The Active Female: Health Issues throughout the Lifespan

Preface
About the Editors
Role and Scope Statement
Audience
Acknowledgments
Contents
Contributors
Part I: Unique Gender and Sex Related Physical, Psychological and Physiological Characteristics of Females
	1: Considerations of Sex Differences in Musculoskeletal Anatomy Between Males and Females
		1.1	 Introduction
		1.2	 Research Findings
			1.2.1	 Sex Differences in the Anatomy of Selected Musculoskeletal Components
				1.2.1.1	 Sex Differences in Skeletal Geometry
				1.2.1.2	 Sex Differences in Musculoskeletal Tissues
			1.2.2	 Selected Regional Considerations in Female Functional Pathoanatomy
				1.2.2.1	 Upper Extremity
					Shoulder
					Elbow
					Wrist and Hand
				1.2.2.2	 Lower Extremity
					Hip Joint
					Knee Complex
					Ankle and Foot
				1.2.2.3	 Spine
					Cervical
					Thoracic
					Lumbar
					Sacroiliac Joint and Pelvis
		1.3	 Contemporary Understanding of the Issues
		1.4	 Future Directions
		1.5	 Conclusion
		Review Questions
		References
	2: Body Image Throughout the Lifespan
		2.1	 Introduction
		2.2	 Research Findings
			2.2.1	 Risk Factors for the Development of Body Dissatisfaction
				2.2.1.1	 Theoretical Perspectives
			2.2.2	 Body Image Concerns Across Age Groups
				2.2.2.1	 Preadolescent and Adolescent Females
				2.2.2.2	 Young Adult Women
				2.2.2.3	 Older Women
			2.2.3	 Body Image Assessment
				2.2.3.1	 Body Image Assessment Scales and Questionnaires
		2.3	 Contemporary Understanding of the Issues
			2.3.1	 Theoretical Foundations
			2.3.2	 Body Image Intervention Strategies
				2.3.2.1	 Socioecological Framework
				2.3.2.2	 Dissonance-Based Prevention
				2.3.2.3	 Physical Activity
				2.3.2.4	 Female Athletes
				2.3.2.5	 Health and Wellness Coaching
				2.3.2.6	 Health Communication Strategies
					Mobile Apps
					Diverse Ad Campaigns
					Social Media Campaigns
		2.4	 Future Directions
			2.4.1	 Emotional Intelligence and Mindfulness
			2.4.2	 Developmental Stages and Life Transitions
			2.4.3	 Spectrum of Body Image and Eating Concerns
			2.4.4	 Mental Health Literacy and eHealth Literacy
			2.4.5	 Assessment
		2.5	 Concluding Remarks
		Appendices
			Appendix 1: Body Image Quality of Life Inventory
			Appendix 2: Body Image Concern Inventory
			Appendix 3: Physical Appearance State and Trait Anxiety Scale: Trait
		Chapter Review Questions
		References
	3: The Psychology of Female Sport Performance from a Gender Perspective
		3.1	 Introduction
		3.2	 Research Findings and Contemporary Understanding of the Issues
			3.2.1	 Confidence
			3.2.2	 Competitive Anxiety
			3.2.3	 Gender Differences in the Motivation for Sport Participation and Competitiveness
			3.2.4	 Group Dynamics, the Cohesion–Performance Relationship and Conflict
			3.2.5	 Stressors and Coping
			3.2.6	 Self-Compassion
			3.2.7	 Weight Pressures, Body Dissatisfaction, and Associated Eating Disorders
			3.2.8	 Coaching and Coach Behaviors
			3.2.9	 Microaggressions Towards Female Athletes
		3.3	 Future Directions and Concluding Remarks
		Chapter Review Questions
		References
	4: Reproductive Changes from Puberty to Menopause and the Effects of the Menstrual Cycle on Bone Formation and Bone Loss
		4.1	 Introduction
		4.2	 Research Findings and Contemporary Understanding of the Issues
			4.2.1	 Puberty
			4.2.2	 Menstrual Cycle
			4.2.3	 Disruption of the Menstrual Cycle
			4.2.4	 Cessation of the Menstrual Cycle
			4.2.5	 Bone Composition and Physiology
			4.2.6	 Effects of Female Sex Hormones on Bone
			4.2.7	 Peak Bone Mass
			4.2.8	 Results of an Abnormal Menstrual Cycle on Peak Bone Mass
			4.2.9	 Menopause and Bone Mineral Density
		4.3	 Future Directions and Concluding Remarks
		Chapter Review Questions
		References
	5: A Modern Understanding of the Models of Energy Deficits in Athletes
		5.1	 Introduction into Energy Availability
			5.1.1	 The Female Athlete Triad (FAT)
			5.1.2	 Relative Energy Deficiency in Sport (RED-S)
		5.2	 Research Findings and Contemporary Understanding of Health Consequences of Low-Energy Availability
			5.2.1	 Eating Disorders
			5.2.2	 Menstrual Dysfunction
			5.2.3	 Bone Health
			5.2.4	 Energy Availability, Bone Health, and Menstrual Dysfunction Interaction
			5.2.5	 Performance Consequences of Low-Energy Availability
		5.3	 Future Directions and Concluding Remarks
			5.3.1	 Importance of Early Intervention and Prevention
			5.3.2	 Conclusion
		Chapter Review Questions
		References
	6: The Physiology of Anorexia Nervosa and Bulimia Nervosa
		6.1	 Introduction
			6.1.1	 Diagnostic Criteria for Anorexia Nervosa
			6.1.2	 Diagnostic Criteria for Bulimia Nervosa
			6.1.3	 Eating Disorder Crossover and Identification
		6.2	 Research Findings
			6.2.1	 Adverse Health Effects of Anorexia Nervosa
				6.2.1.1	 Gastrointestinal Abnormalities
				6.2.1.2	 Fluid and Electrolyte Abnormalities
				6.2.1.3	 Integumentary Abnormalities
				6.2.1.4	 Hematologic Abnormalities
				6.2.1.5	 Skeletal Problems
				6.2.1.6	 Central Nervous System Abnormalities
				6.2.1.7	 Effects on Pregnancy
			6.2.2	 Comorbidities and Mortality Rates for Anorexia Nervosa
				6.2.2.1	 Cardiovascular Abnormalities
				6.2.2.2	 Endocrine Abnormalities
				6.2.2.3	 Mortality Rates
			6.2.3	 Adverse Health Effects of Bulimia Nervosa
				6.2.3.1	 Gastrointestinal Abnormalities
				6.2.3.2	 Gynecological Problems and Hormones
				6.2.3.3	 Cardiovascular Abnormalities
				6.2.3.4	 Immunologic Abnormalities
			6.2.4	 Comorbidities and Mortality Rates for Bulimia Nervosa
		6.3	 Contemporary Understanding of the Issues
			6.3.1	 Genetic Variables and Eating Disorders
			6.3.2	 Neurotransmitters and Neuropeptides
				6.3.2.1	 Serotonin and Tryptophan
				6.3.2.2	 Neural Signaling Response to Food Consumption
				6.3.2.3	 Receptor Subtypes for Serotonin
				6.3.2.4	 Dopamine
				6.3.2.5	 Catechol-O-methyltransferase
			6.3.3	 Peptides and Proteins
				6.3.3.1	 Leptin
				6.3.3.2	 Ghrelin
				6.3.3.3	 Cholecystokinin
				6.3.3.4	 Brain-Derived Neurotrophic Factor
		6.4	 Future Directions
			6.4.1	 Anorexia Nervosa
			6.4.2	 Bulimia Nervosa
			6.4.3	 Secondary Prevention and Education
		6.5	 Concluding Remarks
		Chapter Review Questions
		References
	7: Exercise Metabolism and Menstrual Cycle
		7.1	 Introduction
		7.2	 Research Findings and Contemporary Understanding of the Issues in Substrate Metabolism
			7.2.1	 Methodological Limitations and Recommendations
			7.2.2	 Substrate Metabolism at Rest
				7.2.2.1	 Estrogen Receptors and Estrogen Action
				7.2.2.2	 Effects of Estrogen and Progesterone on Carbohydrate and Fat Metabolism
				7.2.2.3	 Effects of Sex Hormone-Binding Globulin in Estrogen Action
			7.2.3	 Substrate Metabolism During Exercise
				7.2.3.1	 Substrate Metabolism During Aerobic Exercise (AE)
				7.2.3.2	 Substrate Metabolism During Resistance Training (RT)
		7.3	 Future Directions
		7.4	 Concluding Remarks
		Chapter Review Questions
		References
Part II: Inequities in Women’s Health Care and Alternative Management Strategies for Women’s Health
	8: Racism, Health Disparities, Health Inequities, and Black Women’s Health and Healthy Activity
		8.1	 Introduction
		8.2	 Internal Racism and an Absence of Female Consciousness Frameworks
			8.2.1	 Internal Racism
			8.2.2	 An Absence of Female Consciousness
		8.3	 Racism, Racial Discrimination, Health, and Health Care
		8.4	 Bridging the Gaps Study: Health Disparities and Inequities in the African–American Community
			8.4.1	 Procedures
		8.5	 Research Findings
		8.6	 A Quantitative Study of the Impact of Sexism and Racism of Black Women
			8.6.1	 Method
		8.7	 Future Directions and Concluding Remarks
			8.7.1	 Health Inequities and Disparities in Black Communities
			8.7.2	 Black Women’s Experiences of Racial Discrimination
		Chapter Review Questions
		References
	9: The Pandemic Within Systemic Injustice: Intersectional Cultural Dimensions of Women’s Aging, Health, and Case Stories of COVID-19
		9.1	 COVID-19
		9.2	 Cultural Competency
		9.3	 The Disproportionate Impact of COVID-19
			9.3.1	 Structural Racism, Structural Sexism, and Intersectionality
		9.4	 The Essential Intersection of Social Networks and Active Lifestyles as Women Age
		9.5	 The Importance of Social Networks for the LGBTQI Community
		9.6	 Case Stories of COVID-19
			9.6.1	 Knock, Knock, It Is Déjà Vu: Marbley
			9.6.2	 Friends Indeed: Starkey
			9.6.3	 Unsung Shero: Murphy
			9.6.4	 A Chill Is in the Air: Abdullah
		9.7	 Reflection
		9.8	 Conclusion
		9.9	 Recommendations
		Chapter Review Questions
		References
	10: Evidence-Based Disordered Eating Prevention Programs for Active Females Including Mindfulness
		10.1	 Introduction
		10.2	 Research Findings
			10.2.1	 The Transtheoretical Model in Health Behavior Change
			10.2.2	 General Treatment Principles
			10.2.3	 Exercise as Medicine in the Treatment of Eating Disorders Program
			10.2.4	 Dissonance-Based Eating Disorder Prevention Program
			10.2.5	 Riding the [Third] Wave of Mindfulness
				10.2.5.1	 Mindfulness-Based Eating Awareness Training (MB-EAT)
				10.2.5.2	 Mindfulness Disordered Eating Prevention Programs
				10.2.5.3	 Mindful Eating
			10.2.6	 Pharmacological Treatment of Eating Disorders
			10.2.7	 Eating Disorder Organizations and Resources
		10.3	 Contemporary Understanding of the Issues
		10.4	 Future Directions
		10.5	 Concluding Remarks
		Chapter Review Questions
		References
	11: Alternative Treatment Modalities for the Active Female with Musculoskeletal Pain
		11.1	 Introduction
		11.2	 Research Findings and Contemporary Understanding of the Issues
			11.2.1	 Cold Therapy
			11.2.2	 Heat Therapy
			11.2.3	 Heat vs. Cold
			11.2.4	 Exercise
			11.2.5	 Yoga
			11.2.6	 Exergames
			11.2.7	 Pain Neuroscience Education
			11.2.8	 Supplements
			11.2.9	 Chiropractic Therapy
			11.2.10 Acupuncture/Trigger Point Dry Needling
			11.2.11 Dynamic Compression
			11.2.12 Transcutaneous Electrical Nerve Stimulation (TENS)
			11.2.13 Kinesio Taping
			11.2.14 Cupping
			11.2.15 Homeopathy
		11.3	 Future Directions and Concluding Remarks
		Chapter Review Questions
		References
Part III: Screening, Prevention, and Management of Health-Related Issues/Injuries in Active Females
	12: Screening for Eating Disorders, Dysfunctional Exercise, and Menstrual Dysfunction in Female Athletes
		12.1	 Introduction
		12.2	 Definitions
			12.2.1	 Eating Disorders
			12.2.2	 Dysfunctional Exercise
			12.2.3	 Menstrual Dysfunction
		12.3	 Research Findings in Disordered Eating/Eating Disorders, Dysfunctional Exercise, and Menstrual Dysfunction
			12.3.1	 Prevalence
				12.3.1.1	 Prevalence of Disordered Eating/Eating Disorders in Active Females
				12.3.1.2	 Prevalence of Dysfunctional Exercise in Active Females
				12.3.1.3	 Prevalence of Menstrual Dysfunctional in Female Athletes
			12.3.2	 Current Research in Disorder Eating/Eating Disorders, Dysfunctional Exercise, and Menstrual Dysfunction: Screening Tools
				12.3.2.1	 Current Research in Disorder Eating/Eating Disorders
					Screening for Disordered Eating/Eating Disorders and Pre-Participation Examinations
					Reasons to Screen for Disordered Eating or Eating Disorders and Screening Practices
					Functionality of Screening Tools for Disordered Eating or Eating Disorders
					Screening Settings for Disordered Eating or Eating Disorders
					Barriers to Recognition of Disordered Eating/Eating Disorders
					Screening Tools for Disordered Eating/Eating Disorders
						General Screening Tools for Disordered Eating/Eating Disorders and Diagnostic Screening Tools for Eating Disorders (Table 12.5)
						Self-Report Questionnaire Screening Tools, Athlete Specific for Disordered Eating/Eating Disorders
						Non-Gender-Specific Eating Disorder Tools (Table 12.8)
				12.3.2.2	 Current Research in Dysfunctional Exercise Etiology
					Physiological Hypothesis
					Psychological Hypothesis
					Psychobiological Hypothesis
					Dysfunctional Exercise in the Active Female
					Dysfunctional Exercise Components
						Qualitative Component
						Quantitative Component
					Thresholds for Dysfunctional Exercise: What We Know
					Screening Tools for Dysfunctional Exercise
					Classification of the Screening Tools for the Assessment of Dysfunctional Exercise
						Qualitative Screening Tools for Dysfunctional Exercise
						Quantitative Screening Tools
				12.3.2.3	 Current Research in Menstrual Dysfunction Types of Menstrual Dysfunction
					Functional Hypothalamic Amenorrhea
					Who Should Be Screened for Menstrual Dysfunction?
					When to Screen for Menstrual Dysfunction
					Screening Questions for Menstrual Dysfunction
					Evaluation of Menstrual Dysfunction Beyond Screening
					Management of Functional Hypothalamic Amenorrhea
		12.4	 Contemporary Understanding of the Issues
		12.5	 Future Directions
		12.6	 Concluding Remarks
		Appendix 1: Screening Tools
			Appendix 1.1: Eating Disorders/Disordered Eating
				1.1.1 General Screening Tools
					EAT-26
				SCOFF Questionnaire
				Eating Disorders Exam-Questionnaire (EDE-Q)
				Eating Disorder Inventory-3 (EDI-3)
				Eating Disorder Screen for Primary Care (ESP)
				Bulimia Test-Revised (BULIT-R)
				National Eating Disorders Association (NEDA) Screening Program
			1.1.2 Eating Disorders Diagnostic Tools
				Eating Disorders Exam (EDE)
				Interview for Diagnosis of Eating Disorders (IDED)-IV
			1.1.3 Athlete Specific Screening Tools
				Female Athlete Screening Tool (FAST)
				Health, Weight, Dieting, and Menstrual History Questionnaire (HWDMHQ)
				Physiologic Screening Test
				Female Athlete Triad Screening Questionnaire
				Athletic Milieu Direct Questionnaire (AMDQ)
				Athlete
				Low Energy Availability in Females Questionnaire (LEAF-Q)
				Brief Eating Disorder in Athletes Questionnaire (BEDA-Q)
			1.1.4 Non-Gender Specific Screening Tools
				College Health-Related Informational Survey (CHRIS)
				De Palma
				Survey of Eating Disorders Among Athletes (SEDA)
				Pre-participation Physical Evaluation, Fifth Edition
				International Olympic Committee Periodic Health Evaluation of Elite Athletes
			Appendix 1.2: Dysfunctional Exercise Questionnaires
				Obligatory Exercise Questionnaire (OEQ)
				Exercise Addiction Inventory (EAI)
				Compulsive Exercise Test (CET)
				Exercise Dependence Questionnaire (EDQ)
				Commitment to Exercise Scale (CES)
				Exercise Belief Questionnaire (EBQ)
				Bodybuilding Dependence Scale (BDS)
				Exercise Dependence Scale (EDS) and Exercise Dependence Scale Revised (EDS-R)
				Exercise Identity Scale (EIS)
				The Exercise Salience Scale (ESS)
				Exercise and Eating Disorder Questionnaire (EED-Q)
				The Exercise Dependence and Elite Athletes Scales (EDAS)
				Athletes Relationship with Training Scale (ART)
		Chapter Review Questions
			Eating Disorder/Disordered Eating Questions
			Dysfunctional Exercise Questions
			Menstrual Dysfunction Questions
		References
	13: The Importance of Posture and Muscular Balance in the Body for Managing Skeletal Muscle Injuries in Active Females
		13.1	 Introduction to the Active Female and Posture
		13.2	 Research Findings and Contemporary Understanding of the Issues
			13.2.1	 Components of Posture
				13.2.1.1	 The Musculoskeletal System
				13.2.1.2	 The Neuromuscular Junction
				13.2.1.3	 The Nervous System’s Role
			13.2.2	 The Effects of Postural Change
				13.2.2.1	 Gender and Age
				13.2.2.2	 Muscular Imbalances
				13.2.2.3	 Pain and Injury
			13.2.3	 Preventative Measures
				13.2.3.1	 Assessment of Posture
					Flexicurve Ruler
					Bubble Inclinometer
			13.2.4	 Exercise and Physical Activity
				13.2.4.1	 Other Therapeutic Modalities
		13.3	 Future Directions and Concluding Remarks
		Chapter Review Questions
		References
	14: Prevention and Management of Common Musculoskeletal Injuries in Skeletally Immature Female Athletes
		14.1	 Introduction
		14.2	 Research Findings and Contemporary Understanding of the Issues
			14.2.1	 The Important Changes from Prepubescence to Postpubescence in Females As Far As Anatomy and Physiology of the Musculoskeletal System Are Concerned
			14.2.2	 The Pertinent Differences and Similarities Between Young Females and Males in Terms of Anatomy, Physiology, and Biomechanics of the Musculoskeletal System
			14.2.3	 The Occurrence of Various Common Musculoskeletal Injuries More Unique to Young Female Athletes Especially During the Adolescent Growth Spurt
			14.2.4	 Several Measures for Prevention of Athletic Injuries from Occurring in Preadolescent and Adolescent Females
			14.2.5	 Different Methods of Orthopedic Treatment for Musculoskeletal Injuries Incurred by Young Female Athletes, Including Specific Recommendations for a Regular Conditioning Program Once Healing Is Complete in Order to Enhance Their Physical Fitness
		14.3	 Future Directions and Concluding Remarks
		Chapter Review Questions with Scenario
			Scenario
			Questions
			Plausible Answers
		References
	15: Prevention and Management of Common Musculoskeletal Injuries in the Adult Female Athlete
		15.1	 Introduction
		15.2	 Research Findings and Contemporary Understanding of the Issues
			15.2.1	 The Fundamental Differences in Anatomy, Physiology, and Body Composition Between Adolescent and Adult Females in Terms of the Musculoskeletal System
			15.2.2	 The Relative Similarities and Pertinent Differences Between Adult Males and Females Concerning the Anatomy, Body Composition, and Biomechanics of the Musculoskeletal System
			15.2.3	 Various More Common Types of Orthopedic Injuries Sustained by Adult Females Involved in Certain Athletic Activities
			15.2.4	 Several Measures for Prevention of Musculoskeletal Injuries Incurred by Adult Female Athletes
			15.2.5	 Different Modes of Treatment for Orthopedic Injuries Sustained by Adult Females Participating in Certain Sporting Activities
		15.3	 Future Directions and Concluding Remarks
		Chapter Review Questions with Scenario
			Scenario
			Review Questions
			Plausible Answers
		References
	16: Prevention and Management of Common Musculoskeletal Injuries in the Aging Female Athlete
		16.1	 Introduction
		16.2	 Research Findings and Contemporary Understanding of the Issues
			16.2.1	 The Hormonal, Physiological, Anatomical/Musculoskeletal Changes in Female Athletes as they Transition from Young Adulthood into the Middle Age and Beyond
			16.2.2	 The Differences and Similarities Between Older Males Versus Females in Terms of Their Body Composition, Musculoskeletal Components, and Athletic Performance
			16.2.3	 Various Musculoskeletal Injuries and Orthopedic Conditions More Common to Aging and Fairly Unique in Older Female Athletes
			16.2.4	 Several Measures of Prevention to Keep Musculoskeletal Injuries in Older Active Females from Occurring
			16.2.5	 Different Methods of Treatment for Orthopedic Conditions Incurred in Aging Female Athletes, Including Exercise Prescription as Recommended by Various Nationally Recognized Organizations
		16.3	 Future Directions and Concluding Remarks
		Chapter Review Questions with Scenario
			Scenario
			Review Questions
			Plausible Answers
		References
	17: Prevention and Management of Osteoporosis Through Exercise
		17.1	 Introduction and Background
			17.1.1 Diagnosis and Measurement of Osteoporosis
			17.1.2 Bone Histology and Pathophysiology of Osteoporosis
			17.1.3 Changes in Bone Mass Through the Active Female’s Lifespan
			17.1.4 Risk Factors in the Development of Osteoporosis
		17.2	 Research Findings
			17.2.1 Prevention and Management of Osteoporosis Through Exercise: Overview
			17.2.2 Exercise-Related Mechanisms Leading to Bone Accrual
			17.2.3 Exercise Interventions for Preventing and Managing Osteoporosis: Jumping or Hopping
			17.2.4 Exercise Interventions for Preventing and Managing Osteoporosis: Resistance Training
			17.2.5 Exercise Interventions for Preventing and Treating Osteoporosis: Avoiding Low-Impact Exercise
			17.2.6 Exercise Interventions for Preventing Osteoporosis: Whole-Body Vibration
			17.2.7 Exercise Interventions for Preventing and Treating Osteoporosis: Site Specificity
			17.2.8 Exercise Interventions Specifically for Treating Osteoporosis
			17.2.9 Exercise Through the Lifespan
			17.2.10 Subsidiary Benefits of Bone-Loading Exercise
		17.3	 Contemporary Understanding of the Issues
			17.3.1 Estrogen as a Confounding Factor for Bone Strength
			17.3.2 The Confounding Effects of Nutrition on Bone Health
		17.4	 Future Directions
		17.5	 Concluding Remarks
		Chapter Review Questions
		References
Part IV: Nutrition, Energy Balance, and Energy Availability in Active Females
	18: Estimating Energy Requirements
		18.1	 Introduction
		18.2	 Research Findings and Nutritional Terminology
			18.2.1	 Terms Used when Discussing Total Daily Energy Expenditure (TDEE)
				18.2.1.1	 Calorie (Capital C or Uppercase C), Calories (Lowercase c), and Kilocalorie
				18.2.1.2	 Basal Metabolic Rate (BMR)
				18.2.1.3	 Basal Energy Expenditure (BEE)
				18.2.1.4	 Resting Metabolic Rate (RMR)
				18.2.1.5	 Resting Energy Expenditure (REE)
				18.2.1.6	 Thermic Effect of Food
				18.2.1.7	 Energy Balance
				18.2.1.8	 Energy Efficiency from Digestion to Exercise
				18.2.1.9	 Energy Availability
				18.2.1.10	 Estimated Energy Requirement
				18.2.1.11	 Metabolic Equivalent
				18.2.1.12	 Compendium of Physical Activities
			18.2.2	 Energy Requirements Versus Nutrient Requirements
			18.2.3	 Energy Requirements
			18.2.4	 The Components of Energy Expenditure
				18.2.4.1	 Factors Affecting Resting Energy Expenditure
				18.2.4.2	 Factors Affecting the Thermic Effect of Food
				18.2.4.3	 Factors Affecting the Energy Expended in Physical Activity and Exercise
		18.3	 Contemporary Understanding of the Issues
			18.3.1	 Methods of Measuring Energy Expenditure
			18.3.2	 Estimated Energy Expenditure Prediction Equations
		18.4	 Future Directions
			18.4.1	 Resting Metabolic Rate and Adaptive Thermogenesis
				18.4.1.1	 Adaptive Thermogenesis
			18.4.2	 NEAT Definition
			18.4.3	 Estimating TEE Using the Compendium of PA
				18.4.3.1	 Estimating TEE: A Case Study
			18.4.4	 Estimating NEAT
				18.4.4.1	 NEAT Estimation
		18.5	 Concluding Remarks
		Appendix 1 2011 Compendium of Physical Activities [12] (Reprinted with permission from Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett DR, Jr., Tudor-Locke C, et al. The Compendium of Physical Activities tracking guide:
		Appendix 2 2005 Compendium of Physical Activities for Children and Adolescents by Age Group and Sex [14] (Adapted with permission from Harrell JS, McMurray RG, Baggett CD, Pennell ML, Pearce PF, Bangdiwala SI. Energy costs of physical activitie
		Appendix 3 2018 Compendium of Physical Activities for Children and Adolescents by Age Group and Sex [13] (Adapted with permission from Butte NF, Watson KB, Ridley K, Zakeri IF, McMurray RG, Pfeiffer KA, et al. A Youth Compendi
		Chapter Review Questions
		References
	19: Nutritional Guidelines for Active Children
		19.1	 Introduction
		19.2	 Research Findings
			19.2.1	 Dietary Guidelines for Americans (DGA)
			19.2.2	 Macronutrients
			19.2.3	 Micronutrients and Water
			19.2.4	 Nutritional Responsibility
		19.3	 Contemporary Understanding of the Issue
		19.4	 Future Directions
		19.5	 Concluding Remarks
		Appendix 1
		Appendix 2
		Chapter Review Questions
		References
	20: Nutritional Guidelines Including Hydration Recommendations and Energy Needs for the Female Athlete: Preventing Low Energy Availability and Functional Amenorrhea Through Nutritional Therapy
		20.1	 Introduction
		20.2	 Research Findings
		20.3	 Contemporary Understanding of the Issues
			20.3.1	 Energy Availability and Functional Amenorrhea
			20.3.2	 Hormonal Regulation of Food Intake
			20.3.3	 Estimating Energy and Nutritional Intake
		20.4	 Future Directions
			20.4.1	 Nutritional Guidelines for the Female Athlete
				20.4.1.1	 Priority Is Meeting Energy Needs
				20.4.1.2	 Macro and Micronutrients for Athletes
			20.4.2	 The Importance of Hydration Before, During, and After Exercise
		20.5	 Concluding Remarks
		Appendix 1
		Appendix 2 Nutrition questionnaire with 3-day recall (Adapted from Dynamics of nutrition support: assessment, evaluation, and implementation. Krey SH, Murray RL, Appleton-Century-Crofts, 1986 [84])
		Appendix 3 Food Frequency Questionnaire (Adapted from Dynamics of nutrition support: assessment, evaluation, and implementation. Krey SH, Murray RL, Appleton-Century-Crofts, 1986 [84])
		Chapter Review Questions
		References
	21: Nutritional Guidelines and Energy Needs During Pregnancy and Lactation for Active Women
		21.1	 Introduction
			21.1.1	 Nutritional Guidelines During Pregnancy and Lactation
		21.2	 Research Findings and Contemporary Understanding of the Issues
			21.2.1	 Energy Requirements and Important Nutrients for Optimal Pregnancy/Lactation and Infant Outcomes
				21.2.1.1	 Energy Requirements
				21.2.1.2	 Macronutrients
					Carbohydrate
					Protein
					Fat
				21.2.1.3	 Micronutrients
					Folic Acid (Folate)
					Iron
					Iodine
					Vitamin D
		21.3	 Concerns During Pregnancy and Lactation
			21.3.1	 Weight Gain During Pregnancy
			21.3.2	 Vegetarianism and Pregnancy: A New Issue
		21.4	 Future Directions
		21.5	 Concluding Remarks
		Appendix 1
		Chapter Review Questions
		References
	22: Nutritional Guidelines, Energy Balance, and Weight Control: Issues for the Aging Active Female
		22.1	 Introduction
		22.2	 Research Findings
			22.2.1	 Energy Balance and Weight Control
		22.3	 Contemporary Understanding of the Issues
			22.3.1	 Dietary Guidelines for the Mature Woman
			22.3.2	 Important Nutrients, Vitamins, and Minerals for Physically Active Women
		22.4	 Future Directions
			22.4.1	 Vitamin B12 and Folate
			22.4.2	 Vitamin A
			22.4.3	 Thiamin
			22.4.4	 Vitamin C
			22.4.5	 Vitamin E
			22.4.6	 Calcium
			22.4.7	 Iron
		22.5	 Concluding Remarks
		Appendix 1 Dietary Reference Intakes (DRIs) Reports
		Appendix 2 USDA Food Patterns—Food Groups and Subgroups
		Appendix 3 Healthy U.S.-Style Eating Pattern: Recommended Amounts of Food from Each Food Group at 12 Calorie Levels
		Appendix 4 Age Recommendations for Activity
			Key Activity Guidelines for Adults [43]
			Examples of Physical Activities for Older Adults [43]
			Health Benefits Associated with Regular Physical Activity [43]
		Appendix 5 Ideas for Activity
			Some Websites for Being Active
		Appendix 6 Estimated Calorie Needs Per Day by Age and Activity Level [31]
		Chapter Review Questions
		References
	23: Ergogenic Aids and the Female Athlete
		23.1	 Introduction
		23.2	 Research Findings
			23.2.1 What Supplements Are Female Athletes Taking?
			23.2.2 Protein Needs in Female Athletes
			23.2.3 Protein Supplements Sources
				23.2.3.1	 Animal Protein Sources (Milk, Bovine Colostrum, Beef, and Insect)
					Milk Protein Supplements (Whey and Casein)
					Whey Protein Supplements
					Casein Protein Supplements
					Bovine Colostrum Supplements
					Beef and Insect Protein Supplements
				23.2.3.2	 Plant-Based Protein Supplements
					Soy Protein Supplements
					Rice and Pea Protein Supplements
			23.2.4 Nutritional Profile of Different Animals and Plant-Based Protein Supplements
			23.2.5 Acute Dose-Response Effects of Ingesting Different Types of Protein Supplements
			23.2.6 Long-Term Effects of Protein Supplementation
			23.2.7 The Use of Amino Acids as Nutritional Supplements
			23.2.8 Branched Chain Amino Acids (BCAAs)
			23.2.9 β-Hydroxy ß-methylbutyrate (HMB)
			23.2.10 L-Glutamine
			23.2.11 L–Arginine and L-Citrulline
			23.2.12 β-Alanine
			23.2.13 Integrating Supplementation and Diet
			23.2.14 Creatine
		23.3	 Common Ingredients in Energy Drinks and Pre-workouts
			23.3.1 Carnitine
			23.3.2 Caffeine
				23.3.2.1	 Dosage
				23.3.2.2	 Adverse Effects
				23.3.2.3	 High-Intensity Exercise
				23.3.2.4	 Strength
				23.3.2.5	 Endurance
			23.3.3 Ginseng
			23.3.4 Energy Drinks
				23.3.4.1	 The Effects of Energy Drinks on Sprint Performance and High-Intensity Exercise
				23.3.4.2	 The Effects of Energy Drinks on Endurance Performance
				23.3.4.3	 Conclusion: Are Energy Drinks Ergogenic?
			23.3.5 Pre-workouts
		23.4	 Echinacea as an Ergogenic Aid
			23.4.1 Echinacea and Erythropoietin
		23.5	 Multivitamins
		23.6	 Iron
			23.6.1 Does Correcting Iron Insufficiency or Deficiency Improve Performance?
		23.7	 Contemporary Understanding of the Issues
		23.8	 Future Directions
		23.9	 Concluding Remarks
		Chapter Review Questions
		References
Part V: Exercise Guidelines and Precautions for Active Females Throughout the Lifespan
	24: Screening for Safe Exercise Participation and Exercise Guidelines for Health-Related Fitness
		24.1	 Introduction
		24.2	 Current Research Findings and Objectives
		24.3	 Physical Activity Recommendations for Health-Related Fitness from Leading Health Organizations
			24.3.1	 Review of Current Standards
		24.4	 Safe and Effective Exercise for Health-Related Benefits
			24.4.1	 The Pre-exercise Screening Process
			24.4.2	 The Difference Between Moderate Physical Activity, Vigorous Physical Activity, Exercise and Physical Activity, Health-Related Physical Fitness, and Sports-Related Fitness
			24.4.3	 The American College of Sports Medicine’s Exercise Recommendations for Cardiorespiratory Fitness
				24.4.3.1	 Adults
				24.4.3.2	 Children and Adolescents
			24.4.4	 The American College of Sports Medicine’s Exercise Recommendations for Muscular Fitness
			24.4.5	 The American College of Sports Medicine’s Exercise Recommendations for Healthy Body Composition
			24.4.6	 The American College of Sports Medicine’s Exercise Recommendations for Flexibility
		24.5	 Concluding Remarks
		Appendix 1 2021 PAR-Q+
		Appendix 2 Determining Exercise Intensity Using the Heart Rate Reserve Method (HRR) [13]
			Sample Exercise Resistance Program for Postmenopausal Women: 4, 6, 8, and 12-Week Programs
			Sample Resistance Exercises for Women
		Appendix 3 Determining Moderate and Vigorous Exercise Intensity Using the Borg Rating of Perceived Exertion (RPE) Scale [13, 22]
		Chapter Review Questions
		References
	Untitled
	25: Cardiovascular Exercise Guidelines for Optimal Performance of Active Females Throughout the Lifespan Including Children, Adolescents, and the Aging Female
		25.1	 Introduction
		25.2	 Research Findings
			25.2.1	 General Cardiovascular Exercise Guidelines for Children and Adolescents
				25.2.1.1	 Children’s and Adolescents’ Unique Characteristics
				25.2.1.2	 How to Approach Exercise with Children and Adolescents
			25.2.2	 General Cardiovascular Exercise Guidelines for Healthy Adults
				25.2.2.1	 Adult Women’s Unique Characteristics
			25.2.3	 General Cardiovascular Exercise Guidelines for Older Adults
				25.2.3.1	 Postmenopausal Women’s Unique Characteristics
			25.2.4	 Training Principles and Methods
				25.2.4.1	 Principles of Training
					Principle of Individuality
					Principle of Specificity
					Principle of Overload
					Principle of Progression
					Principle of Diminishing Returns
					Principle of Reversibility
					Principle of Recovery
				25.2.4.2	 Examples of Training Load and Specificity for Optimal Performance
				25.2.4.3	 Training Program Designs
					Continuous Training vs. HIIT
					Periodization
					Cardiovascular Exercise Alone vs. Combined Cardiovascular and Resistance Training
		25.3	 Contemporary Understanding of the Issues
		25.4	 Future Directions
		25.5	 Concluding Remarks
		Chapter Review Questions
		References
	26: Resistance Training Guidelines for Active Females Throughout the Lifespan, from Childhood to Elderly
		26.1	 Introduction
		26.2	 Research Findings and Contemporary Understanding of the Issues
			26.2.1	 Skeletal Muscle as an Essential Organ for Health
			26.2.2	 The Importance of Muscle Growth and Its Relationship with Bone Health
		26.3	 Determining Strength Expression During Resistance Exercise Training
			26.3.1	 Physiological and Neurological Variables
				26.3.1.1	 Training Intensity and Volume (Sets and Repetitions)
				26.3.1.2	 Rest Between Sets
				26.3.1.3	 Frequency of Training
				26.3.1.4	 Duration of Session and the Available Time per Session
			26.3.2	 Biomechanical Variables
				26.3.2.1	 Exercises Selection and Order of Execution
				26.3.2.2	 Training Device
		26.4	 Resistance Training for Children and Adolescents
			26.4.1	 How to Approach Strength Training with Children and Adolescents
				26.4.1.1	 Type of Exercise and Order of Execution for Children
				26.4.1.2	 Workout Configuration (Intensity and Volume) for Children
				26.4.1.3	 Rest Intervals Between Sets for Children
				26.4.1.4	 Repetitions and Movement Velocity for Strength Training for Children
				26.4.1.5	 Frequency of Strength Training for Children
				26.4.1.6	 Specific Program Design Considerations and Progression Strategies for Children and Adolescents
			26.4.2	 Resistance Training as a Preventive Factor from Injuries and Healthy Posture Later in Life
		26.5	 Resistance Training for Adults and the Elderly Population, with Emphasis for Females
			26.5.1	 Resistance Training Guidelines for Adults
			26.5.2	 General Guidelines for Adults
				26.5.2.1	 Training Volume
				26.5.2.2	 Types of Exercise/Exercise Selection
				26.5.2.3	 Frequency
				26.5.2.4	 Special Considerations for Women
					Effects of Hormones on Muscular Fitness
					Periodization Strategies and Their Integration with Resistance Training in Women
					Resistance Training and Hormonal Status in Adult Women
			26.5.3	 Specific Recommendations for the Elderly
				26.5.3.1	 Designing and Supervising Resistance Training in Older Adults: Key Points
		26.6	 Future Directions
		26.7	 Concluding Remarks
		Chapter Review Questions
		References
	Untitled
	27: Exercise Guidelines During Pregnancy
		27.1	 Introduction
		27.2	 Research Findings
			27.2.1	 Physiology of Pregnancy
				27.2.1.1	 Cardiovascular Function
				27.2.1.2	 Pulmonary Function
				27.2.1.3	 Endocrine System
				27.2.1.4	 Metabolism, Energy Expenditure, and Weight Control
				27.2.1.5	 Musculoskeletal System
		27.3	 Contemporary Understanding of the Issues
			27.3.1	 Benefits of Exercise in Pregnant Women
				27.3.1.1	 Cardiorespiratory Health
				27.3.1.2	 Decreased Lumbar Pain
				27.3.1.3	 Weight Control
				27.3.1.4	 Prevention of Gestational Diabetes
				27.3.1.5	 Hypertension and Preeclampsia
				27.3.1.6	 Psychological Benefits
				27.3.1.7	 Benefits for the Fetus
					Improved Labor and Birth Outcomes
					More Active Children
			27.3.2	 Risks of Exercise in Pregnant Women
			27.3.3	 Risks of Exercise During Pregnancy for the Fetus
				27.3.3.1	 Acute Hypoxia
				27.3.3.2	 Acute Hyperthermia
				27.3.3.3	 Low Glucose Availability
				27.3.3.4	 Spontaneous Abortion in the First Trimester
				27.3.3.5	 Risk of Preterm Delivery
				27.3.3.6	 Reduced Birth Weight
			27.3.4	 Recommendations for Exercise During Pregnancy
				27.3.4.1	 General Recommendations for Programming Exercise
				27.3.4.2	 Post-delivery
		27.4	 Future Directions
		27.5	 Concluding Remarks
		Chapter Review Questions
		References
	Untitled
	28: Exercise and Immunity: Beliefs and Facts
		28.1	 Introduction
		28.2	 Exercise and Risk of Infection: Challenging the J-Shaped Curve
			28.2.1	 Extrenous Exercise and Risk of Infection
			28.2.2	 Moderate Exercise and Risk of Infection
		28.3	 Effect of Exercise on the Immune System
			28.3.1	 Overview of the Immune System
			28.3.2	 Exercise Influence on Immune Cell Count
				28.3.2.1	 Factors Responsible for Exercise-Induced Leukocytosis
				28.3.2.2	 Enhanced Immunosurveillance After Acute Exercise
			28.3.3	 Effect of Exercise on the Immune Function
				28.3.3.1	 Innate Immune Responses to Exercise
				28.3.3.2	 Adaptive Immune Responses to Exercise
				28.3.3.3	 Cytokine Induction
			28.3.4	 Possible Factors Underlying Immune Suppression Through Intensive Exercise
				28.3.4.1	 Immune Cell Frequency and Function
				28.3.4.2	 Reactivation of Latent Virus
		28.4	 Clinical Implications of Regular Moderate Intensity Exercise
		28.5	 Contemporary Understanding of the Issues
			28.5.1	 Methodological Limitations
			28.5.2	 Role of Nutrition in Exercise-Induced Immune Changes
			28.5.3	 Sex Differences in Immune Response and Exercise
			28.5.4	 Recommendation to Exercise During and After a URTI
			28.5.5	 Exercise, Immune Function and Microbiome
			28.5.6	 Exercise and Immunometabolism
			28.5.7	 Exercise and Immunosenescence
		28.6	 Future Directions
		28.7	 Concluding Remarks
		Chapter Review Questions
		References
	Untitled
	29: Exercise Recommendations for Females Affected by Cancer Throughout the Lifespan
		29.1	 Introduction
		29.2	 Research Findings and Contemporary Understanding of the Issues in Women
			29.2.1	 Cancer in Females
				29.2.1.1	 Most Common Types of Cancer in Women
				29.2.1.2	 Benefits of Physical Activity on Common Cancer Symptoms in Women
		29.3	 Pathophysiology of Cancer and Symptoms Produced
			29.3.1	 Cancer-Related Fatigue
			29.3.2	 Physical Function
			29.3.3	 Lymphedema
			29.3.4	 Anxiety, Depression, and Quality of Life
			29.3.5	 Peripheral Neuropathy
			29.3.6	 Body Composition
			29.3.7	 Other Symptoms
		29.4	 Physical Activity Recommendations
			29.4.1	 Current Standings on Physical Activity for Women with Cancer
			29.4.2	 Considerations to Exercise
		29.5	 Research Findings and Contemporary Understanding of the Issues in Children and Adolescents
			29.5.1	 Prevalence of Cancer in Children and Adolescents
		29.6	 Physical Activity Recommendations for Children with Cancer
			29.6.1	 Exercise and Childhood Cancer Evolution
			29.6.2	 Benefits of Physical Activity in Pediatric Cancer
				29.6.2.1	 Physical Activity Guidelines
			29.6.3	 Considerations to Exercise
		29.7	 Future Directions
		29.8	 Concluding Remarks
		Chapter Review Questions
		References
Part VI: The Obese Active Female
	30: Not So Normal Unhealthy Lean
		30.1	 Introduction
			30.1.1	 Metabolically Unhealthy Normal Weight (MUNW)
			30.1.2	 Normal Weight with Central Obesity (NWCO)
			30.1.3	 Normal Weight Obesity (NWO)
			30.1.4	 Overlap Between Different Unhealthy Lean Phenotypes
		30.2	 Research Findings
			30.2.1	 Prevalence of Unhealthy Normal Weight Phenotypes
				30.2.1.1	 Prevalence of Metabolically Unhealthy Normal Weight (MUNW)
				30.2.1.2	 Prevalence of Normal Weight Central Obesity (NWCO)
				30.2.1.3	 Prevalence of Normal Weight Obesity (NWO)
			30.2.2	 Pathophysiology of Unhealthy Normal Weight Phenotypes
				30.2.2.1	 The Role of Adipose Tissue
				30.2.2.2	 Increased Inflammation and Oxidative Stress
				30.2.2.3	 The Role of Skeletal Muscle
				30.2.2.4	 Changes in Bones
			30.2.3	 Factors Associated with Unhealthy Lean
				30.2.3.1	 Early Life Factors
				30.2.3.2	 Age and Sex
				30.2.3.3	 Ethnicity
				30.2.3.4	 Genetics
				30.2.3.5	 Physical Activity and Physical Fitness
				30.2.3.6	 Dietary Factors
				30.2.3.7	 Alcohol Consumption and Smoking
				30.2.3.8	 Other Sociodemographic Factors
		30.3	 Contemporary Understanding of the Issue
			30.3.1	 Health Risks Associated with Unhealthy Lean
				30.3.1.1	 Increased Cardiovascular Disease Risk
				30.3.1.2	 Increased Risk for Hyperlipidemia and Hypertension
				30.3.1.3	 Increased Risk for Diabetes
				30.3.1.4	 Increased Risk for Mild Cognitive Impairment
				30.3.1.5	 Increased Risk for Cancer
				30.3.1.6	 Increased Mortality Risk
			30.3.2	 Interventions to Improve the Health of Unhealthy Lean
				30.3.2.1	 Normal Weight Status May Be a Barrier to Healthy Behavior
				30.3.2.2	 Dietary Interventions
				30.3.2.3	 Exercise Interventions
				30.3.2.4	 Combined Lifestyle Interventions
		30.4	 Future Directions
			30.4.1	 Consensus on Definitions is Needed
			30.4.2	 Screening for Unhealthy Lean
			30.4.3	 Future Research on Interventions for Unhealthy Lean
		30.5	 Conclusions
		Chapter Review Questions
		References
	31: Maternal Obesity and Its Epigenetic Effects
		31.1	 Introduction
		31.2	 Overview of Epigenetic Reprogramming Mechanisms
			31.2.1	 DNA Methylation
			31.2.2	 Histone Modifications
			31.2.3	 Histone Acetylation
			31.2.4	 Histone Methylation
			31.2.5	 MicroRNAs (miRNAs) in Epigenetic Regulation
			31.2.6	 Interrelationships Between Epigenetic Modifications
				31.2.6.1	 Link Between DNA Methylation and Histone Modifications
				31.2.6.2	 Cross Talk between miRNA, DNA Methylation, and Histone Modifications
		31.3	 Maternal Obesity and Its Epigenetic Effects in Humans
			31.3.1	 Maternal Obesity and Its Effects on the Offspring
			31.3.2	 Maternal Dietary Factors and Epigenetic Changes of the Offspring
			31.3.3	 Maternal Physical Activity and Epigenetic Changes
			31.3.4	 Lifestyle Interventions to Reduce Gestational Weight Gain in Overweight and Obese Women
		31.4	 Animal Models of Maternal Obesity
			31.4.1	 Dietary Regulation in Animal Models
				31.4.1.1	 Dietary Effects on DNA Methylation
				31.4.1.2	 Histone Modification by Dietary Modulation
				31.4.1.3	 Diet-Mediated Alterations of miRNAs
			31.4.2	 Physical Activity in Animal Models
		31.5	 Conclusion and Future Studies
		Chapter Review Questions
		References
	32: Exercise and Nutritional Guidelines for Weight Loss and Weight Maintenance in the Obese Female
		32.1	 Introduction
		32.2	 Nutrition Guidelines for Weight Management
			32.2.1	 Background
			32.2.2	 Understanding Macronutrients (CHO, Protein, and Fats)
			32.2.3	 Pre-testing and Meeting with Health Specialists
			32.2.4	 Diets
			32.2.5	 Summary of Diets
			32.2.6	 Weight Loss Programs
		32.3	 Weight Loss Procedures
		32.4	 Exercise Guidelines for Weight Management
			32.4.1	 Background
			32.4.2	 Pre-testing and Meeting with Health Specialists
			32.4.3	 Health-Related Components of Physical Fitness
			32.4.4	 Research and Contemporary Findings
		32.5	 Future Directions and Concluding Remarks
		Chapter Review Questions
		References
	Untitled
Index