Low energy availability, menstrual dysfunction, and impaired bone health: A survey of elite para athletes

Anxiety, eating disorders and menstrual disturbances risk in Spanish elite female paddlers

Affiliated athletes are frequently subject to higher levels of anxiety due to the intensity of training, competition and many other factors. This anxiety can cause alterations in their health, both physically and mentally, such as menstrual irregularities, eating disorders, etc. In this work we have analysed the anxiety levels of a population of female affiliated paddlers and the possible consequences for their health. The results showed that a third of the female paddlers analysed have a moderate/high risk of suffering from anxiety; and within this group, the less sporting experience the athlete has, the greater the probability is of suffering from anxiety. Moreover, almost half the total of the female paddlers suffers from menstrual dysfunction before an important competition, with this number rising among high performance athletes, even though three out of every four adjust their training schedule to their menstrual cycle. Less-experienced female athletes, who show higher anxiety levels, also present a greater risk of suffering from eating disorders.

Do Paralympic athletes suffer from brittle bones? Prevalence and risk factors of low bone mineral density in Paralympic athletes

Background

Bone health may be a concern in Paralympic athletes, given the presence of multiple risk factors predisposing these athletes to low bone mineral density (BMD). Objective: We aimed to assess the prevalence of low BMD among Paralympic athletes participating in various sport disciplines, and to identify potential risk factors for low BMD.

Methods

Seventy Paralympic athletes, of whom 51 % were wheelchair-dependent, were included in this cross-sectional study. BMD of the whole-body, lumbar spine, total hip, and femoral neck were assessed by dual-energy x-ray absorptiometry. Comparisons between groups were conducted by one-way ANOVA, and regression analyses were conducted to identify potential risk factors for low BMD.

Results

The prevalence of low BMD (Z-score < -1.0) was highest at femoral neck (34 %), followed by total hip (31 %), whole-body (21 %), and lumbar spine (18 %). Wheelchair-dependent athletes had significantly lower BMD Z-scores compared to the non-wheelchair-dependent athletes at whole-body level (-0.5 ± 1.4 vs 0.2 ± 1.3; P = 0.04), total hip (-1.1 ± 1.2 vs 0.0 ± 1.1; P < 0.01), and femoral neck (-1.0 ± 1.3 vs -0.1 ± 1.2; P < 0.01). At the lumbar spine, low BMD was completely absent in wheelchair basketball and tennis players. Regression analyses identified body mass, wheelchair dependence, and type of sport, as the main risk factors for low BMD.

Conclusions

In this cohort of Paralympic athletes, low BMD is mainly present at the hip, and to a lesser extent at the whole-body and lumbar spine. The most prominent risk factors for low BMD in Paralympic athletes are related to mechanical loading patterns, including wheelchair use, the type of sport, and body mass.

A systematic review, meta-analysis, and meta-regression of the prevalence of self-reported disordered eating and associated factors among athletes worldwide

BACKGROUND

The purpose of this meta-analysis was to provide a pooled prevalence estimate of self-reported disordered eating (SRDE) in athletes based on the available literature, and to identify risk factors for their occurrence.

METHODS

Across ten academic databases, an electronic search was conducted from inception to 7th January 2024. The proportion of athletes scoring at or above predetermined cutoffs on validated self-reporting screening measures was used to identify disordered eating (DE). Subgroup analysis per country, per culture, and per research measure were also conducted. Age, body mass index (BMI), and sex were considered as associated/correlated factors.

RESULTS

The mean prevalence of SRDE among 70,957 athletes in 177 studies (132 publications) was 19.23% (17.04%; 21.62%), I2 = 97.4%, τ2 = 0.8990, Cochran's Q p value = 0. Australia had the highest percentage of SRDE athletes with a mean of 57.1% (36.0%-75.8%), while Iceland had the lowest, with a mean of 4.9% (1.2%-17.7%). The SRDE prevalence in Eastern countries was higher than in Western countries with 29.1% versus 18.5%. Anaerobic sports had almost double the prevalence of SRDE 37.9% (27.0%-50.2%) compared to aerobic sports 19.6% (15.2%-25%). Gymnastics sports had the highest SRDE prevalence rate, with 41.5% (30.4%-53.6%) while outdoor sports showed the lowest at 15.4% (11.6%-20.2%). Among various tools used to assess SRDE, the three-factor eating questionnaire yielded the highest SRDE rate 73.0% (60.1%-82.8%). Meta-regression analyses showed that female sex, older age, and higher BMI (all p < 0.01) are associated with higher prevalence rates of SRDE.

CONCLUSION

The outcome of this review suggests that factors specific to the sport affect eating behaviors throughout an athlete's life. As a result, one in five athletes run the risk of developing an eating disorder. Culture-specific and sport-specific diagnostic tools need to be developed and increased attention paid to nutritional deficiencies in athletes.

Mental Health and Disordered Eating in Athletes

Disordered eating (DE) and eating disorders (EDs) are more prevalent in athletes than non-athletes, and can cause devastating health and performance consequences. Although they can affect any athlete, DE/EDs are more common among women and athletes in lean sports, where there is a perceived competitive advantage to being lean. The sports medicine provider plays a crucial role in screening, diagnosis, and treatment of DE/ED. Treatment should involve a multidisciplinary team with a physician, dietitian, and mental health provider. Preventative efforts should seek to educate athletes and their coaches/support staff and should foster a healthy environment, which deemphasizes weight or body image.

High prevalence of low bone mineral density but normal trabecular bone score in Norwegian elite Para athletes

Background

Low bone mineral density (BMD) increases the risk of bone stress injuries (BSI) and is one of several clinical concerns in Para athlete sports medicine. However, whether bone microarchitecture is altered in Para athletes is not known.

Objective

We aimed to investigate BMD, bone microarchitecture and incidence of bone stress injuries in Norwegian elite Para athletes.

Design

In this cross-sectional study in Para athletes, Dual energy x-ray absorptiometry (iDXA, Lunar, GE Health Care) derived areal BMD, trabecular bone score (TBS), a surrogate marker for bone microarchitecture, and body composition (body weight (BW), lean body mass (LBM), fat mass (FM), fat percentage) were investigated and compared between ambulant and non-ambulant athletes. Also, the association between BMD, TBS and body composition variables was investigated. Incidence of BSI was assessed with a questionnaire and confirmed by a sports physician in a clinical interview. BMD Z-score <-1 was defined as low and ≤-2 as osteoporotic. TBS ≥ 1.31 was normal, 1.23-1.31 intermediate and <1.23 low.

Results

Among 38 athletes (26 ± 6 yrs, 14 females), BMD Z-score was low in 19 athletes, and osteoporotic in 11 athletes' lumbar spine (LS) or femoral neck (FN). BMD was lower in non-ambulant vs. ambulant athletes both in LS (1.13 ± 0.19 vs. 1.25 ± 0.14 g/cm2, p = 0.030) and FN (0.90 ± 0.15 vs. 1.07 ± 0.16 g/cm2, p = 0.003). TBS was normal for all athletes. BMD Z-score in LS was positively associated with TBS (r = 0.408, p = 0.013), body weight (r = 0.326, p = 0.046) and lean body mass (r = 0.414, p = 0.010), but not with fat mass or fat percentage. None of the athletes reported any BSI.

Conclusions

Half of the Norwegian elite Para athletes had low BMD, and 29% had BMD Z-score <-2 suggesting osteoporosis. Non-ambulant athletes were more prone to low BMD than ambulant athletes. However, despite high prevalence of low BMD, TBS was normal in all athletes, and BSI was absent in this young population.

Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review

The purpose of this narrative review is to identify health and performance consequences associated with LCA in female endurance athletes. The intake of carbohydrates (CHO) before, during, and after exercise has been demonstrated to support sport performance, especially endurance activities which rely extensively on CHO as a fuel source. However, low energy availability (LEA) and low carbohydrate availability (LCA) are common in female athletes. LEA occurs when energy intake is insufficient compared to exercise energy expenditure, and LEA-related conditions (e.g., Female Athlete Triad (Triad) and Relative Energy Deficiency in Sport (RED-S)) are associated with a myriad of health and performance consequences. The RED-S model highlights 10 health consequences and 10 performance consequences related to LEA. The independent effect of LCA on health and performance has been under-researched, despite current CHO intake being commonly insufficient in athletes. It is proposed that LCA may not only contribute to LEA but also have independent health and performance consequences in athletes. Furthermore, this review highlights current recommendations for CHO intake, as well as recent data on LCA prevalence and menstrual cycle considerations. A literature review was conducted on PubMed, Science Direct, and ResearchGate using relevant search terms (i.e., "low carbohydrate/energy availability", "female distance runners"). Twenty-one articles were identified and twelve met the inclusion criteria. The total number of articles included in this review is 12, with 7 studies illustrating that LCA was associated with direct negative health and/or performance implications for endurance-based athletes. Several studies included assessed male athletes only, and no studies included a female-only study design. Overall, the cumulative data show that female athletes remain underrepresented in sports science research and that current CHO intake recommendations and strategies may fail to consider female-specific adaptations and hormone responses, such as monthly fluctuations in estrogen and progesterone throughout the menstrual cycle. Current CHO guidelines for female athletes and exercising women need to be audited and explored further in the literature to support female athlete health and performance.

Surfboard riders are at risk of low energy availability - A pilot study

BACKGROUND

Surfing is a rapidly growing sport and recreational activity. The previously reported, intermittent high-intensity energetics of surfing place athletes and recreational participants at risk of low energy availability (LEA).

AIM

As such, this pioneering study aims to be the first to investigate LEA risk and the second to investigate dietary intake in surfers.

METHODS

Twenty-one intermediate and advanced surfers (female - 5, male - 16) were recruited to complete an online self-administered questionnaire and 4 consecutive 24-hour food logs to establish LEA risk and asses dietary intake. The Low Energy Availability in Female Questionnaire and Eating Disorder Examination Questionnaire were used to identify at-risk individuals in females and males, respectively, with respective cut-off's of ≥8 and ≥2.3.

RESULTS

Fifty-seven percent were classed as at-risk of LEA (50% and 80% in males and females, respectively). No significant relationship of competitive status, surfing ability and body mass index on risk classification was found. However, a non-significant medium effect of age was observed (p = 0.338, R = 0.549). And 77% of the 70 total analysed food records showed inadequate carbohydrate (CHO) consumption.

CONCLUSION

In summary, an alarmingly high portion of surfers are at risk of LEA and dietary inadequacy. Future studies should confirm whether surfing organisations need to intervene, by addressing limitations of the present study including a small sample, which was heavily biased away from female and high-level competitors.

2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs)

Relative Energy Deficiency in Sport (REDs) was first introduced in 2014 by the International Olympic Committee's expert writing panel, identifying a syndrome of deleterious health and performance outcomes experienced by female and male athletes exposed to low energy availability (LEA; inadequate energy intake in relation to exercise energy expenditure). Since the 2018 REDs consensus, there have been >170 original research publications advancing the field of REDs science, including emerging data demonstrating the growing role of low carbohydrate availability, further evidence of the interplay between mental health and REDs and more data elucidating the impact of LEA in males. Our knowledge of REDs signs and symptoms has resulted in updated Health and Performance Conceptual Models and the development of a novel Physiological Model. This Physiological Model is designed to demonstrate the complexity of either problematic or adaptable LEA exposure, coupled with individual moderating factors, leading to changes in health and performance outcomes. Guidelines for safe and effective body composition assessment to help prevent REDs are also outlined. A new REDs Clinical Assessment Tool-Version 2 is introduced to facilitate the detection and clinical diagnosis of REDs based on accumulated severity and risk stratification, with associated training and competition recommendations. Prevention and treatment principles of REDs are presented to encourage best practices for sports organisations and clinicians. Finally, methodological best practices for REDs research are outlined to stimulate future high-quality research to address important knowledge gaps.

Epidemiology of injuries and illnesses in elite wheelchair basketball players over a whole season - a prospective cohort study

BACKGROUND

Wheelchair basketball is an adaptation of pedestrian basketball and one of the most popular Paralympic sports worldwide. The epidemiology of health problems in wheelchair basketball has been prospectively studied only during the Paralympic Games, the 2018 World Championships, the 2021 South America Wheelchair Basketball Championship, and one season of two American intercollegiate wheelchair basketball teams. The objective of the study was to prospectively monitor and analyze the prevalence, incidence, burden, and characteristics of injuries and illnesses in a wheelchair basketball league during an entire season for the first time.

METHODS

All players of the highest German wheelchair basketball league (Bundesliga) were invited to participate in the study. Included players completed the Oslo Sports Trauma Research Center Questionnaire once a week during the entire season 2020/21 to report health problems. Exposure was captured by self-reported training time and officially-recorded competition time.

RESULTS

Sixty of 117 players (51%, 47 male, 13 female) of the national league participated with an average response of 93%. Seventy health problems (5.5/1000 exposure hours [95% CI: 4.9-6.1]) were reported, including 54 injuries and 16 illnesses. Prevalence of health problems was 60% (95% CI: 48-72). Most injuries affected the shoulder (32% of all injuries), cervical spine/neck (17%), and hand (13%). More overuse injuries (2.9/1000 exposure hours [95% CI: 2.5-3.3]) than acute injuries (1.3/1000 exposure hours [95% CI: 1.0-1.6]) occurred. Of all health problems, 53% were associated with time-loss. The incidences of all health problems, illnesses, injuries, and overuse injuries were higher in women than in men.

CONCLUSIONS

Characteristics and frequency of injuries and illnesses during wheelchair basketball season differed from those during major wheelchair basketball tournaments. The high proportion of overuse injuries and the higher injury rates in women should be regarded in the development of individualized prevention measures. Since results from previous studies during major tournaments are only partially comparable to wheelchair basketball league play, further studies should follow.

Energy Availability and Nutritional Intake during Different Training Phases of Wheelchair Athletes

Optimizing nutritional intake and timing helps athletes to improve performance and long-term health. Different training phases can require varying nutritional needs. In this study, we conducted a descriptive assessment of dietary intake, energy availability (EA), and blood biochemical parameters in elite wheelchair athletes during distinct training phases. Data analyzed in this study were collected as part of a randomized controlled crossover trial exploring the feasibility of probiotics and prebiotic supplementation. Data were obtained from consecutive three-day diaries and blood samples, both collected at four different time points across four consecutive months. We included 14 athletes (mean (standard deviation) age 34 (9) years, eight females, and six males) active in different wheelchair sports. The mean daily nutritional intake (g/kg body mass) for females and males was 2.7 (0.9) and 4.0 (0.7) for carbohydrates, 1.1 (0.3) and 1.5 (0.3) for protein, and 0.8 (0.3) and 1.4 (0.2) for fat. EA did not change across the four time points in either female (p = 0.30) or male (p = 0.05) athletes. The mean EA was lower in female athletes compared to male athletes (p = 0.03). Low EA (≤30 kcal/ kg fat-free mass/day) was observed in female (58 (29) % of days) and male (34 (23) % of days) athletes. Iron deficiency with anemia was observed in two female athletes. Mean vitamin D levels were insufficient (<75 nmol/L). Macronutrient intake, EA, and blood biochemical parameters were suboptimal in this cohort of elite wheelchair athletes, especially in female athletes.

Updates on Molecular Targets and Epigenetic-Based Therapies for PCOS

Polycystic ovarian syndrome (PCOS) can cause infertility in females due to hyperandrogenism and neuroendocrine abnormalities. The aim of this study is to decipher the impact of endocrine variables, hyperandogenism, insulin resistance, oxidative stress, and dietary conditions in PCOS conditions, subsequently to depict the role of epigenetic factors relative to phenotypic manifestations in PCOS conditions. We have reviewed several metabolic milieus pertinent to PCOS conditions. Comparative efficacies of various PCOS therapies, and recent clinical recommendations for the effective management of PCOS and role of metabolic/endocrine variables in PCOS conditions were described. Comparative therapeutic effects were vividly delineated according to the variable pathophysiology and internal variables during PCOS syndrome on the female body through the formation of cascade of endocrine pathology, which affects working capacity and fosters redox stress-induced cardiovascular, neural, and liver abnormalities. GLP-1 agonists, insulin sensitizers (metformin), and diet and exercise regimens efficacy were explained in enhancing the fertility outcomes among the overweight or obese females with PCOS. Comprehensive appraisal of DNA methylation as epigenetic changes and the manifestations of methylated genes in PCOS conditions were discussed particularly to screen novel molecular targets for developing efficient diagnostic indicators for predicting PCOS risk or its progression. Due to the reversible nature of epigenetic modifications, it is possible to screen the "druggable" regions to target or to correct abnormalities in the gene expression subsequently to develop chromatin-modifying therapies against PCOS.

Risk factors for eating disorders: findings from a rapid review

BACKGROUND

Risk factors represent a range of complex variables associated with the onset, development, and course of eating disorders. Understanding these risk factors is vital for the refinement of aetiological models, which may inform the development of targeted, evidence-based prevention, early intervention, and treatment programs. This Rapid Review aimed to identify and summarise research studies conducted within the last 12 years, focusing on risk factors associated with eating disorders.

METHODS

The current review forms part of a series of Rapid Reviews to be published in a special issue in the Journal of Eating Disorders, funded by the Australian Government to inform the development of the National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2021, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, or population studies). Data pertaining to risk factors for eating disorders were synthesised and outlined in the current paper.

RESULTS

A total of 284 studies were included. The findings were divided into nine main categories: (1) genetics, (2) gastrointestinal microbiota and autoimmune reactions, (3) childhood and early adolescent exposures, (4) personality traits and comorbid mental health conditions, (5) gender, (6) socio-economic status, (7) ethnic minority, (8) body image and social influence, and (9) elite sports. A substantial amount of research exists supporting the role of inherited genetic risk in the development of eating disorders, with biological risk factors, such as the role of gut microbiota in dysregulation of appetite, an area of emerging evidence. Abuse, trauma and childhood obesity are strongly linked to eating disorders, however less conclusive evidence exists regarding developmental factors such as role of in-utero exposure to hormones. Comorbidities between eating disorders and mental health disorders, including personality and mood disorders, have been found to increase the severity of eating disorder symptomatology. Higher education attainment, body image-related factors, and use of appearance-focused social media are also associated with increased risk of eating disorder symptoms.

CONCLUSION

Eating disorders are associated with multiple risk factors. An extensive amount of research has been conducted in the field; however, further studies are required to assess the causal nature of the risk factors identified in the current review. This will assist in understanding the sequelae of eating disorder development and in turn allow for enhancement of existing interventions and ultimately improved outcomes for individuals.

Perspectives on relative energy deficiency in sport (RED-S): A qualitative case study of athletes, coaches and medical professionals from a super league netball club

BACKGROUND

Research into relative energy deficiency in sport (RED-S) has increased substantially over recent years given the impact on athletes' health and performance. Most studies have considered sports that place emphasis on the aesthetics, endurance, or weight-restriction. Fewer studies exist in team sports. Netball is a team sport yet to be explored despite players potentially being at risk of RED-S given the high training volumes, sporting culture, internal and external pressures, and small network of coaches and medical professionals. A qualitative case study was used to explore the perspective of athletes, coaches, and medical professionals on RED-S.

METHODS

Semi-structured interviews were conducted with 13 players, 4 coaches and 4 medical professionals affiliated to a Super League club. Interviews were recorded and transcribed verbatim. The data was analysed using thematic analysis.

RESULTS

Five main themes were identified in this study. Awareness of RED-S amongst athletes and coaches was generally inadequate whereas medical professionals had some awareness of RED-S. Some athletes used contraception to reduce discomfort/pain during menstruation whilst others expressed concerns around long-term contraceptive use and previous menstrual cycle disturbance. Sporting demands, individual and contextual factors, and a preoccupation with body image were associated with nutritional restriction, whilst appearance was a source of internal and external pressure. External pressures also extended to coaches, assessments/feedback, social media, and commentary. Strategies suggested to reduce the risk of RED-S included "hard hitting cases", multidisciplinary team involvement, and support from the governing body.

CONCLUSION

The findings of this study provide insight into factors potentially associated with the risk of RED-S from an athletes, coaches, and medical professional perspective. This insight can be used to increase overall awareness of RED-S in key stakeholders as well as improve the recognition for the pressures netball athletes face that might alter the level of risk.

The Role of Diets and Dietitians for Para-Athletes: A Pilot Study Based on Interviews

Efforts to provide nutrition support to para-athletes have not been established to date, and are far behind those established for athletes without disabilities. In the present study, we attempted to clarify the actual situation regarding dietary challenges of para-athletes. The aim of this study was to obtain clues to effective intervention methods that encourage the practice of sports nutrition. Six active elite para-athletes (30–70 years, four males) and a female physical therapist without physical disability participated in semi-structured interviews. All para-athletes had lower-limb disabilities and participated in the international wheelchair sports competitions (tennis, softball, and table tennis, with 2–26 years of player history). The interview items were on the ideal diet for improving competitive performance, evaluation of their typical diets, and the role of the dietitian as support. Responses obtained from participants were analyzed using quantitative content analysis by language analysis software. There are differences in the ideal diet based on the characteristics of the sport, but most participants believed that a nutritionally well-balanced diet with abundant vegetables was ideal for improving competitive performance. Para-athletes who use a wheelchair daily pay attention to their total calorie intake, because gaining weight is a critical issue for operating their wheelchairs and transferring themselves to and from their wheelchairs. Despite their world-class competition levels, none of them received routine dietary advice from dietitians. Some para-athletes did not even feel the need to engage with dietitians. Even for these para-athletes at a high level of competition, the “ideal diet” they considered was not always the optimal diet for improving their competitive performance. In addition, there are various barriers to practicing their optimal diet due to disability characteristics. Dietitians need to understand these barriers, their concerns and conflicts, and how to help them plan the optimal diet to improve their performance and maintain overall health.

Menstrual Cycle Changes Joint Laxity in Females—Differences between Eumenorrhea and Oligomenorrhea

The purpose of this study was to investigate the changes in anterior knee laxity (AKL), stiffness, general joint laxity (GJL), and genu recurvatum (GR) during the menstrual cycle in female non-athletes and female athletes with normal and irregular menstrual cycles. Participants were 19 female non-athletes (eumenorrhea, n = 11; oligomenorrhea, n = 8) and 15 female athletes (eumenorrhea, n = 8; oligomenorrhea, n = 7). AKL was measured as the amount of anterior tibial displacement at 67 N–133 N. Stiffness was calculated as change in (Δ)force/Δ anterior displacement. The Beighton method was used to evaluate the GJL. The GR was measured as the maximum angle of passive knee joint extension. AKL, stiffness, GJL, and GR were measured twice in four phases during the menstrual cycle. Stiffness was significantly higher in oligomenorrhea groups than in eumenorrhea groups, although no significant differences between menstrual cycle phases were evident in female non-athletes. GR was significantly higher in the late follicular, ovulation, and luteal phases than in the early follicular phase, although no significant differences between groups were seen in female athletes. Estradiol may affect the stiffness of the periarticular muscles in the knee, suggesting that GR in female athletes may change during the menstrual cycle.

Case Study: Improving Energy Status in a Wheelchair Athlete With Suppressed Resting Energy Expenditure

PURPOSE

Wheelchair athletes experience a reduction in fat-free mass due to the underlying condition and/or muscle disuse. This leads to a lower resting energy expenditure (REE), as well as a lower energy expenditure during exercise or daily activities. Traditional markers of low energy availability (LEA), including amenorrhea and low bone mineral density, are often inconclusive in wheelchair athletes. This case study provides data from a professional female wheelchair badminton player with multiple sclerosis who presented with a reduced measured-to-predicted REE ratio (REEratio), a common indicator of LEA in able-bodied athletes. Furthermore, a nutrition and exercise intervention was conducted to restore REE.

METHODS

REE and body composition were measured using indirect calorimetry and dual-energy X-ray absorptiometry, respectively. The predicted REE of the REEratio was calculated using 2 separate approaches. An REEratio <0.9 was considered an indicator for LEA. A nutrition and exercise intervention was implemented to normalize REE and induce weight loss through increased meal frequency, a 200- to 400-kcal/d increase in energy intake, and added endurance exercise.

RESULTS

The athlete (33 y, 78 kg, 154 cm) initiallly showed an REEratio of 0.65 to 0.70, which increased to 1.00 to 1.09 after 1 year. The athlete lost 11.8 kg, almost exclusively (11 kg) in the form of fat mass. The athlete reported reduced fatigue and higher perceived fitness.

CONCLUSION

The nutrition and exercise intervention successfully restored energy status, induced sustainable weight loss, and reduced fatigue in a wheelchair athlete with multiple sclerosis with presumed LEA. Methods to assess LEA in this population require further validation.

An Assessment of the Early Symptoms of Energy Deficiency as a Female Athlete Triad Risk among the Polish National Kayaking Team Using LEAF-Q

Background: Kayaking is a high intensity sport that demands high levels of aerobic and anaerobic capacity as well as a great deal of strength and endurance. The aim of this study was an assessment of the frequency of occurrence of early low energy availability symptoms using the Low Energy Availability in Females Questionnaire for women belonging to the Polish national kayaking team. Additionally, quantitative measurements of body composition and levels of calcium were performed. Methods: The study involved 33 women who were competitors in the Polish national kayaking team. Results: An analysis of the results in terms of disorders in the monthly cycle in the tested kayakers found that only five competitors, approximately 15% of the entire group, had this type of problem. Between the participants who had disorders of the menstrual cycle and those whose cycle was normal, there was only a statistically significant difference at the level of p < 0.001 in relation to the age of the kayakers. Conclusions: The Low Energy Availability in Females Questionnaire proved to be a useful screening tool, which allowed for the early detection of Female Athlete Triad symptoms in several young female kayakers from the Polish national team.

'That time of the month' … for the biggest event of your career! Perception of menstrual cycle on performance of Australian athletes training for the 2020 Olympic and Paralympic Games

Objective

This study explored the perceived effect of the menstrual cycle (MC) on the performance of Australian female athletes, preparing for the Tokyo Olympic and/or Paralympic Games.

Methods

195 female athletes, nominated by 24 National Sporting Organisations as preparing for the Tokyo Olympic and/or Paralympic Games, completed an online questionnaire (‘MCq perceptions’). The MCq perceptions investigated menstrual symptoms, hormonal contraceptive (HC) use and a preferred competition window within the MC.

Results

Two-thirds (65.6%) athletes reported that their MC affected their performance; in training (65.6%) compared with competition (58.0%).

Aesthetic-sport athletes were most likely to perceive their performance to be affected by their MC (RR=1.40) compared with endurance (RR=0.88) and strength-sport (RR=1.04) athletes. Athletes experiencing three or more symptoms were twice as likely to identify as affected. Athletes who reported pain (RR=1.89) or the use of analgesia (RR=1.45) were more likely to identify as affected by their MC.

A preferred competition window was identified by athletes as ‘just after your period’ (41.5%). For athletes not using HC, this window was identified by 53.7%.

Conclusion

In Australia, elite-female athletes perceive their MC to affect their performance, and many have a preferred performance window. Performance-focused strategies should be created for ‘affected’ athletes, aiming to provide these athletes with education, and where appropriate, control over predictability, timing and symptoms of their MC.

Risk of Low Energy Availability, Disordered Eating, Exercise Addiction, and Food Intolerances in Female Endurance Athletes

Relative energy deficiency in sport (RED-S) is a complex syndrome describing health and performance consequences of low energy availability (LEA) and is common among female endurance athletes. Various underlying causes of LEA have been reported, including disordered eating behavior (DE), but studies investigating the association with exercise addiction and food intolerances are lacking. Therefore, the aim of this cross-sectional study was to investigate the association between DE, exercise addiction and food intolerances in athletes at risk of LEA compared to those with low risk. Female endurance athletes, 18–35 years, training ≥5 times/week were recruited in Norway, Sweden, Ireland, and Germany. Participants completed an online-survey comprising the LEA in Females Questionnaire (LEAF-Q), Exercise Addiction Inventory (EAI), Eating Disorder Examination Questionnaire (EDE-Q), and questions regarding food intolerances. Of the 202 participants who met the inclusion criteria and completed the online survey, 65% were at risk of LEA, 23% were at risk of exercise addiction, and 21% had DE. Athletes at risk of LEA had higher EDE-Q and EAI scores compared to athletes with low risk. EAI score remained higher in athletes with risk of LEA after excluding athletes with DE. Athletes at risk of LEA did not report more food intolerances (17 vs. 10%, P = 0.198), but were more frequently reported by athletes with DE (28 vs. 11%, P = 0.004). In conclusion, these athletes had a high risk of LEA, exercise addiction, and DE. Exercise addiction should be considered as an additional risk factor in the prevention, early detection, and targeted treatment of RED-S among female endurance athletes.

Low Energy Availability Interferes With Exercise-Associated Bone Effects in Female Long-Distance Triathletes as Detected by HR-pQCT

Female Athlete Triad, initially described as the association of disordered eating, amenorrhea and osteoporosis, was further redefined to focus on low energy availability (EA), which has a central role in development of hypoestrogenism and low bone mineral density (BMD). However, the contribution of each variable, that is, low EA and hypoestrogenism, for bone derangements is still an open question. To evaluate body composition and bone status in long-distance triathletes without hypoestrogenism, as compared to non-athletes, using DXA and HR-pQCT, and the influence of EA. Population comprised 23 triathletes who had completed at least one long-distance race in the previous year, and 17 non-athletic healthy controls. The athletes denied previous oligo-amenorrhea and had spontaneous regular menses or were on hormonal contraceptives. Control patients also had regular menses. Energy deficiency (low EA) was defined as energy intake below the recommended level for athletes, that is, 45 kcal/kg free fat mass/day. Only femoral neck BMD Z-score measured by DXA trended higher in athletes (p = 0.05), whereas high-resolution peripheral quantitative computed tomography detected significantly higher values of entire bone and trabecular bone area, cortical perimeter, trabecular vBMD and trabecular bone volume/tissue volume, and lower trabecular separation and trabecular inhomogeneity in athletes. No difference was found between athletes with spontaneous menses and those on hormone contraceptives in respect to all parameters. The effects of exercise on bone were not so pronounced in athletes with low EA, although they still had better bone parameters than controls. Stress fractures were reported by 4:12 athletes with low EA and by 2:11 athletes with adequate EA. Long-distance female triathletes without hypoestrogenism show higher values of cortical perimeter, bone area, volumetric density and trabecular microstructure, but low EA interferes with exercise-associated bone effects. These innovative findings reinforce the importance of adequate EA in female athletes to guarantee skeletal health.

How Do We Assess Energy Availability and RED-S Risk Factors in Para Athletes?

Low energy availability (LEA) is considered to be the underlying cause of a number of maladaptations in athletes, including impaired physiological function, low bone mineral density (BMD), and hormonal dysfunction. This is collectively referred to as ‘Relative Energy Deficiency in Sport’ (RED-S). LEA is calculated through assessment of dietary energy intake (EI), exercise energy expenditure (EEE) and fat-free mass (FFM). The incidence of LEA in Paralympic athletes is relatively unknown; however, there are legitimate concerns that Para athletes may be at even higher risk of LEA than able-bodied athletes. Unfortunately, there are numerous issues with the application of LEA assessment tools and the criterion for diagnosis within the context of a Para population. The calculation of EEE, in particular, is limited by a distinct lack of published data that cover a range of impairments and activities. In addition, for several RED-S-related factors, it is difficult to distinguish whether they are truly related to LEA or a consequence of the athlete’s impairment and medical history. This narrative review outlines deficits and complexities when assessing RED-S and LEA in Para athletes, presents the information that we do have, and provides suggestions for future progress in this important area of sports nutrition.

Absence of menstruation in female athletes: why they do not seek help

Background

It is known that amenorrhea is highly prevalent among female athletes. However, a large percentage of them do not seek help if this complaint occurs. We performed this study to gain more insight into the reasons why female athletes do not seek help when experiencing amenorrhea and how care for these women could be improved.

Method

Qualitative focus group research. Female athletes were approached to take part in a focus group. They were asked about the main reasons for not reporting amenorrhea and how care for amenorrhea, in their opinion, would ideally be organised. The women were asked to make a list of their top five reasons for both subjects and discuss this among their peers.

Results

According to the participants, the five main reasons for not reporting the amenorrhea were: (1) normalizing of the subject, (2) the absence of menstruation is not perceived as a problem by the athletes themselves, (3) experienced shame and taboo, (4) prioritisation of sports performance, and (5) denial. Factors to improve care around menstrual cycle problems in female athletes were: (1) informing athletes, coaches, trainers and mentors, (2) informing doctors, (3) conducting more research on long-term consequences, (4) breaking the taboo on menstrual problems, and (5) having a multidisciplinary collaboration between different specialisms.

Conclusion

By informing athletes, coaches, trainers, and mentors about menstrual cycle problems in athletes, more awareness among those groups can be created. According to the athletes, more research is needed on the long-term consequences of amenorrhea in sports, to enable them to make a better assessment of their possible future health risks. Women experience a taboo on discussing menstrual problems; role models discussing the problem may help in decreasing the taboo. A multidisciplinary collaboration of health care providers may improve care around female athletes with menstrual problems.

Adaptive Cycling: Injuries and Health Concerns

Para-cycling has high rates of acute injuries. The underlying medical conditions of para-athletes predispose these cyclists to injury patterns and sequelae different from those of their able-bodied counterparts. Such injuries include an increased incidence of upper-extremity and soft tissue injuries, along with predisposition for respiratory, skin, genitourinary, and heat-related illnesses. There are no validated sideline assessment tools or return-to-play protocols for sports-related concussion in wheelchair user para-athletes or those with balance deficits. Para-cyclists may be at increased risk for relative energy deficiency in sport due to competitive pressure to maintain certain weights and increased incidence of low bone mineral density.

Physiological Considerations to Support Podium Performance in Para-Athletes

The twenty-first century has seen an increase in para-sport participation and the number of research publications on para-sport and the para-athlete. Unfortunately, the majority of publications are case reports/case series or study single impairment types in isolation. Indeed, an overview of how each International Paralympic Committee classifiable impairment type impact athlete physiology, health, and performance has not been forthcoming in the literature. This can make it challenging for practitioners to appropriately support para-athletes and implement evidence-based research in their daily practice. Moreover, the lack of a cohesive publication that reviews all classifiable impairment types through a physiological lens can make it challenging for researchers new to the field to gain an understanding of unique physiological challenges facing para-athletes and to appreciate the nuances of how various impairment types differentially impact para-athlete physiology. As such, the purpose of this review is to (1) summarize how International Paralympic Committee classifiable impairments alter the normal physiological responses to exercise; (2) provide an overview of "quick win" physiological interventions targeted toward specific para-athlete populations; (3) discuss unique practical considerations for the para-sport practitioner; (4) discuss research gaps and highlight areas for future research and innovation, and (5) provide suggestions for knowledge translation and knowledge sharing strategies to advance the field of para-sport research and its application by para-sport practitioners.

Nutritional Considerations for Para-Cycling Athletes: A Narrative Review

Para-cycling is a sport including athletes with different disabilities competing on the track and on the roads using bicycles, tandems, tricycles, and handbikes. Scientific literature in this special population is scarce, especially in the field of sports nutrition. This review summarizes the physiological aspects and demands of para-cycling. This information together with the existing literature on nutritional interventions in this population, helps to discuss the nutritional considerations. To date, only a limited amount of recommendations are available for this population. In most para-cycling athletes, a reduction in active muscle mass and consequently a reduction in resting energy expenditure occurs, except for visually impaired athletes. Furthermore, carbohydrate and protein intake and hydration, supplementation, heat, and weight loss need to be tailored to the disability-specific adaptations such as the reduced active muscle mass, neurogenic bladder, and bowel, a reduced metabolic cost during exercise, and a higher risk of micronutrient deficiency.

The Path Towards Progress: A Critical Review to Advance the Science of the Female and Male Athlete Triad and Relative Energy Deficiency in Sport

Energy status plays a key role in the health of athletes and exercising individuals. Energy deficiency/low energy availability (EA), referring to a state in which insufficient energy intake and/or excessive exercise energy expenditure has resulted in compensatory metabolic adaptations to conserve fuel, can affect numerous physiological systems in women and men. The Female Athlete Triad, Male Athlete Triad, and Relative Energy Deficiency in Sport (RED-S) models conceptualize the effects of energy deficiency in athletes, and each model has strengths and limitations. For instance, the Female Athlete Triad model depicts relationships between low EA, reproductive, and bone health, underpinning decades of experimental evidence, but may be perceived as limited in scope, while the more recent RED-S model proposes a wider range of potential health effects of low EA, though many model components require more robust scientific justification. This critical review summarizes current evidence regarding the effects of energy deficiency on athlete health by addressing the quality of the underlying science, the strengths and limitations of each model, and highlighting areas where future research is needed to advance the field. With the health and wellness of athletes and exercising individuals as the overarching priority, we conclude with specific steps that will help focus future research on the Female and Male Athlete Triad and RED-S, and encourage all researchers, clinicians, and practitioners to collaborate to support the common goal of promoting the highest quality science and evidence-based medicine in pursuit of the advancement of athletes' health, well-being, and performance.

Has Menstruation Disappeared? Functional Hypothalamic Amenorrhea-What Is This Story about?

Functional hypothalamic amenorrhea (FHA) is a very common condition affecting women of procreative age. There are many reasons for this disorder, including a low availability of energy in the diet, low micro- and macronutrient intake, overly intensive physical activity, disturbed regeneration processes, sleep disorders, stress, and psychological disorders. The main determinant is long-term stress and an inability to handle the effects of that stress. FHA is a very complex disorder and often goes undiagnosed. Moreover, therapeutic interventions do not address all the causes of the disorder, which could have implications for women’s health. As shown by scientific reports, this condition can be reversed by modifying its causes. This review of the literature aims to update the current knowledge of functional hypothalamic amenorrhea and underscores the complexity of the disorder, with particular emphasis on the nutritional aspects and potential interventions for restoring balance.

Sex Differences in Neurophysiological Changes Following Voluntary Exercise in Adolescent Rats

Background: Adolescence is a period of time characterized by the onset of puberty and is marked by cognitive and social developments and gross physical changes that can play a role in athletic performance. Sex differences are present with differences in body size, height, physiology and behavior which contribute to differences in athletic performance as well. Pre-clinical studies representing this active group are lacking.

Methods: Acute and chronic effects of exercise were evaluated. Male and female adolescent rats were given voluntary access to a running wheel for 10 consecutive days. Running behavior (males and females) and estrous cycling (females only) were analyzed daily. A second group was given 10 days of voluntary access to a running wheel, then rested for 10 days to determine the long-term effects of exercise on the adolescent brain. Brain and muscle tissue were harvested at 10 and 20 day time points to understand exercise-dependent changes in mitochondrial activity and neuroplasticity. Animal cohorts were carried out at two different sites: University of California Los Angeles and Pepperdine University.

Results: On average, running distance, intensity of run, and length of running bout increased for both male and female rats across the 10 days measured. Females ran significantly further and for longer intervals compared to males. Cortical and muscle expression of PGC1α showed similar levels at 10 days regardless of sex and exercise. There was a significant increase in expression at 20 days in all groups correlating with body size (p's < 0.05). Cortical and hippocampal levels of BDNF were similar across all groups, however, BDNF was significantly higher in exercised females at the acute compared to long-term time point.

Discussion: Adolescent rats allowed 10 days of exercise show changes in physiologic function. There are sex differences in running behavior not impacted by sex hormones. These results are important to further our understanding of how exercise impacts the adolescent brain.

Overtraining Syndrome (OTS) and Relative Energy Deficiency in Sport (RED-S): Shared Pathways, Symptoms and Complexities

The symptom similarities between training-overload (with or without an Overtraining Syndrome (OTS) diagnosis) and Relative Energy Deficiency in Sport (RED-S) are significant, with both initiating from a hypothalamic-pituitary origin, that can be influenced by low carbohydrate (CHO) and energy availability (EA). In this narrative review we wish to showcase that many of the negative outcomes of training-overload (with, or without an OTS diagnosis) may be primarily due to misdiagnosed under-fueling, or RED-S, via low EA and/or low CHO availability. Accordingly, we undertook an analysis of training-overload/OTS type studies that have also collected and analyzed for energy intake (EI), CHO, exercise energy expenditure (EEE) and/or EA. Eighteen of the 21 studies (86%) that met our criteria showed indications of an EA decrease or difference between two cohorts within a given study (n = 14 studies) or CHO availability decrease (n = 4 studies) during the training-overload/OTS period, resulting in both training-overload/OTS and RED-S symptom outcomes compared to control conditions. Furthermore, we demonstrate significantly similar symptom overlaps across much of the OTS (n = 57 studies) and RED-S/Female Athlete Triad (n = 88 studies) literature. It is important to note that the prevention of under-recovery is multi-factorial, but many aspects are based around EA and CHO availability. Herein we have demonstrated that OTS and RED-S have many shared pathways, symptoms, and diagnostic complexities. Substantial attention is required to increase the knowledge and awareness of RED-S, and to enhance the diagnostic accuracy of both OTS and RED-S, to allow clinicians to more accurately exclude LEA/RED-S from OTS diagnoses.

The Specificities of Elite Female Athletes: A Multidisciplinary Approach

Female athletes have garnered considerable attention in the last few years as more and more women participate in sports events. However, despite the well-known repercussions of female sex hormones, few studies have investigated the specificities of elite female athletes. In this review, we present the current but still limited data on how normal menstrual phases, altered menstrual phases, and hormonal contraception affect both physical and cognitive performances in these elite athletes. To examine the implicated mechanisms, as well as the potential performances and health risks in this population, we then take a broader multidisciplinary approach and report on the causal/reciprocal relationships between hormonal status and mental and physical health in young (18-40 years) healthy females, both trained and untrained. We thus cover the research on both physiological and psychological variables, as well as on the Athlete Biological Passport used for anti-doping purposes. We consider the fairly frequent discrepancies and summarize the current knowledge in this new field of interest. Last, we conclude with some practical guidelines for eliciting improvements in physical and cognitive performance while minimizing the health risks for female athletes.

New Directions in Dance Medicine: Dancers with Disabilities, Blindness/Low Vision, and/or Deafness/Hard of Hearing

This article explores relevant issues in dance medicine for dancers with disabilities, blindness/low vision, and/or deafness/hard of hearing (DWDBD). Within dance medicine and science, there has been minimal focus on DWDBD. Little is known about injury patterns, injury prevention, or wellness strategies for DWDBD. However, there are increasing numbers of dance programs and companies involving DWDBD at preprofessional and professional levels. This article reviews the history and experience of DWDBD and offers best guidance regarding dance medicine considerations for DWDBD based on the limited research and evidence that exists, extrapolation from para/adaptive sports medicine literature, and expert opinion.

Review: questionnaires as measures for low energy availability (LEA) and relative energy deficiency in sport (RED-S) in athletes

BACKGROUND

A sustained mismatch between energy intake and exercise energy expenditure (EEE) can lead to Low Energy Availability (LEA), health and performance impairments characteristic of Relative Energy Deficiency in Sport (RED-S). Questionnaires can conveniently identify symptoms and/or LEA/ RED-S risk factors. This study aimed to systematically identify, and critique questionnaires used or developed to measure LEA/ RED-S risk in athletic populations.

METHODS

A systematic search was conducted using PubMed database. Full text articles were included if: (i) the questionnaire(s) in the study identified LEA and/or RED-S risk; (ii) studies developed questionnaires to identify LEA and/or RED-S risk; (iii) participants belonged to athletic population(s); and (iv) in English.

RESULTS

Thirty-three articles met the inclusion criteria and were reviewed, 13 questionnaires were identified. Eight questionnaires had undergone validation procedures, and three questionnaires included questions related to EEE. The most widely used validated questionnaires were Low Energy Availability in Females Questionnaire (LEAF-Q) (48% articles) and Eating Disorder Examination Questionnaire (EDE-Q) (12% articles). The LEAF-Q determines LEA risk from symptoms but cannot be used in males as nearly half of the items (n = 12) relate to menstrual function. The EDE-Q serves as a surrogate marker of LEA risk in both sexes, as it measures a major risk factor of LEA, disordered eating. Better validation is needed for many questionnaires and more are needed to address LEA/RED-S risk in male athletes.

CONCLUSION

These questionnaires may be effective in identifying intentional energy restriction but less valuable in identifying inadvertently failure to increase energy intake with increased EEE.

Risk of Low Energy Availability in National and International Level Paralympic Athletes: An Exploratory Investigation

(1) Background: The purpose of this study was to examine the symptoms of low energy availability (LEA) and risk of relative energy deficiency in sport (RED-S) symptoms in para-athletes using a multi-parameter approach. (2) Methods: National level para-athletes (n = 9 males, n = 9 females) completed 7-day food and activity logs to quantify energy availability (EA), the LEA in Females Questionnaire (LEAF-Q), dual energy X-ray absorptiometry (DXA) scans to assess bone mineral density (BMD), and hormonal blood spot testing. (3) Results: Based on EA calculations, no athlete was at risk for LEA (females < 30 kcal·kg⁻¹ FFM·day⁻¹; and males < 25 kcal·kg⁻¹ FFM·day⁻¹; thresholds for able-bodied (AB) subjects). Overall, 78% of females were “at risk” for LEA using the LEAF-Q, and 67% reported birth control use, with three of these participants reporting menstrual dysfunction. BMD was clinically low in the hip (<−2 z-score) for 56% of female and 25% of male athletes (4) Conclusions: Based on calculated EA, the risk for RED-S appears to be low, but hormonal outcomes suggest that RED-S risk is high in this para-athlete population. This considerable discrepancy in various EA and RED-S assessment tools suggests the need for further investigation to determine the true prevalence of RED-S in para-athlete populations.

Relative energy deficiency in sports (RED-S): elucidation of endocrine changes affecting the health of males and females

The purpose of this review is to present a different perspective of the relative energy deficiency syndrome, to improve understanding of associated endocrine alterations, and to highlight the need for further research in this area. The term "female athlete triad" was coined over 25 years ago to describe three interrelated components: disordered eating, menstrual dysfunction, and low bone mass. The syndrome's etiology is attributed to energy intake deficiency relative to energy expenditure required for health, function, and daily living. Recently, it became clear that there was a need to broaden the term, as the disorder is not an issue of only three interrelated problems but of a whole spectrum of insults resulting from low energy availability (LEA; i.e., insufficient energy availability to cover basic physiological demands) that can potentially affect any exerciser, irrespective of gender. The new model, termed relative energy deficiency in sport (RED-S), has received greater scrutiny in sports medicine due to its effects on both health and performance in athletes of both sexes. RED-S results from low-energy diets (intentional or unintentional) and/or excessive exercise. Energy deficiency reduces hypothalamic pulsatile release of gonadotropin-releasing hormone, this impairing anterior pituitary release of gonadotropins. In women, reduced FSH and LH pulsatility produces hypoestrogenism, causing functional hypothalamic amenorrhea and decreased bone mass. In men, it reduces testosterone and negatively affects bone health. Moreover, LEA alters other hormonal pathways, causing physiological consequences, such as alteration of the thyroid hormone signaling pathways, leptin levels, carbohydrate metabolism, the growth hormone/insulin-like growth factor-1 axis, and sympathetic/parasympathetic tone. This review explains and clarifies the effects of RED-S in both sexes.

Energy Availability in Male and Female Elite Wheelchair Athletes over Seven Consecutive Training Days

Background: Low energy availability (LEA) is a major problem as athletes often restrict their energy intake. It has been shown that LEA occurs often in female and endurance athletes and in athletes from weight-sensitive or aesthetic sports. The purpose of this study was to investigate energy availability (EA) in elite wheelchair athletes. Methods: Fourteen elite wheelchair athletes (8 males; 6 females) participated. Data were collected using a weighed seven-day food and training diary to estimate energy intake and exercise energy expenditure. Resting energy expenditure and body composition were measured, whereas energy balance (EB) was calculated. Results: Measured over 7 days, EA was significantly different (36.1 ± 6.7 kcal kg⁻¹ FFM day⁻¹) in male compared to female (25.1 ± 7.1 kcal kg⁻¹ FFM day⁻¹) athletes (p < 0.001). From all analyzed days, LEA occurred in 73% of the days in female athletes and in 30% of the days in male athletes. EB was positive in male athletes (+169.1 ± 304.5 kcal) and negative (−288.9 ± 304.8 kcal) in female athletes. Conclusions: A higher prevalence of LEA was found in female compared to male athletes. A higher energy intake would be recommended to meet energy needs and to maximize training adaptation.

Disordered eating and eating disorders in male elite athletes: a scoping review

Background

Eating disorders (ED) and disordered eating (DE) among male elite athletes share some of the characteristics seen in female elite athletes and the population, but also exhibit some key differences.

Objective

Scoping review of ED and DE in male elite athletes.

Methods

In May 2020, a comprehensive systematic literature search was conducted for DE and ED in male elite athletes.

Results

We identified 80 studies which included 47 uncontrolled, 14 controlled studies, one interventional trial and 18 reviews.

Discussion

There was a wide range of definitions of DE and a high level of heterogeneity regarding competitive level, age and sport type. In adult male elite athletes, ED prevalence rates up to 32.5% were found, higher than in the general population. Prevalence was not higher in young/adolescent male elite athletes. The most frequently associated factor was competing in weight-sensitive sports. Male elite athletes tended to exhibit less body dissatisfaction than controls and were not always associated with DE. There were no studies looking at the prognosis or reporting an evidence-based approach for the management of DE in male elite athletes.

Conclusion

Existing literature indicates high prevalence of DE and ED in male elite athletes, with a wide range of aetiopathogenesis. There is a need for longitudinal studies to characterise the pathology and long-term outcomes, as well as develop standardised tools for assessment and treatments.

Diet in neurogenic bowel management: A viewpoint on spinal cord injury

The aim of this review is to offer dietary advice for individuals with spinal cord injury (SCI) and neurogenic bowel dysfunction. With this in mind, we consider health conditions that are dependent on the level of lesion including skeletal muscle atrophy, autonomic dysreflexia and neurogenic bladder. In addition, SCI is often associated with a sedentary lifestyle, which increases risk for osteoporosis and diseases associated with chronic low-grade inflammation, including cardiovascular and chronic kidney diseases. The Mediterranean diet, along with exercise and dietary supplements, has been suggested as an anti-inflammatory intervention in individuals with SCI. However, individuals with chronic SCI have a daily intake of whole fruit, vegetables and whole grains lower than the recommended dietary allowance for the general population. Some studies have reported an increase in neurogenic bowel dysfunction symptoms after high fiber intake; therefore, this finding could explain the low consumption of plant foods. Low consumption of fibre induces dysbiosis, which is associated with both endotoxemia and inflammation. Dysbiosis can be reduced by exercise and diet in individuals with SCI. Therefore, to summarize our viewpoint, we developed a Mediterranean diet-based diet and exercise pyramid to integrate nutritional recommendations and exercise guidelines. Nutritional guidelines come from previously suggested recommendations for military veterans with disabilities and individuals with SCI, chronic kidney diseases, chronic pain and irritable bowel syndrome. We also considered the recent exercise guidelines and position stands for adults with SCI to improve muscle strength, flexibility and cardiorespiratory fitness and to obtain cardiometabolic benefits. Finally, dietary advice for Paralympic athletes is suggested.

Prevalence and Anatomical Distribution of Bone Stress Injuries in the Elite Para Athlete

Bone stress injury is a common overuse injury in athletes. Risk factors for bone stress injury in athletes include the female athlete triad (triad); this has not been evaluated in para athletes. The aim of this study was to identify risk factors, prevalence, and anatomical distribution of bone stress injury in para athletes. A cross-sectional online survey on health characteristics and previous fractures including bone stress injury was completed by para athletes training for the 2016 or 2018 Paralympic Games. Two hundred sixty para athletes completed the survey (659 invited, response rate = 40%). Half reported previous fracture, and bone stress injury was reported in 9.2% of all athletes. Twenty-four athletes (11 men and 13 women) sustained one or more bone stress injury, including 13 athletes with two bone stress injuries. No risk factors of the triad, disability type, or duration of disability were associated with bone stress injury. Injuries were most common in the metatarsals (n = 8) and hand/wrist (n = 7). In an elite para athlete population, locations for bone stress injury included both the upper and lower limbs. Clinically, para athletes presenting with pain localized to bone require further workup to evaluate for bone stress injury particularly for pain in both upper and lower limbs. Further research is required to identify risk factors for bone stress injury in para athletes.

Low Energy Availability in Athletes 2020: An Updated Narrative Review of Prevalence, Risk, Within-Day Energy Balance, Knowledge, and Impact on Sports Performance

Low energy availability (EA) underpins the female and male athlete triad and relative energy deficiency in sport (RED-S). The condition arises when insufficient calories are consumed to support exercise energy expenditure, resulting in compromised physiological processes, such as menstrual irregularities in active females. The health concerns associated with longstanding low EA include menstrual/libido, gastrointestinal and cardiovascular dysfunction and compromised bone health, all of which can contribute to impaired sporting performance. This narrative review provides an update of our previous review on the prevalence and risk of low EA, within-day energy deficiency, and the potential impact of low EA on performance. The methods to assess EA remain a challenge and contribute to the methodological difficulties in identifying “true” low EA. Screening female athletic groups using a validated screening tool such as the Low Energy Availability in Females Questionnaire (LEAF-Q) has shown promise in identifying endurance athletes at risk of low EA. Knowledge of RED-S and its potential implications for performance is low among coaches and athletes alike. Development of sport and gender-specific screening tools to identify adolescent and senior athletes in different sports at risk of RED-S is warranted. Education initiatives are required to raise awareness among coaches and athletes of the importance of appropriate dietary strategies to ensure that sufficient calories are consumed to support training.