These recommendations are intended to provide certified athletic trainers and others participating in the health maintenance and performance enhancement of athletes with specific knowledge and problem-solving skills to better prevent, detect, and manage DE. The individual biological, psychological, sociocultural, and familial factors for each athlete with DE result in widely different responses to intervention strategies, challenging the best that athletics programs have to offer in terms of resources and expertise. The complexity, time intensiveness, and expense of managing DE necessitate an interdisciplinary approach representing medicine, nutrition, mental health, athletic training, and athletics administration in order to facilitate early detection and treatment, make it easier for symptomatic athletes to ask for help, enhance the potential for full recovery, and satisfy medicolegal requirements. Of equal importance is establishing educational initiatives for preventing DE.

The association between family size and age at menarche was evaluated in 370 university athletes representing seven sports, 291 white and 79 black. Age at menarche, number of children in the family (family size), and birth order were collected retrospectively by questionnaire with a follow-up interview if necessary. The effect of family size on menarche was estimated with linear regression and multiple regression. For each additional sibling in the family-age at menarche was later by 0.17 yr in white athletes, 0.21 yr in black athletes, and 0.16 yr in the total sample (about 2.0-2.5 months). The slopes for white (beta = 0.167) and black (beta = 0.208) athletes did not differ significantly. Controlling for the effects of birth order significantly increased the family size effect in white athletes (beta = 0.221), but not in black athletes (beta = 0.203) or in the total sample (beta = 0.164). The slopes for white and black athletes, after controlling for birth order, also did not significantly differ. Thus, after controlling for birth order, menarche was later by 0.16-0.22 yr (about 2.0-2.6 months) for each additional sibling in the family, which was within the range of family size effects observed in samples of nonathletes and athletes. The family size effect also persists after controlling for maternal age at menarche in a subsample of 134 athletes, thus implying an independent effect of family size. Later ages at menarche observed in athletes may thus be due in part to larger family sizes.

Retrospective ages at menarche were obtained from 109 university athletes and their mothers, and from 77 sisters of the athletes. The athletes were participants in seven sports. Mean age (+/- SD) at menarche of the 109 athletes was identical with that of the total sample of 338 athletes from which they were drawn, 13.8 +/- 1.5 years. Mean age at menarche in the mothers was 13.4 +/- 1.7 years. When mothers were grouped as having been athletes (n = 52) or non-athletes (n = 57), menarcheal ages were, respectively, 13.7 +/- 1.8 years and 13.2 +/- 1.5 years. The mother-daughter correlation for age at menarche was 0.25. Corresponding correlations between athletes and mothers who were athletes and between athletes and mothers who were not athletes were 0.24 and 0.22, respectively. Ages at menarche in athletes who had sisters (n = 62) and their sisters (n = 77) were 14.0 +/- 1.4 and 13.6 +/- 1.6 years, respectively. The intraclass sister-sister correlation was 0.44. Familial resemblance in age at menarche in athletes, their mothers and sisters, is identical with that in the general population, and suggests that later menarche commonly observed in athletes is to a large extent familial.