Bone Health for Female Athletes Across the Lifespan

Good bone health affects your ability to stay active and healthy throughout life. However, when female athletes, especially those training for recreational or elite athletic competition, knowingly or unknowingly exercise too much and eat too little, they may be at risk for low bone mass and fractures.

Athletes across the lifespan are at risk for low bone density and bone stress injuries

The incidence of low bone density and stress fractures, is increasing among competitive and recreational female athletes of all ages, and leads to pain and lost time from training and competition. Osteoporosis, a bone disease caused by weakened, porous bone, occurs silently and progressively over time, often with no symptoms until a fracture occurs. It’s currently estimated that one in three women over the age of 50 will suffer from an osteoporotic fracture www.iofbonehealth.org.

Bone is a living tissue that is constantly changing. Nutrition, physical activity, and certain hormones all play a role in the development and maintenance of healthy bones. With adequate nutrients, in particular calcium, Vitamin D, and protein, as well as weight-bearing exercise, most people achieve a peak bone mineral density by their late 20’s. During the normal aging process, both bone mass and bone strength decrease, with increased declines related to the lack of estrogen, such as with menopause or in female athletes with amenorrhea. Therefore, bone disease prevention begins during childhood and adolescence, as well as lessening the extent of bone loss that occurs during the aging process.

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To optimize bone health, female athletes need to:

1. Consume foods that provide adequate calcium and vitamin D
2. Eat enough calories to support their training
3. Include high quality protein at meals and snacks
4. Participate in strength or resistance exercises that provide an mechanical force on the bone
5. Recognize that menstrual irregularity is a warning sign for low bone mass – and for postmenopausal women, consider having a DEXA bone density scan done to measure your bone density.

The Role of Calcium and Vitamin D

Calcium is an important mineral in the body for maintaining bone strength, regulating muscle contractions, maintaining blood pressure, and transmitting nerve impulses. Most of the body’s calcium is stored in our bones (and teeth); and, without enough calcium each day from the diet, the body will use what it needs from the bone to keep blood calcium levels normal. If more calcium is removed from the bones than is consumed in the diet, the bones may become fragile or weak.

The calcium recommendation for women ages 25 to 50 is 1,000 to 1,200 milligrams per day and 1,200 mg/day for women after age 50. Good sources of calcium include dairy products (milk, yogurt, kefir, and cheese), calcium-fortified juices or plant milks, some types of tofu, certain vegetables (collard greens, kale, broccoli, bok choy), oranges and almonds.

Vitamin D is also vital to bone health as it is needed for the absorption of calcium from the intestines and plays a key role in bone mineralization. The recommended daily allowance is 600 international units (IU) for those women under 70 years of age and 800 IU for those over 71 years of age. Vitamin D is present in only a few foods including fatty fish, egg yolks and fortified foods, like milk and cereal. It is also made in the skin when exposed to sunlight. For those unable to get sunlight or consume sufficient Vitamin D from foods, 2,000 units of Vitamin D daily may be recommended, but you should consult with your doctor before taking any supplement.

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Other Key Nutrients for Bone Health

Consuming enough calories to fuel activity and other body functions is critical. Eating a variety of foods at three meals and two to three snacks throughout the day according to your hunger and fullness will generally meet the energy demands of your sport.

Including a source of protein (lean meat, fish, dairy products, soy foods, beans, legumes and nuts) at each of your meals and snacks will provide the building blocks necessary for building a strong matrix of protein fibers in bone. Achieving peak bone mass during childhood and adolescence, as well as preserving bone mass with aging, is dependent on the body having enough protein available for bone development.

Many other nutrients are needed for healthy bones. Although research is still evolving on their role and benefits, Vitamin K, magnesium, phosphorus, and zinc also have a role in bone health. 

I’m often asked if there is a way to reverse bone loss or if a supplement, like collagen, will help prevent bone loss. There are medications that can help slow bone loss, however these come with side effects. Osteoporosis is not reversable. At this time, there is no evidence to support taking a collagen powder to prevent bone loss. Collagen powders only provide three amino acids that are components of collagen in the body, but there is no way to direct those amino acids to specific tissues in your body (in this case bone) to aid in collagen synthesis. A better strategy would be to consume adequate amounts of high quality protein (such as those foods highlighted above) or include a protein powder that provides the body all of the amino acids (i.e. whey or soy protein).

Bottom line: A food first approach is a superior way to ensure your body is getting all the key nutrients needed for bone metabolism. For advice on customizing a fueling plan, consult a Registered Dietitian who specializes in sports, particularly a Board Certified Specialist in Sports Dietetics (CSSD).

Menopause and Gut Health: The Role of Hormones, Stress and Diet

Fluctuating hormones and the presence or absence of estrogen, that occurs before or during the menstrual cycle – remember puberty – and during the transition to menopause influences the gut-brain connection. The gut-brain connection refers to a bidirectional communication between the “gut” (your digestive system) and the brain. Complex and intricate neurological and physiological factors influence this connection, and in the past decade this has become a hot area of nutritional and psychological research. Scientists continue to reveal information about this two-way highway and the consequential impact of emotions, stress, and hormones on gut function, as well as the influence of the food we eat (and the resulting trillions of microorganisms that exist in the gut) on mood, anxiety, stress, and brain function. Although we know that this complex connection impacts women at all stages of life, the research is still evolving as it relates to the shift in hormones during menopause.

You may become aware of this connection when you experience symptoms such as bloating, gas, constipation and/or diarrhea, along with feeling anxious, moody, fatigue, or suffering with headaches or “brain fog.” More extreme symptoms such as persistent migraines, “urgent diarrhea” or “functional constipation,” could be related to signs of other health concerns and should be discussed with a qualified physician, such as a gastroenterologist or your gynecologist. Additionally, it is recommended if you are suffering from disabling feelings of depression or unmanaged anxiety to visit with a licensed psychologist.

Like hormones, stress and diet also impact the health of the gut-brain connection. Consequently, as women approach their mid-40’s, additional stress such as career changes, kids leaving for college, divorce, aging parents, downsizing, etc. may increase. At the same time, women may unintentionally or intentionally be skipping meals, cooking less at home, and eating out more or more frequently and diet quality may suffer.

A diet rich in plant foods is important for promoting a healthy gut in midlife and beyond.

Nutrition research in this area is relatively new and emerging. We are learning that a diet rich in plant foods and fiber (whole grains, vegetables, fruit, nuts, beans, and legumes), supports a more healthy, diverse microbiome (the name for those trillions of microorganisms) and is associated with improvements in digestion as well as overall physical and mental health. The habitual intake of fermented foods, such as yogurt (with live and active cultures), sauerkraut, and kefir may also help maintain a healthy gut. Negative influences on the gut microbiome that may affect health and disease risk include chronic over consumption of ultra-processed foods (sodas, packaged snacks, energy drinks, energy bars, etc.), diets high in fat and animal protein, as well as yo-yo dieting or going on and off diets, and certain medications.

Battling Midlife Weight Gain: The “Perfect” Problem

“Life, Liberty and the Pursuit of Happiness” is an unalienable right we Americans have. For many women experiencing midlife weight gain, the pursuit of happiness seems to have been replaced by the “prison of perfection.”

I’m often asked by women who are experiencing symptoms of the menopause transition what’s the secret to the “battle of the bulge” – you know that increasing waistline that never used to be a problem? My answer is that the key to success is about making appropriate lifestyle changes that manage the effects of aging and declining hormones (keep reading to learn more about those). I know, I know! Not a very sexy answer, especially for the woman who is desperate and has already made significant attempts at “eating well” and “exercising regularly.”

The problem, I learn after more questions, is not just about what she needs to do to stay healthy through her midlife transition, but really this: “what’s the perfect diet to get thin/stay thin (you know like I was in my 20’s)… and remain ageless?” After all, we’ve been bombarded by messages from media, marketers and society that have seemingly convinced us that “healthy and happy” is found in perfection – the perfect body, job, husband, house, kids, food, skin…

Consider the fact that the number of cosmetic procedures using Botox (botulinum toxin which is a neurotoxic protein produced by the bacterium Clostridium botulinum) have increased a whopping 750% from 2000 to 2014, according to a report from the American Society of Plastic Surgeons. Somehow, cosmetic surgery and these types of procedures have become “normalized” for remaining ageless. We’ve become convinced that challenging the imperfection of aging is the key to happiness.

In fact, the battle with midlife weight gain may actually be a “perfect” problem, as well. The struggle many midlife women have over gaining a few pounds during the menopause transition can become quite intense; resulting in restrictive eating, diet cycling, disordered eating and excessive, compulsive exercise…if not a pathological eating disorder.

“The perfect problem,” according to Margo Maine, PhD, in her book Pursuing Perfection: Eating Disorders, Body Myths and Women at Midlife and Beyond, “promotes the myth that we can find life’s meaning and the answer to every challenge in the shape of our bodies.” Dr. Maine’s book eloquently points out that midlife women are not immune to the cultural pressure to attain a perfect body and may mistakenly underestimate the power of dabbling in pathological behaviors like these. She challenges the reader to many questions, but this one stood out to me:

“When was the last time we were part of an all-woman conversation where no one brought up weight, food, or personal appearance?”

Okay, time out. I’m a born and raised perfectionist, so I’m not here to throw any stones. In fact, my perfectionism has been a gift in many ways – pushing me to academic achievement, career success, and fiscal and financial stability. But, sadly it also got me into a lot of trouble (a prison as Dr. Maine refers to in her book), especially in my 20’s and 30’s as I sought out to have the perfect body, house…you know the list. I was desperate. Desperate to fit in at a time when I didn’t really know who I was. Without going into the gory details, the point is that no matter how hard I tried, it never felt “good enough”.  Someone else always had “it” better. Let’s just say my 30’s didn’t end well.

I’ve come a long way since those days (with a lot of hard work, therapy, faith, and good family and friends), thus the reason I am passionate about helping women of all ages feel confident and at peace with food, exercise and weight – no matter what their size. I want women to know it’s okay to age imperfectly! You are not your body. Wrinkles are normal. Skin will sag. Fat prefers to be stored in the belly after menopause… and, this: “There is no greater power in the world today than the zest of a postmenopausal woman.” ~ Margaret Mead.

So, do we just need to surrender to mediocrity?  Absolutely NOT!

Don’t get me wrong. I want to age as healthfully and gracefully as I can. I want to be strong, energetic and healthy enough to bike the country, travel the world, and chase grandchildren around. The difference is that the pursuit of health is different that the pursuit of perfection. Getting sucked into following the latest trends with food, exercise, skincare, surgery, etc. actually contributes to more stress and anxiety. There will always be something better. Something more “right” and the cycle just continues. Ultimately, none of these behaviors will help you achieve those important life-long goals.

So, the point is this: Do we need to give in to the multi-billion dollar diet, supplement and cosmetic industries – who are working hard to convince women we aren’t good enough the way we are, by the way – to be happy?

No, we don’t! But, what can we do?

Most people I know and work with want to feel in control. Life often feels out of control, so, it’s helpful to know what we CAN control and know it  will make a difference. Spoiler alert: The following list is not “sexy.” You’ve probably heard all this before. But, here’s the deal. These behaviors DO matter. When done consistently, you can be and feel strong, healthy, confident and energetic.

Stay active. Find things you enjoy doing and participate in those activities daily – hiking, gardening, biking, running, golfing, playing volleyball, and lifting something heavier than a soup can!

Cook at home. As we get older, have more money or even more time, eating out can become an all-too-frequent pastime. Change it up. Invite your friends over, explore new recipes, cook with new foods, or just learn to cook if you need to. We know that eating more nutrient dense (versus calorie dense foods) provides more vitamins, minerals, antioxidants, etc. and helps with weight management and overall health. Eating at home provides more control over what you are eating – saves money and can be a lot of fun too!

Eat more fruits and vegetables. I know this point may sound cliche, but the reality is that over 80% of Americans do NOT get the recommended five servings a day of fruits and vegetables, while 60 to 75% of Americans eat more than the recommended servings of grains and protein. So, it wouldn’t hurt to work on eating more of these wholesome nutrient dense foods which will naturally replace over-consumption of other foods. (What We Eat in America, NHANES 2007-2010.)

Eliminate restrictive eating and diet cycling. I can’t say enough about this. But whether intentional or unintentional, restrictive eating sends a powerful message to the body to become very efficient with metabolic processes; use less energy; and, store more fat to protect the body from a state of famine. Thus, although weight loss may happen initially, anything you can’t sustain will backfire with weight regain and likely even more weight stored as fat – in the abdomen! Thus the feeling midlife women have that “their old tricks don’t work anymore.”

Drink less alcohol. Any of the reported benefits associated with alcohol intake are based on drinking in moderation or less than one serving of wine or beer per day and less than three servings at a time. Research demonstrates that women who drink heavily are more prone to central obesity while increasing the risk of breast cancer and cardiovascular disease. Additionally, women at menopause are especially vulnerable to depression, and heavy drinking can just make that worse.

Get good quality sleep. This can be tough for midlife women experiencing shifting hormones that may interfere with sleep. Maintaining a regular bedtime routine and practicing good sleep hygiene (i.e. turn off electronics one hour before bed) may be helpful.

And, let us not forget:

• Don’t smoke – ever. Enough said.
• Brush and floss your teeth regularly.
• Wear sunscreen daily

There is a strong psychological association between taking important steps to take care of yourself and improving body image. For many women, just a week of eating well and regular exercise promotes positive thoughts about their body – even if they didn’t lose weight. There are many reasons for this, but the challenge is to remember that behavior change takes time. Getting support from friends or even a professional, such as a Licensed Psychologist or Registered Dietitian, may be critical to declaring your freedom.

You have a “right” to life, liberty and the pursuit of happiness. Don’t let the “prison of perfection” take that away!

Fighting Midlife Weight Gain

Midlife weight gain is common, but is it inevitable? The complaint I often hear from women goes something like this:

“I never used to struggle with my weight. I’m active and eat well, but since I turned 40, the weight just won’t stay off like it used to.”

For the health-conscious individual, this can feel extremely frustrating. In addition to battling challenges with negative body image, concerns with overall health related to increasing waistlines become overwhelming for women in their 40’s and beyond.

Why do women experience midlife weight gain?

A common misunderstanding is that hormones are to blame for midlife weight gain. Although the menopause-related shift in hormones contributes to the problem, lifestyle and aging play a significant role. As women age, there is a gradual loss of muscle mass or lean tissue, which is more metabolically active. Behavioral factors such as stress and the tendency to move less, sleep less, and increase alcohol and food intake also change as women reach midlife.

“But, why am I gaining all this belly fat?” Numerous studies demonstrate that the change in hormones during the menopause transition is associated with an increase in body fat and more specifically an increase in abdominal or visceral fat. This type of fat is a concern as it is related to several adverse health problems, including cardiovascular disease, diabetes and some cancers, including breast cancer. Visceral fat also contributes to increased inflammation in the body potentially resulting in insulin resistance and further weight gain. Coincidentally, dieting or restrictive eating (at any age) has also been shown to contribute to an accumulation of abdominal fat upon weight re-gain. Therefore, midlife weight gain becomes “a perfect storm” of sorts with the convergence of behavioral factors, aging, and shifting hormones.

What can women do to counteract unwanted weight gain?

Prevention is the key! Minimizing fat gain and maintaining muscle by getting back to the basics of healthy eating and regular exercise are essential for attenuating midlife weight gain. So, do we need to just “eat less and exercise more”?

1. Eat Wisely. Many of the female athletes I work with don’t eat enough to begin with and their body has consequently “learned” to become very efficient with the low amount of calories eaten. Others fill up on easily-digestible, processed foods (including energy bars or highly processed powders and supplements) and wonder why they can’t lose weight with such a low intake. And others struggle with the cycle of “diet at breakfast, diet at lunch and blow it the rest of the day.” So, the message: “eat less” is often misunderstood.  Instead, focus on eating wisely. It has been shown that women who were successful with weight loss and weight management goals used food journals, ate out less, and ate at regular intervals during the day.  Also, eat more nutrient-dense foods, including fruits, vegetables, whole grains, lean meat, fish, beans, yogurt, nuts, seeds, avocados, olives and olive oil.

2. Regular exercise. For the sedentary individual, the message to “move more” may be helpful. In fact, physical activity has been shown to be the single most important factor in preventing age-related weight gain. But, for the active woman, what does this really mean? Too often, I see women running, biking, accumulating “steps” and interpret this message as “just run more, bike more, and accumulate more steps” yet still struggle with weight. While there may be benefits to doing more (for training purposes) adding in a variety of activity, most notably resistance and strength training exercise, is critical for slowing the loss of lean tissue and preventing weight gain.

Midlife weight gain is complex and not easily explained by the effect of one thing, such as hormones. This is an ideal time for women to reassess their health and weight management goals with the support of a qualified medical provider or dietitian. Women can find many helpful resources and certified practitioners on the North American Menopause Society (NAMS) website at www.menopause.org.