Article Text

Healthy Runner Project: a 7-year, multisite nutrition education intervention to reduce bone stress injury incidence in collegiate distance runners
  1. Michael Fredericson1,
  2. Megan Roche2,
  3. Michelle T Barrack3,
  4. Adam Tenforde4,
  5. Kristin Sainani5,
  6. Emily Kraus6,
  7. Andrea Kussman6,
  8. Emily Miller Olson7,8,
  9. Brian Young Kim9,
  10. Katherine Fahy10,
  11. Emily Miller9,
  12. Ellie Diamond11,
  13. Sonya Meraz12,
  14. Sonal Singh13,
  15. Aurelia Nattiv14
  1. 1Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, Stanford, California, USA
  2. 2Department of Epidemiology, Stanford Hospital and Clinics, Stanford, California, USA
  3. 3Department of Family and Consumer Sciences, California State University Long Beach, Long Beach, California, USA
  4. 4Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
  5. 5Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
  6. 6Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Stanford, California, USA
  7. 7Bodor Clinic, Napa, California, USA
  8. 8American Canyon, California, USA
  9. 9Family Medicine, University of California, Los Angeles, Santa Monica, California, USA
  10. 10Department of Family Medicine, University of Washington Medical Center, Seattle, Washington, USA
  11. 11Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
  12. 12School of Nursing, University of Massachusetts System, Boston, Massachusetts, USA
  13. 13School of Medicine, St George’s University, St George’s, Grenada
  14. 14Division of Sports Medicine, Departments of Family Medicine and Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
  1. Correspondence to Dr Michael Fredericson; mfred2{at}


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.

  • intervention
  • bone density/endocrine status
  • nutrition
  • bone

Data availability statement

Data are available upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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Data availability statement

Data are available upon reasonable request.

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  • MF and MR are joint first authors.

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  • Contributors All authors contributed to editing and revising this manuscript and the majority of manuscript writing tasks where shared between MF and MR. KS was the statistician on the study and contributed to interpretation of data and presentation of results. AT and EK were involved in early stage study design and implementation. MTB coordinated intervention design and nutritional protocols along with interpretation of nutritional results. AK, EMO, BYK, KF, EM, ED, SM and SS helped with study implementation and coordination. AN and MF were the principal investigators at each institution. MF is the guarantor of the study and manuscript.

  • Funding This study was funded by the Pac-12 Student Health and Well-Being Grant Program as well as the American Medical Society for Sports Medicine Foundation Grant.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.