manifest eating disorders, only a among women in certain other subcul-
small percentage are likely to be involved in tures.67,68 These subcultures—such as ballet,
serious, competitive sports, given the vul- acting, and modeling—are characterized by
nerability to pathologic fractures, cardiac an explicit emphasis on the desirability of
thinness. Thus, it is not surprising that many concerns, while still limited, suggests that a
ballerinas, actresses, and models are under- high level of physical exercise becomes a
weight; yet, not all or even most have eating risk factor for the development of an eating
disorders. disorder only when it occurs in an individ-
There is evidence that sociocultural back- ual who has other predisposing risk factors,
ground can exert either a protective or a such as conflicts or doubts about sense of
risk-enhancing influence even within such identity, self-esteem, and self-control. Ex-
narrow subcultures. Thus, Hamilton and co- treme physical activity can also be a symp-
workers,69 in a study of ballerinas in nine re- tom of an already-emerging state of AN, but
gional and national dance companies, found then the activity tends to be frenetic and the
mean weight for the entire group to be 12% mental component involves the conscious
below ideal; however, no black American desire to "burn off" calories, rather than a
dancers reported having AN or BN, while desire to experience the sheer fun of exer-
15% of the white American dancers admitted cise or the gratification inherent in success-
to having AN and 19% acknowledged the ful physical competition. It is conceivable
presence of BN. The anorectic ballerinas not that, for some athletes, female or male, ex-
only were thinner than their non-anorectic treme exercise can be a way of defending
ballerina peers but also manifested gener- against certain conscious or unconscious
ally greater psychopathology and were conflicts, just as excessive dieting—or ex-
more likely to be dancers with the most cessive stamp collecting, gambling, or
competitive companies. drinking—might. For most women who now
Finally, there is evidence that the pres- exercise regularly, however, particularly
ence of amenorrhea in ballerinas is medi- those whose exercise is not part of a subcul-
ated not by their extensive physical activity ture that explicitly attaches great status to
but by their inadequate nutritional intake.70 thinness (such as ballet or modeling), the
This may well have implications for the risk of developing an eating disorder does
amenorrhea common to other strenuous ex- not appear to be enhanced, while the bene-
ercisers, such as long-distance runners. fits of exercise to mental and physical well-
Hence, we again note a complex interaction being are undoubtedly substantial.
of multiple variables, perhaps what we
should expect in any exploration of human
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APPENDIX A
Exercise Following Injury, Surgery, or

Infection
I. Exercise Following Breast Trauma or Surgery

CHRISTINE HAYCOCK, M.D.
MINOR TRAUMA
Patients who have minor abrasions or contusions do not require any time
away from their athletic endeavors. Wearing a good supportive bra to minimize
breast motion will suffice to keep them comfortable, along with a simple anal-
gesic such as ibuprofen or aspirin.
MINOR SURGERY
Following minor surgery, such as a breast biopsy or excision of a small cyst,

some limitation of upper arm use, especially throwing or lifting, is indicated for
at least 3 to 5 days to allow good cosmetic wound healing. This is in addition to
good breast support and analgesics.
If the excision has been deep or extensive, requiring a drain for more than
24 hours, then 5 to 7 days of limited upper arm use may be indicated. This is an
individual decision that must be made by the operating surgeon.
If infection is present due to an infected hematoma, or develops postoper-
atively, then upper arm motion must be restricted until all evidence of infection
is gone.
MASTECTOMY
Programs such as "Reach to Recovery," sponsored by the American Cancer

Society, have shown the usefulness of exercise in the rehabilitation of the post-
mastectomy patient. Fortunately, since radical mastectomies are now performed
rarely, most patients do regain their full preoperative range of motion and
strength in the ipsilateral arm.
313
314 Appendix A
The athlete would be encouraged to begin arm raising at about 4 to 5 days

after mastectomy and gradually to increase the motion daily. This routine is true
as a matter of fact for all such patients to prevent formation of scar tissue that
would limit future motion. However, in an athlete, at about the 2-week point, I
would encourage the use of weights, beginning with a pound and gradually
increasing, to build back upper arm strength. Squeezing a ball or other device for
this purpose is also indicated. A good supervised physical therapy regimen is
strongly advocated.
There may be other limitations required for the mastectomy patient if she
requires radiation therapy or chemotherapy. These would have to be individ-
ually determined, as no set rule is feasible. It would depend on such factors as
the amount of radiation given, the duration of the treatment, and the effect on
her skin. Certainly, mild exercise would probably be permissible.
REDUCTION OR AUGMENTATION MAMMOPLASTY
Patients who have reduction mammoplasty would be limited in the same

manner as mastectomy patients. Exercise would be limited until healing is suf-
ficient such that no drainage or raw areas exist; then the same regimen outlined
for mastectomy patients could be followed.
Rehabilitation of the athlete following augmentation mammoplasty should
include careful supervision by the plastic surgeon and a physical therapist, for
physical and legal reasons. The type and size of the prosthesis used would play
a role, especially if a silicone implant was used, since the rupture of such a device
may have serious medical implications.
II. Exercise Following Obstetric/Gynecologic

Surgery
MONA SHANGOLD, M.D.
When to resume one's exercise program after obstetric or gynecologic sur-

gery is best depicted in the accompanying table.
EARLIEST TIME TO RESUME EXERCISE POSTOPERATIVELY

Aerobic Exercise
Nonwater Sports Water Sports Weight Training
Procedure Light Intense Light Intense Light Submaximal
D and C; first- Same or next Same or next When bleeding When bleeding Same day Same day
trimester day day has ceased has ceased
abortion
Vaginal delivery; 2 days 2 days When bleeding When bleeding Same day Same day
second- has ceased has ceased
trimester
abortion
Diagnostic 1-2 days 1-2 days 1-2 days 1-2 days 1-2 days 1-2 days
laparoscopy
Operative 21 days 21 days 21 days 21 days 21 days 21 days
laparoscopy
Cesarean 7 days 21 days 21 days 21 days 7 days 21 days
delivery;
other
laparotomy
III. Exercise Following Common Orthopedic

Injuries and Operative Procedures
LETHA Y. GRIFFIN, M.D., Ph.D.
ANKLE SPRAIN
The proper time to return to activity following an ankle sprain depends on

the severity of the injury. The level of severity is defined by a grading system:
grade I refers to pain at the site of ligamentous injury but no laxity; grade II is
pain at the site of ligamentous injury with mild laxity; and grade III describes pain
at the site of ligamentous injury with significant laxity.
With grade I ankle sprains it may take from several days to several weeks for
the patient to return to activity, whereas with grade III ankle sprains it will take
316 Appendix A
a minimum of several weeks and may take up to several months. In grade I liga-
mentous injuries about the ankle, initial protection, ice, compression, and ele-
vation are followed by rapid rehabilitation, stressing increasing range of motion
and strength, along with return of proprioceptive feedback from the ankle. Range
of motion is achieved by having the athlete do figure-of-eights and circles with
her foot. Rubber tubing can be used as a resistive device for gaining strength in
dorsiflexion and plantarflexion and inversion-eversion.
Gains in proprioceptive feedback can often be maximized by having the ath-
lete stand on the affected extremity with her eyes closed and relearn how to bal-
ance. Also helpful in this regard is a tilt board, a flat board attached to a half circle
of wood, on which the athlete tries to balance her weight with the good foot
planted on the ground and only partial weight on the injured side, which is on
the tilt board. She then gradually increases her weight on the injured side until
she has good balance and can stand independently on it. When the athlete has
full range of motion and 90% strength and can hop independently on her extrem-
ity without pain, she can return to pivotal sports.
The rehabilitation programs for grade II and grade HI sprains about the
ankle are similar. However, the period of immobilization and protection is
longer, to allow for initial healing.
ARTHROMENISCECTOMY
Following an arthromeniscectomy, the athlete is encouraged to ice and ele-

vate her extremity for the first 48 hours. This initial period of rest, compression,
elevation, and icing helps prevent swelling and, hence, minimizes the time off
from sport following this procedure. If after 48 hours the athlete has minimal to
no swelling and good range of motion, she can begin strengthening exercises, as
well as functional strengthening activities such as biking and swimming (pro-
vided sutures are removed), and within several weeks she can begin running.
Pivotal activities are usually not allowed for 3 to 4 weeks, until the new meniscal
rim has remodeled.
PATELLA-STABILIZATION PROCEDURES
Soft Tissue Releases
Following a soft tissue release for patella stabilization (typically a medial

reefing or tightening of the medial muscles, as well as a release of the lateral mus-
cles), the athlete's affected limb is initially protected, iced, and elevated for 5 to
7 days. This allows the initial inflammation to diminish. Isometric exercises for
the quadriceps, especially the vastus medialis, are encouraged during this
period of time. A muscle stimulation unit to maintain the oxidative enzyme con-
tents of the involved muscle cells may be beneficial.
Quadriceps-setting exercises and short arc extension exercises are typically
begun from 5 days to 2 weeks postoperatively. Biking, swimming, and walking
can be begun as soon as the athlete has achieved control of her extremity and
has a functional range of motion. Biking is often very useful in increasing range
of motion, and therefore is to be encouraged. Return to pivotal sports may not
be possible for up to 3 to 6 months, depending on the stability of the repair.
Bony Realignment Procedure for Patella

Dislocation
Following a bony realignment of the patella, the timing for initiating range
of motion and strengthening exercises is dependent upon the bony fixation
device used (e.g., screws, staples, and so on). The period of immobilization var-
ies and should be dictated by the orthopedist.
LUMBAR DISKECTOMY
Immediately following diskectomy, the athlete is encouraged to begin walk-

ing in her hospital room, progressing within 7 to 10 days to walking about the
home and outside the home, going gradually from 10-minute walks to 30- to 45-
minute walks, at an increasing pace. Sutures are removed in 10 to 14 days. If there
is not marked swelling or spasm in the paravertebral muscles, the athlete is also
encouraged to begin swimming at 2 to 3 weeks following surgery. Swimming, like
running, develops abdominal and paravertebral muscle strength and is therefore
to be encouraged.
Pivotal sports are generally permitted within 3 to 4 months, as soon as the
athlete has good muscle strength and no pain with activities of daily living. Gen-
eral consensus is lacking on whether an athlete should be permitted to return to
contact sports following diskectomy. Although many athletes have returned to
long-distance running following diskectomy, one should encourage the athlete
to choose a sport that does not require such impact loading on the lumbar spine.
BUNIONECTOMY
Bunionectomy is not a "simple" procedure. It frequently necessitates bony

realignment of the first metatarsal. A special shoe with a nonflexible wooden sole
may be needed to protect the osteotomy while walking. Ambulation can begin
soon after the procedure, as long as protection is provided by such an appliance.
When early bony union is seen and pain and swelling have subsided, the
hard-soled shoe may be replaced by a comfortable shoe with a nonelevated heel.
Within 3 to 4 weeks, the athlete will probably be allowed to return to swimming
and biking, as well as to weight-training routines, as long as they do not involve
rising up on the toes or impact loading on the feet. Impact-loading activities such
as running, soccer, tennis, and so forth should not be permitted until swelling is
completely resolved, range of motion of the metatarsophalangeal joint of the
great toe is restored, and good bony union is present at the osteotomy site, which
may be any time from 3 to 6 months.
REMOVAL OF MORTON'S NEUROMA
The term "Morton's neuroma" refers to painful scarring about the interme-
tatarsal nerve in the foot. If the neuroma is unresponsive to nonoperative meth-
ods such as metatarsal pads, shoe modification, injection of steroids, and local
anesthesia, then surgical excision can be accomplished.
318 Appendix A
Following this procedure, the athlete is instructed to keep the foot elevated
for several days to diminish swelling. Within 3 to 4 days, she can be performing
normal, routine activities. However, if foot swelling occurs when she attempts to
do so, further elevation is necessary. Generally, swelling has resolved by the sec-
ond or third week. If the athlete is pain-free, swimming and biking are then per-
mitted. It may be 3 to 6 weeks before the athlete can resume running and pivotal
activities without discomfort.
IV. Exercise Following an Infection

GABE MIRKIN, M.D.
It is probably all right to exercise during a systemic infection, provided that

the athlete is afebrile and does not have myalgia before exercising. These same
criteria should be used to determine when to return to exercising after recover-
ing from an infection. However, each case should be decided on its own merits,
rather than by general rules.
Exercising with a fever increases cardiac output far beyond exercising with
a normal body temperature. The heart must pump extra blood to skin to prevent
heat build-up, in addition to its usual tasks of supplying oxygen and nutrients to
exercising muscle. Some viruses that infect the respiratory tract can also infect
the myocardium.1 The combination of increased workload and viral myocarditis
can result in a fatal arrhythmia. 2
When skeletal muscles are infected by respiratory viruses, they usually hurt
during exercise. Exercising when muscles hurt markedly increases susceptibility
to injury. Infected muscles have reduced strength3 and endurance4 and
decreased levels of necessary enzymes such as glyceraldehyde 3-phosphate
dehydrogenase.5
REFERENCES 4. Arnold DL: Excessive intracellular acidosis of

skeletal muscle on exercise in a patient with
1. Burch JA: Viral diseases of the heart. Acta Car- post-viral exhaustion syndrome. Lancet
diol 1:5, 1979. 1:1367,1984.
2. Roberts JA: Viral illnesses and sports perfor- 5. Astrom E: Effect of viral and mycoplasma in-
mance. Sports Med 3:296,1986. fections on ultrastructure and enzyme activi-
3. Friman G: Effect of acute infectious disease on ties in human skeletal muscle. Acta Pathol Mi-
isometric muscle strength. Scand J Clin Lab In- crobiol Immunol Scand 84:113, 1976.
vest 37:303, 1977.
Index
Page numbers followed by F indicate figures; page numbers followed by T indicate tables
Abdominal surgery, exercise after, 315t Amateur Athletic Union, 73
Abortion, 230-231, 315t Amenorrhea
Abruptio placenta, 182 anorexia nervosa and, 296
Acclimatization, lack of, 135, 265 bone mass and, 97-98
Accommodating resistance exercise, 67 defined, 152-153
Achilles tendinitis, 253-254 diagnostic evaluation, 165t, 165-166
Acidosis, 74 hypoestrogenic, 155, 163-165
ACTH, 149, 159, 161 incidence of, athletes and, 156
Action stage in exercise adoption, 43 prevalence of, 153f
Active tissue, defined, 4 primary, 130, 137, 168-169, 169t
Activity. See Physical activity treatment, 166-168, 167t, 168t
Actresses, eating disorders in, 309-310 American Cancer Society, 313
Adenocarcinoma, 162, 168 American College of Cardiology, 288, 289
Adherence rates, 39-43, 44t American College of Obstetricians and Gynecologists,
Adolescence. See also Eating disorder(s) 180
fitness, 31 American College of Sports Medicine (ACSM), 10, 14,
growth spurt, 142 15, 73
rnenarche, 142-143 Amino acids, 103, 105
physical activity, 41t, 143-146 branched-chain, 105, 114
physiological aspects, 141-142 Anaerobic glycolysis, 79
training, growth/maturation and, 146-150 Anaerobic metabolism, 106
Adolescent plateau, performance and, 145-146 Anaerobic power and endurance, 131-132
Aerobic capacity. See also Functional capacity Anaerobic threshold, 13-14
gender and, 18, 282-283 Anaphylaxis, exercise-induced, 272-273
maximal, prepubescence, 131 Androgen, 165
oxygen uptake and, 12, 13 Android pelvis, Q angle and, 237f
Aerobic exercise, 15f, 15-16 Anemia, 116-117, 163, 267-269, 269t
Aerobic power, 198-202 Anhedonia, 297
adolescence, 144-145 Ankle impingement, 250, 250f
prepubescence, 131 Ankle sprain, exercise after, 315-316
Affective disorder(s), 297 Anorexia nervosa
Age. See also Adolescence; Menopause; bone mass, 164, 193
Prepubescence clinical features, 30, 295-297
fitness and, 5, 17, 41t co-morbidity, 302-303
physiologic response to exercise, 130t course, 301-302
strength development and, 69-70 diagnosis, 301-302
Alarm reaction of stress adaptation, 82 differential diagnosis, 301t
Albuterol, 272t endocrine abnormalities, 300-301, 301t
Alcohol intake, 181 epidemiology, 293
Allergic reactions, 270, 272 etiology, theories of, 303-305
Alprazolam, 228 exercise and, 288, 307-309
Altitude, exercise and, 264 incidence, 292-293, 309-310
319
32O Index
Anorexia nervosa Continued BMR (basal metabolic rate), 204

laboratory findings, 299-300, 300t Body composition
physical findings, 298t, 298-299 adolescence, 142, 146-147
prognosis, 301-302 endurance training and, 79-80, 80t
radiographic/EEG/ECG findings, 299, 299t evaluation of, 9
risk factors for, 304t exercise and weight control, 37
setting/onset, 293-294 gender and, 18
thermoregulation and, 135 menarcheand, 136
treatment, 305-307 Body fat
Anovulation euestrogenic, 155 abdominal, 196, 206
Anthropometric measurements, 9 age, exercise and, 205-206
Antihistamines, 272 athletes, elite and, 80t
Anxiety body composition and, 4
disorders, 302 estrogen production, 156
reduction of, exercise and, 6, 8, 38, 157, 207 evaluation of, 9
Anxiolytics, 287 menarche and, 136, 149
Aortic stenosis, 130 physiological aspects, 80
Apolipoprotein, 165, 197 Body image
Appetite, 36-37 distorted, 296
Arrhythmias, cardiac, 130, 285, 318 improvement of, 6, 8, 38
Arsenic, 118 Body mass index (BMI)
Arthralgia, 206 measurement of, 29
Arthromeniscectomy, 316 nomogram for, 29f
Arthroscopic examination, knee joint, 243 risk classification algorithm, 30f
Ascorbic acid, 115 Body size, of adolescence, 142
Aspiration of fluid, knee joint, 241 Bone
Aspirin, 226t, 246 cortical, 90, 90f, 189, 191, 193
Asthma, 130, 270-272, 272t formation, 189-196, 194f, 194t
Astrand, Per-Olaf, 75 hypertrophy, 93-94, 96
Astrand-Rhyming Nomogram, 12 mineral content (BMC), 89, 95f
Atherogenic disease, menopause and, 196-202 physiologic aspects, 89-90
Athletes. See also Diet; Training trabecular, 91, 91f, 189, 190f, 191, 193
endurance, body composition and, 80t Bone density, loss of. See also Osteoporosis
minimum VO2 max values, 76 age and, 89, 90f, 192
vitamin needs, 115 amenorrhea and, 162-164, 168
Athletic pseudosyndromes, 273-275 athletic amenorrhea and, 97-98
ATPase activity, 74, 76, 78, 174-175 exercise, benefits of, 93-94, 96
inactivity and, 93-96
Bone meal, pollution of, 118
B vitamins, 114-115 "Bonking," 107
Back exercises and posture, 195 Bony realignment for patella dislocation, 317
Back pain, low, 256-257 Borderline personality, 297, 302
Ballet dancing Braces, patella stabilizing, 245, 245f, 248
adolescence, 147, 148 Brain endurance, 107
eating disorders, 309-310 Bra, 217-219, 220
prepubescence, 136 Breast cancer, risk of
scoliosis, incidence of, 164 hormone therapy, 205, 264
Basal metabolic rate (BMR), 204 luteal phase deficiency, 162, 163
Base cycles (workouts), 84 Breast(s)
Bayes' theorem, 286 augmentation, 219-220, 314
Bedrest, effects of, 94-95 biopsy, 313
Bee-sting sensitivity, 273 cysts, 220
Behavior Survey and Behavioral Risk Factor fibrocystic, 220-221
Surveillance System (BRFSS), 28 lactation, 220
Bench-stepping, energy requirements, 12t nipple injury, 219
Benzodiazepines, 296 pregnancy, 220
B-endorphins, 149 premenstrual changes, 220-221
Bicycling. See Cycling reduction, 219-220, 314
Biliary tract, 274 support of, 217-219, 218f, 220
Binge eating, 30, 294, 297 surgery/trauma, exercise after, 313-314
Bioelectric impedance measurements, 9 trauma, 219
Birth control pills. See Oral contraceptives Bromocriptine, 228
Bleeding, break-through, 224, 225 Bronchospasm, 270
Blood doping, 75, 77 Bulimia nervosa
Blood pressure clinical features, 30, 297-298
exercise and, 7, 38, 284 co-morbidity, 302-303
obesity and, 29 course, 301-302
Index 321
diagnosis, 302 Carnitine palmitoyl transferase, 82

endocrine abnormalities, 300-301, 301t Carnitine supplementation, 107-108
epidemiology, 293 Catecholamines, 108, 177
etiology, theories of, 303-305 Catecholestrogens, 157, 159
exercise and, 307-309 Cathartics, abuse of, 296-297
forms of, 294-295 Center for Climacteric Studies, 193, 197, 199
incidence, 292-293, 309-310 Cerebral palsy, 130
laboratory findings, 299-300, 300t Cerebrovascular accidents, 8, 38
physical findings, 298t, 298-299 Cesarean delivery, 315t
potassium deficiency with, 119 Chest pain, 275
prognosis, 301-302 Child(ren). See also Prepubescence
radiographic/EEG/ECG findings, 299, 299t fitness, 31
treatment, 305-307 illness and exercise, 129-130
Bunionectomy, exercise after, 317 physical activity, 42f
Bunions, 257-258, 258f, 317 Chlorpromazine, 306
CHOICES (NIH program), 261
Cholesterol
Caffeine, 108 age and menopause, relationship to, 197t
Calcium cardiovascular disease, risk factor of, 7, 38, 196
dietary intake, 117-118, 118t, 194-195 obesity and, 29
homeostasis, serum, 89-90, 90t, 112, 113 Chylomicron particles, 105
loss, excess protein intake and, 114 Cigarette smoking. See Smoking
pregnancy and, 183 Civil Rights Act (1972), Title IX, 73, 147
supplementation, 8, 91-93, 118t Clayton, Derek, 76
transport mechanism(s), 74, 76 Climacteric, defined, 187-188, 188f
Calcium carbonate, 92 Climate. See Cold-weather exercise; Hot-weather
Calcium citrate malate, 92 exercise
Caloric needs Clomiphene citrate, 166
physical activity and, 35t, 157 Clothing, athletic, 266, 266t
pregnancy,182-183 Cocaine, 297
Cancer. See also Breast cancer, colon cancer Coeducational contact/collision sports, 137
obesity and, 29 Cognitive behavioral therapy, 41-42
risk and exercise, 264 Cold injury to nipples, 219
Carbamazepine, 306 Cold intolerance, 296
Carbohydrate(s) Cold-weather exercise, 134-135, 264
composition of, 103, 104f Collagen, 206
dietary intake,113 Collision sports, coeducational, 137
energy per gram, 78 Colon cancer, 264
loading, 108 Condoms, 225
maximal body storage capacity, 106t Contact sports
metabolism, 174-175, 204-205 breast augmentation and, 220
overload, 83 coeducational participation, 137
Carbon dioxide, 14 low back pain and, 257
Carbonated drinks, 113 Contemplation stage in exercise adoption, 42
Cardiac output Contraception, 166, 223-226, 226t. See also Oral
exercise and, 283 contraceptives, names of individual devices.
oxygen uptake, 74-75, 81 Copper, serum level, 119
pregnancy, 173, 174, 176 Coronary artery disease
Cardio-respiratory fitness. See also Functional congenital anomalies, 18
capacity prevention by exercise, 6-7, 7t, 263-264
fitness, as component of, 4-5 risk factors of, 196
menopause and, 196, 198-202 screening for, in women, 286
Cardiovascular disease. See also Coronary artery Corpus luteum, 154, 158
disease Corticosteroids, 119, 271, 272t
exercise limitations in, 287-289 Corticotropin-releasing hormone (CRH), 161
exercise training and, 6-8, 263-264 Cortisol, 149, 161, 175
findings with eating disorders, 299 Creatine kinase, 274-275
menopause and, 196-202 Cromolyn sodium, 272, 272t
obesity and, 29 Cross-country skiing
pseudomyocarditis, 274-275 body composition, 80
risk factors for, 206 endurance performance, 77
Cardiovascular fitness, development of, 14-15 minimum VO2 max values, 76
Cardiovascular system Cross-sectional moment of inertia (CSMI), 193
aerobic capacity, 282-283 Cross training, 20
exercise ECG testing, 286-287 Cyanocobalamin, 115
limitations on, exercise, 287-289 Cycle ergometry
response to, exercise, 283-286, 285f energy requirements, l1t
322 Index
Cycle ergometry Continued Eating. See Diet; Nutrition

oxygen uptake, 12 Eating Attitudes Test (EAT), 159, 308
peak muscle power tests, 132 Eating disorder(s). See also Anorexia nervosa; Bulimia
Cycling nervosa
anaerobic examples of, 132 biology of, 298-299
endurance performance, 77 clinical features, 295-298
endurance performance, gender and, 80, 82 co-morbidity, 302-303
maximal oxygen uptake and, 75 course of, 301-302
menstrual disorders, 152-153 diagnosis, 301-302
muscle glycogen depletion, 106-107 endocrine abnormalities, 300-301
osteoporosis and, 195 epidemiology, 294
Cyproheptadine, 307 etiology, theories of, 303-305
Cystic fibrosis, 130, 135 exercise and, 307-309
Cystocele, 230 laboratory findings, 299-300, 300t
Cysts, breast, 220, 313 menstrual disorders and, 167-168
Cytochrome oxidase activity, 77 overview, 292-293
physical findings in, 298t
prognosis, 301-302
Danazol, 227, 228 radiographic/ECG/EEG findings, 299t
Dean, Penny, 106 setting/onset, 293-295
Death, causes of special subcultures and, 309-310
eating disorders, 302 treatment, 305-307
sudden cardiac, 18-19, 263, 288-289 Eccentric training, 65-67
Dehydration, 111-113, 114, 265-267 ECG. see Electrocardiography.
Depletion training, 107, 108 EEG. see Electroencephalography.
Depression, mental, 207, 294, 297, 302 Efficiency, performance, 78-79
DES exposure, 182 Ejection fraction, 283, 284f
Dexamethasone suppression, 159 Electrocardiography (ECG)
Diabetes insipidus, 135 eating disorders, findings with, 299t
Diabetes mellitus exercise testing, 286f, 286-287
exercise, children and, 130 Electroencephalography (EEG)
exercise, menopause and, 196, 206 eating disorders, findings with, 299t
exercise and, 8, 38 Electrogoniometers, 9
thermoregulation and, 135 Emetics, 296-297
Diaphragm contraceptive, 223, 225 Endometrial hyperplasia, 162, 166, 168
Diarrhea, 119, 135, 269 Endometriosis, 227
Diet. See also Nutrition Endometrium, 154
athletics and, 119-120, 266t Endurance, defined, 106-107
menstrual disorders and, 157-159, 167-168 Endurance development
pregnancy and, 181, 182-183 body composition, 79-80
Dieting, yo-yo, 36 gender and, 80-82, 81t
Digitalis, 74 maximal oxygen consumption, 74-77
Digoxin, 287 mitochondrial density, 77-78
Dilantin, 306 performance, 73, 78-79
Dilatation and curettage (D and C), 230 training, priciples of, 84t
exercise after, 315t training for, 82-85
Disaccharides, 103, 104f Endurance game activities, 14-15
Dislocation, patella, 242-245, 317 Energy expenditure
Disqualifying conditions exercise and, 34-36, 35t
medical illness, 275-276, 281, 287-289 MET equivalents, l0t, l1t
Disseminated intravascular coagulation, 267, 269 oxygen uptake and, 9-10
Distance covered, tests of, 13 Energy storage, 105-106
Diuretics Enzyme abnormalities, 274
abuse of, 30, 296-297 Epilepsy, 130
potassium, serum levels and, 119 Epinephrine, 177, 207, 272, 273
sodium, serum levels and, 118 Erythrocythemia, 75
Dolomite, pollution of, 118 Estradiol
Dopamine, 273 adolescence, training and, 149
Drinking. See Hydration, Exercise drinks menopause and, 188
Drug abuse, 297 menstrual disorders and, 156, 159, 166
Dynamic flexibility, 9 transdermal, 166
Dynamic loading, bone hypertrophy and, 93-94 Estrogen
Dynamic strength, defined, 61 fat tissue and, 156
Dysmenorrhea, 226-227 oral contraceptives, in, 224
Dyspnea, 8, 275 physiologic effect, 154
Index 323
Estrogen therapy development

contraindications, 167t components of, 4-5, 14-16
dosages, 264 economic aspects, 19
osteoporosis, 8, 96 factors affecting, 17-19
Estrone, 148 evaluation of, 8-14
Ethinyl estradiol, 166, 224 maintenance, activity level and, 16-17
Exceed (solution), 111 Flexibility
Exercise. See also Competition; Training; Weight as component of fitness, 4
control and exercise evaluation of, 9
cardiac function and, 283-286, 285f Flexion, of back, 195
medical contraindications to, 275-276 Fluids. See Hydration
metabolic response, 174-175 Fluoxetine, 306, 307
physiologic response, 173-174 FNB (Food Nutrition Board), 115
well-being and, 206-208 Folacin, 115
Exercise, short-term Folic acid, 119
physiologic aspects in prepubescence, 130t, 131t, Follicle-stimulating hormone (FSH), 154, 188
130-132 Follicular phase, 154, 160f
Exercise drinks, 112, 267 Food. See also Diet; Nutrition
Exercise ECG tests, false positive, 286f, 286-287 intake, competition and, 108-111, 109t, 110t, 113
Exercise-induced asthma (EIA), 270-272 Food Nutrition Board (FNB), 115
Exercise overuse (abuse), 47t, 47-48 Foot strike, patella pain and, 236
Exercise program(s) Fracture(s)
avoiding threshold mentality, 43-44 chondral, 243
components of, 14-15 endurance training and, 83
economic aspects, 19 hip, 188-189
physiologic effects, adult women, 55t-56t, 57t-59t stress, 83, 164, 255, 256-257
samples, 23-26 Framingham Heart Study, 263, 288
social aspects, 43 Frank-Starling principle, 74
stages of change in, 42-43 Free fatty acids, 176, 182
Exertion. See Exercise Free weights, 9
Exhaustion Fructose, 103, 113
acute/chronic, symptoms of, 83 Fruit juices, 112
heat, 135, 268t FSH (Follicle-stimulating hormone), 154, 188
stage of stress adaptation, 82 Functional capacity
Extension anaerobic threshold, 13-14
of back, 195 measurement, 10-13
short arc exercises, knee, 244f, 244-245, 248 terminology, 9-10
Fast-twitch fibers (FT), 70, 75, 77, 81, 82 Galactose, 103

Fat. See also Body fat. Gallbladder disease, 29
dietary, 36-37, 78, 107 GAS (General adaptation syndrome), 82
maximal body storage capacity, 106t Gated blood pool scan, 283, 288
metabolism, 106 Gender
utilizing in place of glycogen, 107-108 aerobic power and, 18
Fat fold measurements, 9 cardiovascular status and, 284
Fat-free mass (FFM), 142, 146 endurance performance and, 80-82, 81t
Fatigue, causes of, 119 energy storage, 106
Fatty acids, 105, 105t fitness and, 17-18, 40
Febrile illness, 276, 318 physiologic response, acute exercise, 131t, 131-132
Fenfluramine, 307 thermoregulation and, 135
Ferritin, serum levels of, 116, 117 weight perception and, 28, 30
Ferrous sulfate, 267 General adaptation syndrome (GAS), 82
Fertility, 229 Gilbert's disease, 274
Fetal heart rate, 178-179, 180-182 Girl(s). See Prepubescence
Fetus, maternal exercise and, 178f, 178-182, 179f Glucagon, 175
Fibrocystic breasts, 220 Glucose metabolism, 103, 106, 113
Fick equation, 173 Glycerol, 105, 105t
Fitness. See also Exercise; Training Glycogen
adolescence, 31, 143-146 endurance and, 78, 79, 83, 106-107
benefits of fat storage and, 103-104
healthy individuals, 5-6 utilization of, 107-108
medical illness, 6-8, 37-38, 46 Glycolysis, 13
children, 31 Gonadotropic hormones, 148-149, 159
defined, 3 Gonadotropin-releasing hormone (GnRH), 154
324 Index
Gonadotropin-releasing hormone (GnRH) analog, 227 Hypertension

Goniometer, 9 coronary artery disease, risk factor for, 196, 264
Grade walking, energy requirements, lot exercise training and, 7-8
Gravity, osteogenesis and, 191-192 Hyperthermia, 112, 135, 264
Growth Hypertrophic cardiomyopathy, 18
prepubescence, training and, 135-137 Hypoglycemia, 107, 109, 268t, 300
spurt, adolescence, 142-143, 146, 149 Hypohydration, in children 135
Growth hormone, 175, 202, 301t Hypokalemia, 112, 119, 119t, 299
Gymnastics, 136, 147 Hyponatremia, 112, 118, 265
Gynecoid pelvis, Q angle and, 237f Hypotension, 273
Gynecologic concerns Hypothalamic-pituitary-ovarianaxis, 148-149, 193,
contraception, 223-226 229, 301t
dysmenorrhea, 226-227 Hypothermia, 135, 268t
endometriosis, 227 Hypothyroidism, 165
fertility, 229 Hypovolemia, 270
menstrual cycle and performance, 231-232 Hypovolemic collapse, 268t
postoperative recovery, 230-231 Hypoxemia, 74
premenstrual syndrome, 227-229
stress urinary incontinence, 229-230
Gynecologic surgery, exercise after, 315t
Ibuprofen, 226t
Immobilization and bone loss, 93, 95
Hamstring stretch, 248f Impingement syndromes, 249-253
Health clubs, 19 Inactivity. See also Sedentary lifestyle
Healthy individuals obesity and, 31, 206
benefits of fitness, 5-6 skeletal effects, 94-96
exercise guidelines, 14 Incompetent cervix, 182
Heart defects, congenital, 18, 130 Incontinence, stress urinary, 229-230
Heart disease. See Cardiovascular disease Infection, exercise after, 318
Heart rate, 74, 284 Inhibition test, 239, 241f
fetal, 178-179, 180-182 Injury(ies). See also Orthopedic concerns
target, 15, 15f breast, 219, 313-314
Heat, see also Thermoregulation joint, 180
cramp(s), 111-112, 268t muscle, 274
exhaustion, 135, 268t musculoskeletal, 19
injuries, treatment of, 268t overuse, 19, 85, 137
stress, 264-267, 269-270 sports associated with, 235t
stroke, 114, 135, 267, 268t types, 19, 234
Hemarthrosis, 241, 243 Inotropic agents, 74
Hematuria, 273 Insomnia, 207, 296
Hemoglobin, 81-82 Insulin
Hepatic necrosis, 267 metabolic effects, 175, 204-205
High-density lipoproteins (HDL), 7, 196-198 pregnancy and, 176
Hip fractures, statistics, 188-189 Insulin-dependent diabetes mellitus, 8
"Hitting the wall," 82, 106-107 Interval training, 19-20, 83, 84
Hives, exercise induced, 272, 273 Intrauterine devices (IUDs), 225
Hormonal responses to exercise Iron
adolescence, 148-149 deficiency, 163, 267-269
menstruation and, 159-162 dietary intake, 116
pregnancy and, 176-177 pregnancy and, 183
Hormone replacement therapy, 194f, 194t Isokinetic
Hot flushes, 188, 205 machines, peak muscle power tests, 132
Hot tubs, 266 strength, defined, 9, 61
Hydration training, 67
fluid intake and, 111-113, 266t Isoleucine, 105, 114
heat stress and, 265-267 Isometric
Hydrogen ions, buffering, 14 exercise, 284
Hydrostatic weighing, 9 strength, defined, 61
Hymenoptera, 273 strength, maximal, 8-9
Hyperandrogenism, 165 training, 63-65
Hypercapnia, 74 Isotonic
Hypercholesterolemia, 263-264 strength, defined, 61
Hyperinsulinemia, 109, 196 strength, maximal, 9
Hypernatremia, 112 training, 61-62, 64-65
Hyperprolactinemia, 165 IUDs (intrauterine devices), 225
Index 325
Jenny Craig Foundation, 27 Mastectomy, 313-314

Jogging. See also Running Maturation, sexual, 135-137, 147-149
middle-aged women and injury, 206 MAX (solution), 111
Joint(s) Maximal oxygen uptake. See Oxygen uptake, maximal
injury, 180 (Vo2 max)
range of motion, 4, 9 Maximal voluntary contraction (MVC), 60-61, 69
Judo, 135 Mechanical bone loading, 93-94, 95f
Medical illness
arising during sports
kcal, equivalents, 9,10 anaphylaxis, 272-273
Kegel exercise(s), 230 asthma, 270-272
Ketaprofen, 226t heart disease, 263-264
Kinanthropometrists, 129 heat stress, 264-267
Kristiansen, Ingrid, 103 hematologic effects, 267-268
pseudosyndromes in athletes, 273-274
"runner's diarrhea," 269
Labor, premature, 181, 182 urinary tract, effects on, 269-270
Lactate, 13 urticaria, 273
"Lactate breaking point," 13, 14 differential diagnosis, abnormal test results, 270t
Lactate inflection point, 83 disqualifying conditions, 275-276, 281, 287-289
Lactation, exercise and, 220 exercise, benefits of, 6-8, 18-19, 37-38
Lactic acid screening athletes for, 275, 278-279, 280
clearance capacity, 76, 77, 82 Medroxyprogesterone acetate, 166, 205
production, 14, 78 Mefenamic acid, 226t
Lactose, 103 Megestrol acetate, 205
Laparoscopy, exercise after, 231, 315t Melatonin, 159
Laparotomy, exercise after, 315t Menarche
Laxatives, abuse of, 30 delayed, 136-137, 147, 148-149
LBM (Lean body mass), 9, 37 onset, 142-143
Lead pollution, 118 Menopause
Lean body mass (LBM), 9, 37 atherogenic disease and, 196-202, 197t
Left ventricular function, 283 bone mass, 96
Left ventricular hypertrophy, 285 calcium supplementation, 92-93
Leucine, 105, 114 cardiorespiratory fitness and, 196-202
Leuprolide acetate, 227 defined, 187-188, 188f
Licorice, 119 exercise, fat tissue and, 205-206
Lipase, 105 exercise, osteoarthrosis and, 206
Lipid profiles, 7 exercise, well-being and, 206-208
Lipids, 196-198 muscle tissue, strength and, 202-205
Lipoprotein lipase (LPL) levels , 205 osteoporosis, bone health and, 189-196, 194f,
Lipoproteins, 7, 196-198 194t
Lithium, 306 overview, 187-189
Load cycles (workouts), 84 vasomotor symptoms, 205
Longevity and fitness, 5 Menstrual disorder(s). See also Amenorrhea;
Low back pain, 256-257 Oligomenorrhea
Low-density lipoproteins (LDL), 196-198 consequences of, 162-165
Lumbar diskectomy, 317 diagnostic evaluation of, 165-166
Lupron, 227, 228 dysmenorrhea, 226-227
Luteal phase, 154, 160f premenstrual syndrome, 116, 118, 227-229
Luteal phase deficiency prevalence of, 152-154, 153f
physiologic aspects, 155, 156, 162 treatment, 166-168
treatment, 166 types, 154-155
Luteinizing hormone (LH) Menstruation
menstrual disorders and, 161-162, 162f, 163f cycle changes with exercise/training, 156-159
physiologic aspects, 154 effect on performance, 231-232
endurance training and, 82
hormonal changes with exercise/training, 158f, 159-
MacArthur Foundation Fellowship, 27 162
Magnesium levels, 113 iron deficiency and, 267
Maintenance stage in exercise adoption, 43 physiology of, 154, 155f
Maltodextrin glucose polymer solutions, 111 Mercury pollution, 118
Mammography, 220-221 Metabolic equivalent (MET), 10, 10t, 11t, 15
Mannose, 103 Metabolic rate, 36, 174-175
Marfan's syndrome, 18 METs (Metabolic equivalents), 10
Margaria step-running test, 132 Midluteal phase, 160f
326 Index
Minerals energy storage, 105-106

major/trace, 116t, 116-119 essential nutrients, 103-105
pregnancy and, 183 glycogen utilization, decreasing, 107-108
Minority populations, 39 minerals, 116-119
Mitochondria overview, 102-103
fat content, 107-108 protein requirements, 113-114
oxygen extraction by, 75 vitamins, 114-116
Mitochondrial density
endurance capacity and, 77-78
over-distance training, 83 Oakland (CA) Growth Study, 143
Mitral valve prolapse, 18, 287-288 Obesity
Modeling, eating disorders with, 309-310 demographics of, 39
Monoamine oxidase inhibitors (MAOIs), 306 exercise programs for, 8, 44t
Monoglycerides, 105 inactivity and, 130, 206
Monosaccharides, 103, 104f nature/severity of, 28-31
Mood-elevating effect of exercise, 207 thermoregulation and, 135
Morton's neuroma, 258-259, 317-318 Obligatory runners, 307-308
Motor performance, adolescence, 144 Obstetric surgery, exercise after, 315t
Mullerian agenesis, 168 Oligomenorrhea
Muscle anovulatory, 162-163
contraction, bone mass and, 93-94 athletics and, 152-153, 156
hyperplasia of fibers, 68 bone loss and, 98
hypertrophy, 68-69 diagnostic evaluation, 165t, 165-166
injury, 274 treatment, 166t, 166-168, 168t
mass, 142 1, 25-(OH)2 vitamin D, 89
tissue loss, 202-205 Oral contraceptives
Muscle endurance biphasic, 224
defined,4 bone density and, 117
evaluation of, 8-9 iron needs and, 116
nutrition and, 106 low-dose, 224, 231
Muscle strength menstrual disorders and, 164, 166-167
adolescence, 143-144 mineral needs and, 119
defined, 4 physiologic aspects, 224-225
evaluation of, 8-9 vitamin needs and, 115
menopause and, 202-205 Orthopedic concerns
prepubescence, 131-132 Achilles tendinitis, 253-254
Muscular dystrophy, 130 bunions, 257-258
Myocardial contractility, 74 exercise after, 315-318
Myocardial infarction, 38, 196, 263 impingement syndromes, 249-253
Myoglobinuria, 269, 270 low back pain, 256-257
Morton's neuroma, 258-259
overview, 234-235
Nafarelin acetate, 227 patella dislocation, 242-245
Naloxone, 149 patella pain, 235-242, 249
Naproxen, 226t patella plica, 249
National Academy of Science, 115 patella subluxation, 245-247
National Health Examination Survey, 143 patellofemoral stress syndrome, 247-249
National Heart, Lung and Blood Institute, 289 shin splints, 254-255
National Institute on Aging, 187 sports and related injuries, 235t
National Institutes of Health, 261 stress fractures, 255
National Research Council, 115 Orthostatic hypotension, 196
Nautilus Sports/Medical Industries, Inc., 187 Osgood-Schlatter's disease, 241, 241f
Neuroendocrine response to exercise, 175 Osteoarthritis, 29, 206
Niacin, 115, 119 Osteoblastic activity, 93-94
Nichols, Cynthia, 106 Osteogenesis, 189-196
Nipple injury, 219 Osteoporosis
Non-insulin dependent diabetes mellitus, 29 causes, 89
Norepinephrine, 175, 177, 181, 207 eating disorders and, 298-299
Norplant, 225-226 economic aspects, 90-91
Nutrients, essential, 103t, 103-105 exercise and, 8, 195-196
Nutrition incidence, 90-91
athletes, diet and, 119-120 trabecular bone, 190f
competition, diet and, 108-111, 113 Ovarian failure, 164, 165
competition, fluid intake and, 111-113 Ovarian follicle, 154
eating before exercise, 110 Ovarian hormones, 148-149
endurance, 106-107, 108 Over-distance training, 83
Index 327
Overload, components of, 83-84 Physiologic effects of exercise

Overtraining, 85, 149-150 adult women, 55t-56t, 57t-59t, 83, 262
Overuse injury(ies), 19, 85, 137 children, 130
Overweight. See Obesity prepubescence, 130-132
Oxygen, energy cost equivalent, 9 Plateau of dieting, 37
Oxygen uptake PMS. See Premenstrual syndrome.
measurements, 9-10 Polycystic ovary disease, 162
pregnancy, 174, 175-176 Polysaccharides, 103, 104f
prepubescence, 130-131 Potassium, 118-119
Oxygen uptake, maximal (Vo2 max), 5, 9-10, 173 deficiency, 118
adolescence, 144-145 levels, 112-113
age and, 284 supplementation, 265
calculation, 74 PRE (Progressive resistance exercise), 61
endurance performance and, 74-77, 81 Precontemplation stage in exercise adoption, 42
measurement of, 10-13 Predictive tests, oxygen uptake, 12f, 12-13, 13f
menopause and, 198, 199f, 200t, 201t, 202f, 203f Pregnancy
over-distance training, 83 breast enlargement, 220
pregnancy, 175-176 exercise during, fetus and, 178f, 178-180, 179f, 180-
prepubescence, 131, 133 182
guidelines for, 180-182
metabolic response to, 176-177
Pain physiologic response to, 175-176
chest, 275 thermoregulation and, 177f, 177-178, 181
low back, 256-257 overview, 172-173
patella, 235-242, 249 physiologic changes of, 173
Pantothenic acid, 115 Preload, defined, 74
ParaGard (IUD), 225 Premenstrual syndrome (PMS), 118, 227-229
Parathyroid hormone, 89, 90t vitamins and, 116
Pars interarticularis, 255, 256 Preparation stage in exercise adoption, 42-43
Passive tissue, defined, 4 Prepubescence
Patella coeducational contact/collision sports and,
anatomy, 235-236 137
contact areas, 239f growth/puberty, training and, 135-137
Q angle and pelvis type, 237f overview, 129-130
quadriceps muscle, 236f short-term exercise, physiology of, 130-132
Patella dislocation thermoregulatory capacity, 133-135
acute traumatic, 242-245 trainability, 132-133
bony realignment, 317 President's Council on Physical Fitness, 3
pain, 235-242, 249 Progestasert (IUD), 225
plica, 249 Progesterone, 158, 159, 160f
shelf, 249 Progestin, 166, 224
stabilization procedures, 316 Progressive resistance exercise (PRE), 61
subluxation, 245-247 Prolactin, 149, 159
tracking, 236, 240f Proliferative phase, 154
Patellofemoral joint, 238f Prostaglandin inhibitors, 226t, 226-227
Patellofemoral stress syndrome, 237, 247-249 Protein, nutritional requirements, 103, 105, 113-114
Peak cycles (workouts), 84 pregnancy and, 182
Peak height velocity, 142, 143, 144 Prozac, 306
Peak velocity, 142 Pseudoanemia, 267, 269t, 273
Pediatric Exercise Sciences (journal), 130 Pseudohepatitis, 274
Pediatric Work Physiology Group, 130 Pseudomyocarditis, 274-275
Performance efficiency, 78-79 Pseudonephritis, 269, 273-274
Periactin, 307 Pseudosyndromes in athletes, 273-275
Perinatal outcome, maternal exercise and, 179-180 Psychologic aspects of weight control, 27-28, 33-34,
Perspiration, physiologic aspects, 112, 134, 264-267 39t, 39-40, 45. See also Eating disorder(s)
Phenytoin, 306 Psychologic benefits of fitness, 5-6, 38, 46, 206-
Phospholipids, 105 208
Phosphorus, 89 Psychomotor speed, 208, 208t
Physical activity. See also Sedentary lifestyle Puberty, training and, 135-137
adolescence, 143-146 Pulmonary function
benefits to bone mass, 93-94, 96 chronic obstructive airways disease, 8
caloric values of, 35t endurance training and, 75-76
developmental stages and, 40, 41t, 42f exercise-induced asthma, 270-272
middle-aged women, 207 pregnancy, 173
weight control and, 31 Purging, of bulimia nervosa, 294, 298
Physical fitness. See Fitness Pyridoxine, 115, 116, 119
328 Index
Q angle, 235, 237f, 238 Sexual maturation. See also Menarche

Quadriceps muscle(s), 236f adolescence, 147-149
Questionnaire, medical screening, 275, 278-279 puberty, 135-137
SGOT, 105
SGPT, 105
Range of motion Shin splints, 254-255
defined, 4 Shoes, athletic, 248, 258
measurement of, 9 Shoulder impingement, 251f, 251-253
repetition maximum (RM), 9 Sickle cell trait, 269
RDAs (Recommended Dietary Allowances), 115, 157 Sit-and-reach test, 9
"Reach to Recovery," 313 Skeleton. See Bone, Bone density.
Recommended Dietary Allowances (RDAs), 115, 157 Skin fold measurements, 9
Recreational exercise Sleep disturbances, 207, 296
pregnancy and, guidelines for, 180-182 Slow-twitch fibers, 70, 75, 77, 81, 82
role of, 17 Smoking, 7, 181, 263, 264
Rectocele, 230 "Social" exercisers, 43
Renal disease, end-stage, 8 Sodium intake, 112-113, 118
Renal failure, acute, 267, 269 Soft drinks, 112
Repetition maximum (RM), 9 Soft tissue releases, patella stabilization, 316
Resistance development stage of stress adaptation, "Solo" exercisers, 43
82 Specificity, principle of, 84
Resistance training, 7, 37 Spine bone loss, 91, 92f, 92-93, 97
Respiratory infection(s), 115, 276 Spirometry, 270, 271f
Rest periods in training, 83-84 Spironolactone, 228, 229
Resting metabolic rate (RMR), 36, 159 Spitz, Mark, 80
Resting range of motion, 9 Spondylolisthesis, 256f, 257
Rhabdomyolysis, 267, 269, 270, 274 Spondylolysis, 256, 256f
Riboflavin, 115 Sprains, 83, 234
RM (Repetition maximum), 9 Static loading, bone hypertrophy and, 93-94
RMR (Resting metabolic rate), 36, 159 Static range of motion, 9
Rotator cuff exercise(s), 252f, 252-253 Static strength, defined, 61
"Runner's anemia," 267, 273 Step tests, 12t
"Runner's diarrhea," 269 Steroids
"Runner's high," 207 anabolic, adverse effects, 68, 264
"Runner's nipples," 219 intra-articular injection, 246, 253
Running "Sticking point," 64
anaerobic examples of, 132 Stimulants, 297
body composition, 106 Strain and bone mass, 94, 96
dehydration with, 111 Strain gauge tensiometers, 9
distance-covered tests, 13 Strains, 83, 234
endurance performance, 77 Strength, defined, 60-61
endurance performance, gender and, 80, 82 Strength development, 205
energy requirements, l1t aging and, 69-70
maximal oxygen uptake and, 75 eccentric, 65-67
medical advice, 266t isokinetic exercise, 67
menstrual disorders, 152-153 isometric, 63-65
minimum VO2 max values, 76 isotonic, 61-62, 64-65
muscle glycogen depletion, 106-107 skeletal muscle hypertrophy, 68-69
psychologic aspects, 307-308 Strength ratios, 62
Stress, emotional
exhaustion and, 83
Salt intake, 228, 265 menstruation and, 153, 157
Saunas, 266 Stress adaptation, endurance training and,
Scoliosis, 164 82
Screening athletes for medical clearance, 275 Stress fractures
Secondary amenorrhea. See Amenorrhea diagnosis, 255
Secondary sex characteristics, 141-142 endurance training and, 83
Secretory phase, 154 menstrual disorders and, 164
Sedatives, 297 treatment, 256-257
Sedentary lifestyle "Stress hormones" and exercise, 161
aerobic capacity, 282-283 Stress urinary incontinence, 229-230
exercise programs for, 23-24 Stroke. See Cerebrovascular accidents
pregnancy exercise and, 181 Stroke volume, 74, 81
Seizures, 107 pregnancy, 173, 176
Seles, Monica, 17 Subluxation, patella, 245-247
Index 329
Submaximal oxygen uptake prepubescents, response of, 132-133

menopause and, 202 sample programs, 23-26
prepubescence, 130-131 Training-sensitive zones, 15f
Succinate dehydrogenase, 82 Training stimulus, 83-84
Sucrose, 103 Transaminases, 105
Sudden cardiac death Trauma. See Injury(ies)
exercise and, 18-19, 263, 288-289 Treadmill testing, 11t,287
Sugars, 103, 104f Triathlete, exercise program(s), 25
Surgery, exercise after Triglycerides, 7, 105, 106, 176
breast, 219-220, 313-314 Trunk flexion/extension test, 9
obstetric/gynecologic, 315t 12-minute walk/run test, 13
orthopedic, 315-318 Tyramine-containing foods, 306
recommendations, 275
Swimming
body composition, 106 Urethral syndrome, 188
breast surgery and, 219-220 Urethritis, 165
dehydration with, 111 Urethrocele, 230
endurance performance, 77 Urinary incontinence, 188
endurance performance, gender and, 80, 81t Urinary tract, 269-270
maximal oxygen uptake, 75 Urogenital epithelium, 165
menstrual disorders, 152-153 Urticaria, exercise induced, 272, 273
minimum VO2 max values, 76 Uterus
osteogenesis and, 192 absence of, 168-169
osteoporosis, as exercise for descent of, 230
prepubescence, 136
thermoregulation and, 135
Sympathomimetic agents, 107
Synarel, 227 Vaginal delivery, exercise after, 230, 315t
Syncope, 107, 275 Vaginal epithelium, 165
Synovial fluid, 241 Vaginitis, 165, 188
Synovial plica, 249 Valine, 105, 114
Syrup of ipecac, 296, 299 Valvular disease, acquired, 18
Vasomotor symptoms of menopause, 205
"Ventilation breaking point," 13-14
Task Force on Cardiovascular Abnormalities, 289 Ventilatory muscle training, 8
Tegretol, 306 Ventilatory threshold, 174
Terbutaline sulfate, 272t Vertebral apophysitis, 257
Testosterone, 148-149, 159 Very low density lipoproteins (VLDL), 197
Theophylline, 272t Viral illness, 275-276
Thermoregulation Vitamin C, 115, 117
anorexia nervosa and, 296 Vitamin D, 117
exercise during pregnancy and, 177f, 177-178, 181 Vitamin K, 115
fluid intake and, 112 Vitamin(s)
heat stress and, 264-267 birth control pills and, 115
prepubescence, 133-135, 134t colds and vitamin C, 115
Thiamine, 115 mechanism of function, 114-115
Thinness, 156-157. See also Weight. menstrual disorders and, 157
Thirst, 112, 267 needs of female athletes, 115
Thorazine, 306 pregnancy and, 183
Threshold concept, 43-44 premenstrual syndrome and, 116
Tibia, stress fractures of, 255 toxicity, 119
Tissot spirometer, 10 VO2 max. See Oxygen uptake, maximal (VO2 max)
Title IX legislation, 73, 147 Volume transducer, 10
Total exercise time (TET), 204f Vomiting
Trace minerals, 119 hypohydration, 135
Training. See also Strength development potassium deficiency, 119, 119t
adolescent growth/maturation and, 146-150 self-induced, 30, 296, 298, 300
competition and, 19-20, 25
depletion, 107
eccentric, 65-67 Waist-to-hip ratio, 38
hormonal changes with, 159-162 Waitz, Crete, 76
isometric, 63-65 Walking
isotonic, 61-62, 64-65 distance covered tests, 13
menstrual cycle changes with, 156t, 156- maximal oxygen uptake, 199
159 osteoporosis and, 195
330 Index
Weight. See also Eating disorder(s); Obesity maintenance and relapse, 32, 32f
bearing, benefits to bone mass, 93-94 physical activity and, 31
cultural aspects, 30, 45 Weight lifting, maximal oxygen uptake, 75
ideal versus healthy, 45-46, 46t Weight training, 284
loss of, 156-157, 295 Wilton, Maureen, 103
Weight Control and exercise. See also Weight Control Wingate anaerobic test, 132
programs, Women's health issues, research on, 261-262. See also
adherence Menopause; Prepubescence
challenges to, 39t, 39-40 Wrist impingement, 250-251
maximizing, 44t
relapse prevention, 41-42
studies of, 40-43 Yale Center for Eating and Weight Disorders,
appetite decrease, 36-37 Fellowship Program of, 27
body composition, 37 Youth. See Adolescence; Child(ren)
consistency, 44 Youth Risk Behavior Surveillance System (YRBSS), 28,
education for, 45 31
energy expenditure, 34-36, 35t
linking mechanisms, 33-34, 34t
long-term effectiveness, 32-33, 33f, 34f
morbidity/mortality rates of women, 37f, 37-38 Zinc, 119
Weight control program(s).
economic aspects, 27

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Women and Exercise:

Physiology and Sports Medicine

MONA M. SHANGOLD, M.D.

GABE MIRKIN, M.D.

F. A. DAVIS COMPANY • Philadelphia

Copyright © 1994 by F. A. Davis Company

Printed in the United States of America

Last digit indicates print number: 1 0 9 8 7 6 5 4 3 2 1

Acquisitions Editor: Robert H. Craven

Library of Congress Cataloging-in-Publication Data

Mona Shangold, M.D.

Mona Shangold, M.D.

Oded Bar-Or, M.D

Jack L. Katz, M.D. Department of Orthopaedic Surgery

1. Fitness: Definition and Development 3

2. Exercise and Regulation of Body Weight 27

Appetite and Hunger 36

3. Training for Strength 60

6. Nutrition for Sports 102

7. The Prepubescent Female 129

Anaerobic Power and Muscle Endurance 131

8. Growth, Performance, Activity, and Training During Adolescence 141

9. Menstruation and Menstrual Disorders 152

10. Pregnancy 172

11. Menopause 187

13. Gynecologic Concerns in Exercise and Training 223

14. Orthopedic Concerns 234

15. Medical Conditions Arising During Sports 261

Serum Enzyme Abnormalities: Muscle Injury and Pseudohepatitis 274

16. Cardiovascular Issues 282

17. Eating Disorders 292

Exercise Following Injury, Surgery, or Infection 313

COMPONENTS OF FITNESS Flexibility

T he term "physical fitness" connotes a state of optimal physical well-being.

Table 1-1. BIOLOGIC MECHANISMS BY WHICH EXERCISE MAY CONTRIBUTE TO THE

Maintain or increase myocardial oxygen supply

highest Vo2 max reported in the literature Measurement

Table 1-2. APPROXIMATE ENERGY REQUIREMENTS IN METS FOR HORIZONTAL AND

0 8.6 10.2 11.7 12.5 13.3 14.8 16.3

0 8.6 10.2 11.7 12.5 13.3 14.8 16.3

Table 1-4. ENERGY EXPENDITURE IN METS DURING BICYCLE ERGOMETRY

Figure 1-2. Application of the linear relation-

breaking point" to describe this alteration in FITNESS DEVELOPMENT AND

(eds): Therapeutics Through Exercise. 63. Bergh U, Thorstensson A, Sjodin B, et al:

Sample Training Programs

SAMPLE 8-WEEK PROGRAM FOR A SEDENTARY

Cool-down. 5 min walking (HR = 100-110 bpm); 5 min stretching, as

SAMPLE 8-WEEK PROGRAM FOR SEDENTARY 60-

SAMPLE 8-WEEK PROGRAM FOR A MODERATELY

Aerobic Phase. 25 min of vigorous walking, jogging, stationary cycling, row-

GUIDELINES FOR THE COMPETITIVE ATHLETE

1 Training should be in three stages, comparable to those shown earlier but

SAMPLE PROGRAM FOR A USTS DISTANCE

(0.9-mile swim, 25-mile bike, 6.2-mile run)

order to complete the nine workouts, single workouts can be done on 5

Exercise and Regulation

THE NATURE AND SEVERITY OF Obstacles to Exercise for the

gevity. Approximately 27% of women and ronmental, cultural, socioeconomic, and

Figure 2-1. Nomogram for body

ing and physical activity to the point where

THE ASSOCIATION BETWEEN cert with the significant decline in physical

Figure 2-3. Maintenance and re-

Table 2-2. CALORIC VALUES FOR 10