Original Paper

Stress Fractures in Female Army Recruits: Implications

of Bone Density, Calcium Intake, and Exercise

Alana D. Cline, PhD, RD, G. Richard Jansen, PhD, and Christopher L. Melby, PhD
Department of Food Science and Human Nutrition, Colorado State University, Ft. Collins
Key words: stress fracture, bone density, physical activity, calcium, exercise

Objective: To identify characteristics and factors associated with increased risk for stress fractures in
military women.
Design: Case-control study to retrospectively examine physical activity, prior calcium intake, and bone
density as predictors of stress fractures.
Setting: A military training installation which incorporates physical training for women.
Subjects: Forty-nine female soldiers with confirmed stress fractures (cases) and 78 female soldiers with no
orthopedic injuries (controls), aged 18 to 33 years.
Measures: Retrospective self-reports of habitual exercise, sports participation, and food intake; current
height, weight, and body mass index (BMI); demographic variables (age, ethnicity, menstrual patterns, smoking
habits); and bone density on radiologically defined stress fractures.
Results: Cases and controls were similar in height, weight, and BMI. Measurements of bone density (g/cm2)
at the trochanter (cases, 0.7760.09; controls, 0.7760.08); femoral neck (cases, 0.9460.10; controls,
0.9460.09); Ward’s triangle (cases, 0.9160.11; controls, 0.9360.11); lumbar spine (cases, 1.2160.12; controls,
1.2460.10); and radius shaft (cases, 0.6760.09; controls, 0.6860.05) were not different between groups.
Calcium intake was not different between groups (cases, 11546751 mg/day; controls, 9446513 mg/day) and did
not correlate with bone density (r50.01 to 20.06 at four sites). Sports participation positively correlated with
bone density in the hip (r50.49). Leisure activity energy expenditure (kcal/day) tended toward association with
lower stress fracture risk as expenditure level increased (p50.06).
Conclusion: Stress fracture in female Army recruits was not correlated with bone density or calcium intake
during adolescence, although a weak relationship to prior physical activity was observed.

INTRODUCTION increased emphasis on physical conditioning and participation

Stress fracture has long been considered a hazard of military
life. This type of injury occurs in a normal bone and is attrib-
uted to repeated stress from unaccustomed submaximal exer-
cise, usually weight-bearing. In military basic training, the
stress fracture is a common orthopedic problem, causing loss of
manpower, loss of training time, expense of medical care, and
recycling or discharge of affected soldiers [1]. Prevention of
even a small number of these injuries would yield large bene-
fits, both monetarily and in troop productivity. This condition,
however, is not confined only to military personnel. With
in sports by the general population, it is quite possible that the
incidence of stress fractures will increase in the future.
Since the first description of stress fracture in a soldier,
many extensive clinical surveys of stress fractures in military
recruits in various geographical areas have been reported. The
majority of these studies have included only men, but as more
women enter the services, several recent studies have included
the latter as well [1–5]. No studies have identified nutritional
predictors of stress fracture or low bone density in military
personnel.
Women entering the military have a much higher incidence

Disclaimer: “The opinions or assertations contained herein are the private views of the author(s) and are not to be construed as official or as reflecting the views of the
U.S. Army or the Department of Defense.”
Presented in part at the 1995 Experimental Biology Conference, Atlanta GA.
Address reprint requests to: Alana D. Cline, PhD, RD, Pennington Biomedical Research Center, Louisiana State University, 6400 Perkins Road, Baton Rouge, LA
70808-4124.

Journal of the American College of Nutrition, Vol. 17, No. 2, 128 –135 (1998)
Published by the American College of Nutrition

128

of stress fracture injury during basic training than men, with
approximately 1 to 3% and 10 to 12% of new male and female
recruits, respectively, being affected [4,6]. Although studies of
female athletes [7,8] and ballerinas [9,10] have provided some
useful information investigating the relationships of bone den-
sity, calcium intake, or amenorrhea to stress fractures, there are
no studies which have investigated these relationships in fe-
male military recruits. Several military studies have considered
the relationship of physical activity to stress fractures [4,5,11].
However, there is no current consensus on what factors play the
greatest role in incidence of stress fracture.
With the rising recruitment of women into the armed forces,
data are needed on their response to physical training and on
any physical differences that may limit their performance. At
the same time, the number of women engaged in sports is
increasing. As a result, there has been a significant increase in
the number of lower extremity stress fractures in women. In the
few studies that have compared men and women, it has been
shown that women have a higher incidence of stress fractures
than men while participating in the same physical activities.
The distribution patterns among civilian runners and joggers
are very similar to those stated previously for military trainees
[3,6,12].
The underlying objective of this study was to identify those
characteristics and factors associated with increased risk for
stress fractures in military women. The hypotheses tested were
that female soldiers who experience stress fractures (cases)
compared to female soldiers without stress fractures (controls)
have: a) decreased bone density, b) a history of less physical
activity during high school than those with no stress fractures,
and c) a history of lower dietary calcium consumption. The
correlation between bone density and body mass index (BMI)
was also investigated.
MATERIALS AND METHODS
Subjects
The research design was a case-control study of female
Army recruits who had recently completed their 12-week basic
training course. Volunteers were asked to complete evaluation
procedures, which included anthropometric data, diet and ex-
ercise questionnaires, and bone density measurement. A total of
141 women (63 cases, 78 controls) volunteered to participate,
of which 51 (38 cases, 13 controls) received bone density
evaluation, and 127 (49 cases, 78 controls) completed ques-
tionnaires. There was a disparity between number of women
completing questionnaires and those receiving bone density
evaluation due to high drop-out rates by controls for density
evaluation. Study volunteers were reluctant to miss additional
training time for non-medical appointments for density evalu-
ation so withdrew from further participation in the study after
completing questionnaires. Women with stress fractures (cases)
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
Stress Fractures in Female Army Recruits
were identified upon medical examination during evaluation
and treatment of pain. A small group of women (cases) with
incomplete questionnaires were included in the study because
valuable data on physical characteristics and bone density were
available. All stress fractures were confirmed by bone scan, and
patients were referred to the principal investigator for recruit-
ment into the study. Control subjects were randomly selected
from women reporting to the troop medical clinic for non-
orthopedic, minor health problems. All subjects gave their
informed consent, and the Committee on Human Research at
Colorado State University and the Brooke Army Medical Cen-
ter Clinical Investigation Committee approved the research plan.
Demographic information collected included age, race, geo-
graphic location during adolescence, date of menarche, men-
strual patterns, use of oral contraceptives, and smoking habits;
anthropometric data collected were height, weight, and BMI
(kg/m2).
Food Frequency Questionnaire
To evaluate the nutrient intake of participants, an abbrevi-
ated version of the Health Habits and Diet Questionnaire by
Block et al [13] was used, with a slight modification in the
instructions to ask participants to recall food habits during
adolescence. The questionnaire began with the following state-
ment: “This section is about your usual eating habits. Thinking
back over your TEENAGE (ages 13 to 18) years, how often did
you usually eat the foods listed on the next page?” An addi-
tional question asked if participants had limited intake of dairy
products for any reason during the same time period. The
60-item questionnaire evaluates 18 major nutrients and in-
cludes foods representing approximately 93% of total United
States caloric consumption.
Validation of use of a food frequency questionnaire (FFQ)
to recall diet 4 years in the past has been reported by Willett et
al [14], indicating that a self-administered FFQ can be used to
provide information about previous diet. Reasonable correla-
tions with diet 10 to 15 years previous were obtained by
interview with a FFQ for a variety of nutrients by Sobell et al
[15], and Frazier et al [16] reported reproducibility with use of
a FFQ to measure adolescent diet recall in women aged 40 to
65, suggesting that recall is reasonably reproducible.
Nutrient estimates for dietary assessment were provided by
computer software and are based on the NHANES II nutrient
content database [17]. Questionnaires were designed to be
self-administered; they were returned directly to the study
dietitian who conferred individually with each subject to verify
information before coding for computer analysis.
Exercise Questionnaire
Exercise and energy expenditure from leisure and sports
activities in the year immediately prior to entry into the Army
were evaluated by a modification of the Minnesota Leisure
129
Stress Fractures in Female Army Recruits
Activities Questionnaire [18], which is designed to assess lei-
sure activities during the past year. Use of this modified ques-
tionnaire has been validated and reported by Jones et al [19] on
numerous studies with Army recruits. Energy expenditure from
activities during the prior year was calculated using reference
formulas and intensity codes [20,21]. Participation in organized
or varsity sports during high school, and the individual’s per-
ception of her physical activity level (prior year) on a scale of
1 (inactive) to 4 (very active) were also reported.
Bone Density Evaluation
Single-photon absorptiometry (LUNAR SP2, Lunar Radia-
tion Co., Madison, WI) was used to determine bone mineral
content and mineral density of the radius [22]. The site of
measurement was one-third of the distance from the ulnar
styloid process to the olecranon on the non-dominant arm,
which contains approximately 95% cortical bone. Measurement
was also made on the ulna and radius distal to the site of
juxtaposition of the radius and ulna at the wrist sites, which
contain predominantly trabecular bone. The coefficient of vari-
ation (CV) of repeated measurements at these two sites using
this technique was approximately 2.1 and 2.3%.
Bone mineral measurements of the lumbar spine and hip,
both predominantly trabecular bone, were made using dual-
photon absorptiometry (LUNAR DP3, Lunar Radiation Co.,
Madison, WI) which permits a quantitative assessment of skel-
etal bone mineral by use of a gadolinium-153 radionuclide
source [23]. Precision error (CV) of this technique was approx-
imately 2.0% for the spine and 2.7% for the hip. All scans were
performed by the same experienced technician over a 1-month
period; standardized calibration techniques were used for qual-
ity control at the start of each day.
Data Analysis
Statistical Package for the Social Sciences (SPSS, New
York:McGraw-Hill, 1983) Release 4.0 was used to analyze
data. The Student’s t-test was first used to determine if there
were significant group differences in historical calcium intake,
exercise levels, intake of other nutrients, bone density, and
physical characteristics. Statistical significance was determined
Table 1. Physical Characteristics1 of Subjects Studied
Age
(year)
All subjects
Cases (n563) 21.463.7
Controls (n578) 20.562.9
Subjects w/questionnaires and bone density
Cases (n538) 20.664.3
Controls (n513) 20.562.6
1
Mean6SD.
2
Body Mass Index.
130
using a two-tailed test and a 5% level of significance for each
test.
Relationships between variables were examined using sim-
ple correlation procedures, and stepwise multiple regression
analysis was used to identify major predictors of bone density.
The stepwise procedure was used so that independent vari-
able(s) remaining in the model would only be those that were
statistically significant. Chi square analysis was used to exam-
ine differences between stress fracture and control subjects
when examined by race, smoking, menstrual status, oral con-
traceptive use, activity level, calcium, and exercise energy
expenditure [24].
Case and control groups were initially divided into non-
blacks and blacks for statistical analysis; Hispanics were in-
cluded in the non-black group after analysis revealed no dif-
ferences between groups with or without their inclusion. Of the
29 black study participants, only seven received bone density
evaluation. They did not differ from other participants in bone
density, calcium intake, or physical activity. Because of the
small sample size, no attempt was made to evaluate the influ-
ence of race on outcome variables in the study. Therefore, cases
and controls were considered as single groups without dividing
by race.
RESULTS
Table 1 shows no significant differences in age, height,
weight, and BMI between injured (case) and control soldiers.
Because of the narrow age range for enlistment into the mili-
tary, there was little between group heterogeneity in age.
Stress Fractures vs. Bone Density
Distribution of stress fractures was determined at eight
skeletal locations, with the greatest percentages occurring at the
tibia (32%), metatarsals (26%), pubic ramus (23%), and femur
(11%). Forty-nine percent of the cases had multiple fracture
sites. Table 2 shows that bone density did not vary significantly
between case (injured) and control subjects at the six sites
measured.
Height Weight BMI2
(cm) (kg) (kg/m2)
162.767.2 59.466.1 22.462.1
164.667.3 60.168.2 22.162.4
162.768.5 58.167.7 21.962.1
161.867.7 58.967.2 22.362.4
VOL. 17, NO. 2
 Stress Fractures in Female Army Recruits

Table 2. Bone Density (g/cm2) of Study Participants

%,1 SD2
Cases Controls
Location P Standards1
(n538) (n513)
Case Control
Trochanteric 0.7760.09 0.7760.08 .952 0.8160.12 17 15
Femoral neck 0.9460.10 0.9460.09 .861 0.9960.12 19 15
Ward’s triangle 0.9160.11 0.9360.11 .668 0.9260.14 11 8
Lumbar (L2-L4) 1.2160.12 1.2460.10 .443 1.2760.13 27 15
Radius shaft 0.6760.09 0.6860.05 .552 0.7160.05 48 38
Distal radius 0.4060.06 0.3660.08 .062 0.3660.05 14 31
Mean6SD.
1
Young normal bone density values for women [25].
2
Percentage of individual subjects,1 SD below age-predicted standard.

Physical Activity and Amenorrhea vs. Bone Density square53.7, df51, p50.06) almost reaching the 0.05 level of
statistical significance.
The incidence of amenorrhea (temporary cessation of men-
Thirty-seven percent of all subjects reported involvement in
ses) during basic training was 53% and 42% among injured and
varsity sports while in school, with no differences between
control soldiers, respectively, but the difference did not reach
cases and controls. Correlations were found between bone
statistical significance (Table 3). A large number of women,
mineral density of the trochanter and height (r50.36, p,0.01),
63% of injured subjects and 48% of control subjects, were also
weight (r50.29, p,0.05), and high school organized or varsity
on oral contraceptives prior to entering the Army (chi
sports participation (r50.49, p,0.01).
square52.22, df51, p50.14). Of 23 amenorrheic cases, 17
Stepwise multiple regression analysis was used to examine
individuals were also on oral contraceptives. Of 31 amenor-
possible relationships between independent and dependent
rheic controls, 17 were on oral contraceptives. Average age at
variables. The dependent variables of bone mineral density
menarche was 13 years for both groups. A total of 28 women
of the radius (BMDR), bone mineral density of L2-L4 spine
(24%) reported that they had experienced menstrual irregular-
(BMDL2L4), bone mineral density of the femoral neck
ities (less than one menstrual cycle a month) prior to entering
(BMDFN), bone mineral density of Ward’s triangle (BMDWT),
the service; no correlations were seen with bone density or
and bone mineral density of the trochanter (BMDTR) were com-
stress fracture. The percentage of smokers was not significantly
pared with the independent variables of all nutrients, physical
different: 25% of injured subjects and 37% of control subjects
characteristics, demographic characteristics, and stress fracture
smoked.
occurrence. Weak associations at three sites, negative for
There were no significant differences between groups in
BMDWT with percent fat calories eaten (r50.43, P,0.05), pos-
physical activity energy expenditure prior to active duty: in-
itive BMDTR with sports participation (r50.47, p,0.05), and
jured soldiers averaged 611 kcal/day vs. control soldiers who
negative BMDL2L4 with stress fracture (r50.44, p,0.05) were
averaged 617 kcal/day. Chi square analysis, comparing high
most likely due to chance and are not considered to be informative.
exercise (.400 kcal/day) vs. low exercise (,400 kcal/day)
No independent variables tested were significantly associated with
showed that only 42% of injured subjects were in the high
bone mineral density at any skeletal site.
exercise category for leisure-time activities compared to 59%
of control subjects, with differences between groups (chi
Calcium and Nutrient Intake vs. Bone Density
Table 3. Physical, Athletic, and Menstrual Histories of Reported intakes of protein, carbohydrate, fat, and energy
Study Participants during adolescence were not significantly different between
injured and control subjects (Table 4). The intake level of most
Cases (n549) Controls (n578)
nutrients approximated or exceeded Recommended Dietary
Physical activity (kcal/day)1,2 6116836 6176540
Allowances (RDA) levels [26]. Intakes of vitamins, minerals,
Sports participation2,3 2.661.1 2.761.2
Age at menarche (year)2 13.161.9 13.061.6 and fiber and their percentages of RDA also were not different
Training amenorrhea (%)4 53 42 between groups (Table 4). Regular vitamin supplementation
Oral contraceptives (%)5 63 48 (multivitamin plus iron) was reported by 31% of cases and 27%
Cigarette smoking (%)5 25 37 of controls. Additionally, four subjects (controls) reported tak-
1
Calculated for year prior to basic training. ing supplemental vitamins A, C, and E; six cases and six
2
Mean6SD.
3
controls, supplemental iron; and one subject (control), calcium.
Prior to enlistment: 15no sports, 25individual sports, 35organized team sports
(intramurals), 45varsity sports.
Injured subjects averaged a dietary calcium intake of
4
During basic training. 11546751 mg/day, while control subjects averaged 9436513
5
Begun at least one year prior to enlistment; percentage of subjects. mg/day; with intakes ranging from 143 mg to 3407 mg. Chi

JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 131

Stress Fractures in Female Army Recruits

Table 4. Daily Reported Adolescent Nutrient Intakes of Study Participants1

Nutrient Cases (n547) % RDA Controls (n574) % RDA

Total energy (mJ) 9.3636.9 9.564.1
(22266928)2 101 (22726986)2 114
Protein (g) 87.0636.9 198 83.8633.9 190
% energy 16 15
Fat (g)3 93.5645.3 — 96.9648.5 —
% energy 37 38
Carbohydrate (g)3 259.26112.8 — 265.86121.7 —
% energy 47 47
Calcium (mg)4 11546751 96 9446513 79
Phosphorus (mg) 15166734 126 13876578 116
Ca:P5 1:1.31 1:1.50
Iron (mg) 13.465.5 89 14.266.5 95
Sodium (mg)3 294861279 — 308461437 —
Potassium (mg)3 345761447 — 328761285 —
Vitamin A (IU) 845165032 169 863466890 173
Thiamin (mg) 1.660.7 145 1.660.7 145
Riboflavin (mg) 2.461.2 185 2.161.1 162
Niacin (mg) 20.668.2 137 21.369.7 142
Vitamin C (mg) 2216147 368 2306150 383
Dietary fiber (g)3 12.465.9 — 12.766.3 —
1
Mean6SD.
2
(kilocalories).
3
No RDA for these nutrients.
4
Calcium intake including supplements.
5
Calcium:phosphorous ratio.

square analysis showed no difference between high (.800 mg)
and low calcium (,799 mg) intake and stress fracture rates (chi
square50.36, df51, p50.55). High calcium values were des-
ignated as two-thirds of the RDA or greater to provide com-
parison with values used in previous studies.
Servings of dairy products consumed per week were higher
in the stress fracture (case) group (14.563.1) than in the control
group (11.168.4) (p,0.05). Assessment of the relationship of
patterns of dairy consumption to bone density at each of the
measured sites indicated that individuals who had at least three
servings of dairy products per day (i.e., a dairy serving with
each meal) (n510) had no significant difference in bone den-
sity when compared with those who reported eating dairy
products less frequently (n526).
No significant correlations were found in the relationship of
individual nutrients (calcium, phosphorus, iron, sodium, potas-
sium, and dietary fiber) with bone density measurements. Sta-
tistical regressions of bone density measures BMDFN, BMDR,
BMDL2L4, BMDTR, and BMDWT, on calcium intake were
not statistically significant (p.0.05), with correlation coeffi-
cients ranging from 0.009 to 0.055.
DISCUSSION
Stress Fractures vs. Bone Density
Weight, height, and BMI of this study population were not
different from comparable values in other studies of young
normal women in similar age groups for these variables
[23,27]. Based on this finding, it appears that this sample of
women enlisting in the Army had physical characteristics sim-
ilar to a cross-section of the general population of women the
same age. Women who enter the military are screened for
medical problems, so they are likely to be in better health than
their civilian counterparts in this age group, in general. Al-
though the mean height of this study group was comparable to
ballerinas with stress fractures [9], the ballerinas weighed less.
Height and weight of this study group were comparable to
values in other studies of military females with stress fractures
[3–5]. Jones et al [19], in a study on basic trainees, reported
similar data for height, weight, and BMI. In the current study,
chi-square analysis revealed no significant relationship be-
tween race, age, or height and stress fracture. These findings
differ from those of Brudvig et al [1], who reported that race
and age were factors related to the development of stress
fractures. Findings of this study are consistent with those of
Reinker and Ozburn [3], and Hopson et al [2], who found that
these factors were unrelated to stress fracture risk.
Bone density values in the current study are lower than
those of white young women as reported by Mazess and Barden
[25] (Table 2), but not significantly different. One individual
had a vertebral mineral density below the fracture threshold as
defined by Riggs et al [27], of 0.965 g per square centimeter,
and 12 (10 cases) were in the range of 21 to 22.5 standard
deviations (SD) for osteopenia. Table 2 indicates percentages

132 VOL. 17, NO. 2


of subjects with BMD more than 1 SD below reference value
for each site measured.
Comparison of bone density values from the current study
group with ballerinas who experienced stress fractures [9]
showed there were no significant differences between stress
fracture and non-stress fracture groups in both studies. Balle-
rinas had slightly lower bone density values than the soldiers,
which may be a reflection of the body build of those girls most
likely to participate in ballet.
These results differed from a stress fracture study on ath-
letes in South Africa [28], in which athletes with stress frac-
tures had significantly lower bone mineral densities than con-
trols; the lower density was in both trabecular and cortical
bone.
Winters et al [29] reported lumbar bone mineral densities
similar to those in the present study in comparisons of trained
runners and moderately active controls. However, half of the
runners reported stress fractures, compared to one incidence in
the controls, and they had significantly lower total bone cal-
cium per kg of soft lean tissue obtained from DEXA scans.
Physical Activity and Amenorrhea vs. Bone Density
The few studies investigating stress fractures in female
athletes reported an association between amenorrhea and stress
fracture [28,9]. The association most frequently discussed is
that of amenorrhea and lower bone density values, which then
appears to result in more stress fractures in amenorrheic ath-
letes. The absence of menses reported by the current study
participants was temporary, and occurred only during their
basic training for a duration of approximately 2 to 3 months.
The short duration may explain why no relationship was evi-
dent between bone density values and stress fractures in am-
enorrheic soldiers. This finding supports a study by Hetland et
al [30], which reported that women who began a running
program experienced irregularities in their menstrual cycles,
but found no statistically significant relation between running
activity and bone mineral measurements or bone turnover.
Previous studies on athletes reported amenorrhea that lasted
from 1 to 7 years or longer resulting in disturbances of estrogen
and other sex-steroid hormone levels.
Recently it has been reported that ovulatory disturbances
which are common during exercise training may be detrimental
to bone health, even in women who have apparently normal
menstrual cycles. Physically active women with shortened lu-
teal phases or anovulatory cycles have shown lower BMD than
physically active women with normal cycles [29,31,32]. Be-
cause almost one-fourth of the subjects in this study had re-
ported recent menstrual irregularities, incidence equally distrib-
uted between the two groups, ovulatory disturbances associated
with bone loss may have been present which were not mea-
sured in this study.
Energy expenditure for leisure activity of over 600 kcal/day
in both groups of the current study is comparable with athlete
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
Stress Fractures in Female Army Recruits
values reported in a study by Lewis [33] that compared athletes
and non-athletes. This suggests that women who enlist in the
Army tend to be physically active prior to entry. Because
exercise participation was equally high in both groups, the
effect of exercise on bone may explain bone density values that
are similar in both groups.
The findings of this study agree with those of previous
studies [2,4,11] that individuals who are less physically active
prior to entering the military are more likely to get stress
fractures. This differs from the finding of Ozburn et al [5], that
physical conditioning is not a factor.
Exercise has a positive effect on bone density [34 –36],
which may be reflected in this study by correlations between
varsity or organized sports participation and bone density, both
requiring some degree of physical training. An exception to this
is a negative correlation between training and bone mineral
density of the spine and femur in all subjects reported by
Myburgh [28]. Cross-sectional studies demonstrated that exer-
cise history in individuals indicated a greater bone mass, but the
difference between adults who exercised and those who did not
was less than 10% [34,37].
The only correlates in this study that appear to have a
relationship with bone density or stress fracture are high school
sports with bone density in the hip, and a trend toward signif-
icance of leisure activity energy expenditure with stress fracture.
Calcium and Nutrient Intake vs. Bone Density
When comparing retrospective adolescent food consump-
tion data of current study participants with the report by
McKoy [38] on adolescents from the South, and with NHANES
III [39,40], intake of current study participants was higher in
some nutrients, but differences were not large. Diet analysis in
other studies utilized either a 3-day diary or a 7-day diary, with
the exception of the study by Frusztajer et al [9], which used a
food frequency questionnaire. Current study participants were
asked to recall diet habits from 1 to approximately 18 years in
the past, which has been reported as being valid and a reason-
able way of retrospectively assessing diet [14,15]. Consensus is
that correlation between past diet and recall of that diet is
greater than the impact of the current diet on recall. Good recall
has been seen in milk products, whole milk, fish, and alcohol,
most likely because of the dominant role they play in consump-
tion patterns. Also to be considered is that adolescent diets may
have associated memories that enable better recall, and that
meal consumption in the family situation may be more rigid
than adult self-selection. Although written instructions are pro-
vided with the questionnaires, it remains important for fol-
low-up instructions and interviews with respondents to clarify
answers and review questionable responses. This became ap-
parent in the present study as questionnaires were reviewed
with volunteers upon completion.
Energy intake in the current study was, on the average,
133
Stress Fractures in Female Army Recruits
approximately 20% higher than the National Food Consump-
tion Survey [41], NHANES III [39,40], and Southern adoles-
cents [38,42]. Higher energy consumption may be explained
by the fact that subjects in this study were physically active in
high school and required more energy to participate in sports
activities.
Myburgh et al [28] reported that subjects with stress frac-
tures had lower intakes of dietary calcium and dairy products
than did control subjects, and that there was a significant
positive correlation between calcium intake and bone mineral
density in the weight-bearing bones. In the current study,
although stress fracture subjects reported a higher intake of
dairy products than controls, calcium intake was not signifi-
cantly different between groups.
Bone density was not found to differ between injured sol-
diers and control soldiers, nor was it correlated significantly
with calcium consumption during adolescence. This differs
from previously reported studies that showed a positive influ-
ence of calcium intake on bone mass [43,44]. However, it
agrees with the report by Ulrich et al [45] that no significant
associations were found between any measures of milk con-
sumption or calcium intake and BMD.
Although calcium intake during training was not assessed in
this group, recent studies on nutritional intake of women in
basic training have reported mean calcium intakes of 907 and
728 mg [46,47], which, if similar to our study population,
would reflect a significantly lower intake of calcium than that
reported prior to training. Also unknown is how quickly a
change in bone density occurs if calcium intake decreases in
combination with increased exercise, or what effect a decrease
of calcium may have had on bone remodeling during increased
stress on bone.
CONCLUSION
The occurrence of stress fractures in female Army recruits
was not associated with decreased bone density measured at
five different sites, with reported calcium intake during ado-
lescence, or with adolescent sports participation. Leisure activ-
ity energy expenditure (kcal/day) tended toward association
with lower stress fracture risk as expenditure level increased.
Bone density at several sites was positively related to adoles-
cent sports participation, but was unrelated to reported adoles-
cent calcium intake. Although no relationship was seen in this
study between diet or bone density with stress fracture, numer-
ous questions must still be answered regarding the high stress
fracture incidence in young women entering the military.
ACKNOWLEDGMENTS
The authors thank the staff of the Brooke Army Medical
Center Nuclear Medicine Clinic for providing bone density
evaluations for study volunteers.
134
REFERENCES
1. Brudvig TJ, Gudger TD, Obermeyer L: Stress fractures of 295
trainees: a one-year study of incidence as related to age, sex, and
race. Milit Med 148:666–667, 1983.
2. Hopson CN, Perry DR: Stress fractures of the calcaneous in
women marine recruits. Clin Orthop 128:159–162, 1977.
3. Reinker KA, Ozburn S: A comparison of male and female ortho-
pedic pathology in basic training. Milit Med 144:532–536, 1979.
4. Kowal DM: Nature and causes of injuries in women resulting from
an endurance training program. Am J Sports Med 8:265–269,
1980.
5. Ozburn MS, Nichols JW: Pubic ramus and adductor insertion
stress fractures in female basic trainees. Milit Med 146:332–334,
1981.
6. Friedl KE, Nuovo JA, Patience TH, Dettori JR: Factors associated
with stress fracture in young Army women: indications for further
research. Milit Med 157:334–338, 1992.
7. Drinkwater BL, Nilson K, Chestnut CH, Bremner WJ, Shainholtz
S, Southworth MB: Bone mineral content of amenorrheic and
eumenorrheic athletes. N Engl J Med 311:279–281, 1984.
8. Lindberg JS, Fears WB, Hunt MM, Powell MR, Boll D, Wade CE:
Exercise-induced amenorrhea and bone density. Ann Int Med
101:647–648, 1984.
9. Frusztajer NT, Dhuper S, Warren MP, Brooks-Gunn J, Fox RP:
Nutrition and the incidence of stress fractures in ballet dancers.
Am J Clin Nutr 51:779–783, 1990.
10. Olson BR: Exercise-induced amenorrhea. Am Fam Phys 39:213–
221, 1989.
11. Gardner L, Dziados JE, Jones BH, Brundage JF, Harris JM, Sul-
livan R, Grill R: Prevention of lower extremity stress fractures: a
controlled trial of shock absorbent insole. Am J Pub Health 78:
1563–1567, 1988.
12. Protzman RR: Physiologic performance of women compared to
men. Am J Sports Med 7:191–194, 1979.
13. Block G, Hartman AM, Naughton D: A reduced dietary question-
naire: development and validation. Epidemiol 1:58–64, 1990.
14. Willett WC, Sampson L, Browne ML, Stampfer MJ, Rosner B,
Hennekens CH, Speizer FE: The use of a self-administered ques-
tionnaire to assess diet four years in the past. Am J Epidemiol
127:188–199, 1988.
15. Sobell J, Block G, Koslowe P, Tobin J, Andres R: Validation of a
retrospective questionnaire assessing diet 10–15 years ago. Am J
Epidemiol 130:173–187, 1989.
16. Frazier AL, Willett WC, Colditz GA: Reproducibility of recall of
adolescent diet: Nurses’ Health Study (United States). Cancer
Causes and Control 6:499–506, 1995.
17. Smucker R, Block G, Coyle L, Harvin A, Kessler L: A dietary and
risk factor questionnaire and analysis system for personal comput-
ers. Am J Epidemiol 129:445–449, 1989.
18. Taylor HL, Jacobs DR, Schucker B, Knudsen J, Leon AS, De-
backer G: A questionnaire for the assessment of leisure time
physical activities. J Chron Dis 31:741–755, 1978.
19. Jones BH, Bovee MW, Knapik JJ: The association between body
composition, physical fitness, and injury among male and female
Army trainees. Proc Nat Acad Sci Comm on Mil Nutr Res, Body
Composition and Physical Performance, Washington DC, 1992.
VOL. 17, NO. 2

20. Peterson MS, Peterson K: “Eat To Compete.” Chicago, IL: Year
Book Medical Publishers, Inc., 1988.
21. Berning JR, Steen SN: “Sports Nutrition for the 90’s.” Gaithers-
burg, MD: Aspen Publishers, 1991.
22. Cameron JR, Mazess RB, Sorenson JA: Precision and accuracy of
bone mineral determination by direct photon absorptiometry. In-
vest Radiol 3:141–150, 1968.
23. Mazess RB, Barden HS, Ettinger M, Johnston C, Dawson-Hughes
B, Baran D, Powell M, Notelovitz M: Spine and femur density
using dual-photon absorptiometry in U.S. white women. Bone
Miner 2:211–219, 1987.
24. Steel RGD, Torrie JH: “Principles and Procedures of Statistics.”
New York, NY: McGraw-Hill, 1980.
25. Mazess RB, Barden HA: Interrelationships among bone densitom-
etry sites in normal young women. Bone Miner 11:347–356, 1990.
26. National Research Council: “Recommended Dietary Allowances,”
10th ed. Washington, DC: National Academy Press, 1989.
27. Riggs BL, Wahner HW, Dunn WL, Mazess RB, Offord KP,
Melton LJ: Differential changes in bone mineral density of the
appendicular and axial skeleton with aging. J Clin Invest 67:328–
335, 1981.
28. Myburgh KH, Hutchins J, Fataar AB, Hough SF, Noakes TD: Low
bone density is an etiologic factor for stress fractures in athletes.
Ann Intern Med 113:754–759, 1990.
29. Winters KM, Adams WC, Meredith CN, Van Loan MD, Lasley
BL: Bone density and cyclic ovarian function in trained runners
and active controls. Med Sci Sports Exerc 28:776–785, 1996.
30. Hetland ML, Haarbo J, Christiansen C, Larsen T: Running induces
menstrual disturbances but bone mass is unaffected, except in
amenorrheic women. Am J Med 95:53–60, 1993.
31. Prior JC, Vigna YM, Schechter MT, Burgess AE: Spinal bone loss
and ovulatory disturbances. N Engl J Med 323:1221–1227, 1990.
32. Drinkwater BL: Exercise and bones: lessons learned from female
athletes. Am J Sports Med 24:S33–S35, 1996.
33. Lewis A: The effects of habitual activity patterns on the body
composition and maximal aerobic capacity of young women. (The-
sis). Minneapolis, MN: University of Minnesota, 1977.
34. Suominen H: Bone mineral density and long term exercise. an
overview of cross-sectional athlete studies. Sports Med 16:316–
330, 1993.
35. Turner JG, Gilchrist NL, Ayling EM, Hassall AJ, Hooke EA,
Sadler WA: Factors affecting bone mineral density in high school
girls. NZ Med J 105:95–96, 1992.
36. Greendale GA, Barrett-Connor E, Edelstein S, Ingles S, Haile R:
Lifetime Leisure Exercise and Osteoporosis. Am J Epidemiol
141(10):951–959, 1995.
37. Forwood MR, Burr DB: Physical activity and bone mass: exercise
in futility? Bone Min 21:89–112, 1993.
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
Stress Fractures in Female Army Recruits
38. McKoy H, Kenney MA, Kirby A, Disney G, Ercanli FG, Glover E,
Korslund M, Lewis H, Liebman M, Livant E, Moak S, Stallings
SF, Wakefield T, Schilling P, Ritchey SJ: Nutrient intakes of
female adolescents from eight southern states. J Am Diet Assoc
84:1453–1460, 1984.
39. National Center for Health Statistics. Advance Data. Energy and
Macronutrient Intakes of Persons Ages 2 Months and Over in the
United States: Third National Health and Nutrition Examination
Survey, Phase 1, 1988–91. No 255, DHHS Publ No (PHS)95-1250,
Hyattsville, MD: U.S. Dept of Health and Human Services, 1994.
40. National Center for Health Statistics. Advance Data. Dietary intake
of vitamins, minerals, and fiber of persons ages 2 months and over
in the United States: Third National Health and Nutrition Examina-
tion Survey, Phase 1, 1988–91. No 258, DHHS Publ No (PHS)95-
1250, Hyattsville, MD: U.S. Dept of Health and Human Services,
1994.
41. National Center for Health Statistics: Dietary Intake Source Data:
United States, 1976–80. Vital Statistics Series 11, No 231. DHHS
Publ No (PHS)83-1681, Hyattsville, MD: U.S. Dept of Health and
Human Services, 1983.
42. Kenney MA, McCoy JH, Kirby AL, Carter E, Clark AJ, Disney
GW, Floyd CD, Glover EE, Korslund MK, Lewis H, Liebman M,
Moak SW, Ritchey SJ, Stallings SF: Nutrients supplied by food
groups in diets of teenaged girls. J Am Diet Assoc 86:1549–1555,
1986.
43. Nieves JW, Golden AL, Siris E, Kelsey JL, Linsay R: Teenage and
current calcium intake are related to bone mineral density of the
hip and forearm in women aged 30–39 years. Am J Epidemiol
141(4):342–351, 1995.
44. Metz JA, Anderson JJB, Gallagher PN: Intakes of calcium, phos-
phorus, and protein, and physical-activity level are related to radial
bone mass in young adult women. Am J Clin Nutr 58:537–542,
1993.
45. Ulrich CM, Georgiou C, Snow-Harter CH, Gillis DE: Bone min-
eral density in mother-daughter pairs: relations to lifetime milk
consumption, and calcium supplements. Am J Clin Nutr 63:72–79,
1996.
46. King N, Fridlund KE, Askew EW: Nutrition issues of military
women. J Am Coll Nutr 12:344–348, 1993.
47. King N, Arsenault JE, Mutter SH, Champagne C, Murphy TC,
Westphal KA, Askew EW: “Nutritional intake of female soldiers
during the U.S. Army basic combat training.” Natick, MA: US
Army Research Institute of Environmental Medicine, USARIEM
Technical Report T94-17, 1994.
Received May 1997; revision accepted October 1997.
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