Endocrine Effects of Relative Energy Deficiency in Sport

Relative Energy Deficiency in Sport (REDs) and knee injuries: current concepts for female athletes

In athletes, a mismatch between caloric intake and energy expended in exercise can eventually lead to Relative Energy Deficiency in Sport (REDs), where the athlete suffers from physiological derangements and decreased sport performance. The prevalence of REDs is higher in females than males. Females are already at a higher risk of knee injuries, which has been attributed to a multitude of factors such as hormonal influences, differences in musculoskeletal anatomy and neuromuscular control compared to males. The literature demonstrates an even higher risk of knee injuries in female athletes with symptoms of REDs. We propose the various factors that influence this risk. A reduction in anabolic hormones can affect muscle development and tendon repair. A relationship between poor neuromuscular control and knee injury has been established, and this can be further worsened in patients with menstrual dysfunction. Chronic deficiency in nutrients such as collagen and vitamin D can result in poorer recovery from microtrauma in tendons and ligaments. All these factors may contribute to increasing the risk of knee injuries, which may include anterior cruciate ligament tears, patella tendinopathy and patellofemoral pain syndrome. This review aims to educate sports clinicians to have a high index of suspicion when treating knee injuries in females; to screen and then manage for REDs if present, for holistic patient care.

Beyond Menstrual Dysfunction: Does Altered Endocrine Function Caused by Problematic Low Energy Availability Impair Health and Sports Performance in Female Athletes?

Low energy availability, particularly when problematic (i.e., prolonged and/or severe), has numerous negative consequences for health and sports performance as characterized in relative energy deficiency in sport. These consequences may be driven by disturbances in endocrine function, although scientific evidence clearly linking endocrine dysfunction to decreased sports performance and blunted or diminished training adaptations is limited. We describe how low energy availability-induced changes in sex hormones manifest as menstrual dysfunction and accompanying hormonal dysfunction in other endocrine axes that lead to adverse health outcomes, including negative bone health, impaired metabolic activity, undesired outcomes for body composition, altered immune response, problematic cardiovascular outcomes, iron deficiency, as well as impaired endurance performance and force production, all of which ultimately may influence athlete health and performance. Where identifiable menstrual dysfunction indicates hypothalamic-pituitary-ovarian axis dysfunction, concomitant disturbances in other hormonal axes and their impact on the athlete's health and sports performance must be recognized as well. Given that the margin between podium positions and "losing" in competitive sports can be very small, several important questions regarding low energy availability, endocrinology, and the mechanisms behind impaired training adaptations and sports performance have yet to be explored.

A literature review of biomarkers used for diagnosis of relative energy deficiency in sport

Introduction

The review aims to summarize the markers used in diagnosing relative energy deficiency in sport (REDs) and compare them with the REDs CAT2 score.

Methods

A systematic search was performed in the PubMed, Web of Science, and SPORTDiscus databases during April 2023. The descriptors used were "athlete" AND "REDs," along with respective entry terms. The selection process followed the PRISMA 2020 recommendations, identifying 593 records, from which 13 studies were ultimately selected. Seventy-nine markers were identified and categorized into six groups: bone mineral density (BMD), metabolic resting rate, blood biomarkers, anthropometrics, nutritional intake, and performance parameters. The most frequently utilized biomarkers included BMD, anthropometric parameters (e.g., body mass index, body mass, and fat mass), and the triiodothyronine (T3) concentration.

Results

According to the REDs CAT2 pointed indicators, the biomarkers varied among the studies, while 7 out of the 13 included studies achieved a ≥60% agreement rate with this tool. The prevalence of low energy availability, an etiological factor in the development of REDs, was detected in 4 out of 13 studies, with an average of 39.5%.

Conclusion

In conclusion, this review highlights the most commonly used markers in diagnosing REDs, such as BMD, anthropometric parameters, and T3 hormone concentration. Due to the current inconsistencies, standardizing diagnostic methodologies is crucial for future research. By focusing on widely used markers, this review aids future research planning and result interpretation and points out the ongoing need for methodological consistency in evolving diagnostic tools.

Systematic Review Registration

https://www.crd.york.ac.uk/, PROSPERO (CRD42022320007).

The Role of Musculoskeletal Training During Return to Performance Following Relative Energy Deficiency in Sport

BACKGROUND

Relative energy deficiency in sport (REDs) is a condition that is associated with negative health and performance outcomes in athletes. Insufficient energy intake relative to exercise energy expenditure, resulting in low energy availability, is the underlying cause, which triggers numerous adverse physiological consequences including several associated with musculoskeletal (MSK) health and neuromuscular performance.

PURPOSE

This commentary aims to (1) discuss the health and performance implications of REDs on the skeletal and neuromuscular systems and (2) examine the role that MSK training (ie, strength and plyometric training) during treatment and return to performance following REDs might have on health and performance in athletes, with practical guidelines provided.

CONCLUSIONS

REDs is associated with decreases in markers of bone health, lean body mass, maximal and explosive strength, and muscle work capacity. Restoration of optimal energy availability, mainly through an increase in energy intake, is the primary goal during the initial treatment of REDs with a return to performance managed by a multidisciplinary team of specialists. MSK training is an effective nonpharmacological component of treatment for REDs, which offers multiple long-term health and performance benefits, assuming the energy needs of athletes are met as part of their recovery. Supervised, prescribed, and gradually progressive MSK training should include a combination of resistance training and high-impact plyometric-based exercise to promote MSK adaptations, with an initial focus on achieving movement competency. Progressing MSK training exercises to higher intensities will have the greatest effects on bone health and strength performance in the long term.

Development of an LC-HRMS/MS Method for Quantifying Steroids and Thyroid Hormones in Capillary Blood: A Potential Tool for Assessing Relative Energy Deficiency in Sport (RED-S)

Relative energy deficiency in sport (RED-S) is a condition that arises from persistent low energy availability (LEA), which affects the hypothalamic-pituitary axis and results in alterations of several hormones in both male and female athletes. As frequent blood hormone status determinations using venipuncture are rare in sports practice, microsampling offers promising possibilities for preventing and assessing RED-S. Therefore, this study aimed at developing a liquid chromatography-high-resolution tandem mass spectrometry (LC-HRMS/MS) method for quantifying relevant steroids and thyroid hormones in 30 μL of capillary blood obtained using Mitra® devices with volumetric absorptive microsampling technology (VAMS®). The results of the study showed that all validation criteria were met, including a storage stability of more than 28 days in a frozen state (-18 °C) and 14 days at room temperature (20 °C). The validated assay provided precise (<12%) and accurate (<13%) results for all the target analytes. Furthermore, as a proof of concept, autonomously collected VAMS® samples from 50 female and male, healthy, active adults were analyzed. The sensitivity of all analytes was adequate to quantify the decreased hormone concentrations in the RED-S state, as all authentic samples could be measured accordingly. These findings suggest that self-collected VAMS® samples offer a practical opportunity for regular hormone measurements in athletes and can be used for early RED-S assessment and progress monitoring during RED-S recovery.

Patterns of energy availability and carbohydrate intake differentiate between adaptable and problematic low energy availability in female athletes

Background

Problematic low energy availability (EA) is the underlying culprit of relative energy deficiency in sport (REDs), and its consequences have been suggested to be exacerbated when accompanied by low carbohydrate (CHO) intakes.

Objectives

This study compared dietary intake, nutrition status and occurrence of REDs symptoms in groups of female athletes, displaying different patterns of EA and CHO intake.

Methods

Female athletes (n = 41, median age 20.4 years) from various sports weighed and recorded their food intake and training for 7 consecutive days via a photo-assisted mobile application. Participants were divided into four groups based on patterns of EA and CHO intakes: sufficient to optimal EA and sufficient to optimal CHO intake (SEA + SCHO), SEA and low CHO intake (SEA + LCHO), low energy availability and SCHO (LEA + SCHO), and LEA and LCHO (LEA + LCHO). SEA patterns were characterised by EA ≥30 and LEA by EA <30 kcal/kg fat free mass, and SCHO patterns characterised by CHO intake ≥3.0 and LCHO <3.0 g/kg body weight for most of the registered days. Body composition was measured with dual energy x-ray absorptiometry, resting metabolic rate with indirect calorimetry and serum blood samples were collected for evaluation of nutrition status. Behavioural risk factors and self-reported symptoms of REDs were assessed with the Low Energy Availability in Females Questionnaire, Eating Disorder Examination Questionnaire Short (EDE-QS), Exercise Addiction Inventory, and Muscle Dysmorphic Disorder Inventory.

Results

In total, 36.6% were categorised as SEA + SCHO, of which 5/16 were ball sport, 7/10 endurance, 1/7 aesthetic, 2/5 weight-class, and 0/3 weight-class athletes. Of LEA + LCHO athletes (19.5% of all), 50% came from ball sports. Aesthetic and endurance athletes reported the greatest training demands, with weekly training hours higher for aesthetic compared to ball sports (13.1 ± 5.7 vs. 6.7 ± 3.4 h, p = 0.012). Two LEA + LCHO and one SEA + LCHO athlete exceeded the EDE-QS cutoff. LEA + LCHO evaluated their sleep and energy levels as worse, and both LEA groups rated their recovery as worse compared to SEA + SCHO.

Conclusion

Repeated exposures to LEA and LCHO are associated with a cluster of negative implications in female athletes. In terms of nutrition strategies, sufficient EA and CHO intakes appear to be pivotal in preventing REDs.

Influence of energy availability on metabolic hormonal profiles in east African female and male distance runners

BACKGROUND

Energy availability (EA) and relative energy deficiency in sport (RED-S) are understudied in East African endurance athletes, both females (F) and males (M). This study assessed the metabolic hormonal profiles of such athletes relative to their EA status.

METHODS

Forty athletes (F=16, M=24) had their EA status, training, maximal oxygen uptake, and resting blood samples assessed using standard research practices. Subjects were stratified into two groups, high EA (HiEA) and low EA (LoEA) based on combined median value.

RESULTS

Cortisol (P=0.034) and insulin (P=0.044) were significantly elevated in the LoEA group, while growth hormone (P=0.045) was significantly suppressed; and, prolactin (P=0.078) trended towards suppression, respectively compared to the HiEA group. All other hormonal comparison were non-significant.

CONCLUSIONS

Metabolic hormonal profiles of female and male African distance runners are affected by their EA status. Aspects of these alterations agree in part with published findings based upon White populations, although some differences exist and need further investigation.

A Comprehensive Review of Bone Health in a Child: From Birth to Adulthood

Bone health is critical for growth and development during childhood. Although fractures are common in children, fractures occurring in the absence of trauma should prompt physicians to consider underlying bone health disorders. This article provides an overview of the current definition of osteoporosis in children, highlighting its limitations and the potential for underdiagnosis. It also discusses the timing of screening initiation and various techniques used to assess bone health, along with their respective benefits and limitations. In addition, this article identifies several causes of primary and secondary osteoporosis in children, shedding light on previously overlooked disorders that can contribute to poor bone quality. The article emphasizes the importance of a multidisciplinary approach to therapeutic management and aims to optimize patient outcomes and improve the overall care of pediatric bone health disorders.

Biologic therapies in stress fractures: Current concepts

Stress fractures, a common overuse injury in physically active individuals, present a significant challenge for athletes and military personnel. Patients who sustain stress fractures have demanding training regimes where periods of rest and immobilisation have unacceptable negative consequences on sports goals and finances. Aside from being an overuse injury, there are various contributing risk factors that put certain individuals at risk of a stress fracture. The main two being nutritional deficiencies and hormonal variations, which have significant effects on bone metabolism and turnover. Historically, treatment of stress fractures focused on conservative strategies such as rest and immobilisation. Calcium and vitamin D deficiencies have been closely linked to stress fractures and so over time supplementation has also played a role in treatment. With the introduction of biologics into orthopaedics, newer treatment strategies have been applied to accelerate fracture healing and perhaps improve fracture callus quality. If such therapies can reduce time spent away from sport and activity, it would be ideal for treating stress fractures. This article aims to offer insights into the evolving landscape of stress fracture management. It investigates the pre-clinical evidence and available published clinical applications. Though fracture healing is well understood, the role of biologics for fracture healing is still indeterminate. Available literature for the use of biologic therapies in stress fractures are restricted and most reports have used biologics as a supplement to surgical fixation in subjects in studies that lack control groups. Randomised control trials have been proposed and registered by a few groups, with results awaited. Assessing individuals for risk factors, addressing hormonal imbalances and nutritional deficiencies seems like an effective approach to addressing the burden of stress fractures. We await better designed trials and studies to accurately determine the clinical benefit of adding biologics to the management of these injuries.

Sex differences in energy balance, body composition, and metabolic and endocrine markers during prolonged arduous military training

This study investigated sex differences in energy balance, body composition, and metabolic and endocrine markers during prolonged military training. Twenty-three trainees (14 women) completed 44-wk military training (three terms of 14 wk with 2-wk adventurous training). Dietary intake and total energy expenditure were measured over 10 days during each term by weighed food and doubly labeled water. Body composition was measured by dual-energy X-ray absorptiometry (DXA) at baseline and at the end of each term. Circulating metabolic and endocrine markers were measured at baseline and at the end of terms 2 and 3. Absolute energy intake and total energy expenditure were higher, and energy balance was lower, for men than women (P ≤ 0.008). Absolute energy intake and balance were lower, and total energy expenditure was higher, during term 2 than terms 1 and 3 (P < 0.001). Lean mass did not change with training (P = 0.081). Fat mass and body fat increased from term 1 to terms 2 and 3 (P ≤ 0.045). Leptin increased from baseline to terms 2 and 3 in women (P ≤ 0.002) but not in men (P ≥ 0.251). Testosterone and free androgen index increased from baseline to term 3 (P ≤ 0.018). Free thyroxine (T4) decreased and thyroid-stimulating hormone (TSH) increased from baseline to term 2 and term 3 (P ≤ 0.031). Cortisol decreased from baseline to term 3 (P = 0.030). IGF-I and total triiodothyronine (T3) did not change with training (P ≥ 0.148). Men experienced greater energy deficits than women during military training due to higher total energy expenditure.NEW & NOTEWORTHY Energy deficits are common in military training and can result in endocrine and metabolic disturbances. This study provides first investigation of sex differences in energy balance, body composition, and endocrine and metabolic markers in response to prolonged and arduous military training. Men experienced greater energy deficits than women due to higher energy expenditure, which was not compensated for by increased energy intake. These energy deficits were not associated with decreases in fat or lean mass or metabolic or endocrine function.

Perspectives on Concurrent Strength and Endurance Training in Healthy Adult Females: A Systematic Review

BACKGROUND

Both strength and endurance training are included in global exercise recommendations and are the main components of training programs for competitive sports. While an abundance of research has been published regarding concurrent strength and endurance training, only a small portion of this research has been conducted in females or has addressed their unique physiological circumstances (e.g., hormonal profiles related to menstrual cycle phase, menstrual dysfunction, and hormonal contraceptive use), which may influence training responses and adaptations.

OBJECTIVE

The aim was to complete a systematic review of the scientific literature regarding training adaptations following concurrent strength and endurance training in apparently healthy adult females.

METHODS

A systematic electronic search for articles was performed in July 2021 and again in December 2022 using PubMed and Medline. This review followed, where applicable, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality of the included studies was assessed using a modified Downs and Black checklist. Inclusion criteria were (1) fully published peer-reviewed publications; (2) study published in English; (3) participants were healthy normal weight or overweight females of reproductive age (mean age between > 18 and < 50) or presented as a group (n > 5) in studies including both females and males and where female results were reported separately; (4) participants were randomly assigned to intervention groups, when warranted, and the study included measures of maximal strength and endurance performance; and (5) the duration of the intervention was ≥ 8 weeks to ensure a meaningful training duration.

RESULTS

Fourteen studies met the inclusion criteria (seven combined strength training with running, four with cycling, and three with rowing or cross-country skiing). These studies indicated that concurrent strength and endurance training generally increases parameters associated with strength and endurance performance in female participants, while several other health benefits such as, e.g., improved body composition and blood lipid profile were reported in individual studies. The presence of an "interference effect" in females could not be assessed from the included studies as this was not the focus of any included research and single-mode training groups were not always included alongside concurrent training groups. Importantly, the influence of concurrent training on fast-force production was limited, while the unique circumstances affecting females were not considered/reported in most studies. Overall study quality was low to moderate.

CONCLUSION

Concurrent strength and endurance training appears to be beneficial in increasing strength and endurance capacity in females; however, multiple research paradigms must be explored to better understand the influence of concurrent training modalities in females. Future research should explore the influence of concurrent strength and endurance training on fast-force production, the possible presence of an "interference effect" in athletic populations, and the influence of unique circumstances, such as hormone profile, on training responses and adaptations.

Association between Low Energy Availability (LEA) and Impaired Sleep Quality in Young Rugby Players

Low energy availability (LEA) has been associated with several physiological consequences, but its impact on sleep has not been sufficiently investigated, especially in the context of young athletes. This study examined the potential association between energy availability (EA) status and objective sleep quality in 42 male rugby players (mean age: 16.2 ± 0.8 years) during a 7-day follow-up with fixed sleep schedules in the midst of an intensive training phase. Participants' energy intake was weighed and recorded. Exercise expenditure was estimated using accelerometry. Portable polysomnography devices captured sleep on the last night of the follow-up. Mean EA was 29.3 ± 9.14 kcal·kg FFM-1·day-1, with 47.6% of athletes presenting LEA, 35.7% Reduced Energy Availability (REA), and 16.7% Optimal Energy Availability (OEA). Lower sleep efficiency (SE) and N3 stage proportion, along with higher wake after sleep onset (WASO), were found in participants with LEA compared to those with OEA (p = 0.04, p = 0.03 and p = 0.005, respectively, with large effect sizes). Segmented regression models of the EA-sleep outcomes (SE, sleep onset latency [SOL]), WASO and N3) relationships displayed two separate linear regions and produced a best fit with a breakpoint between 21-33 kcal·kg FFM-1·day-1. Below these thresholds, sleep quality declines considerably. It is imperative for athletic administrators, nutritionists, and coaches to conscientiously consider the potential impact of LEA on young athletes' sleep, especially during periods of heavy training.

Hormonal contraception for female athletes presents special needs and concerns

PURPOSE

Oral contraceptives (OCs) are commonly used by female athletes raising concerns regarding the possible adverse effects of OCs on physical performance, musculoskeletal injuries, and bone density. We aimed to review all current studies on the physiological effects of OCs in physically active women.

MATERIALS AND METHODS

A review of literature in electronic search in PubMed and Google Scholar databases from December 2002 to December 2022 using relevant keywords. The reference lists of the articles found eligible were also reviewed.

RESULTS

Out of 344 articles in the initial database, 54 clinical studies were eligible for inclusion in our literature review. OCs are used by about two-thirds of female athletes. Current research suggests that OCs' effects on endurance performance and muscle strength are mostly reassuring. OCs do not seem to have a major negative impact on bone health or sports injuries. In fact, new data suggests that they may even significantly reduce the risk of anterior cruciate ligament (ACL) injury.

CONCLUSIONS

OCs can be safely used by young female athletes, who may also benefit from better menstrual cycle control. OCs offer newly realised protection from ACL injuries. The use of OCs must be carefully individualised according to their preferences, expectations, and experience.

Direct and indirect impact of low energy availability on sports performance

Low energy availability (LEA) occurs inadvertently and purposefully in many athletes across numerous sports; and well planned, supervised periods with moderate LEA can improve body composition and power to weight ratio possibly enhancing performance in some sports. LEA however has the potential to have negative effects on a multitude of physiological and psychological systems in female and male athletes. Systems such as the endocrine, cardiovascular, metabolism, reproductive, immune, mental perception, and motivation as well as behaviors can all be impacted by severe (serious and/or prolonged or chronic) LEA. Such widely diverse effects can influence the health status, training adaptation, and performance outcomes of athletes leading to both direct changes (e.g., decreased strength and endurance) as well as indirect changes (e.g., reduced training response, increased risk of injury) in performance. To date, performance implications have not been well examined relative to LEA. Therefore, the intent of this narrative review is to characterize the effects of short-, medium-, and long-term exposure to LEA on direct and indirect sports performance outcomes. In doing so we have focused both on laboratory settings as well as descriptive athletic case-study-type experiential evidence.

Dietary Intake and Menstrual Health among Acrobatics and Tumbling NCAA Division I Student-Athletes

OBJECTIVE

Acrobatics & Tumbling (A&T) is an emerging sport in the National Collegiate Athletic Association that lacks research regarding the dietary intake and health of A&T student-athletes (A&Tsa). This study assessed the dietary intake adequacy, estimated energy availability (EA), self-reported menstrual health, and body composition of A&Tsa.

METHODS

Twenty-four female A&Tsa participated during week 8 of the preseason (11 top: Age= 20.1 ± 0.9 years; BMI= 22.1 ± 1.7 kg/m2; 13 base: Age= 19.5 ± 1.3 years; BMI= 26.2 ± 2.7 kg/m2). Total energy intake (TEI) and macronutrient intakes were assessed via a paper-based 3-day dietary recall. Resting Metabolic Rate [RMR = 500 + 22 * fat-free mass (FFM)] and energy availability [EA = (TEI - exercise energy expenditure)/FFM)] were estimated; and LEAF-Q assessed menstrual health. Body composition was measured using Dual-Energy X-Ray Absorptiometry. Macronutrient intakes and EA were compared to sports nutrition recommendations (carbohydrate: 6-10 g/kg; protein: 1.2-2.0 g/kg) and the Acceptable Macronutrient Distribution Range (carbohydrate: 45-65%; protein: 10-35%; fat: 20-35%).

RESULTS

TEI was 1753 ± 467 kcal (top) and 1980 ± 473.8 kcal (base). A total of 20.8% of A&Tsa failed to meet RMR with TEI, with a higher prevalence in the top (-266 ± 219.2 kcal, n = 3) vs. base (-414.3 ± 534.4 kcal, n = 2) A&Tsa. Top and base A&Tsa had both low EA (28.8 ± 13.4 kcals·FFM-1; 23.8 ± 9.5 kcals·FFM-1) and inadequate carbohydrate intake averages (4.2 ± 1.3 g/kg; 3.5 ± 1.1 g/kg, p < 0.001), respectively. A total of 17% of A&Tsa reported secondary amenorrhea, with a higher prevalence in the top (27.3%, n = 3) vs. the base (7.7%, n = 1).

CONCLUSION

TEI and carbohydrate intake of the majority of A&Tsa were below recommendations. Sports dietitians should encourage and educate A&Tsa about following an adequate diet that meets energy and sports-specific macronutrient needs.

Effects of fat loss and low energy availability on the serum cardiometabolic profile of physique athletes

Low energy availability (LEA) is a health concern for athletes, although it may paradoxically lead to improved cardiometabolic health in the general population. We investigated the associations between LEA, body composition, and serum cardiometabolic profile in 23 physique athletes (DIET) and 21 controls (CONT) during a 5-month pre-competition diet (MID), followed by 1 week of increased energy availability (COMP) and a 5-month weight regain period (POST). Quantification of 250 serum metabolome variables was conducted by NMR spectroscopy, body composition by dual-energy x-ray absorptiometry, dietary intake by food diaries, and exercise levels by training logs. Body fat percentage decreased from 19.5 ± 7.0% to 8.3 ± 5.3% (p < 0.001) in DIET through increased exercise levels and decreased energy intake, while CONT maintained those constant. In MID, DIET had increased (FDR < 0.01) HDL cholesterol, HDL particle size and number, and decreased (FDR < 0.05) VLDL lipids, serum triglycerides, and low-grade inflammation (glycoprotein acetyls) compared to baseline and CONT. The changes were associated with reduced android fat mass (-78 ± 13%) and energy intake (-28 ± 10%). In COMP, most of the metabolic changes found in MID persisted, except for altered triglycerides in all lipoprotein classes. After weight regain in POST, serum metabolome, body composition, energy intake, and exercise levels had reverted to baseline levels. In conclusion, fat loss and LEA may have beneficial yet transient effects on the serum cardiometabolic profile of lean individuals. Especially the HDL lipidome and lipoprotein triglycerides offer potential novel biomarkers for detecting LEA in athletes.

Nutritional intake and anthropometric characteristics are associated with endurance performance and markers of low energy availability in young female cross-country skiers

BACKGROUND

Low energy availability (LEA) can have negative performance consequences, but the relationships between LEA and performance are poorly understood especially in field conditions. In addition, little is known about the contribution of macronutrients to long-term performance. Therefore, the aim of this study was to evaluate if energy availability (EA) and macronutrient intake in a field-based situation were associated with laboratory-measured performance, anthropometric characteristics, blood markers, training volume, and/or questionnaire-assessed risk of LEA in young female cross-country (XC) skiers. In addition, the study aimed to clarify which factors explained performance.

METHODS

During a one-year observational study, 23 highly trained female XC skiers and biathletes (age 17.1 ± 1.0 years) completed 3-day food and training logs on four occasions (September-October, February-March, April-May, July-August). Mean (±SD) EA and macronutrient intake from these 12 days were calculated to describe yearly overall practices. Laboratory measurements (body composition with bioimpedance, blood hormone concentrations, maximal oxygen uptake (VO_2max), oxygen uptake (VO₂) at 4 mmol·L^-1 lactate threshold (OBLA), double poling (DP) performance (time to exhaustion), counter movement jump (height) and the Low Energy Availability in Females Questionnaire (LEAF-Q)) were completed at the beginning (August 2020, M₁) and end of the study (August 2021, M₂). Annual training volume between measurements was recorded using an online training diary.

RESULTS

The 12-day mean EA (37.4 ± 9.1 kcal·kg FFM^-1·d^-1) and carbohydrate (CHO) intake (4.8 ± 0.8 g·kg^-1·d^-1) were suboptimal while intake of protein (1.8 ± 0.3 g·kg^-1·d^-1) and fat (31 ± 4 E%) were within recommended ranges. Lower EA and CHO intake were associated with a higher LEAF-Q score (r  = 0.44, p  = 0.042; r  = 0.47, p  = 0.026). Higher CHO and protein intake were associated with higher VO_2max (r  = 0.61, p  = 0.005; r  = 0.54, p  = 0.014), VO₂ at OBLA (r  = 0.63, p  = 0.003; r  = 0.62, p  = 0.003), and DP performance at M₂ (r  = 0.42, p  = 0.051; r  = 0.44, p  = 0.039). Body fat percentage (F%) was negatively associated with CHO and protein intake (r = -0.50, p  = 0.017; r = -0.66, p  = 0.001). Better DP performance at M₂ was explained by higher training volume (R²  = 0.24, p  = 0.033) and higher relative VO_2max and VO₂ at OBLA at M₂ by lower F% (R²  = 0.44, p  = 0.004; R²  = 0.47, p  = 0.003). Increase from M₁ to M₂ in DP performance was explained by a decrease in F% (R²  = 0.25, p  = 0.029).

CONCLUSIONS

F%, and training volume were the most important factors explaining performance in young female XC skiers. Notably, lower F% was associated with higher macronutrient intake, suggesting that restricting nutritional intake may not be a good strategy to modify body composition in young female athletes. In addition, lower overall CHO intake and EA increased risk of LEA determined by LEAF-Q. These findings highlight the importance of adequate nutritional intake to support performance and overall health.

Signs of low energy availability in elite male volleyball athletes but no association with risk of bone stress injury and patellar tendinopathy

Relative Energy Deficiency in Sport (RED-S) syndrome is associated with undesirable health and performance outcomes. The aetiology of RED-S syndrome is low energy availability (LEA). LEA has been reported in male athletes in various sports, but there is little information in team sports. Therefore, the aims of this study were to assess the point-prevalence of surrogate markers of LEA in elite male volleyball players and examine the association between low and normal total-testosterone (TES) on endocrine markers, resting metabolic rate, bone mineral density (BMD), and history of injury/illness. Using a cross-sectional design, 22 elite male volleyball players underwent anthropometric, dual-energy X-ray absorptiometry (DEXA or DXA) and resting metabolic rate testing, bloodwork, dietary analysis, the three-factor eating questionnaire-R18, injury/illness questionnaire and Victorian Institute of Sport Assessment - patellar tendon questionnaire. The primary finding of this investigation was that 36% of athletes had ≥2 surrogate markers of LEA. Although fasted insulin was lower and cortisol was higher in players with low-total TES, low BMD, low RMR and various other endocrine markers linked to LEA were not observed. More research is required to define surrogate markers of LEA in male athletes.HIGHLIGHTS Thirty-six percent of volleyball players had ≥2 surrogate markers of LEA.The Cunningham, 1991 predictive RMR equation and/or the cut-off point (<0.9) may be unsuitable for detecting energy conservation associated with LEA in large male athletes.There was no association between total-TES and risk of bone stress injury, illness and patellar tendinopathy.

Male Runners With Lower Energy Availability Have Impaired Skeletal Integrity Compared to Nonathletes

CONTEXT

Female athletes, particularly runners, with insufficient caloric intake for their energy expenditure [low energy availability (EA) or relative energy deficiency] are at risk for impaired skeletal integrity. Data are lacking in male runners.

OBJECTIVE

To determine whether male runners at risk for energy deficit have impaired bone mineral density (BMD), microarchitecture, and estimated strength.

DESIGN

Cross-sectional.

SETTING

Clinical research center.

PARTICIPANTS

39 men (20 runners, 19 controls), ages 16-30 years.

MAIN OUTCOME MEASURES

Areal BMD (dual-energy x-ray absorptiometry); tibia and radius volumetric BMD and microarchitecture (high-resolution peripheral quantitative computed tomography); failure load (microfinite element analysis); serum testosterone, estradiol, leptin; energy availability.

RESULTS

Mean age (24.5 ± 3.8 y), lean mass, testosterone, and estradiol levels were similar; body mass index, percent fat mass, leptin, and lumbar spine BMD Z-score (-1.4 ± 0.8 vs -0.8 ± 0.8) lower (P < .05); and calcium intake and running mileage higher (P ≤ .01) in runners vs controls. Runners with EA

CONCLUSIONS

Despite weight-bearing activity, skeletal integrity is impaired in male runners with lower caloric intake relative to exercise energy expenditure, which may increase bone stress injury risk. Lower estradiol and lean mass are associated with lower tibial strength in runners.

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Key Words

• HR-pQCT
• athletes
• bone density
• energy availability

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MESH Headings

• Humans
• Male
• Female
• Leptin
• Cross-Sectional Studies
• Calcium
• Bone Density
• Absorptiometry, Photon
• Lumbar Vertebrae
• Testosterone
• Estradiol

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Grants

• K23 DK115903 NIDDK NIH HHS
• K24 HD071843 NICHD NIH HHS
• 1UL1TR002541-01 NIH HHS
• K24 HL092902 NHLBI NIH HHS
• Massachusetts General Hospital Executive Committee on Research
• National Institutes of Health
• Department of Defense Research Participation Program
• U.S. Army Research Institute of Environmental Medicine
• Oak Ridge Institute for Science and Education

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Affiliation(s)

Melanie S Haines Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA Harvard Medical School, Boston, MA 02115, USA
Snimarjot Kaur Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA Harvard Medical School, Boston, MA 02115, USA
Geetanjali Scarff Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
Meghan Lauze Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
Anu Gerweck Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
Meghan Slattery Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
Nicolas M Oreskovic Harvard Medical School, Boston, MA 02115, USA Department of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA 02114, USA
Kathryn E Ackerman Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA Harvard Medical School, Boston, MA 02115, USA Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Boston, MA 02115, USA
Adam S Tenforde Harvard Medical School, Boston, MA 02115, USA Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Cambridge, MA 02129, USA
Kristin L Popp Harvard Medical School, Boston, MA 02115, USA Endocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, USA Department of Energy, Oak Ridge Institute for Science and Education, Oak Ridge, TN 37830, USA
Mary L Bouxsein Harvard Medical School, Boston, MA 02115, USA Endocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA
Karen K Miller Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA Harvard Medical School, Boston, MA 02115, USA
Madhusmita Misra Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA Harvard Medical School, Boston, MA 02115, USA Division of Pediatric Endocrinology, Massachusetts General Hospital, Boston, MA 02114, USA

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Review of the scientific rationale, development and validation of the International Olympic Committee Relative Energy Deficiency in Sport Clinical Assessment Tool: V.2 (IOC REDs CAT2)-by a subgroup of the IOC consensus on REDs

Relative Energy Deficiency in Sport (REDs) has various different risk factors, numerous signs and symptoms and is heavily influenced by one's environment. Accordingly, there is no singular validated diagnostic test. This 2023 International Olympic Committee's REDs Clinical Assessment Tool-V.2 (IOC REDs CAT2) implements a three-step process of: (1) initial screening; (2) severity/risk stratification based on any identified REDs signs/symptoms (primary and secondary indicators) and (3) a physician-led final diagnosis and treatment plan developed with the athlete, coach and their entire health and performance team. The CAT2 also introduces a more clinically nuanced four-level traffic-light (green, yellow, orange and red) severity/risk stratification with associated sport participation guidelines. Various REDs primary and secondary indicators have been identified and 'weighted' in terms of scientific support, clinical severity/risk and methodological validity and usability, allowing for objective scoring of athletes based on the presence or absence of each indicator. Early draft versions of the CAT2 were developed with associated athlete-testing, feedback and refinement, followed by REDs expert validation via voting statements (ie, online questionnaire to assess agreement on each indicator). Physician and practitioner validity and usability assessments were also implemented. The aim of the IOC REDs CAT2 is to assist qualified clinical professionals in the early and accurate diagnosis of REDs, with an appropriate clinical severity and risk assessment, in order to protect athlete health and prevent prolonged and irreversible outcomes of REDs.

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.

Primary, secondary and tertiary prevention of Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the IOC consensus on REDs

Relative Energy Deficiency in Sport (REDs) is common among female and male athletes representing various sports at different performance levels, and the underlying cause is problematic low energy availability (LEA). It is essential to prevent problematic LEA to decrease the risk of serious health and performance consequences. This narrative review addresses REDs primary, secondary and tertiary prevention strategies and recommends best practice prevention guidelines targeting the athlete health and performance team, athlete entourage (eg, coaches, parents, managers) and sport organisations. Primary prevention of REDs seeks to minimise exposure to and reduce behaviours associated with problematic LEA. Some of the important strategies are educational initiatives and de-emphasising body weight and leanness, particularly in young and subelite athletes. Secondary prevention encourages the early identification and management of REDs signs or symptoms to facilitate early treatment to prevent development of more serious REDs outcomes. Recommended strategies for identifying athletes at risk are self-reported screening instruments, individual health interviews and/or objective assessment of REDs markers. Tertiary prevention (clinical treatment) seeks to limit short-term and long-term severe health consequences of REDs. The cornerstone of tertiary prevention is identifying the source of and treating problematic LEA. Best practice guidelines to prevent REDs and related consequences include a multipronged approach targeting the athlete health and performance team, the athlete entourage and sport organisations, who all need to ensure a supportive and safe sporting environment, have sufficient REDs knowledge and remain observant for the early signs and symptoms of REDs.

One Season in Professional Cycling Is Enough to Negatively Affect Bone Health

Cycling is a very popular sport worldwide, and several studies have already indicated that cycling at various levels has a negative impact on bone health. This is of concern to both performance and health managers of many cycling teams at different levels because of its economic and social impact. Based on the scientific literature, we hypothesize that a single season at the professional level can negatively affect bone health status. The aim of this study was to assess how professional cycling affects bone health markers after one season. Densitometry was used to measure the bone mineral density (BMD), bone mineral content (BMC), bone area (BA), fat mass (FM), fat-free mass (FFM), T-score and Z-score in professional cyclists after one season. After one season at the professional level, cyclists' BMD decreased significantly in the legs, trunk, ribs and pelvis (p ≤ 0.05). BMC decreased in the arms and spine (p ≤ 0.05). BA decreased significantly in the arms and spine (p ≤ 0.05). In addition, a significant decrease in Z-score (p ≤ 0.05) and a decreasing trend in T-score and total BMD (p = 0.06) were observed. One season of professional cycling is enough to negatively affect bone health status.

Factors Influencing Nutritional Intake and Interests in Educational Content of Athletes and Sport Professionals Toward the Development of a Clinician-Supported Mobile App to Combat Relative Energy Deficiency in Sport: Formative Research and a Description of App Functions

BACKGROUND

Relative energy deficiency in sport (RED-S) as a consequence of athlete malnutrition remains a prominent issue. However, it remains underrecognized, in part due to the perceived outward health of athletes. The Eat2Win app was designed to combat RED-S and athlete malnutrition by providing education, behavior modification, and direct communication with expert sports dietitians to athletes and sport professionals (professionals who work with athletes, eg, sport coaches and athletic trainers).

OBJECTIVE

The purpose of this formative research was to gain critical insight on motivators and barriers to optimal nutritional intake from both the athletes' and sport professionals' perspectives. Additionally, since these 2 groups represent the primary end users of an app aimed at improving athlete nutrition and reducing the risk of RED-S, a secondary objective was to gain insight on the preferences and perceptions of app-based educational content and functionality.

METHODS

An electronic survey was developed by an interdisciplinary team of experts. Survey questions were established based upon prevailing literature, professional dietetic field experience, and app design considerations to obtain respondent knowledge on key sports nutrition topics along with motivations and barriers to meal choices. Additionally, the survey included questions about the development of an integrative, clinician-support app aimed at addressing RED-S. These questions included preferences for educational content, modes of in-app information, and communication delivery for the target population (app end users: athletes and sport professionals). The survey was distributed through Research Electronic Data Capture (REDCap) to athletes and sport professionals using targeted email, social media, and community engagement campaigns. The electronic survey was available from May 4 to August 2, 2022.

RESULTS

Survey respondents (n=1352) included athletes and professionals who work with athletes from a variety of settings, like high school, collegiate, professional, and club sports. Respondents reported high interest in 8 core sports nutrition topics. The preferred modes of information and communication delivery were visual formats (eg, videos and infographics) and in-app alerts (eg, direct messaging and meal reminders). Only athlete respondents were asked about motivators and barriers that influence meal choices. "Health" and "sports performance" were the highest scoring motivators, while the highest scoring barriers were "cost of food," "easy access to unhealthy food," and "time to cook or prepare food." Notably, survey respondents provided positive feedback and interest using a novel function of the app: real-time meal feedback through food photography.

CONCLUSIONS

The Eat2Win app is designed to combat RED-S and athlete malnutrition. Results from this study provide critical information on end-user opinions and preferences and will be used to further develop the Eat2Win app. Future research will aim to determine whether the Eat2Win app can prevent RED-S and the risk of athlete malnutrition to improve both health and performance.

Carbohydrate intake in young female cross-country skiers is lower than recommended and affects competition performance

Purpose

(1) To evaluate if energy availability (EA), macronutrient intake and body composition change over four training periods in young, highly trained, female cross-country skiers, and (2) to clarify if EA, macronutrient intake, body composition, and competition performance are associated with each other in this cohort.

Methods

During a one-year observational study, 25 female skiers completed 3-day food and training logs during four training periods: preparation, specific preparation, competition, and transition periods. A body composition measurement (bioimpedance analyzer) was performed at the end of the preparation, specific preparation, and competition periods. Competition performance was determined by International Ski Federation (FIS) points gathered from youth national championships.

Results

EA (36-40 kcal·kg FFM^-1·d^-1) and carbohydrate (CHO) intake (4.4-5.1 g·kg^-1·d^-1) remained similar, and at a suboptimal level, between training periods despite a decrease in exercise energy expenditure (p = 0.002) in the transition period. Higher EA (r = -0.47, p = 0.035) and CHO intake (r = -0.65, p = 0.002) as well as lower FM (r = 0.60, p = 0.006) and F% (r = 0.57, p = 0.011) were associated with lower (better) FIS-points. CHO intake was the best predictor of distance competition performance (R² = 0.46, p = 0.004).

Conclusions

Young female cross-country skiers had similar EA and CHO intake over four training periods. Both EA and CHO intake were at suboptimal levels for performance and recovery. CHO intake and body composition are important factors influencing competition performance in young female cross-country skiers.

Evaluating the Suitability of the Low Energy Availability in Females Questionnaire (LEAF-Q) for Female Football Players

BACKGROUND

The Low Energy Availability in Females Questionnaire (LEAF-Q) is a screening tool developed to detect endurance athletes and dancers at risk for development of persistent low energy availability (LEA) and the female athlete triad (Triad). This study investigated the applicability of the LEAF-Q in a cohort of sixty professional female football players.

METHODS

The participants were classified as at risk (≥ 8) or not at risk (< 8) for persistent LEA and the Triad according to their LEAF-Q score, before being compared. Receiver operating curves were then conducted to examine the ability of the overall LEAF-Q and subcategories to correctly determine the presence of clinically defined markers of the Triad. Additionally, Youden's index was calculated to determine the best fitting cut-off values.

RESULTS

Thirty-two percent of participants were classified as at risk by the LEAF-Q. We found no statistically significant differences between the two groups for any markers associated with persistent LEA. Except for acceptable accuracy in determining menstrual status, all other LEAF-Q components exhibited poor accuracy and predictive values. Youden's index scores imply that increasing the overall and injury cut-off values to ≥ 10 and ≥ 5 respectively, would yield increased performance.

CONCLUSIONS

Our findings do not support the use of the LEAF-Q for the purpose of detecting LEA and Triad conditions among female football players.

Recognition of Nonneoplastic Hypercortisolism in the Evaluation of Patients With Cushing Syndrome

The evaluation of suspected hypercortisolism is one of the most challenging problems in medicine. The signs and symptoms described by Dr Harvey Cushing are common and often create diagnostic confusion to even experienced endocrinologists. Cushing syndrome is classically defined as neoplastic hypercortisolism resulting from an ACTH-secreting tumor or from autonomous secretion of excess cortisol associated with benign or malignant adrenal neoplasia. The increasing recognition of the negative cardiometabolic effects of mild cortisol excess without overt physical signs of Cushing syndrome has led to more screening for endogenous hypercortisolism in patients with adrenal nodular disease, osteoporosis, and the metabolic syndrome. However, sustained or intermittent activation of the dynamic hypothalamic-pituitary-adrenal axis caused by chemical (alcohol), inflammatory (chronic kidney disease), psychologic (major depression), and physical (starvation/chronic intense exercise) stimuli can result in clinical and/or biochemical features indistinguishable from neoplastic hypercortisolism. Nonneoplastic hypercortisolism (formerly known as pseudo-Cushing syndrome) has been recognized for more than 50 years and often causes diagnostic uncertainty. This expert consultation describes two patients with features of Cushing syndrome who were referred for inferior petrosal sinus sampling for the differential diagnosis of ACTH-dependent hypercortisolism. Both patients were discovered to have nonneoplastic hypercortisolism: one from a covert alcohol use disorder and the other to chronic kidney disease. This consultation emphasizes the value of a good history and physical examination, appropriate laboratory testing, and the desmopressin acetate stimulation test to aid in distinguishing neoplastic from nonneoplastic hypercortisolism.

Menstrual Function, Eating Disorders, Low Energy Availability, and Musculoskeletal Injuries in British Servicewomen

PURPOSE

This study aimed to investigate associations between menstrual function, eating disorders, and risk of low energy availability with musculoskeletal injuries in British servicewomen.

METHODS

All women younger than 45 yr in the UK Armed Forces were invited to complete a survey about menstrual function, eating behaviors, exercise behaviors, and injury history.

RESULTS

A total of 3022 women participated; 2% had a bone stress injury in the last 12 months, 20% had ever had a bone stress injury, 40% had a time-loss musculoskeletal injury in the last 12 months, and 11% were medically downgraded for a musculoskeletal injury. Menstrual disturbances (oligomenorrhea/amenorrhea, history of amenorrhea, and delayed menarche) were not associated with injury. Women at high risk of disordered eating (Female Athlete Screening Tool score >94) were at higher risk of history of a bone stress injury (odds ratio (OR; 95% confidence interval (CI)), 2.29 (1.67-3.14); P < 0.001) and time-loss injury in the last 12 months (OR (95% CI), 1.56 (1.21-2.03); P < 0.001) than women at low risk of disordered eating. Women at high risk of low energy availability (Low Energy Availability in Females Questionnaire score ≥8) were at higher risk of bone stress injury in the last 12 months (OR (95% CI), 3.62 (2.07-6.49); P < 0.001), history of a bone stress injury (OR (95% CI), 2.08 (1.66-2.59); P < 0.001), a time-loss injury in the last 12 months (OR (95% CI), 9.69 (7.90-11.9); P < 0.001), and being medically downgraded with an injury (OR (95% CI), 3.78 (2.84-5.04); P < 0.001) than women at low risk of low energy availability.

CONCLUSIONS

Eating disorders and risk of low energy availability provide targets for protecting against musculoskeletal injuries in servicewomen.

New perspectives in functional hypogonadotropic hypogonadism: beyond late onset hypogonadism

Functional hypogonadotropic hypogonadism (FHH) is an increasingly frequent condition, whose pathological mechanisms are not yet fully clarified. The concept of FHH has now completely replaced that of late onset hypogonadism, that only concerned the ageing man. FHH is the result of an impairment of the hypothalamic-pituitary gonadal axis (HPG-A) function, resulting in decreased testosterone concentrations associated with low or inappropriately normal gonadotropin levels and infertility; it can be diagnosed once organic causes of hypogonadism are excluded. The growing occurrence of FHH derives from its association with widespread conditions, such as obesity and diabetes mellitus, but also to the increasing ease and frequency of use of several drugs, such as opioids, glucocorticoids, and sex steroids. Moreover, given the tendency of many subjects to excessive physical activity and drastic reduction in caloric intake, FHH may also be secondary to low energy availability. Finally, the association with HIV infection should not be overlooked. Therefore, there is an important variability in the diseases that can lead to FHH. Despite the heterogeneity of the underlying pathologies, the mechanisms leading to FHH would seem quite similar, with the initial event represented by the impairment at the HPG-A level. Nevertheless, many different biological pathways are involved in the pathogenesis of FHH, therefore the aim of the current paper is to provide an overview of the main relevant mechanisms, through a detailed analysis of the literature, focusing specifically on pathogenesis and clinical, diagnostic and therapeutic aspects.

Alterations in Measures of Body Composition, Neuromuscular Performance, Hormonal Levels, Physiological Adaptations, and Psychometric Outcomes during Preparation for Physique Competition: A Systematic Review of Case Studies

The present paper aimed to systematically review case studies on physique athletes to evaluate longitudinal changes in measures of body composition, neuromuscular performance, chronic hormonal levels, physiological adaptations, and psychometric outcomes during pre-contest preparation. We included studies that (1) were classified as case studies involving physique athletes during the pre-contest phase of their competitive cycle; (2) involved adults (18+ years of age) as participants; (3) were published in an English-language peer-reviewed journal; (4) had a pre-contest duration of at least 3 months; (5) reported changes across contest preparation relating to measures of body composition (fat mass, lean mass, and bone mineral density), neuromuscular performance (strength and power), chronic hormonal levels (testosterone, estrogen, cortisol, leptin, and ghrelin), physiological adaptations (maximal aerobic capacity, resting energy expenditure, heart rate, blood pressure, menstrual function, and sleep quality), and/or psychometric outcomes (mood states and food desire). Our review ultimately included 11 case studies comprising 15 ostensibly drug-free athletes (male = 8, female = 7) who competed in various physique-oriented divisions including bodybuilding, figure, and bikini. The results indicated marked alterations across the array of analyzed outcomes, sometimes with high inter-individual variability and divergent sex-specific responses. The complexities and implications of these findings are discussed herein.

Oral Contraceptives and Female Rowers' Skeletal Health

ABSTRACT

Redinger, AL and Baker, BS. Oral contraceptives and female rowers' skeletal health. J Strength Cond Res 37(3): 669-677, 2023-Previous studies suggest that women using oral contraceptives (OC) experience fewer skeletal benefits from exercise compared with non-OC users. These findings may be especially important for athletes competing in weight-supported sports with a high prevalence of low bone mineral density and fracture, such as rowing. The purpose of this study was to examine skeletal health and bone injuries in collegiate female rowers. Forty-nine National Collegiate Athletic Association Division I female rowers completed general health, menstrual history, and bone physical activity questionnaire (BPAQ) surveys. Dual-energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT) scans were used to assess bone content, density, and geometry. Contraceptive (OC users n = 14, non-OC users n = 35) and self-reported stress fracture (SFx n = 11, None n = 38) groups were analyzed using analysis of covariance and independent t -tests. Additionally, effect sizes ( d ) were calculated and significance was set at p ≤ 0.05. Oral contraceptive users had reduced lumbar spine areal bone mineral density after adjustment for Total BPAQ ( d = 0.58; p = 0.041) compared with non-OC users, but all other total body and site-specific DXA measures of bone mineral content and density were similar between contraceptive and injury groups. When comparing bone geometry of the 4, 38, and 66% tibiae using pQCT, no significant differences were found after adjustment for either contraceptive or injury group (all p > 0.060). Our findings suggest that OC usage was not associated with reduced skeletal health in competitive female rowers as evidenced by all Z-scores being above -2.0 and similar bone indices of mineralized content, density, geometry, and estimated strength between the groups.

Measurement of Energy Intake Using the Principle of Energy Balance Overcomes a Critical Limitation in the Assessment of Energy Availability

Prolonged low energy availability, which is the underpinning aetiology of the Relative Energy Deficiency in Sport and the Female and Male Athlete Triad frameworks, can have unfavourable impacts on both health and performance in athletes. Energy availability is calculated as energy intake minus exercise energy expenditure, expressed relative to fat free mass. The current measurement of energy intake is recognized as a major limitation for assessing energy availability due to its reliance on self-report methods, in addition to its short-term nature. This article introduces the application of the energy balance method for the measurement of energy intake, within the context of energy availability. The energy balance method requires quantification of the change in body energy stores over time, with concurrent measurement of total energy expenditure. This provides an objective calculation of energy intake, which can then be used for the assessment of energy availability. This approach, the Energy Availability - Energy Balance (EA_EB) method, increases the reliance on objective measurements, provides an indication of energy availability status over longer periods and removes athlete burden to self-report energy intake. Implementation of the EA_EB method could be used to objectively identify and detect low energy availability, with implications for the diagnosis and management of Relative Energy Deficiency in Sport and the Female and Male Athlete Triad.

A Scoping Review of Transgender Policies in the 15 Most Commonly Played UK Professional Sports

INTRODUCTION

There has been much debate recently on the participation of transgender and gender-diverse (TGD) athletes in sport, particularly in relation to fairness, safety and inclusion. The 2021 IOC Framework on Fairness, Inclusion and Non-discrimination acknowledges the central role that eligibility criteria play in ensuring fairness, particularly in the female category, and states that athletes should not be excluded solely on the basis of their TGD identity.

AIMS

To identify policies that address TGD athlete participation in the 15 major United Kingdom (UK) sporting organisations and to summarise the evidence for each of these policies.

METHODS

A scoping review of TGD policies from the 15 major UK sporting organisations.

RESULTS

Eleven of the governing bodies had publicly available TGD policies. Most of the sporting associations drew guidance from the official 2015 IOC Consensus Meeting on Sex Reassignment and Hyperandrogenism, particularly with regard to physiological testosterone levels. Many organisations referenced their policies as a guide for decision making but stated that they ultimately made case-by-case decisions on an athlete's eligibility. Relevant considerations not addressed in most policies included pre- versus post-pubertal athletes, justification for testosterone thresholds, the length of time out of competitive action (if any) for transitioning athletes, the irreversible advantage from male puberty (if any), the responsibility for and frequency of follow up for hormonal testing and the consequences for athletes outside set testosterone limits.

CONCLUSIONS

There is a lack of consensus among the top 15 UK sporting organizations relating to elite sport participation for TGD athletes. It would be useful for sport organizations to work together to develop greater standardization/consensus for TGD athlete policies, taking into consideration fairness, safety and inclusion in each sport.

Urinary Incontinence in Elite Female Athletes

PURPOSE OF REVIEW

To summarize the current understanding on the epidemiology, pathophysiology, and management strategies of urinary incontinence (UI) in female athletes, highlighting findings specific to nulliparous elite athletes.

RECENT FINDINGS

UI occurs in about 20-50% of female athletes of all ages and parity status, around 40% for younger nulliparous athletes, and is more prevalent in high-impact sports. Possible contributing factors to UI in female elite athletes include pelvic floor laxity and bladder neck descent, pelvic floor muscle fatigue, low energy availability, and hypermobility syndrome. In female elite athletes, urinary symptoms negatively affect quality of life, although the effects of symptoms on exercise participation are not well understood. Current management strategies are primarily conservative and centered on behavioral modifications and pelvic floor muscle physiotherapy. UI in female elite athletes appears to be multifactorial. Clarifying how individual factors influence UI in this population will inform athlete counseling, prevention, and treatment strategies.

The Low Energy Availability in Females Questionnaire (LEAF-Q) as a Useful Tool to Identify Female Triathletes at Risk for Menstrual Disorders Related to Low Energy Availability

BACKGROUND

Nutrition in sport is a priority; it is the basis for maintaining optimal health and a prerequisite for the high performance necessary for competitions. The aim of this study was to assess low energy availability and its possible consequences among female triathletes by using the Low Energy Availability in Females Questionnaire (LEAF-Q).

METHODS

The study involved 30 female triathetes. The LEAF-Q was used in the study. An analysis of the body composition was carried out with the seca device mBCA 515 medical Body Composition Analyzer.

RESULTS

Of the 30 female triathletes studied, 23.3% had a monthly cycle disorder, defined as an amenorrhea state for more than 90 days. No differences were found in injury rates or training days lost to injury due to menstrual disturbances. Menstruation changes were significantly greater due to increases in exercise intensity, frequency, and duration in the group experiencing menstrual disturbances (85.7 [95% CIs: 42.1-99.6] vs. 8.7 [95% CIs: 1.1-28.0]). The menstrual disorder group had a greater incidence of their periods stopping for more than 3 months than the group without menstrual disturbances.

CONCLUSIONS

The female triathletes did not show abnormalities in body weight or composition, and these were not related to the incidence of menstrual disturbances. However, 20% of the triathletes either had, at the time of the study, or had had in the past monthly cycle disorders that could indicate an immediate risk of low energy availability. The LEAF-Q identified 10% of the triathletes as at risk (score > 8) of low energy availability and the physiological and performance consequences related to relative energy deficiency in sports (RED-S).

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.

Chronic Low or High Nutrient Intake and Myokine Levels

Inadequate nutrient availability has been demonstrated to be one of the main factors related to endocrine and metabolic dysfunction. We investigated the role of inadequate nutrient intakes in the myokine levels of runners. Sixty-one amateur runners participated in this study. The myokine levels were determined using the Human Magnetic Bead Panel from plasma samples collected before and after the marathon. Dietary intake was determined using a prospective method of three food records. The runners with lower carbohydrate and calcium intakes had higher percentages of fat mass (p < 0.01). The runners with a sucrose intake comprising above 10% of their energy intake and an adequate sodium intake had higher levels of BDNF (p = 0.027 and p = 0.031). After the race and in the recovery period, the runners with adequate carbohydrate intakes (g/kg) (>5 g/kg/day) had higher levels of myostatin and musclin (p < 0.05). The runners with less than 45% of carbohydrate of EI had lower levels of IL-15 (p = 0.015) and BNDF (p = 0.013). The runners with higher cholesterol intakes had lower levels of irisin (p = 0.011) and apelin (p = 0.020), and those with a low fiber intake had lower levels of irisin (p = 0.005) and BDNF (p = 0.049). The inadequate intake influenced myokine levels, which promoted cardiometabolic tissue repair and adaptations to exercise.

Exogenous glucose oxidation during endurance exercise under low energy availability

The present study was conducted to determine the effect of endurance exercise under low energy availability (EA) on exogenous glucose oxidation during endurance exercise. Ten active males (21.4 ± 0.6 years, 170.4 ± 1.4 cm, 62.4 ± 1.5 kg, 21.5 ± 0.4 kg/m²) completed two trials, consisting of two consecutive days (days 1 and 2) of endurance training under low EA (19.9 ± 0.2 kcal/kg fat free mass [FFM]/day, LEA trial) or normal EA (46.4 ± 0.1 kcal/kg FFM/day, NEA trial). The order of these two trials was randomized with at least a 1-week interval between trials. As an endurance training, participants performed 60 min of treadmill running at 70% of maximal oxygen uptake (V˙O2max) during two consecutive days (on days 1 and 2). On day 1, the endurance training was performed with consumed individually manipulated meals. During the endurance exercise on day 2, exogenous glucose oxidation was evaluated using ¹³C-labeled glucose, and respiratory gas samples were collected. In addition, blood glucose and lactate concentrations were measured immediately after exercise on day 2. Body composition, blood parameters, and resting respiratory gas variables were evaluated under overnight fasting on days 1 and 2. Body weight was significantly reduced in the LEA trial on day2 (day1: 61.8 ± 1.4 kg, day 2: 61.3 ± 1.4 kg, P < 0.001). There were no significant differences between trials in ¹³C excretion (P = 0.33) and area under the curve during the 60 min of exercise (LEA trial: 40.4 ± 3.1 mmol•60min, NEA trial: 40.4 ± 3.1 mmol•60min, P = 0.99). However, the respiratory exchange ratio (RER, LEA trial: 0.88 ± 0.01, NEA trial: 0.90 ± 0.01) and carbohydrate oxidation (LEA trial: 120.1 ± 8.8 g, NEA trial: 136.8 ± 8.6 g) during endurance exercise showed significantly lower values in the LEA trial than in the NEA trial (P = 0.01 for RER and carbohydrate oxidation). Serum insulin and total ketone body concentrations were significantly changed after a day of endurance training under low EA (P = 0.04 for insulin, P < 0.01 for total ketone). In conclusion, low EA during endurance exercise reduced systemic carbohydrate oxidation; however, exogenous glucose oxidation (evaluated by ¹³C excretion) remained unchanged during exercise under low EA.

Body Composition and Its Perception among Professional Female Volleyball Players and Fitness Athletes (Silesia, Poland)

Female athletes experience both sociocultural and sport-specific pressures of an ideal body and appearance and are vulnerable to dissatisfaction with their bodies. Among sport-specific pressures, the type of sport is a predictor of body image dissatisfaction. The study included 150 females: 50 volleyball players, 50 bodybuilding and fitness athletes, and 50 female students, who were the control group. Body composition and perception and evaluation of one's own body were assessed. BMI was similar in the study group of female athletes and the control group, but the bodybuilding and fitness athletes had the lowest body fat, while the control group had the highest. Perception of one's own body in the aspect of the evaluation of specific body parts was highest among bodybuilding and fitness athletes, while in the aspect of body condition, the best results were obtained by volleyball players. Most female volleyball players were dissatisfied with their current body weight, as were women in the control group, in contrast to female bodybuilding and fitness athletes, who were most often satisfied with their current body weight.

Relative energy deficiency in sport (RED - S)

Relative Energy Deficiency in Sport (RED-S) refers to a condition in which energy imbalance leads to impaired physiological function of multiple organ systems and expands on the diagnosis previously known as the Female Athlete Triad. Researchers attribute the medical complications of RED-S to low energy availability, in which energy availability is defined as dietary energy intake minus exercise energy expenditure divided by fat-free mass. This article reviews the history of this diagnosis, the changing terminology, and the reasons for the expansion. Accepted definitions of each part of the energy availability equation are considered and the difficulties that exist using these equations in practice or comparatively in the literature are assessed. The review analyzes the broad spectrum of health consequences of RED-S, especially as it relates to hypoestrogenemia and menstrual function, gives guidance to those caring for athletes on the identification and management of RED-S, and sheds lights on the important role of coaches, athletic trainers, and families in recognizing this diagnosis and in helping getting patients to care.

Markers of Low Energy Availability in Overreached Athletes: A Systematic Review and Meta-analysis

BACKGROUND

Overreaching is the transient reduction in performance that occurs following training overload and is driven by an imbalance between stress and recovery. Low energy availability (LEA) may drive underperformance by compounding training stress; however, this has yet to be investigated systematically.

OBJECTIVE

The aim of this study was to quantify changes in markers of LEA in athletes who demonstrated underperformance, and exercise performance in athletes with markers of LEA.

METHODS

Studies using a ≥ 2-week training block with maintained or increased training loads that measured exercise performance and markers of LEA were identified using a systematic search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Changes from pre- to post-training were analyzed for (1) markers of LEA in underperforming athletes and (2) performance in athletes with ≥ 2 markers of LEA.

RESULTS

From 56 identified studies, 14 separate groups of athletes demonstrated underperformance, with 50% also displaying ≥ 2 markers of LEA post-training. Eleven groups demonstrated ≥ 2 markers of LEA independent of underperformance and 37 had no performance reduction or ≥ 2 markers of LEA. In underperforming athletes, fat mass (d =  - 0.29, 95% confidence interval [CI] - 0.54 to - 0.04; p = 0.02), resting metabolic rate (d =  - 0.63, 95% CI - 1.22 to - 0.05; p = 0.03), and leptin (d =  - 0.72, 95% CI - 1.08 to - 0.35; p < 0.0001) were decreased, whereas body mass (d =  - 0.04, 95% CI - 0.21 to 0.14; p = 0.70), cortisol (d =  - 0.06, 95% CI - 0.35 to 0.23; p = 0.68), insulin (d =  - 0.12, 95% CI - 0.43 to 0.19; p = 0.46), and testosterone (d =  - 0.31, 95% CI - 0.69 to 0.08; p = 0.12) were unaltered. In athletes with ≥ 2 LEA markers, performance was unaffected (d = 0.09, 95% CI - 0.30 to 0.49; p = 0.6), and the high heterogeneity in performance outcomes (I² = 84.86%) could not be explained by the performance tests used or the length of the training block.

CONCLUSION

Underperforming athletes may present with markers of LEA, but overreaching is also observed in the absence of LEA. The lack of a specific effect and high variability of outcomes with LEA on performance suggests that LEA is not obligatory for underperformance.

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.

Non-shoulder Injuries in Swimming: A Systematic Review

OBJECTIVE

The shoulder is the most common injury in swimming, followed by the knee and spine. The repetitive nature of swimming training may predispose a swimmer to injury. Several risk factors have been previously identified, but the level of evidence and level of certainty that these risk factors predispose a swimmer to injury risk has yet to be evaluated critically in a systematic review.

DESIGN

Systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

DATA SOURCES

Data were obtained through PubMed, Cochrane, and Google Scholar. The database search was limited to articles that were published between January 1980 and December 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Level I, II, and III studies were included in this review. All studies must have been conducted in swimmers or swimming, a description of the specific pathology and provide at least one identified risk factor with an association (P < 0.05).

RESULTS

A total of 19 critically appraised articles identified 28 potential risk factors for musculoskeletal injuries in swimmers. The risk factors were grouped by the anatomical region: neck and back, pelvis and hip, and the knee. Only 2 risk factors were appraised at a moderate level of certainty, both occurring in the knee. The remaining 26 identified risk factors were appraised at a low level of certainty. There is a clear lack of research surrounding nonshoulder injuries in swimmers.

Psychological and Physiological Changes in Response to the Cumulative Demands of a Women's Division I Collegiate Soccer Season

ABSTRACT

McFadden, BA, Walker, AJ, Bozzini, BN, Hofacker, M, Russell, M, and Arent, SM. Psychological and physiological changes in response to the cumulative demands of a women's division I collegiate soccer season. J Strength Cond Res 36(5): 1373-1382, 2022-This study sought to determine the effects of a women's collegiate soccer season on psychological markers, biomarkers, sleep, and performance. Athletes participated in maximal countermovement vertical jump height (CMJ) assessments and biomarker monitoring in conjunction with subjective measures of psychological wellness and sleep questionnaires before preseason (S1) and every 4 weeks following (S2, S3, and S4). Training was monitored during practices and games using global positioning satellite systems and heart rate technology. Total training load was highest from S1 to S2, decreased from S2 to S3 (effect size [ES] = -2.5; p < 0.001), and remained stable from S3 to S4. CMJ declined at S2 (ES1-2 = -0.51; p = 0.001) and returned to baseline at S3. Increases from S1 to S2 were seen for creatine kinase (ES1-2 = 1.74), free testosterone (ES1-2 = 1.27), total testosterone (ES1-2 = 3.5), and free cortisol (ES1-2 = 0.88) (p < 0.03) before returning to baseline by S3 and S4 (free cortisol). Total cortisol was elevated throughout the season before declining at S4 (ES1-4 = -0.41; p = 0.03). Iron declined from S1 to S2 (ES1-2 = -0.73; p = 0.01) and returned to baseline values at S4, whereas growth hormone declined at S2 (ES1-2 = -0.50; p = 0.01) and remained depressed. Interleukin-6 increased at S4 (ES1-4 = 0.71; p = 0.02). Total training distress decreased from S1 to S2 (ES1-2 = -0.38; p = 0.02), returned to baseline by S3, and increased by S4 (ES1-4 = 0.57; p = 0.01). No changes were observed in markers of sleep (p > 0.05). Biomarkers showed notable changes after the highest workload period (S1-S2), which coincided with CMJ decrements. Biomarker perturbations preceded declines in subjective psychological wellness (S4) which occurred in the latter half of the season, indicating an accumulation of fatigue as the season progressed.

Low energy availability surrogates associated with lower bone mineral density and bone stress injury site

BACKGROUND

Exercise is an osteogenic stimulus that should increase bone mineral density (BMD) and protect against injury. However, some female athletes have lower BMD and increased bone stress injury (BSI) risk. Impaired bone health seen in athletes may be explained by low energy availability as described by concepts of Relative Energy Deficiency in Sport (RED-S) and Female Athlete Triad (Triad).

OBJECTIVE

To elucidate the relationship between RED-S/Triad risk factors and BSI to high-risk (femoral neck, sacrum) and low-risk (other) bones.

DESIGN

Cross-sectional survey and retrospective chart review.

SETTING

Tertiary care academic center.

PATIENTS

Female athletes aged 15-30 years participating in ≥4 h/week of exercise presenting to sports medicine/orthopedics clinic who had a self-reported BSI and available dual-energy x-ray absorptiometry (DXA) measurement of BMD.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASUREMENTS

Location of BSI.

RESULTS

In 127 athletes, high-risk BSI was associated with surrogates of low energy availability (p = .032) and having a DXA Z-score < -1 (p = .035) but not a current/past history of menstrual dysfunction (p = .348). Accumulating RED-S/Triad risk factors increase the odds of incurring a high-risk BSI (p = .048).

CONCLUSIONS

Adolescent/young female athletes who sustain BSI at high-risk sites (femoral neck, sacrum) may have underlying risk factors (eg, low energy availability, poor overall bone health) that should prompt further workup and referral to optimize health in these athletes.

Bone stress injuries

Bone stress injuries, including stress fractures, are overuse injuries that lead to substantial morbidity in active individuals. These injuries occur when excessive repetitive loads are introduced to a generally normal skeleton. Although the precise mechanisms for bone stress injuries are not completely understood, the prevailing theory is that an imbalance in bone metabolism favours microdamage accumulation over its removal and replacement with new bone via targeted remodelling. Diagnosis is achieved by a combination of patient history and physical examination, with imaging used for confirmation. Management of bone stress injuries is guided by their location and consequent risk of healing complications. Bone stress injuries at low-risk sites typically heal with activity modification followed by progressive loading and return to activity. Additional treatment approaches include non-weight-bearing immobilization, medications or surgery, but these approaches are usually limited to managing bone stress injuries that occur at high-risk sites. A comprehensive strategy that integrates anatomical, biomechanical and biological risk factors has the potential to improve the understanding of these injuries and aid in their prevention and management.

Examination of the Prevalence of Female Athlete Triad Components among Competitive Cheerleaders

The purpose of this study was to examine individual and combined Female Athlete Triad components within collegiate cheerleaders, an at-risk group. Cheerleaders (n = 19; age: 20.3 ± 1.2 years) completed anthropometric measurements, health history questionnaires, resting metabolic rate, the eating disorder inventory-3 and symptom checklist, blood sample, and DXA scan. Participants completed dietary and exercise logs for 7 days and used heart rate monitors to track daily and exercise energy expenditure. Proportions were calculated for low energy availability (LEA) risk, disordered eating risk, and pathogenic behaviors. Chi-square analysis was used to determine the difference between cheerleaders who experience low EA with or without disordered eating risk. All cheerleaders demonstrated LEA for the days they participated in cheerleading practice, 52.6% demonstrated LEA with eating disorder risk and 47.4% demonstrated LEA without eating disorder risk, 52.6% self-reported menstrual dysfunction, 14% experienced menstrual dysfunction via hormonal assessment, and 0% demonstrated low bone mineral density. Overall, 47.7% presented with one Triad component, 52.6% demonstrated two Triad components using self-reported menstrual data, and 10.5% demonstrated two Triad components using hormonal assessments. All cheerleaders displayed LEA. These findings support the need for increased education on the individual components of the Triad and their potential consequences by qualified personal.

Metabolic Risk Factors in Young Men With Healthy Body Fat But Different Level of Physical Activity

The study was performed to evaluate metabolic risk in young lean individuals characterized by different physical activity. A total of 194 students (93 active with 5–7 h weekly physical activity and 101 inactive) were accepted for the study. The following percentages of body fat were accepted as characteristic for lean men: 14% to 17% in active and 18% to 24% in inactive participants. Circulating glucose, insulin, triacylglycerols (TG), total cholesterol (TC), and high-dendity lipoprotein (HDL)-cholesterol (HDL-C) were assayed. Daily intake of energy and macronutrients was briefly assessed from 24 h food records collected over 4 days preceding blood collection. Insulin and TG differed with respect to physical activity and was lower by 37.5% and 12.5%, respectively, in active versus inactive participants. In active students with upper quartile of body fat percentage, the only significant difference was found between circulating insulin (by 28%, p < .04). In inactive participants with upper quartile of body fat, significant differences were found between levels of insulin and TG (by 25% and by 37.5%, respectively). Diet composition did not differ with respect to the percentage of energy derived from protein, fat, and carbohydrates. An inverse association between insulin level and the percentage of body fat seems to be physiological one because it has been noted in both active and inactive individuals. On the contrary, elevation in circulating TG found exclusively in inactive subjects seems to be secondary to the changes in adiposity and circulating insulin and is followed by tendency to higher levels of TC.