The Culture and Consequences of Low Energy Availability in National Collegiate Athletic Association Division One Female Distance Runners: A Mixed Methods Investigation

Low energy availability (EA), a mismatch between caloric energy intake and exercise energy expenditure, underpins the ten physiological and psychological consequences of the Relative Energy Deficiency in Sport (RED-S) framework. This framework expands on the Female Athlete Triad (Triad) to include cardiovascular health, gastrointestinal health, metabolic function, growth and development, immune health and psychological health, in addition to tenants of menstrual function and bone health named in the Triad. National Collegiate Athletic Association (NCAA) Division One (DI) female distance runners are at high risk of low EA, given significant pressures to excel at both school and sport, in addition to risks that affect all female athletes, such as sport-specific body ideals and cultural pressures to be thin. The purpose of the first aim of this dissertation was to describe NCAA DI female distance runners’ experiences of perceived body image norms and disordered eating in their sport, as well as coach-athlete power dynamics. We completed interviews with 29 current and former female NCAA DI distance runners with current or past history of disordered eating and/or current or past history of the Triad. We completed a thematic analysis and two major themes emerged: 1) sport body ideals and body image norms that persist in the sport, and 2) the power dynamic between coach and athletes. Findings revealed that sport body image ideals and the power dynamic between coach and athlete may contribute to female athlete’s risk of disordered eating and body image disturbance, resulting in adverse health consequences. In the second aim, we enrolled a randomly sampled, national cohort of 211 current NCAA DI female Cross Country runners. We collected rosters from all NCAA DI Cross Country teams and randomly sampled five women per team, and email addresses were collected for each woman sampled. Sampled women were contacted via email for participation and completed a self-administered survey about RED-S consequences, demographics, disordered eating and emotional health. The purpose of this aim was to identify patterns of clustering of the ten RED-S health consequences using latent class analysis. The latent class analysis identified three distinct classes: Class 1, the “Low RED-S Consequence Class” representing 39% of the sample, class 2, the “High RED-S Consequence Class” representing 16% of the sample, and class 3, the “Anxious, High RED-S Consequence Class” representing 45% of the sample. Results highlight three unique presentations of RED-S consequences in this population. The purpose of the final aim was to examine the association between latent class membership and bone injury outcomes, in our sample of 211 current NCAA DI female Cross Country runners. We used Chi-Square tests to assess the relationship between latent class membership and bone injury outcomes ever and during college. Participants reported 122 total bone injuries over the course of their athletic careers; 57.3% of athletes (n=121) reported at least one bone injury, and 82.6% (n=100) of these injuries occurred during college. We observed no statistically significant difference in the burden of bone injury between the three latent classes. Future longitudinal studies are required to better understand temporal relationships between bone injury and latent classes of RED-S consequences. Taken together, the results of this dissertation add novel data and findings to our understanding of RED-S in collegiate female athletes. Findings bring attention to disordered eating and the significant burden of RED-S among NCAA D1 female distance runners.PHDEpidemiological ScienceUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/168009/1/tlcars_1.pd