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Sim A, Tan HQ, Ali Y, Burns SF. Original investigation: manipulating energy availability in male endurance runners: a randomised controlled trial. Appl Physiol Nutr Metab 2024. [PMID: 38713922 DOI: 10.1139/apnm-2024-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Abstract
This study investigated the effect of 4 days low energy availability (LEA) on physiological markers and mood states in male endurance runners. Twelve participants (mean (standard deviation); age: 25.8 (3.8) years; fat-free mass (FFM): 52.8 (5.5) kg) completed three 4-day conditions: adequate energy availability (AEA): 45 kcal/kg FFM/day; LEA1: 30 kcal/kg FFM/day; and LEA2: 15 kcal/kg FFM/day, in a randomized order. Participants ran on a treadmill at 65% of V̇O2max until they expended 15 kcal/kg FFM/day of energy. Energy intake was adjusted to achieve the desired energy availability. Pre- and post-measurements of bone turnover, metabolism, testosterone and estradiol (plasma), resting metabolic rate (indirect calorimetry), and mood states (Brunel Mood Scale) were assessed. The results reported a significant decrease in testosterone (condition × time interaction, p = 0.03) occurred on LEA2 (Pre: 23.8 (7.0) nmol/L vs. Post: 20.3 (7.7) nmol/L) compared with AEA (Pre: 22.9 (5.5) nmol/L vs. Post: 23.3 (6.1) nmol/L) or LEA1 (Pre: 23.6 (8.6) nmol/L vs. Post: 20.9 (8.8) nmol/L). Fatigue level significantly increased (condition × time interaction, p = 0.02) in LEA2 (Pre: 3.5 (1.7) vs. Post: 6.5 (2.9)) but did not change in AEA (Pre: 2.8 (1.5) vs. Post: 2.5 (2.7)) or LEA1 (Pre: 2.8(2.4) vs. Post: 2.9 (2.0)). Other measures were unaffected by the interventions. In conclusion, this study suggests that testosterone and fatigue may serve as early indicators of LEA in male runners. However, other physiological markers and mood states appeared largely unaffected, aligning with existing literature indicating minimal disruption of physiological functions during acute LEA in male athletes. Study registration: Australian New Zealand Clinical Trials Registry (Trial No.: 381278).
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Affiliation(s)
- Alexiaa Sim
- Physical Education and Sports Science, National Institute of Education, Nanyang Technological University, 637616, Singapore
| | - Hui Qing Tan
- Physical Education and Sports Science, National Institute of Education, Nanyang Technological University, 637616, Singapore
| | - Yusuf Ali
- Lee Kong Chian School of Medicine, Nanyang Technological University, 308232, Singapore
| | - Stephen F Burns
- Physical Education and Sports Science, National Institute of Education, Nanyang Technological University, 637616, Singapore
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O'Neill JER, Corish CA, Horner K. Accuracy of Resting Metabolic Rate Prediction Equations in Athletes: A Systematic Review with Meta-analysis. Sports Med 2023; 53:2373-2398. [PMID: 37632665 PMCID: PMC10687135 DOI: 10.1007/s40279-023-01896-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Resting metabolic rate (RMR) prediction equations are often used to calculate RMR in athletes; however, their accuracy and precision can vary greatly. OBJECTIVE The aim of this systematic review and meta-analysis was to determine which RMR prediction equations are (i) most accurate (average predicted values closest to measured values) and (ii) most precise (number of individuals within 10% of measured value). DATA SOURCES A systematic search of PubMed, CINAHL, SPORTDiscus, Embase, and Web of Science up to November 2021 was conducted. ELIGIBILITY CRITERIA Randomised controlled trials, cross-sectional observational studies, case studies or any other study wherein RMR, measured by indirect calorimetry, was compared with RMR predicted via prediction equations in adult athletes were included. ANALYSIS A narrative synthesis and random-effects meta-analysis (where possible) was conducted. To explore heterogeneity and factors influencing accuracy, subgroup analysis was conducted based on sex, body composition measurement method, athlete characteristics (athlete status, energy availability, body weight), and RMR measurement characteristics (adherence to best practice guidelines, test preparation and prior physical activity). RESULTS Twenty-nine studies (mixed sports/disciplines n = 8, endurance n = 5, recreational exercisers n = 5, rugby n = 3, other n = 8), with a total of 1430 participants (822 F, 608 M) and 100 different RMR prediction equations were included. Eleven equations satisfied criteria for meta-analysis for accuracy. Effect sizes for accuracy ranged from 0.04 to - 1.49. Predicted RMR values did not differ significantly from measured values for five equations (Cunningham (1980), Harris-Benedict (1918), Cunningham (1991), De Lorenzo, Ten-Haaf), whereas all others significantly underestimated or overestimated RMR (p < 0.05) (Mifflin-St. Jeor, Owen, FAO/WHO/UNU, Nelson, Koehler). Of the five equations, large heterogeneity was observed for all (p < 0.05, I2 range: 80-93%) except the Ten-Haaf (p = 0.48, I2 = 0%). Significant differences between subgroups were observed for some but not all equations for sex, athlete status, fasting status prior to RMR testing, and RMR measurement methodology. Nine equations satisfied criteria for meta-analysis for precision. Of the nine equations, the Ten-Haaf was found to be the most precise, predicting 80.2% of participants to be within ± 10% of measured values with all others ranging from 40.7 to 63.7%. CONCLUSION Many RMR prediction equations have been used in athletes, which can differ widely in accuracy and precision. While no single equation is guaranteed to be superior, the Ten-Haaf (age, weight, height) equation appears to be the most accurate and precise in most situations. Some equations are documented as consistently underperforming and should be avoided. Choosing a prediction equation based on a population of similar characteristics (physical characteristics, sex, sport, athlete status) is preferable. Caution is warranted when interpreting RMR ratio of measured to predicted values as a proxy of energy availability from a single measurement. PROSPERO REGISTRATION CRD42020218212.
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Affiliation(s)
- Jack Eoin Rua O'Neill
- Institute for Sport and Health and School of Public Health, Physiotherapy and Sport Science, University College Dublin, Belfield, Dublin 4, Ireland.
| | - Clare A Corish
- School of Public Health, Physiotherapy and Sport Science, University College Dublin, Dublin 4, Ireland
| | - Katy Horner
- Institute for Sport and Health and School of Public Health, Physiotherapy and Sport Science, University College Dublin, Belfield, Dublin 4, Ireland
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Lodge MT, Ward-Ritacco CL, Melanson KJ. Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review. Nutrients 2023; 15:4457. [PMID: 37892531 PMCID: PMC10609849 DOI: 10.3390/nu15204457] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/11/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
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.
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Affiliation(s)
- Melissa T. Lodge
- Department of Kinesiology, College of Health Sciences, University of Rhode Island, Kingston, RI 02881, USA;
| | - Christie L. Ward-Ritacco
- Department of Kinesiology, College of Health Sciences, University of Rhode Island, Kingston, RI 02881, USA;
| | - Kathleen J. Melanson
- Department of Nutrition, College of Health Sciences, University of Rhode Island, Kingston, RI 02881, USA;
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4
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Sesbreno E, Blondin DP, Dziedzic C, Sygo J, Haman F, Leclerc S, Brazeau AS, Mountjoy M. Signs of low energy availability in elite male volleyball athletes but no association with risk of bone stress injury and patellar tendinopathy. Eur J Sport Sci 2023; 23:2067-2075. [PMID: 36480965 DOI: 10.1080/17461391.2022.2157336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Erik Sesbreno
- l'Institut National du Sport du Québec, Montréal, Canada
- French-speaking Olympic Sports Medicine Research Network (ReFORM), Montréal, Canada
- School of Human Nutrition, McGill University, Montréal, Canada
| | - Denis P Blondin
- Division of Neurology, Department of Medicine, Faculty of Medicine and Health Sciences, Centre de Recherche du CHUS, Université de Sherbrooke, Sherbrooke, Canada
| | | | | | - François Haman
- School of Human Kinetics, University of Ottawa, Ottawa, Canada
| | - Suzanne Leclerc
- l'Institut National du Sport du Québec, Montréal, Canada
- French-speaking Olympic Sports Medicine Research Network (ReFORM), Montréal, Canada
| | | | - Margo Mountjoy
- Association for Summer Olympic International Federations (ASOIF), Lausanne, Switzerland
- Department of Family Medicine. Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
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5
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Stellingwerff T, Mountjoy M, McCluskey WT, Ackerman KE, Verhagen E, Heikura IA. 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. Br J Sports Med 2023; 57:1109-1118. [PMID: 37752002 DOI: 10.1136/bjsports-2023-106914] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 09/28/2023]
Abstract
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.
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Affiliation(s)
- Trent Stellingwerff
- Canadian Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Margo Mountjoy
- Association for Summer Olympic International Federations (ASOIF), Lausanne, Switzerland
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Evert Verhagen
- Amsterdam Collaboration on Health and Safety in Sports and Department of Public and Occupational Health, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Ida A Heikura
- Canadian Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
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6
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Mountjoy M, Ackerman KE, Bailey DM, Burke LM, Constantini N, Hackney AC, Heikura IA, Melin A, Pensgaard AM, Stellingwerff T, Sundgot-Borgen JK, Torstveit MK, Jacobsen AU, Verhagen E, Budgett R, Engebretsen L, Erdener U. 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med 2023; 57:1073-1097. [PMID: 37752011 DOI: 10.1136/bjsports-2023-106994] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2023] [Indexed: 09/28/2023]
Abstract
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.
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Affiliation(s)
- Margo Mountjoy
- Family Medicine, McMaster University Michael G DeGroote School of Medicine, Waterloo, Ontario, Canada
- Games Group, International Olympic Committee, Lausanne, Switzerland
| | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Louise M Burke
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Naama Constantini
- Sports Medicine Center, Shaare Zedek Medical Center, The Hebrew University, Jerusalem, Israel
| | - Anthony C Hackney
- Exercise and Sport Science, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ida Aliisa Heikura
- Canada Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Anna Melin
- Department of Sport Science - Swedish Olympic Committee Research Fellow, Linnaeus University, Kalmar, Sweden
| | - Anne Marte Pensgaard
- Department of Sport and Social Sciences, Norwegian School of Sports Sciences, Oslo, Norway
| | - Trent Stellingwerff
- Canada Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | | | | | | | - Evert Verhagen
- Amsterdam Collaboration on Health & Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Richard Budgett
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
| | - Lars Engebretsen
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
| | - Uğur Erdener
- Department of Ophthalmology, Hacettepe University, Ankara, Turkey
- World Archery, Lausanne, Switzerland
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Ackerman KE, Rogers MA, Heikura IA, Burke LM, Stellingwerff T, Hackney AC, Verhagen E, Schley S, Saville GH, Mountjoy M, Holtzman B. Methodology for studying Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the International Olympic Committee (IOC) consensus on REDs. Br J Sports Med 2023; 57:1136-1147. [PMID: 37752010 DOI: 10.1136/bjsports-2023-107359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/28/2023]
Abstract
In the past decade, the study of relationships among nutrition, exercise and the effects on health and athletic performance, has substantially increased. The 2014 introduction of Relative Energy Deficiency in Sport (REDs) prompted sports scientists and clinicians to investigate these relationships in more populations and with more outcomes than had been previously pursued in mostly white, adolescent or young adult, female athletes. Much of the existing physiology and concepts, however, are either based on or extrapolated from limited studies, and the comparison of studies is hindered by the lack of standardised protocols. In this review, we have evaluated and outlined current best practice methodologies to study REDs in an attempt to guide future research.This includes an agreement on the definition of key terms, a summary of study designs with appropriate applications, descriptions of best practices for blood collection and assessment and a description of methods used to assess specific REDs sequelae, stratified as either Preferred, Used and Recommended or Potential Researchers can use the compiled information herein when planning studies to more consistently select the proper tools to investigate their domain of interest. Thus, the goal of this review is to standardise REDs research methods to strengthen future studies and improve REDs prevention, diagnosis and care.
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Affiliation(s)
- Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Margot Anne Rogers
- Australian Institute of Sport, Bruce, South Australia, Australia
- University of Canberra Research Institute for Sport and Exercise (UCRISE), Canberra, Australian Capital Territory, Australia
| | - Ida A Heikura
- Canadian Sport Institute-Pacific, Victoria, British Columbia, Canada
- Department of Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Louise M Burke
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Trent Stellingwerff
- Canadian Sport Institute-Pacific, Victoria, British Columbia, Canada
- Department of Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Anthony C Hackney
- Exercise and Sport Science, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Evert Verhagen
- Amsterdam Collaboration on Health and Safety in Sports and Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands
| | - Stacey Schley
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Grace H Saville
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Margo Mountjoy
- Family Medicine, McMaster University Michael G DeGroote School of Medicine, Waterloo, Ontario, Canada
- Games Group, International Olympic Committee, Lausanne, Switzerland
| | - Bryan Holtzman
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Mass General for Children, Boston, Massachusetts, USA
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8
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Siedler MR, De Souza MJ, Albracht-Schulte K, Sekiguchi Y, Tinsley GM. The Influence of Energy Balance and Availability on Resting Metabolic Rate: Implications for Assessment and Future Research Directions. Sports Med 2023; 53:1507-1526. [PMID: 37213050 DOI: 10.1007/s40279-023-01856-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2023] [Indexed: 05/23/2023]
Abstract
Resting metabolic rate (RMR) is a significant contributor to an individual's total energy expenditure. As such, RMR plays an important role in body weight regulation across populations ranging from inactive individuals to athletes. In addition, RMR may also be used to screen for low energy availability and energy deficiency in athletes, and thus may be useful in identifying individuals at risk for the deleterious consequences of chronic energy deficiency. Given its importance in both clinical and research settings within the fields of exercise physiology, dietetics, and sports medicine, the valid assessment of RMR is critical. However, factors including varying states of energy balance (both short- and long-term energy deficit or surplus), energy availability, and prior food intake or exercise may influence resulting RMR measures, potentially introducing error into observed values. The purpose of this review is to summarize the relationships between short- and long-term changes in energetic status and resulting RMR measures, consider these findings in the context of relevant recommendations for RMR assessment, and provide suggestions for future research.
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Affiliation(s)
- Madelin R Siedler
- Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, TX, USA
| | - Mary Jane De Souza
- Departments of Kinesiology and Physiology, Pennsylvania State University, University Park, PA, USA
| | | | - Yasuki Sekiguchi
- Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, TX, USA
| | - Grant M Tinsley
- Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, TX, USA.
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Findling JW, Raff H. Recognition of Nonneoplastic Hypercortisolism in the Evaluation of Patients With Cushing Syndrome. J Endocr Soc 2023; 7:bvad087. [PMID: 37440963 PMCID: PMC10334485 DOI: 10.1210/jendso/bvad087] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Indexed: 07/15/2023] Open
Abstract
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.
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Affiliation(s)
- James W Findling
- Department of Medicine (Endocrinology and Molecular Medicine), Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Hershel Raff
- Correspondence: Hershel Raff, PhD, Endocrinology Research HRC4150, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA.
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10
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Dasa MS, Friborg O, Kristoffersen M, Pettersen G, Plasqui G, Sundgot-Borgen JK, Rosenvinge JH. Energy expenditure, dietary intake and energy availability in female professional football players. BMJ Open Sport Exerc Med 2023; 9:e001553. [PMID: 36865769 PMCID: PMC9972418 DOI: 10.1136/bmjsem-2023-001553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2023] [Indexed: 03/04/2023] Open
Abstract
Objectives To quantify energy expenditure and intake in professional female footballers playing on a national and/or international level. Second, to determine the prevalence of low energy availability among these players, defined as <30 kcal/kg fat-free mass (FFM)/day. Methods Fifty-one players completed a 14-day prospective observational study during the 2021/2022 football season. Energy expenditure was determined using the doubly labelled water method. Energy intake was assessed using dietary recalls, while global positioning system determined the external physiological load. Descriptive statistics, stratification and the correlation between explainable variables and outcomes were conducted to quantify the energetic demands. Results The mean energy expenditure for all players (22±4 years) was 2918±322 kcal. Mean energy intake was 2274±450 kcal, resulting in a discrepancy of ~22%. Carbohydrate intake was below the recommended guidelines on match day at 4.5±1.9 g/kg. The mean energy availability was 36.7±17.7 kcal/kg FFM/day on matchday and 37.9±11.7 kcal/kg FFM/day on training days, resulting in a prevalence of 36% and 23% for low energy availability during the observational period, respectively. Conclusion These elite female football players displayed moderate energy expenditure levels and failed to meet the recommended levels of carbohydrate intake. In conjunction with inadequate nutritional periodisation, this will likely hamper performance through inadequate muscle glycogen resynthesis. In addition, we found a considerable prevalence of low energy availability on match and training days.
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Affiliation(s)
- Marcus Smavik Dasa
- Department of Health and Care Sciences, UiT The Arctic University of Norway, Tromso, Norway
| | - Oddgeir Friborg
- Department of Psychology, UiT The Arctic University of Norway, Tromso, Norway
| | - Morten Kristoffersen
- Department of Sport, Food and Natural Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Gunn Pettersen
- Department of Health and Care Sciences, UiT The Arctic University of Norway, Tromso, Norway
| | - Guy Plasqui
- Department of Nutrition and Movement Sciences, Maastricht University, Maastricht, Netherlands
| | | | - Jan H Rosenvinge
- Department of Psychology, UiT The Arctic University of Norway, Tromso, Norway
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Dietary Intake, Serum Hormone Concentrations, Amenorrhea and Bone Mineral Density of Physique Athletes and Active Gym Enthusiasts. Nutrients 2023; 15:nu15020382. [PMID: 36678253 PMCID: PMC9862069 DOI: 10.3390/nu15020382] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/07/2023] [Accepted: 01/08/2023] [Indexed: 01/15/2023] Open
Abstract
As the diet, hormones, amenorrhea, and bone mineral density (BMD) of physique athletes (PA) and gym enthusiasts (GE) are little-explored, we studied those in 69 females (50 PA, 19 GE) and 20 males (11 PA, 9 GE). Energy availability (EA, kcal·kgFFM−1·d−1 in DXA) in female and male PA was ~41.3 and ~37.2, and in GE ~39.4 and ~35.3, respectively. Low EA (LEA) was found in 10% and 26% of female PA and GE, respectively, and in 11% of male GE. In PA, daily protein intake (g/kg body mass) was ~2.9−3.0, whereas carbohydrate and fat intakes were ~3.6−4.3 and ~0.8−1.0, respectively. PA had higher protein and carbohydrate and lower fat intakes than GE (p < 0.05). Estradiol, testosterone, IGF-1, insulin, leptin, TSH, T4, T3, cortisol, or BMD did not differ between PA and GE. Serum IGF-1 and leptin were explained 6% and 7%, respectively, by EA. In non-users of hormonal contraceptives, amenorrhea was found only in PA (27%) and was associated with lower fat percentage, but not EA, BMD, or hormones. In conclusion, off-season dietary intakes, hormone levels, and BMD meet the recommendations in most of the PA and GE. Maintaining too-low body fat during the off-season may predispose to menstrual disturbances.
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Lundy B, Torstveit MK, Stenqvist TB, Burke LM, Garthe I, Slater GJ, Ritz C, Melin AK. Screening for Low Energy Availability in Male Athletes: Attempted Validation of LEAM-Q. Nutrients 2022; 14:nu14091873. [PMID: 35565840 PMCID: PMC9101736 DOI: 10.3390/nu14091873] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/22/2022] [Accepted: 04/26/2022] [Indexed: 02/06/2023] Open
Abstract
A questionnaire-based screening tool for male athletes at risk of low energy availability (LEA) could facilitate both research and clinical practice. The present options rely on proxies for LEA such screening tools for disordered eating, exercise dependence, or those validated in female athlete populations. in which the female-specific sections are excluded. To overcome these limitations and support progress in understanding LEA in males, centres in Australia, Norway, Denmark, and Sweden collaborated to develop a screening tool (LEAM-Q) based on clinical investigations of elite and sub-elite male athletes from multiple countries and ethnicities, and a variety of endurance and weight-sensitive sports. A bank of questions was developed from previously validated questionnaires and expert opinion on various clinical markers of LEA in athletic or eating disorder populations, dizziness, thermoregulation, gastrointestinal symptoms, injury, illness, wellbeing, recovery, sleep and sex drive. The validation process covered reliability, content validity, a multivariate analysis of associations between variable responses and clinical markers, and Receiver Operating Characteristics (ROC) curve analysis of variables, with the inclusion threshold being set at 60% sensitivity. Comparison of the scores of the retained questionnaire variables between subjects classified as cases or controls based on clinical markers of LEA revealed an internal consistency and reliability of 0.71. Scores for sleep and thermoregulation were not associated with any clinical marker and were excluded from any further analysis. Of the remaining variables, dizziness, illness, fatigue, and sex drive had sufficient sensitivity to be retained in the questionnaire, but only low sex drive was able to distinguish between LEA cases and controls and was associated with perturbations in key clinical markers and questionnaire responses. In summary, in this large and international cohort, low sex drive was the most effective self-reported symptom in identifying male athletes requiring further clinical assessment for LEA.
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Affiliation(s)
- Bronwen Lundy
- Rowing Australia, Canberra, ACT 2600, Australia;
- Mary MacKillop Institute of Health Research, Australian Catholic University, Melbourne, VIC 3000, Australia
| | - Monica K. Torstveit
- Department of Sport Science and Physical Education, Faculty of Health and Sport Science, University of Agder, 4630 Kristiansand, Norway; (M.K.T.); (T.B.S.)
| | - Thomas B. Stenqvist
- Department of Sport Science and Physical Education, Faculty of Health and Sport Science, University of Agder, 4630 Kristiansand, Norway; (M.K.T.); (T.B.S.)
| | - Louise M. Burke
- Mary MacKillop Institute of Health Research, Australian Catholic University, Melbourne, VIC 3000, Australia
- Correspondence:
| | - Ina Garthe
- Norwegian Olympic Sports Centre, Department of Sports Nutrition, 0806 Oslo, Norway;
| | - Gary J. Slater
- School of Health and Behavioural Sciences, University of the Sunshine Coast, Sippy Downs, QLD 4556, Australia;
| | - Christian Ritz
- National Institute of Public Health—SDU, 1455 Copenhagen, Denmark;
| | - Anna K. Melin
- Department of Sport Science, Faculty of Social Sciences, Linnaeus University, 351 95 Vaxjo, Sweden;
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De Souza MJ, Strock NCA, Ricker EA, Koltun KJ, Barrack M, Joy E, Nattiv A, Hutchinson M, Misra M, Williams NI. The Path Towards Progress: A Critical Review to Advance the Science of the Female and Male Athlete Triad and Relative Energy Deficiency in Sport. Sports Med 2021; 52:13-23. [PMID: 34665451 DOI: 10.1007/s40279-021-01568-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2021] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Mary Jane De Souza
- Department of Kinesiology and Physiology, Pennsylvania State University, University Park, PA, USA
| | - Nicole C A Strock
- Department of Kinesiology, Pennsylvania State University, University Park, PA, 16802, USA
| | - Emily A Ricker
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, USA
| | - Kristen J Koltun
- Department of Sports Medicine and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michelle Barrack
- Department of Family and Consumer Sciences, California State University Long Beach, Long Beach, CA, USA
| | | | - Aurelia Nattiv
- Department of Sports Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Mark Hutchinson
- Department of Orthopedics and Sports Medicine, University of Illinois Chicago, Chicago, IL, USA
| | - Madhusmita Misra
- Division of Pediatric Endocrinology, Massachusetts General Hospital, Boston, MA, USA
| | - Nancy I Williams
- Department of Kinesiology, Pennsylvania State University, University Park, PA, 16802, USA.
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