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The Culture and Consequences of Low Energy Availability in National The Culture and Consequences of Low Energy Availability in National Collegiate Athletic Association Division One Female Distance Runners: A Mixed Methods Investigation by Traci L. Carson A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy (Epidemiological Science) in The University of Michigan 2021 Doctoral Committee: Assistant Professor, Carrie A. Karvonen-Gutierrez, Chair Associate Professor, Philippa J. Clarke Professor, Sioban D. Harlow Professor, Kendrin Sonneville Research Associate Professor Brady T. West Professor, Ron Zernicke Traci L. Carson [email protected] ORCID iD: 0000-0003-0484-7252 © Traci L. Carson 2021 Dedication This dissertation is dedicated to every female athlete who has struggled with an eating disorder. I hope this work begins to change the narrative for the next generation of “us”. ii Acknowledgments There are so many people who supported me throughout this dissertation process and made me excited to wake up every day to do this work. When I began my academic career at the University of Michigan in 2012, I could have never imagined that I would still be here (pursuing a career in science) eight years later. I look back fondly on PH200, the course that inspired me to pursue a career in public health, during my junior year of undergrad. First, I would like to thank my dissertation chair, Dr. Carrie Karvonen-Gutierrez, for your incredible mentorship over the past three and a half years. I am grateful for the unwavering support and guidance you provided me in pursuing my independent research interests. You always knew when to push me and when to let me navigate the journey and make mistakes (to learn from) on my own. Thank you for always making me feel that my wellbeing was more important than my productivity; this is something I will always look back on with the greatest admiration. I would also like to thank my dissertation committee: Drs. Philippa Clarke, Sioban Harlow, Kendrin Sonneville, Brady West, and Ron Zernicke. Without their support, this dissertation would not have been possible. I was thrilled to form such a diverse and interdisciplinary group of mentors, and I am so grateful for their time and thoughtful guidance. Thank you, Dr. Kendrin Sonneville, for inviting me to join your lab group during my MPH and continuing to inspire my passion for eating disorder prevention and advocacy throughout graduate school. Thank you to Dr. Sioban Harlow, for your guidance and feedback in menstrual iii and reproductive health, as well as your invaluable mentorship in navigating academia and professional boundaries. Dr. Brady West, thank you for your mentorship throughout the survey data collection and analysis process. I truly admire your ability to explain complex concepts in simple and direct terms that made me feel confident in my abilities. To Dr. Ron Zernicke, thank you for your genuine support over the years and inspiration to pursue female athlete research. I appreciate your thoughtful feedback on my work and genuine encouragement. Dr. Philippa Clarke, thank you for your guidance in my qualitative study, as well as your thoughtful feedback and encouragement throughout the dissertation process. I appreciate your passion for mentorship and hope to carry this spirit with me into my career. To my incredible cohort, this experience was way more tolerable with you by my side. At the start of first year, I had no idea that my comps study group would become my very best friends. Steph, Alexis and Aliya, we will always be bonded over our shared love of DAG’s and Brkson's bias. Your friendship made this entire PhD process worth it. To Cara, my biking and coffee partner, you helped me persist and stay the course more than you know. Of course, my family deserves the utmost acknowledgment. Thank you to Mom and Dad for the love and unconditional encouragement during this process. To my older brother and life- long science tutor, Ross, you're my biggest fan and inspiration. Our two-hour phone calls about endocrinology, with lots of life lessons shared, helped me make it through my toughest weeks. Kyle, you’ve inspired me to be my authentic self and follow my own path without apology. This dissertation work was greatly supported by the help of three amazing research assistants. I am forever grateful to Troy Toutnaut, Emily Zheutlin, Halimat Olaniyan and Cassie Gaskins for their help with the qualitative aim, including hours of interview transcribing and scouring the internet for email addresses. iv I would be remiss not to thank the female athletes who generously and selflessly gave their time to participate in my studies and made this dissertation possible. I was lucky to be part of the Institute for Research on Women and Gender (IRWG) Community of Scholars during the summer of 2019 and am thankful to my cohort for helping me improve my understanding of feminist theory and refine the theoretical underpinning of my dissertation. Additionally, thank you to my Eating Disorders and Clinical Research Program (EDCRP) at Massachusetts General Hospital fellowship mentors Drs. Eddy, Thomas and Franko for their feedback on Chapter 3 during the summer of 2020. A special shout out to a couple of unofficial mentors: Dr. Bill Lopez for his guidance on the development of my qualitative aim and advice on navigating academia with purpose; Dr. Vivienne Hazzard for her incredible support as a fellow GSI and friend along the way; and Kristefer Stojanovski for his influential support and example in strengthening my voice and advocating for myself throughout the PhD process. Finally, thank you to Dr. Emily Youatt for your teaching mentorship and for having me on the PH200 team for two consecutive years. Lastly, a dedication to the city of Ann Arbor, my home of almost ten years, and to Roos Roast coffee, my second office location and consistent source of motivation and caffeination. v Preface Chapter 2 (Cultural and Environmental Associations with Body Image, Diet, and Wellbeing in NCAA DI Female Distance Runners: A Qualitative Analysis) has been accepted for publication in the British Journal of Sports Medicine. The full list of authors is: Traci Carson, Troy Tournat, Kendrin Sonneville, Ron Zernicke and Carrie Karvonen-Gutierrez. vi Table of Contents Dedication ii Acknowledgments iii Preface vi List of Figures x List of Tables xi Abstract xii Chapter 1. Introduction 1 Foundations of Female Athlete Health Research 1 Physiological Mechanisms 5 Epidemiology of the Triad and RED-S 11 Known Risk Factors for the Triad and RED-S 12 Theoretical Framework 15 Specific Aims 17 Figures 19 Chapter 2. Cultural and Environmental Associations with Body Image, Diet, and Wellbeing in NCAA DI Female Distance Runners: A Qualitative Analysis 35 Abstract 35 Introduction 36 Methods 37 vii Analysis 39 Results 40 Discussion 53 Conclusion 61 Tables 62 Chapter 3. Identifying Latent Classes of RED-S Consequences in A Sample of NCAA DI Female Cross Country Runners 68 Abstract 68 Introduction 69 Methods 71 Analysis 76 Results 76 Discussion 79 Conclusion 84 Tables and Figures 86 Chapter 4. Differences in Bone Injury Between Latent Classes Defined by RED-S Consequences in a Sample of NCAA DI Female Cross Country Runners 99 Abstract 99 Introduction 100 Methods 102 Analysis 103 Results 104 Discussion 105 Conclusion 109 viii Tables and Figures 111 Chapter 5. Conclusion 118 Summary and Implications of Main Findings 119 Strengths and Limitations 122 Future Research 125 Public Health Significance 126 Conclusion 128 Appendices 133 Semi-Structured Qualitative Interview Guide Chapter 2 133 Survey Chapter 3 and 4: The FASHT Cohort 137 ix List of Figures Figure 1.1. Female Athlete Triad (Triad) Framework 19 Figure 1.2. Relative Energy Deficiency in Sport (RED-S) Framework 19 Figure 3.1. Relative Energy Deficiency in Sport (RED-S) Health Consequences Framework 86 Figure 3.2. Latent Classes of RED-S Consequences 87 x List of Tables Table 2.1. Qualitative Study Example Questions 62 Table 2.2. Age and Average Low Energy Availability in Females Questionnaire (LEAF-Q) and Female Athlete Screening tool (FAST) Scores for Study Participants 63 Table 3.1. Demographic, Disordered Eating and Emotional Health Characteristics by Latent Class 88 Table 3.2. RED-S Health Consequences by Latent Class 91 Table 3.3. Latent Class Analysis Model Fit Statistics 91 Table 3.4. Probability of RED-S Consequence by Latent Class 92 Table 4.1. Latent Classes of RED-S Consequences (Without Bone Injury) 111 Table 4.2. Prevalence of Bone Injury Type 111 Table 4.3. Chi-Square Test of Bone Injury (Ever) Distribution by Latent Class 112 Table 4.4. Chi-Square Test of Bone Injury (College) Distribution by Latent Class 112 xi ABSTRACT 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 to capture athletes’ perceptions on 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.
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