Healthy Runner Project: a 7-year, multisite nutrition education intervention to reduce bone stress injury incidence in collegiate distance runners

Michael Fredericson; Megan Roche; Michelle T Barrack; Adam Tenforde; Kristin Sainani; Emily Kraus; Andrea Kussman; Emily Miller Olson; Brian Young Kim; Katherine Fahy; Emily Miller; Ellie Diamond; Sonya Meraz; Sonal Singh; Aurelia Nattiv

doi:10.1136/bmjsem-2023-001545

Healthy Runner Project: a 7-year, multisite nutrition education intervention to reduce bone stress injury incidence in collegiate distance runners

BMJ Open Sport Exerc Med. 2023 May 8;9(2):e001545. doi: 10.1136/bmjsem-2023-001545. eCollection 2023.

Authors

Michael Fredericson¹, Megan Roche², Michelle T Barrack³, Adam Tenforde⁴, Kristin Sainani⁵, Emily Kraus⁶, Andrea Kussman⁶, Emily Miller Olson^{7

8}, Brian Young Kim⁹, Katherine Fahy¹⁰, Emily Miller⁹, Ellie Diamond¹¹, Sonya Meraz¹², Sonal Singh¹³, Aurelia Nattiv¹⁴

Affiliations

¹ Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, Stanford, California, USA.
² Department of Epidemiology, Stanford Hospital and Clinics, Stanford, California, USA.
³ Department of Family and Consumer Sciences, California State University Long Beach, Long Beach, California, USA.
⁴ Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA.
⁵ Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA.
⁶ Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Stanford, California, USA.
⁷ Bodor Clinic, Napa, California, USA.
⁸ American Canyon, California, USA.
⁹ Family Medicine, University of California, Los Angeles, Santa Monica, California, USA.
¹⁰ Department of Family Medicine, University of Washington Medical Center, Seattle, Washington, USA.
¹¹ Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA.
¹² School of Nursing, University of Massachusetts System, Boston, Massachusetts, USA.
¹³ School of Medicine, St George's University, St George's, Grenada.
¹⁴ Division of Sports Medicine, Departments of Family Medicine and Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA.

Abstract

Objectives: We evaluated the effect of a nutrition education intervention on bone stress injury (BSI) incidence among female distance runners at two NCAA Division I institutions.

Methods: Historical BSI rates were measured retrospectively (2010-2013); runners were then followed prospectively in pilot (2013-2016) and intervention (2016-2020) phases. The primary aim was to compare BSI rates in the historical and intervention phases. Pilot phase data are included only for descriptive purposes. The intervention comprised team nutrition presentations focused on optimising energy availability plus individualised nutrition sessions for runners with elevated Female Athlete Triad risk. Annual BSI rates were calculated using a generalised estimating equation Poisson regression model adjusted for age and institution. Post hoc analyses were stratified by institution and BSI type (trabecular-rich or cortical-rich).

Results: The historical phase included 56 runners and 90.2 person-years; the intervention phase included 78 runners and 137.3 person-years. Overall BSI rates were not reduced from the historical (0.52 events per person-year) to the intervention (0.43 events per person-year) phase. Post hoc analyses demonstrated trabecular-rich BSI rates dropped significantly from 0.18 to 0.10 events per person-year from the historical to intervention phase (p=0.047). There was a significant interaction between phase and institution (p=0.009). At Institution 1, the overall BSI rate dropped from 0.63 to 0.27 events per person-year from the historical to intervention phase (p=0.041), whereas no decline was observed at Institution 2.

Conclusion: Our findings suggest that a nutrition intervention emphasising energy availability may preferentially impact trabecular-rich BSI and depend on team environment, culture and resources.

Keywords: bone; bone density/endocrine status; intervention; nutrition.