title: Ultra-Marathon Athletes at Risk for the Female Athlete Triad.
abstract: BACKGROUND
  Worldwide female participation in ultra-endurance events may place them at risk for the female athlete triad (FAT). The study objectives were to establish triad knowledge, occurrence of disordered eating and triad risk amongst participants of the 2014 89-km Comrades Marathon event.
  
  
  METHODS
  A survey utilising the Low Energy Availability in Females questionnaire (LEAF-Q) and Female Athlete Screening Tool (FAST) questionnaire was conducted on female participants in order to determine the risk. In addition, seven questions pertaining to the triad were asked in order to determine the athlete's knowledge of the triad. Athletes were requested to complete the anonymous questionnaire after written informed consent was obtained while waiting in the event registration queues. Statistical analyses included Pearson product-moment correlations, chi-square tests and cross-tabulations to evaluate associations of interest.
  
  
  RESULTS
  Knowledge of the triad was poor with 92.5 % of participants having not heard of the triad before and most of those who had, gained their knowledge from school or university. Only three athletes were able to name all 3 components of the triad. Amenorrhoea was the most commonly recalled component while five participants were able to name the component of low bone mineral density. Of the 306 athletes included in the study, 44.1 % were found to be at risk for the female athlete triad. One-third of participants demonstrated disordered eating behaviours with nearly half reporting restrictive eating behaviours. There is a significant association between athletes at risk for the triad according to the LEAF-Q and those with disordered eating (χ2(1) = 8.411,p= 0.014) but no association (or interaction) between triad knowledge and category (at risk/not at risk) of LEAF-Q score (χ2(1) = 0.004,p= 0.949). More athletes in the groups with clinical and sub-clinical eating disorders are at risk for the triad than expected under the null hypothesis for no association.
  
  
  CONCLUSIONS
  Only 7.5 % of the female Comrades Marathon runners knew about the triad despite 44.1 % being at a high risk for the triad. Therefore, education and regular screening programmes targeting these athletes are overdue. Postmenopausal athletes are at particularly high risk for large losses in bone mass if they experience chronic energy deficiency and hence require special focus.
authors.affiliation: Section Sports Medicine, Faculty of Health Sciences, University of Pretoria, Hatfield, Pretoria, 0002 South Africa.
authors.forename: Lindy-Lee
authors.initials: LL
authors.lastname: Folscher
authors.affiliation: Section Sports Medicine, Faculty of Health Sciences, University of Pretoria, Hatfield, Pretoria, 0002 South Africa.
authors.forename: Catharina C
authors.initials: CC
authors.lastname: Grant
authors.affiliation: Department of Statistics, University of Pretoria, Hatfield, Pretoria, 0002 South Africa.
authors.forename: Lizelle
authors.initials: L
authors.lastname: Fletcher
authors.affiliation: Section Sports Medicine, Faculty of Health Sciences, University of Pretoria, Hatfield, Pretoria, 0002 South Africa.
authors.forename: Dina Christina
authors.initials: DC
authors.lastname: Janse van Rensberg
keywords: Female athlete triad; Knowledge of female athlete triad; Risk of female athlete triad; Ultra-marathon runners