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Jeukendrup AE, Areta JL, Van Genechten L, Langan-Evans C, Pedlar CR, Rodas G, Sale C, Walsh NP. Does Relative Energy Deficiency in Sport (REDs) Syndrome Exist? Sports Med 2024:10.1007/s40279-024-02108-y. [PMID: 39287777 DOI: 10.1007/s40279-024-02108-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2024] [Indexed: 09/19/2024]
Abstract
Relative energy deficiency in sport (REDs) is a widely adopted model, originally proposed by an International Olympic Committee (IOC) expert panel in 2014 and recently updated in an IOC 2023 consensus statement. The model describes how low energy availability (LEA) causes a wide range of deleterious health and performance outcomes in athletes. With increasing frequency, sports practitioners are diagnosing athletes with "REDs," or "REDs syndrome," based largely upon symptom presentation. The purpose of this review is not to "debunk" REDs but to challenge dogmas and encourage rigorous scientific processes. We critically discuss the REDs concept and existing empirical evidence available to support the model. The consensus (IOC 2023) is that energy availability, which is at the core of REDs syndrome, is impossible to measure accurately enough in the field, and therefore, the only way to diagnose an athlete with REDs appears to be by studying symptom presentation and risk factors. However, the symptoms are rather generic, and the causes likely multifactorial. Here we discuss that (1) it is very difficult to isolate the effects of LEA from other potential causes of the same symptoms (in the laboratory but even more so in the field); (2) the model is grounded in the idea that one factor causes symptoms rather than a combination of factors adding up to the etiology. For example, the model does not allow for high allostatic load (psychophysiological "wear and tear") to explain the symptoms; (3) the REDs diagnosis is by definition biased because one is trying to prove that the correct diagnosis is REDs, by excluding other potential causes (referred to as differential diagnosis, although a differential diagnosis is supposed to find the cause, not demonstrate that it is a pre-determined cause); (4) observational/cross-sectional studies have typically been short duration (< 7 days) and do not address the long term "problematic LEA," as described in the IOC 2023 consensus statement; and (5) the evidence is not as convincing as it is sometimes believed to be (i.e., many practitioners believe REDs is well established). Very few studies can demonstrate causality between LEA and symptoms, most studies demonstrate associations and there is a worrying number of (narrative) reviews on the topic, relative to original research. Here we suggest that the athlete is best served by an unbiased approach that places health at the center, leaving open all possible explanations for the presented symptoms. Practitioners could use a checklist that addresses eight categories of potential causes and involve the relevant experts if and when needed. The Athlete Health and Readiness Checklist (AHaRC) we introduce here simply consists of tools that have already been developed by various expert/consensus statements to monitor and troubleshoot aspects of athlete health and performance issues. Isolating the purported effects of LEA from the myriad of other potential causes of REDs symptoms is experimentally challenging. This renders the REDs model somewhat immune to falsification and we may never definitively answer the question, "does REDs syndrome exist?" From a practical point of view, it is not necessary to isolate LEA as a cause because all potential areas of health and performance improvement should be identified and tackled.
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Affiliation(s)
- Asker E Jeukendrup
- Loughborough University, Loughborough, UK
- Netherlands Olympic Committee, Arnhem, The Netherlands
| | | | | | | | | | - Gil Rodas
- Medical Department, Futbol Club Barcelona, Barça Innovation Hub, Barcelona, Spain
| | - Craig Sale
- Manchester Metropolitan University, Manchester, UK
| | - Neil P Walsh
- Liverpool John Moores University, Liverpool, UK.
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Yildiz C, Köhler K, Wasserfurth P, Özilgen M. Assessment of entropy accumulation in human subjects when exposed to low energy availability. Heliyon 2024; 10:e36792. [PMID: 39286208 PMCID: PMC11402755 DOI: 10.1016/j.heliyon.2024.e36792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 08/16/2024] [Accepted: 08/22/2024] [Indexed: 09/19/2024] Open
Abstract
Background & aims Adequate energy availability is essential for the body to maintain its physiological functions and achieve optimal health, especially among athletes. Unfortunately, low energy availability (LEA) is common among athletes, and it has been associated with impairments in health and performance. In contrast, an energy-restricted diet has been linked to longevity, but it is unclear how LEA affects athletes' lifespans. The goal of the present study was to assess the impact of LEA thermodynamically on the lifespan of athletes. Methods Data from seven healthy young endurance-trained athletes (24 ± 4 years) who underwent short-term low energy availability (125 (kJ/day) per kg FFM) once with low protein content (LEA-LP; 0.8 g/kg) and with high protein content (LEA-HP; 125 (kJ/day) per kg FFM, 1.7 g/kg), as well as a control diet (CON; 230 (kJ/day) per kg FFM, 1.7 g/kg), were used in the calculations. The athletes followed each diet for five days and expended 67.5 (kJ/day) per kg FFM. entropy generation-based thermodynamic calculations were performed based on the metabolic activity of the athletes, which was determined from oxygen consumption and carbon dioxide production rates. Results Low energy availability was successfully induced during LEA-LP (62 ± 8 (kJ/day) per kg FFM; 95%Cl: 53-70) and LEA-HP (64 ± 8 (kJ/day) per kg FFM; 95%Cl: 56-71) diets. Despite of achieving energy deficit of -6658 ± 2110 kJ/day (95%Cl: 8609-(-) 4707) (LEA-LP), -5781 ± 623 (95%Cl: 26591-(-)4707) (LEA-HP) and excessive energy of 772 ± 1915 (95%Cl: 845-2388) (CON) statistical analyses revealed no significant differences in lifespan estimations among diets (CON: 72 ± 8 years (95%Cl: 65-79), LEA-LP: 74 ± 7 years (95%Cl: 68-80), and LEA-HP: 73 ± 11 (95%Cl: 62-83)). Conclusions This study suggests valuable insights into the intricate relationship between energy availability, entropy generation, and lifespan among athletes. Whereas entropy generation levels and the lifespan of athletes remained stable depending on diets, the distinguished differences in energy deficiency and energy availability underline the need for a profounder investigation of underlying physiological mechanisms to improve the health and performance of athletes.
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Affiliation(s)
- Cennet Yildiz
- Department of Food Engineering, Yeditepe University, Istanbul, Turkey
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Karsten Köhler
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Paulina Wasserfurth
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Mustafa Özilgen
- Department of Food Engineering, Yeditepe University, Istanbul, Turkey
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Angelidi AM, Stefanakis K, Chou SH, Valenzuela-Vallejo L, Dipla K, Boutari C, Ntoskas K, Tokmakidis P, Kokkinos A, Goulis DG, Papadaki HA, Mantzoros CS. Relative Energy Deficiency in Sport (REDs): Endocrine Manifestations, Pathophysiology and Treatments. Endocr Rev 2024; 45:676-708. [PMID: 38488566 DOI: 10.1210/endrev/bnae011] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Indexed: 09/18/2024]
Abstract
Research on lean, energy-deficient athletic and military cohorts has broadened the concept of the Female Athlete Triad into the Relative Energy Deficiency in Sport (REDs) syndrome. REDs represents a spectrum of abnormalities induced by low energy availability (LEA), which serves as the underlying cause of all symptoms described within the REDs concept, affecting exercising populations of either biological sex. Both short- and long-term LEA, in conjunction with other moderating factors, may produce a multitude of maladaptive changes that impair various physiological systems and adversely affect health, well-being, and sport performance. Consequently, the comprehensive definition of REDs encompasses a broad spectrum of physiological sequelae and adverse clinical outcomes related to LEA, such as neuroendocrine, bone, immune, and hematological effects, ultimately resulting in compromised health and performance. In this review, we discuss the pathophysiology of REDs and associated disorders. We briefly examine current treatment recommendations for REDs, primarily focusing on nonpharmacological, behavioral, and lifestyle modifications that target its underlying cause-energy deficit. We also discuss treatment approaches aimed at managing symptoms, such as menstrual dysfunction and bone stress injuries, and explore potential novel treatments that target the underlying physiology, emphasizing the roles of leptin and the activin-follistatin-inhibin axis, the roles of which remain to be fully elucidated, in the pathophysiology and management of REDs. In the near future, novel therapies leveraging our emerging understanding of molecules and physiological axes underlying energy availability or lack thereof may restore LEA-related abnormalities, thus preventing and/or treating REDs-related health complications, such as stress fractures, and improving performance.
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Affiliation(s)
- Angeliki M Angelidi
- Department of Medicine, Boston VA Healthcare System, Boston, MA 02115, USA
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Konstantinos Stefanakis
- Department of Medicine, Boston VA Healthcare System, Boston, MA 02115, USA
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
- First Propaedeutic Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens 11527, Greece
- Department of Internal Medicine, 251 Air Force General Hospital, Athens 11525, Greece
| | - Sharon H Chou
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital (BWH), Harvard Medical School, Boston, MA 02115, USA
| | - Laura Valenzuela-Vallejo
- Department of Medicine, Boston VA Healthcare System, Boston, MA 02115, USA
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Konstantina Dipla
- Exercise Physiology and Biochemistry Laboratory, Department of Sports Science at Serres, Aristotle University of Thessaloniki, Serres 62100, Greece
| | - Chrysoula Boutari
- Second Propaedeutic Department of Internal Medicine, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Konstantinos Ntoskas
- Department of Internal Medicine, 251 Air Force General Hospital, Athens 11525, Greece
| | - Panagiotis Tokmakidis
- First Propaedeutic Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens 11527, Greece
- Department of Internal Medicine, 251 Air Force General Hospital, Athens 11525, Greece
| | - Alexander Kokkinos
- First Propaedeutic Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Helen A Papadaki
- Department of Hematology, University Hospital of Heraklion, School of Medicine, University of Crete, Heraklion 71500, Greece
| | - Christos S Mantzoros
- Department of Medicine, Boston VA Healthcare System, Boston, MA 02115, USA
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital (BWH), Harvard Medical School, Boston, MA 02115, USA
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Isola V, Hulmi JJ, Mbay T, Kyröläinen H, Häkkinen K, Ahola V, Helms ER, Ahtiainen JP. Changes in hormonal profiles during competition preparation in physique athletes. Eur J Appl Physiol 2024:10.1007/s00421-024-05606-z. [PMID: 39261323 DOI: 10.1007/s00421-024-05606-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 08/30/2024] [Indexed: 09/13/2024]
Abstract
PURPOSE Physique athletes engage in rigorous competition preparation involving intense energy restriction and physical training to enhance muscle definition. This study investigates hormonal changes and their physiological and performance impacts during such preparation. METHODS Participants included female (10 competing (COMP) and 10 non-dieting controls (CTRL)) and male (13 COMP and 10 CTRL) physique athletes. COMP participants were tested 23 weeks before (PRE), one week before (MID), and 23 weeks after the competition (POST). Non-dieting CTRL participants were tested at similar intervals. Measurements included body composition (DXA), muscle cross-sectional area (ultrasound), energy availability (EA) derived by subtracting exercise energy expenditure (EEE) from energy intake (EI) and dividing by fat-free mass (FFM), muscle strength, and various serum hormone concentrations (ACTH, cortisol, estradiol, FSH, IGF-1, IGFBP-3, insulin, and free and total testosterone and SHBG). RESULTS During the diet, EA (p < 0.001), IGF-1 (p < 0.001), IGFBP-3 (p < 0.01), and absolute muscle strength (p < 0.01-0.001) decreased significantly in both sexes in COMP. Decreases in IGF-1 were also associated with higher loss in FFM. In males, testosterone (p < 0.01) and free testosterone (p < 0.05) decreased, while SHBG (p < 0.001) and cortisol (p < 0.05) increased. Insulin decreased significantly only in males (p < 0.001). Mood disturbances, particularly increased fatigue in males (p < 0.05), highlighted the psychological strain of competition preparation. All these changes were restored by increased EA during the post-competition recovery period. CONCLUSION Significant reductions in IGF-1 and IGFBP-3 during competition preparation may serve as biomarkers for monitoring physiological stress. This study offers valuable insights into hormonal changes, muscle strength, and mood state during energy-restricted intense training.
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Affiliation(s)
- Ville Isola
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, P.O. Box 35, 40014, Jyväskylä, Finland.
| | - Juha J Hulmi
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, P.O. Box 35, 40014, Jyväskylä, Finland
| | - Theo Mbay
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, P.O. Box 35, 40014, Jyväskylä, Finland
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, 70211, Kuopio, Finland
| | - Heikki Kyröläinen
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, P.O. Box 35, 40014, Jyväskylä, Finland
| | - Keijo Häkkinen
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, P.O. Box 35, 40014, Jyväskylä, Finland
| | - Vilho Ahola
- Sports and Exercise Medicine, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Eric R Helms
- Sports Performance Research Institute New Zealand (SPRINZ), Auckland University of Technology, Auckland, New Zealand
- Department of Exercise Science and Health Promotion, Muscle Physiology Research Laboratory, Florida Atlantic University, Boca Raton, FL, 33431, USA
| | - Juha P Ahtiainen
- Faculty of Sport and Health Sciences, Neuromuscular Research Center, University of Jyväskylä, P.O. Box 35, 40014, Jyväskylä, Finland
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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; 49:1163-1174. [PMID: 38713922 DOI: 10.1139/apnm-2024-0037] [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: 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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Hutson MJ, Varley I. An Opinion on the Interpretation of Bone Turnover Markers Following Acute Exercise or Nutrition Intervention and Considerations for Applied Research. Int J Sport Nutr Exerc Metab 2024; 34:315-321. [PMID: 38925537 DOI: 10.1123/ijsnem.2024-0003] [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] [Received: 01/08/2024] [Revised: 05/24/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024]
Abstract
It is important for athlete and public health that we continue to develop our understanding of the effects of exercise and nutrition on bone health. Bone turnover markers (BTMs) offer an opportunity to accelerate the progression of bone research by revealing a bone response to exercise and nutrition stimuli far more rapidly than current bone imaging techniques. However, the association between short-term change in the concentration of BTMs and long-term bone health remains ambiguous. Several other limitations also complicate the translation of acute BTM data to applied practice. Importantly, several incongruencies exist between the effects of exercise and nutrition stimuli on short-term change in BTM concentration compared with long-term bone structural outcomes to similar stimuli. There are many potential explanations for these inconsistencies, including that short-term study designs fail to encompass a full remodeling cycle. The current article presents the opinion that data from relatively acute studies measuring BTMs may not be able to reliably inform applied practice aiming to optimize bone health. There are important factors to consider when interpreting or translating BTM data and these are discussed.
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Affiliation(s)
- Mark J Hutson
- School of Sport, Faculty of Life and Health Sciences, Ulster University, Coleraine, United Kingdom
| | - Ian Varley
- School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
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Ihalainen JK, Mikkonen RS, Ackerman KE, Heikura IA, Mjøsund K, Valtonen M, Hackney AC. Beyond Menstrual Dysfunction: Does Altered Endocrine Function Caused by Problematic Low Energy Availability Impair Health and Sports Performance in Female Athletes? Sports Med 2024; 54:2267-2289. [PMID: 38995599 PMCID: PMC11393114 DOI: 10.1007/s40279-024-02065-6] [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: 06/04/2024] [Indexed: 07/13/2024]
Abstract
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.
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Affiliation(s)
- Johanna K Ihalainen
- Biology of Physical Activity, Faculty of Sport and Health Sciences, University of Jyväskylä, PO Box 35, 40014, Jyväskylä, Finland.
- Finnish Institute of High Performance Sport KIHU, Jyväskylä, Finland.
| | - Ritva S Mikkonen
- Biology of Physical Activity, Faculty of Sport and Health Sciences, University of Jyväskylä, PO Box 35, 40014, Jyväskylä, Finland
- Sports Technology Unit, Faculty of Sport and Health Sciences, University of Jyväskylä, Vuokatti, Finland
| | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Boston, MA, USA
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ida A Heikura
- Canadian Sport Institute-Pacific, Victoria, BC, Canada
- Exercise Science, Physical and Health Education, University of Victoria, Victoria, BC, Canada
| | - Katja Mjøsund
- Paavo Nurmi Centre and Unit for Health and Physical Activity, University of Turku, Turku, Finland
- National Olympic Training Centre Helsinki, Helsinki, Finland
| | - Maarit Valtonen
- Finnish Institute of High Performance Sport KIHU, Jyväskylä, Finland
| | - Anthony C Hackney
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Jeppesen JS, Caldwell HG, Lossius LO, Melin AK, Gliemann L, Bangsbo J, Hellsten Y. Low energy availability increases immune cell formation of reactive oxygen species and impairs exercise performance in female endurance athletes. Redox Biol 2024; 75:103250. [PMID: 38936255 PMCID: PMC11260862 DOI: 10.1016/j.redox.2024.103250] [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] [Received: 05/28/2024] [Accepted: 06/18/2024] [Indexed: 06/29/2024] Open
Abstract
INTRODUCTION The effects of low energy availability (LEA) on the immune system are poorly understood. This study examined the effects of 14 days of LEA on immune cell redox balance and inflammation at rest and in response to acute exercise, and exercise performance in female athletes. METHODS Twelve female endurance athletes (age: 26.8 ± 3.4 yrs, maximum oxygen uptake (V˙O2max): 55.2 ± 5.1 mL × min-1 × kg-1) were included in a randomized, single-blinded crossover study. They were allocated to begin with either 14 days of optimal energy availability diet (OEA, 52 ± 2 kcal × kg fat free mass (FFM)-1 × day-1) or LEA diet (22 ± 2 kcal × kg FFM-1 × day-1), followed by 3 days of refueling (OEA) with maintained training volume. Peripheral blood mononuclear cells (PBMCs) were isolated, and plasma obtained at rest before and after each dietary period. The PBMCs were used for analysis of mitochondrial respiration and H2O2 emission and specific proteins. Exercise performance was assessed on cycle by a 20-min time trial and time to exhaustion at an intensity corresponding to ∼110 % V˙O2max). RESULTS LEA was associated with a 94 % (P = 0.003) increase in PBMC NADPH oxidase 2 protein content, and a 22 % (P = 0.013) increase in systemic cortisol. LEA also caused an alteration of several inflammatory related proteins (P < 0.05). Acute exercise augmented H2O2 emission in PBMCs (P < 0.001) following both OEA and LEA, but to a greater extent following LEA. LEA also reduced the mobilization of white blood cells with acute exercise. After LEA, performance was reduced in both exercise tests (P < 0.001), and the reduced time trial performance remained after the 3 days of refueling (P < 0.001). CONCLUSION 14 days of LEA in female athletes increased cortisol levels and had a pronounced effect on the immune system, including increased capacity for ROS production, altered plasma inflammatory proteome and lowered exercise induced mobilization of leukocytes. Furthermore, LEA resulted in a sustained impairment in exercise performance.
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Affiliation(s)
- Jan S Jeppesen
- The August Krogh Section for Human Physiology, Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, Denmark
| | - Hannah G Caldwell
- The August Krogh Section for Human Physiology, Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, Denmark
| | - Lone O Lossius
- Linnaeus University, Department of Sport Science, Växjö/Kalmar, Sweden
| | - Anna K Melin
- Linnaeus University, Department of Sport Science, Växjö/Kalmar, Sweden
| | - Lasse Gliemann
- The August Krogh Section for Human Physiology, Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, Denmark
| | - Jens Bangsbo
- The August Krogh Section for Human Physiology, Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, Denmark
| | - Ylva Hellsten
- The August Krogh Section for Human Physiology, Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, Denmark.
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McHaffie SJ, Langan-Evans C, Strauss JA, Areta JL, Rosimus C, Evans M, Waghorn R, Grant J, Cuthbert M, Hambly C, Speakman JR, Morton JP. Energy expenditure, intake and availability in female soccer players via doubly labelled water: Are we misrepresenting low energy availability? Exp Physiol 2024. [PMID: 39145767 DOI: 10.1113/ep091589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 07/16/2024] [Indexed: 08/16/2024]
Abstract
Female soccer players have been identified as presenting with low energy availability (LEA), though the prevalence of LEA may be overestimated given inaccuracies associated with self-reporting dietary intakes. Accordingly, we aimed to quantify total daily energy expenditure (TDEE) via the doubly labelled water (DLW) method, energy intake (EI) and energy availability (EA). Adolescent female soccer players (n = 45; 16 ± 1 years) completed a 9-10 day 'training camp' representing their national team. Absolute and relative TDEE was 2683 ± 324 and 60 ± 7 kcal kg-1 fat free mass (FFM), respectively. Mean daily EI was lower (P < 0.01) when players self-reported using the remote food photography method (RFPM) (2047 ± 383 kcal day-1) over a 3-day period versus DLW derived EI estimates accounting for body mass (BM) changes (2545 ± 518 kcal day-1) over 7-8 days, representing a mean daily Δ of 499 ± 526 kcal day-1 and 22% error when using the RFPM. Estimated EA was different (P < 0.01) between methods (DLW: 48 ± 14 kcal kg-1 FFM, range: 22-82; RFPM: 37 ± 8 kcal kg-1 FFM, range: 22-54), such that prevalence of LEA (<30 kcal kg-1 FFM) was lower in DLW compared with RFPM (5% vs. 15%, respectively). Data demonstrate the potential to significantly underestimate EI when using self-report methods. This approach can therefore cause a misrepresentation and an over-prevalence of LEA, which is the underlying aetiology of 'relative energy deficiency in sport' (REDs). HIGHLIGHTS: What is the central question of this study? Do self-reported dietary intakes (via remote food photography method, RFPM) overestimate low energy availability (LEA) prevalence in female soccer players compared with energy intake evaluation from the doubly labelled water (DLW) method? What is the main finding and its importance? Estimated energy availability is greater with the DLW method compared with RFPM, such that the prevalence of LEA is greater when self-reporting dietary intakes. Accordingly, data demonstrate the potential to misrepresent the prevalence of LEA, an underlying factor in the aetiology of 'relative energy deficiency in sport' (REDs).
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Affiliation(s)
- Samuel J McHaffie
- Research Institute for Sport and Exercise Sciences (RISES), Liverpool John Moores University, Liverpool, UK
| | - Carl Langan-Evans
- Research Institute for Sport and Exercise Sciences (RISES), Liverpool John Moores University, Liverpool, UK
| | - Juliette A Strauss
- Research Institute for Sport and Exercise Sciences (RISES), Liverpool John Moores University, Liverpool, UK
| | - José L Areta
- Research Institute for Sport and Exercise Sciences (RISES), Liverpool John Moores University, Liverpool, UK
| | | | - Martin Evans
- The Football Association, Needwood, Burton-Upon-Trent, UK
| | - Ruth Waghorn
- The Football Association, Needwood, Burton-Upon-Trent, UK
| | - James Grant
- The Football Association, Needwood, Burton-Upon-Trent, UK
| | | | - Catherine Hambly
- Institute of Biological and Environmental Sciences, University of Aberdeen, Aberdeen, UK
| | - John R Speakman
- Institute of Biological and Environmental Sciences, University of Aberdeen, Aberdeen, UK
| | - James P Morton
- Research Institute for Sport and Exercise Sciences (RISES), Liverpool John Moores University, Liverpool, UK
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10
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Suzuki D, Suzuki Y. Identifying and Analyzing Low Energy Availability in Athletes: The Role of Biomarkers and Red Blood Cell Turnover. Nutrients 2024; 16:2273. [PMID: 39064716 PMCID: PMC11279570 DOI: 10.3390/nu16142273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/28/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Low energy availability (LEA) is a growing concern that can lead to several problems for athletes. However, adaptation to LEA occurs to maintain balance over time, making diagnosis difficult. In this review, we categorize LEA into two phases: the initial phase leading to adaptation and the phase in which adaptation is achieved and maintained. We review the influence of LEA on sports performance and health and discuss biomarkers for diagnosing LEA in each phase. This review also proposes future research topics for diagnosing LEA, with an emphasis on the recently discovered association between red blood cell turnover and LEA.
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Affiliation(s)
- Daisuke Suzuki
- Department of Biological Production Science, United Graduate School of Agricultural Science, Tokyo University of Agriculture and Technology, Fuchu 183-8509, Tokyo, Japan;
| | - Yoshio Suzuki
- Graduate School of Health and Sports Science, Juntendo University, Inzai 276-1695, Chiba, Japan
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11
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Dvořáková K, Paludo AC, Wagner A, Puda D, Gimunová M, Kumstát M. A literature review of biomarkers used for diagnosis of relative energy deficiency in sport. Front Sports Act Living 2024; 6:1375740. [PMID: 39070233 PMCID: PMC11273787 DOI: 10.3389/fspor.2024.1375740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/17/2024] [Indexed: 07/30/2024] Open
Abstract
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).
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Affiliation(s)
- Kristýna Dvořáková
- Department of Sport Performance and Exercise Testing, Faculty of Sports Studies, Masaryk University, Brno, Czechia
| | - Ana Carolina Paludo
- Department of Sport Performance and Exercise Testing, Faculty of Sports Studies, Masaryk University, Brno, Czechia
| | - Adam Wagner
- Department of Sport Performance and Exercise Testing, Faculty of Sports Studies, Masaryk University, Brno, Czechia
| | - Dominik Puda
- Department of Sport Performance and Exercise Testing, Faculty of Sports Studies, Masaryk University, Brno, Czechia
| | - Marta Gimunová
- Department of Physical Activities and Health Sciences, Faculty of Sports Studies, Masaryk University, Brno, Czechia
| | - Michal Kumstát
- Department of Sport Performance and Exercise Testing, Faculty of Sports Studies, Masaryk University, Brno, Czechia
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12
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McGuire A, Warrington G, Walsh A, Byrne T, Doyle L. Measurement of energy availability in highly trained male endurance athletes and examination of its associations with bone health and endocrine function. Eur J Nutr 2024:10.1007/s00394-024-03433-8. [PMID: 38953963 DOI: 10.1007/s00394-024-03433-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 05/17/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE Despite the introduction of Relative Energy Deficiency in Sport (RED-s) in 2014, there is evidence to suggest that male endurance athletes still present with a high prevalence of low energy availability (LEA). Previous findings suggest that energy availability (EA) status is strongly correlated with impairments in endocrine function such as reduced leptin, triiodothyronine (T3), and insulin, and elevated bone loss. This study aimed to report the current EA status, endocrine function and bone health of highly trained Irish male endurance athletes. METHODS In this cross-sectional study, participants (n = 3 triathletes; n = 10 runners) completed a 7-day testing period during the competition season using lab-based measures, to ascertain EA status, hormone level and rates of bone metabolism. Serum blood samples were obtained to assess hormone levels and markers of bone metabolism. RESULTS Mean EA was < 30 kcal/kg lean body mass (LBM)/day in 76.9% of athletes. There was a strong association between LEA and low carbohydrate intake, and lower LBM. Mean levels of insulin, IGF-1 and leptin were significantly lower than their reference ranges. Elevated mean concentrations of β-CTX and a mean P1NP: β-CTX ratio < 100, indicated a state of bone resorption. CONCLUSION The EA level, carbohydrate intake, hormone status and bone metabolism status of highly trained male endurance athletes are a concern. Based on the findings of this study, more frequent assessment of EA across a season is recommended to monitor the status of male endurance athletes, in conjunction with nutritional education specific to EA and the associated risks.
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Affiliation(s)
- Amy McGuire
- Department of Sport and Early Childhood Studies, Technological University of the Shannon, Limerick, Ireland.
- ACTIVE Research Group, Technological University of the Shannon, Limerick, Ireland.
| | - Giles Warrington
- Department of Physical Education and Social Sciences, University of Limerick, Limerick, Ireland
- Sport and Human Performance Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Adam Walsh
- Department of Sport and Exercise Science, South East Technological University, Cork Road, Waterford, Ireland
| | - Thomas Byrne
- Department of Sport and Exercise Science, South East Technological University, Cork Road, Waterford, Ireland
| | - Lorna Doyle
- Department of Sport and Exercise Science, South East Technological University, Cork Road, Waterford, Ireland
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13
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Jagim AR, Moschelli JS, Woodroffe LM, Horswill CA, Bloomfield SA, Oppliger RA. Contemporary Issue: Health and Safety of Female Wrestlers. Curr Sports Med Rep 2024; 23:262-269. [PMID: 38941548 DOI: 10.1249/jsr.0000000000001183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
ABSTRACT Female wrestling has grown exponentially over the past decade. Within the United States, 46 states now recognize female high school wrestling, and 153 colleges have programs. It is on track to become an NCAA championship-level sport in 2026. A primary health and safety risk among this cohort pertains to rapid weight loss strategies. These can lead to intentional caloric restriction and decreased body fatness, with the perceived goal of attaining a competitive advantage. Low energy availability and low body fatness are associated with a number of health concerns including menstrual dysfunction and loss of bone mineral density in girls and women. The current recommendation of 12% as a minimum for percentage body fat is very likely too low, opening the door for health perturbations among this population. The minimum threshold might more appropriately fall within the range of 18% to 20%. Body fat assessment methods, primarily skinfold measures that are used to guide weight class selection, have not been adequately validated among this population and therefore should be an area of research focus, while also exploring alternative assessment techniques. Further, we recommend that weight cycling, restrictive energy intake, and intentional dehydration be avoided. Research should assess the effects of frequent weight cycling (to "make weight") and prolonged periods of low body fat on the reproductive and bone health of these athletes. Finally, research and clinical evaluations on female wrestlers are limited, and we offer a list of research priorities for future investigation into this contemporary issue.
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Affiliation(s)
- Andrew R Jagim
- Sports Medicine, Mayo Clinic Health System, La Crosse, WI
| | - Jill S Moschelli
- Sports Medicine and Orthopedics, Michigan State University, East Lansing, MI
| | | | - Craig A Horswill
- Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, IL
| | - Susan A Bloomfield
- Kinesiology and Sport Management, Texas A&M University - College Station, TX
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14
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Vardardottir B, Olafsdottir AS, Gudmundsdottir SL. A real-life snapshot: Evaluating exposures to low energy availability in male athletes from various sports. Physiol Rep 2024; 12:e16112. [PMID: 38923409 PMCID: PMC11194298 DOI: 10.14814/phy2.16112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/06/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
Problematic low energy availability (LEA) is the underlying cause of relative energy deficiency in sport (REDs). Male specific etiology, as well as the duration and degree of LEA exposures resulting in REDs remain to be adequately described. The present study aimed to assess occurrences of LEA (energy availability [EA] <25 kcal/kg fat-free mass/day) in male athletes from various sports over 7 days. Associations between number of LEA days, physiological measures, and body image concerns were subsequently evaluated. The athletes recorded their weighed food intakes and training via photo-assisted mobile application. Body composition and resting metabolic rates were measured, and venous blood samples collected for assessments of hormonal and nutrition status. Participants also answered the Low Energy Availability in Males Questionnaire (LEAM-Q), Eating Disorder Examination-Questionnaire Short (EDE-QS), Exercise Addiction Inventory (EAI), and Muscle Dysmorphic Disorder Inventory (MDDI). Of 19 participants, 13 had 0-2, 6 had 3-5, and none had 6-7 LEA days. No associations were found between the number of LEA days with the physiological and body image outcomes, although those with greatest number of LEA days had highest EEE but relatively low dietary intakes. In conclusion, this group displayed considerable day-to-day EA fluctuations but no indication of problematic LEA.
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Affiliation(s)
- Birna Vardardottir
- Faculty of Health Promotion, Sport & Leisure StudiesUniversity of IcelandReykjavikIceland
| | - Anna S. Olafsdottir
- Faculty of Health Promotion, Sport & Leisure StudiesUniversity of IcelandReykjavikIceland
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15
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Vardardottir B, Gudmundsdottir SL, Tryggvadottir EA, Olafsdottir AS. Patterns of energy availability and carbohydrate intake differentiate between adaptable and problematic low energy availability in female athletes. Front Sports Act Living 2024; 6:1390558. [PMID: 38783864 PMCID: PMC11111999 DOI: 10.3389/fspor.2024.1390558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/17/2024] [Indexed: 05/25/2024] Open
Abstract
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.
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16
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Oxfeldt M, Marsi D, Christensen PM, Andersen OE, Johansen FT, Bangshaab M, Risikesan J, Jeppesen JS, Hellsten Y, Phillips SM, Melin AK, Ørtenblad N, Hansen M. Low Energy Availability Followed by Optimal Energy Availability Does Not Benefit Performance in Trained Females. Med Sci Sports Exerc 2024; 56:902-916. [PMID: 38181220 DOI: 10.1249/mss.0000000000003370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
PURPOSE Short periods of reduced energy availability are commonly undertaken by athletes to decrease body mass, possibly improve the power-to-mass ratio, and enhance physical performance. Our primary aim was to investigate the impact of 10 d of low energy availability (LEA) followed by 2 d of optimal energy availability (OEA) on physical performance parameters in trained females. Second, physiological markers at the whole-body and molecular level related to performance were evaluated. METHODS Thirty young trained eumenorrheic females were matched in pairs based on training history and randomized to a 10-d intervention period of LEA (25 kcal·fat-free mass (FFM) -1 ·d -1 ) or OEA (50 kcal·FFM -1 ·d -1 ) along with supervised exercise training. Before the intervention, participants underwent a 5-d run-in period with OEA + supervised exercise training. After the LEA intervention, 2 d of recovery with OEA was completed. Participants underwent muscle biopsies, blood sampling, physical performance tests, body composition measurements, and resting metabolic rate measurements. A linear mixed model was used with group and time as fixed effects and subject as random effects. RESULTS Compared with OEA, LEA resulted in reduced body mass, muscle glycogen content, repeated sprint ability, 4-min time-trial performance, and rate of force development of the knee extensors (absolute values; P < 0.05). Two days of recovery restored 4-min time-trial performance and partly restored repeated sprint ability, but performance remained inferior to the OEA group. When the performance data were expressed relative to body mass, LEA did not enhance performance. CONCLUSIONS Ten days of LEA resulted in impaired performance (absolute values), with concomitant reductions in muscle glycogen. Two days of recovery with OEA partially restored these impairments, although physical performance (absolute values) was still inferior to being in OEA. Our findings do not support the thesis that LEA giving rise to small reductions in body mass improves the power-to-mass ratio and thus increases physical performance.
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Affiliation(s)
- Mikkel Oxfeldt
- Department of Public Health, Aarhus University, Aarhus C, DENMARK
| | - Daniel Marsi
- Department of Public Health, Aarhus University, Aarhus C, DENMARK
| | | | | | | | | | - Jeyanthini Risikesan
- Department of Child and Adolescent Medicine, Regional Hospital Gødstrup, Gødstrup, DENMARK
| | - Jan S Jeppesen
- Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, DENMARK
| | - Ylva Hellsten
- Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, DENMARK
| | - Stuart M Phillips
- Department of Kinesiology, McMaster University, Hamilton, Ontario, CANADA
| | - Anna K Melin
- Department of Sport Science, Linnaeus University, Växjö/Kalmar, SWEDEN
| | - Niels Ørtenblad
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, DENMARK
| | - Mette Hansen
- Department of Public Health, Aarhus University, Aarhus C, DENMARK
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17
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Raiser SN, Schroeder AN, Lawley RJ, Tenforde AS. Bone health and the masters runner. PM R 2024; 16:363-373. [PMID: 38532664 DOI: 10.1002/pmrj.13175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/13/2024] [Accepted: 02/25/2024] [Indexed: 03/28/2024]
Abstract
Masters runners are often defined as those ages 35 years and older who train and compete in running events. These runners represent a growing population of the overall running community and experience running-related injuries including bone stress injuries (BSIs). Similar to younger runners, health considerations in masters runners include the goal to optimize bone health with focus on mitigating age-associated loss of bone strength and preventing BSIs through a combination of ensuring appropriate physical activity, optimizing nutrition, and correcting faulty biomechanics. Importantly, BSIs in masters runners may include characteristics of both overuse injury from insufficient recovery and failure of bone weakened by age-related loss of bone (insufficiency fractures). This narrative review covers the limited available research on strategies to optimize bone health in masters runners. Applying knowledge on masters athletes and extrapolating from other populations, we propose strategies on treatment and prevention of BSIs. Finally, the review highlights gaps in knowledge that require further age-specific discoveries to advance treatment and prevention.
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Affiliation(s)
- Sara N Raiser
- Department of Physical Medicine & Rehabilitation, University of Virginia, Charlottesville, Virginia, USA
| | - Allison N Schroeder
- Department of Orthopedics, University Hospitals and Case Western Reserve University, Cleveland, Ohio, USA
| | - Richard J Lawley
- Department of Physical Medicine & Rehabilitation, Loyola University Medical Center, Maywood, Illinois, USA
| | - Adam S Tenforde
- Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
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18
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O'Leary TJ, Gifford RM, Knight RL, Wright J, Handford S, Venables MC, Reynolds RM, Woods D, Wardle SL, Greeves JP. Sex differences in energy balance, body composition, and metabolic and endocrine markers during prolonged arduous military training. J Appl Physiol (1985) 2024; 136:938-948. [PMID: 38385180 PMCID: PMC11305646 DOI: 10.1152/japplphysiol.00864.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 02/23/2024] Open
Abstract
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.
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Affiliation(s)
- Thomas J O'Leary
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
- Division of Surgery and Interventional Science, UCL, London, United Kingdom
| | - Robert M Gifford
- University/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Rebecca L Knight
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
| | - Jennifer Wright
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
| | - Sally Handford
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
| | - Michelle C Venables
- Medical Research Council, Elsie Widdowson Laboratory, Cambridge, United Kingdom
| | - Rebecca M Reynolds
- University/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - David Woods
- Research and Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, United Kingdom
- Research Institute for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, United Kingdom
- Northumbria and Newcastle NHS Trusts, Wansbeck General and Royal Victoria Infirmary, Newcastle, United Kingdom
| | - Sophie L Wardle
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
- Division of Surgery and Interventional Science, UCL, London, United Kingdom
| | - Julie P Greeves
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
- Division of Surgery and Interventional Science, UCL, London, United Kingdom
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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Lu Y, Lu P, Lin L, Chen H, Zhang F, Li X. Characteristics of bone mineral density in patients with functional hypothalamic amenorrhoea and its association with reproductive hormones and body composition. Clin Endocrinol (Oxf) 2024; 100:358-365. [PMID: 38229276 DOI: 10.1111/cen.15016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/16/2023] [Accepted: 12/23/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE Bone mineral density (BMD) is typically reduced in patients with female athlete triad (FAT) and anorexia nervosa (AN). However, bone health in most patients with functional hypothalamic amenorrhoea (FHA), who may not suffer from severe energy deficiency, has not received adequate attention in clinical practice. This study aimed to investigate BMD and its association with clinical and endocrine features in individuals with FHA and to provide clinical evidence for improving bone loss and preventing osteoporosis in FHA. DESIGN To assess the bone status of patients with FHA and investigate its association with various clinical and endocrinological characteristics. PATIENTS We retrospectively analysed 80 patients with FHA who attended the Obstetrics and Gynecology Hospital of Fudan University from January 2022 to March 2023. MEASUREMENTS The levels of reproductive hormones, including luteinising hormone (LH), follicle-stimulating hormone, oestradiol (E2 ) and total testosterone (TT), were examined at the time of initial diagnosis, and a body composition analyser was used to measure body fat percentage (BF%), lean body mass (LBM) and segmental muscle/fat. Dual-emission X-ray absorptiometry was used to measure lumbar spine BMD and femoral neck BMD in patients with FHA, and the Z score was calculated. RESULTS The study cohort consisted of 80 female patients with FHA. The average age of the patients was 24.64 ± 6.02 years, and their body mass index (BMI) was 19.47 ± 2.86 kg/m2 . The duration of weight loss was 12 (6, 24) months, while the duration of oligo/amenorrhoea was 12 (4.5, 24) months. The mean degree of weight loss was 18.39 ± 9.53%. Low BMD were present in 15% of patients with FHA at the lumbar spine and/or femoral neck; 12.5% and 10% had low bone mass at the lumbar spine and femoral neck, respectively. The low bone mass group experienced a longer period of weight loss than the normal group [24 (16.5, 60) vs. 12 (4.5, 24) months, p = .037]. In addition, the abnormal group had a lower BMR (basal metabolic rate, BMR) [1158 ± 85 vs. 1231 ± 91 kcal/day, p = .011] and lower bone mineral content [2.15 ± 0.26 vs. 2.43 ± 0.31 kg, p = .009] than the normal group. Both LBMD and femoral neck BMD (Fn BMD) were positively correlated with BMI, BF%, LBM, and regional muscle/fat mass (all p < .05). There was also a positive correlation between LBMD and basal LH levels (p = .009) and waist-to-hip ratio (p = .034), whereas Fn BMD was positively correlated with TT levels (p = .029). Multiple linear regression analysis showed that LBM was positively associated with LBMD (β = .007, 95% confidence interval [CI] = 0.004-0.009, p < .001), while trunk muscle mass was positively associated with Fn BMD (β = .046, 95% CI = 0.013-0.080, p = .008). CONCLUSION Fifteen percent of the patients with FHA exhibited low bone mass, a condition associated with prolonged weight loss. The basal LH and TT levels showed positive correlations with LBMD and Fn BMD, respectively. Meanwhile, BMR levels, BMI, BF%, and muscle mass were all positively correlated with LBMD and Fn BMD. Clinically, we should be attentive to suboptimal bone health in patients with FHA and take early screening, diagnosis and intervention measures, especially appropriate muscle mass gain, to prevent the onset of osteoporosis and fragility fractures in the long term.
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Affiliation(s)
- Ye Lu
- Department of Reproductive Endocrinology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Ping Lu
- Department of Obstetrics and Gynecology, Maternity and Child Health Care Hospital of Sheyang County, Jiangsu, China
| | - Lixian Lin
- Department of Obstetrics and Gynecology, The First Hospital of Putian City, Fujian, China
| | - Hang Chen
- Department of Reproductive Endocrinology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Feifei Zhang
- Department of Reproductive Endocrinology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Xin Li
- Department of Reproductive Endocrinology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
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20
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Seidman L, Seidman DS, Constantini NW. Hormonal contraception for female athletes presents special needs and concerns. EUR J CONTRACEP REPR 2024; 29:8-14. [PMID: 38108091 DOI: 10.1080/13625187.2023.2287960] [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] [Received: 08/25/2023] [Accepted: 11/17/2023] [Indexed: 12/19/2023]
Abstract
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.
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Affiliation(s)
- Liron Seidman
- Soroka Medical School, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Daniel S Seidman
- Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama W Constantini
- Heidi Rothberg Sport Medicine Center, Shaare Zedek Medical Center, affiliated to the Hebrew University, Jerusalem, Israel
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21
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Grabia M, Perkowski J, Socha K, Markiewicz-Żukowska R. Female Athlete Triad and Relative Energy Deficiency in Sport (REDs): Nutritional Management. Nutrients 2024; 16:359. [PMID: 38337644 PMCID: PMC10857508 DOI: 10.3390/nu16030359] [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] [Received: 11/23/2023] [Revised: 01/18/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
The female athlete triad (TRIAD) is a spectrum of disorders involving low energy availability (LEA), low bone mineral density, and menstrual disorders. It is increasingly common to use the term 'relative energy deficiency in sport' (RED), emphasising the extensive impact of LEA on the body. The aim of this narrative review was to gather original research encompassing female athletes across various sports as well as to collect findings on the potential of a nutrition-focused approach to prevent or treat the aforementioned disorders. A comprehensive search was conducted in PubMed and Scopus. Several challenges were identified regarding the adequacy of the energy availability, protein, and carbohydrate requirements in the diets of female athletes. Moreover, insufficient intake of vitamin D has been observed across all athlete groups studied. This insufficiency also extends to the average requirement for Ca, Mg, the Ca/P ratio, Zn, and Fe. To address those concerns, a nutritional approach is proposed in the latter part of this review. The factors that can improve the absorption of micronutrients have also been discussed. The TRIAD/REDs affect an ever-growing number of women and require appropriate therapeutic management, particularly through nutritional care. Therefore, cooperation within an interdisciplinary team comprising a physician, nutritionist, physiotherapist, and psychologist is crucial.
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Affiliation(s)
- Monika Grabia
- Department of Bromatology, Faculty of Pharmacy with the Division of Laboratory Medicine, Medical University of Białystok, 2D Mickiewicza Street, 15-222 Białystok, Poland (K.S.)
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22
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Lebron MA, Stout JR, Fukuda DH. Physiological Perturbations in Combat Sports: Weight Cycling and Metabolic Function-A Narrative Review. Metabolites 2024; 14:83. [PMID: 38392975 PMCID: PMC10890020 DOI: 10.3390/metabo14020083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/12/2024] [Accepted: 01/21/2024] [Indexed: 02/25/2024] Open
Abstract
Combat sports athletes seeking a competitive edge often engage in weight management practices to become larger than their opponents, which ultimately includes periods of gradual weight loss, rapid weight loss, and weight regain. This pattern of weight loss and regain is known as weight cycling and often includes periods of low energy availability, making combat sports athletes susceptible to metabolic dysfunction. This narrative review represents an effort to explore the metabolic perturbations associated with weight cycling and outline the short-, medium-, and long-term effects on metabolic flexibility, function, and health. The short-term effects of rapid weight loss, such as a reduced metabolic rate and alterations to insulin and leptin levels, may prelude the more pronounced metabolic disturbances that occur during weight regain, such as insulin resistance. Although definitive support is not currently available, this cycle of weight loss and regain and associated metabolic changes may contribute to metabolic syndrome or other metabolic dysfunctions over time.
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Affiliation(s)
- Modesto A Lebron
- Physiology of Work and Exercise Response Laboratory, Institute of Exercise Physiology and Rehabilitation Science, University of Central Florida, Orlando, FL 32816, USA
| | - Jeffrey R Stout
- Physiology of Work and Exercise Response Laboratory, Institute of Exercise Physiology and Rehabilitation Science, University of Central Florida, Orlando, FL 32816, USA
| | - David H Fukuda
- Physiology of Work and Exercise Response Laboratory, Institute of Exercise Physiology and Rehabilitation Science, University of Central Florida, Orlando, FL 32816, USA
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23
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Melin AK, Areta JL, Heikura IA, Stellingwerff T, Torstveit MK, Hackney AC. Direct and indirect impact of low energy availability on sports performance. Scand J Med Sci Sports 2024; 34:e14327. [PMID: 36894187 DOI: 10.1111/sms.14327] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/27/2023] [Accepted: 02/01/2023] [Indexed: 03/11/2023]
Abstract
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.
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Affiliation(s)
- Anna K Melin
- Department of Sport Science, Faculty of Social Sciences, Swedish Olympic Committee Research Fellow, Linnaeus University, Växjö/Kalmar, Sweden
| | - José L Areta
- School of Sport and Exercise Sciences, Faculty of Science, Liverpool John Moores University, Liverpool, UK
| | - Ida A Heikura
- Canadian Sport Institute - Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Trent Stellingwerff
- Canadian Sport Institute - Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Monica Klungland Torstveit
- Department of Sport Science and Physical Education, Faculty of Health and Sport Science, University of Agder, Kristiansand, Norway
| | - Anthony C Hackney
- Department of Exercise & Sport Science, University of North Carolina, Chapel Hill, North Carolina, USA
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24
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Kettunen O, Mikkonen R, Linnamo V, Mursu J, Kyröläinen H, Ihalainen JK. Nutritional intake and anthropometric characteristics are associated with endurance performance and markers of low energy availability in young female cross-country skiers. J Int Soc Sports Nutr 2023; 20:2226639. [PMID: 37342913 DOI: 10.1080/15502783.2023.2226639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 06/12/2023] [Indexed: 06/23/2023] Open
Abstract
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 (VO2max), 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 VO2max (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 VO2max 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.
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Affiliation(s)
- Oona Kettunen
- Faculty of Sport and Health Sciences, University of Jyväskylä, Vuokatti, Finland
| | - Ritva Mikkonen
- Faculty of Sport and Health Sciences, University of Jyväskylä, Vuokatti, Finland
| | - Vesa Linnamo
- Faculty of Sport and Health Sciences, University of Jyväskylä, Vuokatti, Finland
| | - Jaakko Mursu
- Faculty of Sport and Health Sciences, University of Jyväskylä, Vuokatti, Finland
| | - Heikki Kyröläinen
- Faculty of Sport and Health Sciences, University of Jyväskylä, Vuokatti, Finland
| | - Johanna K Ihalainen
- Faculty of Sport and Health Sciences, University of Jyväskylä, Vuokatti, Finland
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25
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Castellanos-Mendoza MC, Galloway SDR, Witard OC. Free-living competitive racewalkers and runners with energy availability estimates of <35 kcal·kg fat-free mass -1·day -1 exhibit peak serum progesterone concentrations indicative of ovulatory disturbances: a pilot study. Front Sports Act Living 2023; 5:1279534. [PMID: 38046932 PMCID: PMC10690956 DOI: 10.3389/fspor.2023.1279534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/17/2023] [Indexed: 12/05/2023] Open
Abstract
Introduction The release of luteinising hormone (LH) before ovulation is disrupted during a state of low energy availability (EA). However, it remains unknown whether a threshold EA exists in athletic populations to trigger ovulatory disturbances (anovulation and luteal phase deficiency) as indicated by peak/mid-luteal serum progesterone concentration (Pk-PRG) during the menstrual cycle. Methods We assessed EA and Pk-PRG in 15 menstrual cycles to investigate the relationship between EA and Pk-PRG in free-living, competitive (trained-elite) Guatemalan racewalkers (n = 8) and runners (n = 7) [aged: 20 (14-41) years; post-menarche: 5 (2-26) years; height: 1.53 ± 0.09 m; mass: 49 ± 6 kg (41 ± 5 kg fat-free mass "FFM")]. EA was estimated over 7 consecutive days within the follicular phase using food, training, and physical activity diaries. A fasted blood sample was collected during the Pk-PRG period, 6-8 days after the LH peak, but before the final 2 days of each cycle. Serum progesterone concentration was quantified using electrochemiluminescence immunoassay. Results Participants that reported an EA of <35 kcal·kg FFM-1·day-1 (n = 7) exhibited ovulatory disturbances (Pk-PRG ≤9.40 ng·mL-1). Athletes with EA ≥36 kcal·kg FFM-1·day-1 (n = 8) recorded "normal"/"potentially fertile" cycles (Pk-PRG >9.40 ng·mL-1), except for a single racewalker with the lowest reported protein intake (1.1 g·kg body mass-1·day-1). EA was positively associated with Pk-PRG [r(9) = 0.79, 95% confidence interval (CI): 0.37-0.94; p = 0.003; 1 - β = 0.99] after excluding participants (n = 4) that likely under-reported/reduced their dietary intake. Conclusions The result from the linear regression analysis suggests that an EA ≥ 36 kcal·kg FFM-1·day-1 is required to achieve "normal ovulation." The threshold EA associated with ovulatory disturbances in athletes and non-invasive means of monitoring the ovulatory status warrant further research.
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Affiliation(s)
- M. Carolina Castellanos-Mendoza
- Physiology, Exercise and Nutrition Research Group, Faculty of Health Sciences and Sport, University of Stirling, Stirling, United Kingdom
| | - Stuart D. R. Galloway
- Physiology, Exercise and Nutrition Research Group, Faculty of Health Sciences and Sport, University of Stirling, Stirling, United Kingdom
| | - Oliver C. Witard
- Centre for Human and Applied Physiological Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
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26
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Areta JL. Physical performance during energy deficiency in humans: An evolutionary perspective. Comp Biochem Physiol A Mol Integr Physiol 2023; 284:111473. [PMID: 37406958 DOI: 10.1016/j.cbpa.2023.111473] [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] [Received: 03/07/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 07/07/2023]
Abstract
Energy deficiency profoundly disrupts normal endocrinology, metabolism, and physiology, resulting in an orchestrated response for energy preservation. As such, despite energy deficit is typically thought as positive for weight-loss and treatment of cardiometabolic diseases during the current obesity pandemic, in the context of contemporary sports and exercise nutrition, chronic energy deficiency is associated to negative health and athletic performance consequences. However, the evidence of energy deficit negatively affecting physical capacity and sports performance is unclear. While severe energy deficiency can negatively affect physical capacity, humans can also improve aerobic fitness and strength while facing significant energy deficit. Many athletes, also, compete at an elite and world-class level despite showing clear signs of energy deficiency. Maintenance of high physical capacity despite the suppression of energetically demanding physiological traits seems paradoxical when an evolutionary viewpoint is not considered. Humans have evolved facing intermittent periods of food scarcity in their natural habitat and are able to thrive in it. In the current perspective it is argued that when facing limited energy availability, maintenance of locomotion and physical capacity are of high priority given that they are essential for food procurement for survival in the habitat where humans evolved. When energetic resources are limited, energy may be allocated to tasks essential for survival (e.g. locomotion) while minimising energy allocation to traits that are not (e.g. growth and reproduction). The current perspective provides a model of energy allocation during energy scarcity supported by observation of physiological and metabolic responses that are congruent with this paradigm.
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Affiliation(s)
- José L Areta
- Research Institute for Sport and Exercise Sciences, School of Sport and Exercise Sciences, Liverpool John Moores University, UK.
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27
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Wyatt PM, Drager K, Groves EM, Stellingwerff T, Billington EO, Boyd SK, Burt LA. Comparison of Bone Quality Among Winter Endurance Athletes with and Without Risk Factors for Relative Energy Deficiency in Sport (REDs): A Cross-Sectional Study. Calcif Tissue Int 2023; 113:403-415. [PMID: 37578531 DOI: 10.1007/s00223-023-01120-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/29/2023] [Indexed: 08/15/2023]
Abstract
Relative Energy Deficiency in Sport (REDs) is a syndrome describing the relationship between prolonged and/or severe low energy availability and negative health and performance outcomes. The high energy expenditures incurred during training and competition put endurance athletes at risk of REDs. The objective of this study was to investigate differences in bone quality in winter endurance athletes classified as either low-risk versus at-risk for REDs. Forty-four participants were recruited (M = 18; F = 26). Bone quality was assessed at the distal radius and tibia using high resolution peripheral quantitative computed tomography (HR-pQCT), and at the hip and spine using dual X-ray absorptiometry (DXA). Finite element analysis was used to estimate bone strength. Participants were grouped using modified criteria from the REDs Clinical Assessment Tool Version 1. Fourteen participants (M = 3; F = 11), were classified as at-risk of REDs (≥ 3 risk factors). Measured with HR-pQCT, cortical bone area (radius) and bone strength (radius and tibia) were 6.8%, 13.1% and 10.3% lower (p = 0.025, p = 0.033, p = 0.027) respectively, in at-risk compared with low-risk participants. Using DXA, femoral neck areal bone density was 9.4% lower in at-risk compared with low-risk participants (p = 0.005). At-risk male participants had 21.9% lower femoral neck areal bone density (via DXA) than low-risk males (p = 0.020) with no significant differences in females. Overall, 33.3% of athletes were at-risk for REDs and had lower bone quality than those at low-risk.
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Affiliation(s)
- Paige M Wyatt
- McCaig Institute for Bone and Joint Health, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Canadian Sport Institute Calgary, Calgary, AB, Canada
| | - Kelly Drager
- Canadian Sport Institute Calgary, Calgary, AB, Canada
| | - Erik M Groves
- Canadian Sport Institute Calgary, Calgary, AB, Canada
| | - Trent Stellingwerff
- Canadian Sport Institute Pacific, Victoria, BC, Canada
- Department of Exercise Science, Physical and Health Education, University of Victoria, Victoria, BC, Canada
| | - Emma O Billington
- McCaig Institute for Bone and Joint Health, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Steven K Boyd
- McCaig Institute for Bone and Joint Health, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lauren A Burt
- McCaig Institute for Bone and Joint Health, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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28
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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: 12] [Impact Index Per Article: 12.0] [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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29
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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: 47] [Impact Index Per Article: 47.0] [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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30
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Burke LM, Ackerman KE, Heikura IA, Hackney AC, Stellingwerff T. Mapping the complexities of Relative Energy Deficiency in Sport (REDs): development of a physiological model by a subgroup of the International Olympic Committee (IOC) Consensus on REDs. Br J Sports Med 2023; 57:1098-1108. [PMID: 37752007 DOI: 10.1136/bjsports-2023-107335] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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
The 2023 International Olympic Committee (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs) notes that exposure to low energy availability (LEA) exists on a continuum between adaptable and problematic LEA, with a range of potential effects on both health and performance. However, there is variability in the outcomes of LEA exposure between and among individuals as well as the specific manifestations of REDs. We outline a framework for a 'systems biology' examination of the effect of LEA on individual body systems, with the eventual goal of creating an integrated map of body system interactions. We provide a template that systematically identifies characteristics of LEA exposure (eg, magnitude, duration, origin) and a variety of moderating factors (eg, medical history, diet and training characteristics) that could exacerbate or attenuate the type and severity of impairments to health and performance faced by an individual athlete. The REDs Physiological Model may assist the diagnosis of underlying causes of problems associated with LEA, with a personalised and nuanced treatment plan promoting compliance and treatment efficacy. It could also be used in the strategic prevention of REDs by drawing attention to scenarios of LEA in which impairments of health and performance are most likely, based on knowledge of the characteristics of the LEA exposure or moderating factors that may increase the risk of harmful outcomes. We challenge researchers and practitioners to create a unifying and dynamic physiological model for each body system that can be continuously updated and mapped as knowledge is gained.
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Affiliation(s)
- Louise M Burke
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ida A Heikura
- Canadian Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Anthony C Hackney
- Department of Exercise & Sport Science, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Trent Stellingwerff
- Canadian Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
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Hutson MJ, O'Donnell E, Brooke-Wavell K, James LJ, Raleigh CJ, Carson BP, Sale C, Blagrove RC. High-impact jumping mitigates the short-term effects of low energy availability on bone resorption but not formation in regularly menstruating females: A randomized control trial. Scand J Med Sci Sports 2023; 33:1690-1702. [PMID: 37365858 DOI: 10.1111/sms.14437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
Low energy availability (LEA) is prevalent in active individuals and negatively impacts bone turnover in young females. High-impact exercise can promote bone health in an energy efficient manner and may benefit bone during periods of LEA. Nineteen regularly menstruating females (aged 18-31 years) participated in two three-day conditions providing 15 (LEA) and 45 kcals kg fat-free mass-1 day-1 (BAL) of energy availability, each beginning 3 ± 1 days following the self-reported onset of menses. Participants either did (LEA+J, n = 10) or did not (LEA, n = 9) perform 20 high-impact jumps twice per day during LEA, with P1NP, β-CTx (circulating biomarkers of bone formation and resorption, respectively) and other markers of LEA measured pre and post in a resting and fasted state. Data are presented as estimated marginal mean ± 95% CI. P1NP was significantly reduced in LEA (71.8 ± 6.1-60.4 ± 6.2 ng mL-1 , p < 0.001, d = 2.36) and LEA+J (93.9 ± 13.4-85.2 ± 12.3 ng mL-1 , p < 0.001, d = 1.66), and these effects were not significantly different (time by condition interaction: p = 0.269). β-CTx was significantly increased in LEA (0.39 ± 0.09-0.46 ± 0.10 ng mL-1 , p = 0.002, d = 1.11) but not in LEA+J (0.65 ± 0.08-0.65 ± 0.08 ng mL-1 , p > 0.999, d = 0.19), and these effects were significantly different (time by condition interaction: p = 0.007). Morning basal bone formation rate is reduced following 3 days LEA, induced via dietary restriction, with or without high-impact jumping in regularly menstruating young females. However, high-impact jumping can prevent an increase in morning basal bone resorption rate and may benefit long-term bone health in individuals repeatedly exposed to such bouts.
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Affiliation(s)
- Mark J Hutson
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
- School of Sport, Faculty of Life and Health Sciences, Ulster University, Coleraine, UK
| | - Emma O'Donnell
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | | | - Lewis J James
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Conor J Raleigh
- Department of Physical Education & Sport Sciences, University of Limerick, Limerick, Ireland
| | - Brian P Carson
- Department of Physical Education & Sport Sciences, University of Limerick, Limerick, Ireland
| | - Craig Sale
- Department of Sport and Exercise Sciences, Institute of Sport, Manchester Metropolitan University, Manchester, UK
| | - Richard C Blagrove
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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Oxfeldt M, Phillips SM, Andersen OE, Johansen FT, Bangshaab M, Risikesan J, McKendry J, Melin AK, Hansen M. Low energy availability reduces myofibrillar and sarcoplasmic muscle protein synthesis in trained females. J Physiol 2023; 601:3481-3497. [PMID: 37329147 DOI: 10.1113/jp284967] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/14/2023] [Indexed: 06/18/2023] Open
Abstract
Low energy availability (LEA) describes a state where the energy intake is insufficient to cover the energy costs of both exercise energy expenditure and basal physiological body functions. LEA has been associated with various physiological consequences, such as reproductive dysfunction. However, the effect of LEA on skeletal muscle protein synthesis in females performing exercise training is still poorly understood. We conducted a randomized controlled trial to investigate the impact of LEA on daily integrated myofibrillar and sarcoplasmic muscle protein synthesis in trained females. Thirty eumenorrheic females were matched based on training history and randomized to undergo 10 days of LEA (25 kcal · kg fat-free mass (FFM)-1 · day-1 ) or optimal energy availability (OEA, 50 kcal · kg FFM-1 · day-1 ). Before the intervention, both groups underwent a 5-day 'run-in' period with OEA. All foods were provided throughout the experimental period with a protein content of 2.2 g kg lean mass-1 · day-1 . A standardized, supervised combined resistance and cardiovascular exercise training programme was performed over the experimental period. Daily integrated muscle protein synthesis was measured by deuterium oxide (D2 O) consumption along with changes in body composition, resting metabolic rate, blood biomarkers and 24 h nitrogen balance. We found that LEA reduced daily integrated myofibrillar and sarcoplasmic muscle protein synthesis compared with OEA. Concomitant reductions were observed in lean mass, urinary nitrogen balance, free androgen index, thyroid hormone concentrations and resting metabolic rate following LEA. These results highlight that LEA may negatively affect skeletal muscle adaptations in females performing exercise training. KEY POINTS: Low energy availability (LEA) with potential health and performance impairments is widespread among female athletes. We investigated the impact of 10 days of LEA on daily integrated myofibrillar and sarcoplasmic muscle protein synthesis in young, trained females. We show that LEA impairs myofibrillar and sarcoplasmic muscle protein synthesis in trained females performing exercise training. These findings suggest that LEA may have negative consequences for skeletal muscle adaptations and highlight the importance of ensuring adequate energy availability in female athletes.
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Affiliation(s)
- Mikkel Oxfeldt
- Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - Stuart M Phillips
- Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Ole Emil Andersen
- Department of Public Health, Aarhus University, Aarhus C, Denmark
- Steno Diabetes Center Aarhus, Aarhus University, Aarhus, Denmark
| | | | - Maj Bangshaab
- Steno Diabetes Center Aarhus, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark
| | - Jeyanthini Risikesan
- Department of Child and Adolescent Medicine, Regional Hospital Gødstrup, Gødstrup, Denmark
| | - James McKendry
- Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | | | - Mette Hansen
- Department of Public Health, Aarhus University, Aarhus C, Denmark
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BURKE LOUISEM, WHITFIELD JAMIE, ROSS MEGANLR, TEE NICOLIN, SHARMA AVISHP, KING ANDYJ, HEIKURA IDAA, MORABITO AIMEE, MCKAY ALANNAHKA. Short Severe Energy Restriction with Refueling Reduces Body Mass without Altering Training-Associated Performance Improvement. Med Sci Sports Exerc 2023; 55:1487-1498. [PMID: 36940222 PMCID: PMC10348613 DOI: 10.1249/mss.0000000000003169] [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: 03/21/2023]
Abstract
PURPOSE We investigated short-term (9 d) exposure to low energy availability (LEA) in elite endurance athletes during a block of intensified training on self-reported well-being, body composition, and performance. METHODS Twenty-three highly trained race walkers undertook an ~3-wk research-embedded training camp during which they undertook baseline testing and 6 d of high energy/carbohydrate (HCHO) availability (40 kcal·kg FFM -1 ·d -1 ) before being allocated to 9 d continuation of this diet ( n = 10 M, 2 F) or a significant decrease in energy availability to 15 kcal·kg FFM -1 ·d -1 (LEA: n = 10 M, 1 F). A real-world 10,000-m race walking event was undertaken before (baseline) and after (adaptation) these phases, with races being preceded by standardized carbohydrate fueling (8 g·kg body mass [BM] -1 for 24 h and 2 g·kg BM -1 prerace meal). RESULTS Dual-energy x-ray absorptiometry-assessed body composition showed BM loss (2.0 kg, P < 0.001), primarily due to a 1.6-kg fat mass reduction ( P < 0.001) in LEA, with smaller losses (BM = 0.9 kg, P = 0.008; fat mass = 0.9 kg, P < 0.001) in HCHO. The 76-item Recovery-Stress Questionnaire for Athletes, undertaken at the end of each dietary phase, showed significant diet-trial effects for overall stress ( P = 0.021), overall recovery ( P = 0.024), sport-specific stress ( P = 0.003), and sport-specific recovery ( P = 0.012). However, improvements in race performance were similar: 4.5% ± 4.1% and 3.5% ± 1.8% for HCHO and LEA, respectively ( P < 0.001). The relationship between changes in performance and prerace BM was not significant ( r = -0.08 [-0.49 to 0.35], P = 0.717). CONCLUSIONS A series of strategically timed but brief phases of substantially restricted energy availability might achieve ideal race weight as part of a long-term periodization of physique by high-performance athletes, but the relationship between BM, training quality, and performance in weight-dependent endurance sports is complicated.
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Affiliation(s)
- LOUISE M. BURKE
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, AUSTRALIA
| | - JAMIE WHITFIELD
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, AUSTRALIA
| | - MEGAN L. R. ROSS
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, AUSTRALIA
| | - NICOLIN TEE
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, AUSTRALIA
| | | | - ANDY J. KING
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, AUSTRALIA
| | - IDA A. HEIKURA
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, AUSTRALIA
- Canadian Sport Institute–Pacific, Victoria, British Columbia, CANADA
- Exercise Science, Physical and Health Education, University of Victoria, Victoria, British Columbia, CANADA
| | - AIMEE MORABITO
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, AUSTRALIA
| | - ALANNAH K. A. MCKAY
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, AUSTRALIA
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Dyches KD, Friedl KE, Greeves JP, Keller MF, McClung HL, McGurk MS, Popp KL, Teyhen DS. Physiology of Health and Performance: Enabling Success of Women in Combat Arms Roles. Mil Med 2023; 188:19-31. [PMID: 37490562 DOI: 10.1093/milmed/usac256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 02/28/2022] [Accepted: 08/16/2022] [Indexed: 07/27/2023] Open
Abstract
INTRODUCTION The modern female soldier has yet to be fully characterized as she steps up to fill new combat roles that have only recently been opened to women. Both U.S. and U.K. military operational research efforts are supporting a science-based evolution of physical training and standards for female warfighters. The increasing representation of women in all military occupations makes it possible to discover and document the limits of female physiological performance. METHOD An informal Delphi process was used to synthesize an integrated concept of current military female physiological research priorities and emerging findings using a panel of subject matter experts who presented their research and perspectives during the second Women in Combat Summit hosted by the TriService Nursing Research Program in February 2021. RESULTS The physical characteristics of the modern soldier are changing as women train for nontraditional military roles, and they are emerging as stronger and leaner. Capabilities and physique will likely continue to evolve in response to new Army standards and training programs designed around science-based sex-neutral requirements. Strong bones may be a feature of the female pioneers who successfully complete training and secure roles traditionally reserved for men. Injury risk can be reduced by smarter, targeted training and with attention directed to female-specific hormonal status, biomechanics, and musculoskeletal architecture. An "estrogen advantage" appears to metabolically support enhanced mental endurance in physically demanding high-stress field conditions; a healthy estrogen environment is also essential for musculoskeletal health. The performance of female soldiers can be further enhanced by attention to equipment that serves their needs with seemingly simple solutions such as a suitable sports bra and personal protective equipment that accommodates the female anatomy. CONCLUSIONS Female physiological limits and performance have yet to be adequately defined as women move into new roles that were previously developed and reserved for men. Emerging evidence indicates much greater physical capacity and physiological resilience than previously postulated.
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Affiliation(s)
- Karmon D Dyches
- Military Operational Medicine Research Program, U.S. Army Medical Research and Development Command, Fort Detrick, MD 21702, USA
| | - Karl E Friedl
- Biophysics and Biomedical Modeling Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
| | - Julie P Greeves
- Department of Army Health and Performance Research (AHPR), British Army, Andover, Hampshire SP11 8HT, UK
| | - Margaux F Keller
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
| | - Holly L McClung
- Biophysics and Biomedical Modeling Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
| | - Michael S McGurk
- Research and Analysis Directorate, U.S. Army Center for Initial Military Training, Fort Eustis, VA 23604, USA
| | - Kristin L Popp
- Military Performance Division, U.S. Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
| | - Deydre S Teyhen
- Chief, U.S. Army Medical Specialist Corps, U.S. Army Medical Command, Falls Church, VA 22042, USA
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Raj RD, Fontalis A, Grandhi TSP, Kim WJ, Gabr A, Haddad FS. The impact of the menstrual cycle on orthopaedic sports injuries in female athletes. Bone Joint J 2023; 105-B:723-728. [PMID: 37391203 DOI: 10.1302/0301-620x.105b7.bjj-2022-1262.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
There is a disparity in sport-related injuries between sexes, with females sustaining non-contact musculoskeletal injuries at a higher rate. Anterior cruciate ligament ruptures are between two and eight times more common than in males, and females also have a higher incidence of ankle sprains, patellofemoral pain, and bone stress injuries. The sequelae of such injuries can be devastating to an athlete, resulting in time out of sport, surgery, and the early onset of osteoarthritis. It is important to identify the causes of this disparity and introduce prevention programmes to reduce the incidence of these injuries. A natural difference reflects the effect of reproductive hormones in females, which have receptors in certain musculoskeletal tissues. Relaxin increases ligamentous laxity. Oestrogen decreases the synthesis of collagen and progesterone does the opposite. Insufficient diet and intensive training can lead to menstrual irregularities, which are common in female athletes and result in injury, whereas oral contraception may have a protective effect against certain injuries. It is important for coaches, physiotherapists, nutritionists, doctors, and athletes to be aware of these issues and to implement preventive measures. This annotation explores the relationship between the menstrual cycle and orthopaedic sports injuries in pre-menopausal females, and proposes recommendations to mitigate the risk of sustaining these injuries.
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Affiliation(s)
- Rhody D Raj
- Department of Trauma & Orthopaedic Surgery, University College Hospital, London, UK
| | - Andreas Fontalis
- Department of Trauma & Orthopaedic Surgery, University College Hospital, London, UK
| | - Tarani S P Grandhi
- Department of Trauma & Orthopaedic Surgery, University College Hospital, London, UK
| | - Woo J Kim
- Department of Trauma & Orthopaedic Surgery, University College Hospital, London, UK
| | - Ayman Gabr
- Department of Trauma & Orthopaedic Surgery, University College Hospital, London, UK
| | - Fares S Haddad
- Department of Trauma & Orthopaedic Surgery, University College Hospital, London, UK
- The Bone & Joint Journal , London, UK
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O'Leary TJ, Coombs CV, Perrett C, Double RL, Keay N, Wardle SL, Greeves JP. Menstrual Function, Eating Disorders, Low Energy Availability, and Musculoskeletal Injuries in British Servicewomen. Med Sci Sports Exerc 2023; 55:1307-1316. [PMID: 36893306 DOI: 10.1249/mss.0000000000003154] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
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.
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Affiliation(s)
| | - Charlotte V Coombs
- Army Health and Performance Research, Army Headquarters, Andover, UNITED KINGDOM
| | - Caitlin Perrett
- Division of Surgery and Interventional Science, UCL, London, UNITED KINGDOM
| | - Rebecca L Double
- Army Health and Performance Research, Army Headquarters, Andover, UNITED KINGDOM
| | - Nicky Keay
- Division of Medicine, UCL, London, UNITED KINGDOM
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Bloomfield SA, Swift SN, Metzger CE, Baek K, De Souza MJ, Lenfest S, Shirazi-Fard Y, Hogan HA. Exercise training modifies the bone and endocrine response to graded reductions in energy availability in skeletally mature female rodents. Front Endocrinol (Lausanne) 2023; 14:1141906. [PMID: 37455901 PMCID: PMC10338226 DOI: 10.3389/fendo.2023.1141906] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 05/23/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction Reductions in energy availability leading to weight loss can induce loss of bone and impact important endocrine regulators of bone integrity. We sought to elucidate whether endurance exercise (EX) can mitigate bone loss observed in sedentary (SED) skeletally mature rodents subjected to graded energy deficits. Methods Female virgin rats (n=84, 5-mo-old; 12/group) were randomized to baseline controls and either sedentary (SED) or exercise (EX) conditions, and within each exercise status to adlib-fed (ADLIB), or moderate (MOD) or severe (SEV) energy restriction diets for 12 weeks. Rats assigned to EX groups performed treadmill running to increase weekly energy expenditure by 10%. MOD-ER-SED, SEV-ER-SED, MOD-ER-EX and SEV-ER-EX were fed modified AIN93M diets with 20%, 40% 10%, and 30% less energy content, respectively, with 100% of all other nutrients provided. Results Energy availability (EA) was effectively reduced by ~14% and ~30% in the MOD-ER and SEV-ER groups, respectively. MOD-ER for 12 weeks resulted in few negative impacts on bone and, except for serum leptin in MOD-ER-SED rats, no significant changes in endocrine factors. By contrast, SEV-ER in SED rats resulted in significantly lower total body and femoral neck bone mass, and reduced serum estradiol, IGF-1 and leptin. EX rats experiencing the same reduction in energy availability as SEV-ER-SED exhibited higher total body mass, lean mass, total BMC, and higher serum IGF-1 at the end of 12 weeks. Bone mechanical properties at 3 bone sites (mid-femur, distal femur, femoral neck) were minimally impacted by ER but positively affected by EX. Discussion These findings indicate that combining increased EX energy expenditure with smaller reductions in energy intake to achieve a targeted reduction in EA provides some protection against loss of bone mass and lean mass in skeletally mature female rats, likely due to better preservation of circulating IGF-1, and that bone mechanical integrity is not significantly degraded with either moderate or severe reduced EA.
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Affiliation(s)
- Susan A. Bloomfield
- Bone Biology Laboratory, Department of Kinesiology & Sport Management, Texas A&M University, College Station, TX, United States
- Bone Biology Laboratory, Department of Nutrition, Texas A&M University, College Station, TX, United States
| | - Sibyl N. Swift
- Bone Biology Laboratory, Department of Nutrition, Texas A&M University, College Station, TX, United States
| | - Corinne E. Metzger
- Bone Biology Laboratory, Department of Kinesiology & Sport Management, Texas A&M University, College Station, TX, United States
| | - Kyunghwa Baek
- Bone Biology Laboratory, Department of Nutrition, Texas A&M University, College Station, TX, United States
| | - Mary Jane De Souza
- Women’s Health and Exercise Laboratory, Department of Kinesiology, The Pennsylvania State University, University Park, PA, United States
- Women’s Health and Exercise Laboratory, Department of Physiology, The Pennsylvania State University, University Park, PA, United States
| | - Scott Lenfest
- Bone Mechanics Laboratory, Department of Mechanical Engineering, Texas A&M University, College Station, TX, United States
| | - Yasaman Shirazi-Fard
- Bone Mechanics Laboratory, Department of Mechanical Engineering, Texas A&M University, College Station, TX, United States
| | - Harry A. Hogan
- Bone Mechanics Laboratory, Department of Mechanical Engineering, Texas A&M University, College Station, TX, United States
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Fredericson M, Roche M, Barrack MT, Tenforde A, Sainani K, Kraus E, Kussman A, Miller Olson E, Kim BY, Fahy K, Miller E, Diamond E, Meraz S, Singh S, Nattiv A. Healthy Runner Project: a 7-year, multisite nutrition education intervention to reduce bone stress injury incidence in collegiate distance runners. BMJ Open Sport Exerc Med 2023; 9:e001545. [PMID: 37180969 PMCID: PMC10174024 DOI: 10.1136/bmjsem-2023-001545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2023] [Indexed: 05/16/2023] Open
Abstract
Objectives We evaluated the effect of a nutrition education intervention on bone stress injury (BSI) incidence among female distance runners at two NCAA Division I institutions. Methods Historical BSI rates were measured retrospectively (2010-2013); runners were then followed prospectively in pilot (2013-2016) and intervention (2016-2020) phases. The primary aim was to compare BSI rates in the historical and intervention phases. Pilot phase data are included only for descriptive purposes. The intervention comprised team nutrition presentations focused on optimising energy availability plus individualised nutrition sessions for runners with elevated Female Athlete Triad risk. Annual BSI rates were calculated using a generalised estimating equation Poisson regression model adjusted for age and institution. Post hoc analyses were stratified by institution and BSI type (trabecular-rich or cortical-rich). Results The historical phase included 56 runners and 90.2 person-years; the intervention phase included 78 runners and 137.3 person-years. Overall BSI rates were not reduced from the historical (0.52 events per person-year) to the intervention (0.43 events per person-year) phase. Post hoc analyses demonstrated trabecular-rich BSI rates dropped significantly from 0.18 to 0.10 events per person-year from the historical to intervention phase (p=0.047). There was a significant interaction between phase and institution (p=0.009). At Institution 1, the overall BSI rate dropped from 0.63 to 0.27 events per person-year from the historical to intervention phase (p=0.041), whereas no decline was observed at Institution 2. Conclusion Our findings suggest that a nutrition intervention emphasising energy availability may preferentially impact trabecular-rich BSI and depend on team environment, culture and resources.
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Affiliation(s)
- Michael Fredericson
- Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, Stanford, California, USA
| | - Megan Roche
- Department of Epidemiology, Stanford Hospital and Clinics, Stanford, California, USA
| | - Michelle T Barrack
- Department of Family and Consumer Sciences, California State University Long Beach, Long Beach, California, USA
| | - Adam Tenforde
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | - Kristin Sainani
- Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
| | - Emily Kraus
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Stanford, California, USA
| | - Andrea Kussman
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Stanford, California, USA
| | | | - Brian Young Kim
- Family Medicine, University of California, Los Angeles, Santa Monica, California, USA
| | - Katherine Fahy
- Department of Family Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Emily Miller
- Family Medicine, University of California, Los Angeles, Santa Monica, California, USA
| | - Ellie Diamond
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Sonya Meraz
- School of Nursing, University of Massachusetts System, Boston, Massachusetts, USA
| | - Sonal Singh
- School of Medicine, St George’s University, St George’s, Grenada
| | - Aurelia Nattiv
- Division of Sports Medicine, Departments of Family Medicine and Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
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Barrack MT, Domino S, Gray VB, Cotter JA, Rauh MJ, Nichols JF. Support for inadvertent undereating in female adolescent athletes with clinical indicators of low energy availability. J Sci Med Sport 2023:S1440-2440(23)00072-5. [PMID: 37248163 DOI: 10.1016/j.jsams.2023.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 05/31/2023]
Abstract
OBJECTIVES This study evaluated pathways to low energy availability in a sample of female adolescent athletes (n = 464). DESIGN Cross-sectional. METHODS Participants (age 13-18 y) underwent assessments for height, weight, eating attitudes and behaviors, and menstrual function. Bone mineral density and body composition were evaluated by dual-energy x-ray absorptiometry in a subset of participants (n = 209). Athletes were classified with clinical indicators of low energy availability if they met criteria for 1) primary or secondary amenorrhea or 2) clinical underweight status (body mass index-for-age < 5th percentile). Disordered eating was assessed using the Eating Disorder Examination Questionnaire. RESULTS Thirty (6.5%) athletes exhibited clinical indicators of low energy availability, with higher estimates in leanness than non-leanness sports (10.9% vs. 2.1%, p < 0.005). Among athletes with clinical indicators of low energy availability, 80% (n = 24) did not meet criteria for disordered eating, eating disorder, or report the desire to lose weight. Athletes with (vs. without) clinical indicators of low energy availability exhibited lower lumbar spine (-1.30 ± 1.38 vs. -0.07 ± 1.21, p < 0.001) and total body (-0.30 ± 0.98 vs. 0.53 ± 0.97, p < 0.006) bone mineral density Z-scores. CONCLUSIONS A majority of female adolescent athletes with clinical indicators of low energy availability did not exhibit characteristics consistent with intentional dietary restriction, supporting the significance of the inadvertent pathway to low energy availability and need for increased nutrition education in this population.
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Affiliation(s)
- Michelle T Barrack
- Department of Family and Consumer Sciences, California State University Long Beach, United States of America.
| | - Sarah Domino
- Department of Family and Consumer Sciences, California State University Long Beach, United States of America
| | - Virginia B Gray
- Department of Family and Consumer Sciences, California State University Long Beach, United States of America
| | - Joshua A Cotter
- Department of Kinesiology, California State University Long Beach, United States of America
| | - Mitchell J Rauh
- Doctor of Physical Therapy Program, San Diego State University, United States of America
| | - Jeanne F Nichols
- Herbert Wertheim School of Public Health, University of California San Diego, United States of America; School of Exercise and Nutritional Sciences, San Diego State University, United States of America
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Greeves JP, Beck B, Nindl BC, O'Leary TJ. Current risks factors and emerging biomarkers for bone stress injuries in military personnel. J Sci Med Sport 2023:S1440-2440(23)00075-0. [PMID: 37188615 DOI: 10.1016/j.jsams.2023.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 04/01/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Bone stress injuries (BSIs) have plagued the military for over 150 years; they afflict around 5 to 10% of military recruits, more so in women, and continue to place a medical and financial burden on defence. While the tibia generally adapts to the rigours of basic military training, the putative mechanisms for bone maladaptation are still unclear. METHODS This paper provides a review of the published literature on current risk factors and emerging biomarkers for BSIs in military personnel; the potential for biochemical markers of bone metabolism to monitor the response to military training; and, the association of novel biochemical 'exerkines' with bone health. RESULTS The primary risk factor for BSI in military (and athletic) populations is too much training, too soon. Appropriate physical preparation before training will likely be most protective, but routine biomarkers will not yet identify those at risk. Nutritional interventions will support a bone anabolic response to training, but exposure to stress, sleep loss, and medication is likely harmful to bone. Monitoring physiology using wearables-ovulation, sleep and stress-offer potential to inform prevention strategies. CONCLUSIONS The risk factors for BSIs are well described, but their aetiology is very complex particularly in the multi-stressor military environment. Our understanding of the skeletal responses to military training is improving as technology advances, and potential biomarkers are constantly emerging, but sophisticated and integrated approaches to prevention of BSI are warranted.
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Affiliation(s)
- Julie P Greeves
- Army Health and Performance Research, Army HQ, Andover, United Kingdom; Norwich Medical School, University of East Anglia, United Kingdom; Division of Surgery and Interventional Science, UCL, United Kingdom.
| | - Belinda Beck
- School of Health Sciences and Social Work, Griffith University, Australia; The Bone Clinic, Australia.
| | - Bradley C Nindl
- School of Health and Rehabilitation Sciences, University of Pittsburgh, United States.
| | - Thomas J O'Leary
- Army Health and Performance Research, Army HQ, Andover, United Kingdom; Division of Surgery and Interventional Science, UCL, United Kingdom.
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Carson TL, West BT, Sonneville K, Zernicke RF, Clarke P, Harlow S, Karvonen-Gutierrez C. Identifying latent classes of Relative Energy Deficiency in Sport (RED-S) consequences in a sample of collegiate female cross country runners. Br J Sports Med 2023; 57:153-159. [PMID: 36137732 DOI: 10.1136/bjsports-2021-104083] [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: 09/07/2022] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The purpose of this study was to identify patterns of clustering of the 10 health consequences identified in the Relative Energy Deficiency in Sport (RED-S) framework among collegiate female Cross-Country runners. We also assessed risk characteristics associated with each cluster. METHODS This randomly sampled population included 211 current National Collegiate Athletics Association (NCAA) Division I (DI) female cross country runners who completed a quantitative survey. We used latent class analysis (LCA) to group athletes into mutually exclusive classes based on shared response patterns of RED-S consequences. We computed descriptive statistics to identify demographics, personal characteristics, disordered eating and emotional health characteristics associated with each class. RESULTS The average age of the sample was 21 years with mean body mass index 20.4 kg/m2. The LCA identified three unique classes of potential RED-S presentations: (1) low probability of RED-S consequences; (2) complex physical and psychological concerns with a higher burden of cardiovascular concern and (3) very high probability of anxiety with high burden of menstrual disturbance, bone injury and gastrointestinal concern. All classes were characterised by high levels of menstrual disturbance and distinguished by the number and burden of other potential RED-S consequences and in reported abuse history, emotional regulation and perfectionism. CONCLUSION This study identified a high burden of menstrual disturbance in NCAA D1 cross country runners, and three unique presentations of RED-S consequences. Future research is warranted to better understand how early prevention and intervention strategies may mitigate RED-S consequences in distance runners.
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Affiliation(s)
- Traci Lyn Carson
- Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Brady T West
- Institute for Social Research (ISR), University of Michigan, Ann Arbor, Michigan, USA
| | - Kendrin Sonneville
- Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Ronald F Zernicke
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Philippa Clarke
- Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Sioban Harlow
- Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
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Andrew Naylor T, Naylor S. Distribution and risk factors for stress fractures in competitive figure skaters and association with acute fractures. PHYSICIAN SPORTSMED 2023; 51:45-49. [PMID: 34529544 DOI: 10.1080/00913847.2021.1981748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Figure skating combines esthetic components with high impact, technically demanding elements requiring high volume repetitive training. The evidence base for the sport is limited, particularly regarding stress fracture injuries. This study aims to describe the prevalence and anatomical distribution of stress fracture injuries and assess for risk factors, as well as associations with acute fractures. METHODS An online anonymous retrospective survey of competitive figure skaters was distributed through social media networks and e-mail for completion by skaters from all three disciplines of figure skating. RESULTS In a sample of 164 skaters from novice to Olympic level, career prevalence of stress fractures was 24.4%, most commonly affecting tibia and ankle. There was statistically significant increased risk of stress fracture in those training ≥12 times/week (33.3% vs. 17.8%; P = 0.028) but no increased risk associated with level or gender of skater. There was a higher prevalence of acute fracture in those with a history of stress fracture (45.0% vs. 21.8%; P = 0.007). CONCLUSIONS Figure skaters are at a high risk of stress fractures, independent of the level performed at. There is a higher risk in those training more frequently and an association with additional acute fractures. Results advocate education on fracture features and bone health measures to skaters, coaches, and physicians, at all levels of the sport to facilitate early diagnosis and management.
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Affiliation(s)
- Thomas Andrew Naylor
- Orthopaedic Registrar, Trauma & Orthopaedic Department, Manchester University NHS Foundation Trust, Manchester, UK
| | - Samuel Naylor
- Anaesthetic Trainee, Anaesthetics Department, Homerton University Hospital, London, UK
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Graybeal AJ, Kreutzer A, Moss K, Rack P, Augsburger G, Braun-Trocchio R, Willis JL, Shah M. Chronic and Postprandial Metabolic Responses to a Ketogenic Diet Compared to High-Carbohydrate and Habitual Diets in Trained Competitive Cyclists and Triathletes: A Randomized Crossover Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1110. [PMID: 36673864 PMCID: PMC9859046 DOI: 10.3390/ijerph20021110] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 06/17/2023]
Abstract
Extreme carbohydrate deficits during a ketogenic diet (KD) may result in metabolic adaptations reflective of low energy availability; however, the manifestation of these adaptations outside of exercise have yet to be elucidated in cyclists and triathletes. The purpose of this study is to investigate the chronic and postprandial metabolic responses to a KD compared to a high-carbohydrate diet (HCD) and habitual diet (HD) in trained competitive cyclists and triathletes. For this randomized crossover trial, six trained competitive cyclist and triathletes (F: 4, M: 2) followed an ad libitum KD and HCD for 14 d each after their HD. Fasting energy expenditure (EE), respiratory exchange ratio (RER), and fat and carbohydrate oxidation (FatOx and CarbOx, respectively) were collected during their HD and after 14 d on each randomly assigned KD and HCD. Postprandial measurements were collected on day 14 of each diet following the ingestion of a corresponding test meal. There were no significant differences in fasting EE, RER, FatOx, or CarbOx among diet conditions (all p > 0.050). Although postprandial RER and CarbOx were consistently lower following the KD meal, there were no differences in peak postprandial RER (p = 0.452), RER incremental area under the curve (iAUC; p = 0.416) postprandial FatOx (p = 0.122), peak FatOx (p = 0.381), or FatOx iAUC (p = 0.164) between the KD and HD meals. An ad libitum KD does not significantly alter chronic EE or substrate utilization compared to a HCD or HD; postprandial FatOx appears similar between a KD and HD; this is potentially due to the high metabolic flexibility of cyclists and triathletes and the metabolic adaptations made to habitual high-fat Western diets in practice. Cyclists and triathletes should consider these metabolic similarities prior to a KD given the potential health and performance impairments from severe carbohydrate restriction.
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Affiliation(s)
- Austin J. Graybeal
- School of Kinesiology & Nutrition, College of Education and Human Sciences, University of Southern Mississippi, Hattiesburg, MS 39406, USA
| | - Andreas Kreutzer
- Department of Kinesiology, Harris College of Nursing and Health Sciences, Texas Christian University, Fort Worth, TX 76129, USA
- School of Health Promotion and Kinesiology, College of Health Sciences, Texas Woman’s University, Denton, TX 76209, USA
| | - Kamiah Moss
- Department of Kinesiology, Harris College of Nursing and Health Sciences, Texas Christian University, Fort Worth, TX 76129, USA
- Physical Medicine and Rehabilitation, Baylor Institute for Rehabilitation, Dallas, TX 75246, USA
| | - Petra Rack
- Department of Kinesiology, Harris College of Nursing and Health Sciences, Texas Christian University, Fort Worth, TX 76129, USA
| | - Garrett Augsburger
- Department of Kinesiology, Harris College of Nursing and Health Sciences, Texas Christian University, Fort Worth, TX 76129, USA
| | - Robyn Braun-Trocchio
- Department of Kinesiology, Harris College of Nursing and Health Sciences, Texas Christian University, Fort Worth, TX 76129, USA
| | - Jada L. Willis
- Department of Nutritional Sciences, College of Science & Engineering, Texas Christian University, Fort Worth, TX 76129, USA
| | - Meena Shah
- Department of Kinesiology, Harris College of Nursing and Health Sciences, Texas Christian University, Fort Worth, TX 76129, USA
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Carson TL, Hazzard VM, Finn E, Lipson SK. Participation in varsity sports, dance, and Greek life associated with menstrual disturbance in a national sample of female college students. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2022; 70:2365-2372. [PMID: 35380508 PMCID: PMC9532456 DOI: 10.1080/07448481.2020.1862852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 09/29/2020] [Accepted: 12/06/2020] [Indexed: 06/14/2023]
Abstract
Objective: The objective of this study was to identify university-sponsored activities associated with increased odds of menstrual disturbance among female college students. Participants: The sample included 3,277 female-identifying students at 12 colleges and universities participating in the Healthy Bodies Study during the 2013-2014 and 2014-2015 academic years. Methods: Crude and adjusted logistic regression models were run to report odds of any menstrual disturbance and amenorrhea (AMN) for participants in sports, dance, and Greek Life. Survey weights were used to account for response bias. Results: In the adjusted models, participation in varsity sport (OR = 1.82, CI 1.37, 2.37), dance (OR = 1.68, CI 1.37, 2.05) and Greek life (OR= 2.12, CI 0.13,0.18) was significantly associated with increased odds of menstrual disturbance, compared to non-participants. Conclusions: Findings suggest additional need for prevention and intervention programming against menstrual disturbance in varsity sports, dance, and Greek life activities.
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Affiliation(s)
- Traci L. Carson
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | | | - Erin Finn
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Sarah K. Lipson
- Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
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Fensham NC, Heikura IA, McKay AKA, Tee N, Ackerman KE, Burke LM. Short-Term Carbohydrate Restriction Impairs Bone Formation at Rest and During Prolonged Exercise to a Greater Degree than Low Energy Availability. J Bone Miner Res 2022; 37:1915-1925. [PMID: 35869933 PMCID: PMC9804216 DOI: 10.1002/jbmr.4658] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 07/14/2022] [Accepted: 07/20/2022] [Indexed: 01/05/2023]
Abstract
Bone stress injuries are common in athletes, resulting in time lost from training and competition. Diets that are low in energy availability have been associated with increased circulating bone resorption and reduced bone formation markers, particularly in response to prolonged exercise. However, studies have not separated the effects of low energy availability per se from the associated reduction in carbohydrate availability. The current study aimed to compare the effects of these two restricted states directly. In a parallel group design, 28 elite racewalkers completed two 6-day phases. In the Baseline phase, all athletes adhered to a high carbohydrate/high energy availability diet (CON). During the Adaptation phase, athletes were allocated to one of three dietary groups: CON, low carbohydrate/high fat with high energy availability (LCHF), or low energy availability (LEA). At the end of each phase, a 25-km racewalk was completed, with venous blood taken fasted, pre-exercise, and 0, 1, 3 hours postexercise to measure carboxyterminal telopeptide (CTX), procollagen-1 N-terminal peptide (P1NP), and osteocalcin (carboxylated, gla-OC; undercarboxylated, glu-OC). Following Adaptation, LCHF showed decreased fasted P1NP (~26%; p < 0.0001, d = 3.6), gla-OC (~22%; p = 0.01, d = 1.8), and glu-OC (~41%; p = 0.004, d = 2.1), which were all significantly different from CON (p < 0.01), whereas LEA demonstrated significant, but smaller, reductions in fasted P1NP (~14%; p = 0.02, d = 1.7) and glu-OC (~24%; p = 0.049, d = 1.4). Both LCHF (p = 0.008, d = 1.9) and LEA (p = 0.01, d = 1.7) had significantly higher CTX pre-exercise to 3 hours post-exercise but only LCHF showed lower P1NP concentrations (p < 0.0001, d = 3.2). All markers remained unchanged from Baseline in CON. Short-term carbohydrate restriction appears to result in reduced bone formation markers at rest and during exercise with further exercise-related increases in a marker of bone resorption. Bone formation markers during exercise seem to be maintained with LEA although resorption increased. In contrast, nutritional support with adequate energy and carbohydrate appears to reduce unfavorable bone turnover responses to exercise in elite endurance athletes. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Nikita C Fensham
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Ida A Heikura
- Canadian Sport Institute Pacific, Victoria, Canada.,Exercise Science, Physical & Health Education, University of Victoria, Victoria, Canada
| | - Alannah K A McKay
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Nicolin Tee
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Kathryn E Ackerman
- Divisions of Sports Medicine and Endocrinology, Boston Children's Hospital, Boston, MA, USA.,Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Louise M Burke
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
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Kraus E, Rizzone K, Walker M, Brown N, Kaur J, Magrini D, Glover J, Nussbaum E. Stress Injuries of the Knee. Clin Sports Med 2022; 41:707-727. [DOI: 10.1016/j.csm.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Kalpana K, Cherian KS, Khanna GL. Energy availability and RED-S risk assessment among Kho-Kho players in India. SPORT SCIENCES FOR HEALTH 2022; 19:1-8. [PMID: 36061453 PMCID: PMC9425793 DOI: 10.1007/s11332-022-00996-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/29/2022] [Indexed: 11/26/2022]
Abstract
Purpose Energy availability (EA) is considered an important measure for athletes, particularly due to the possible health and performance outcomes defined under the RED-S. Low EA is reported to have far-reaching health consequences among female athletes, especially in weight-sensitive sport. However, it is less explored among male athletes, particularly in the traditional Indian tag sport called Kho-Kho. This cross-sectional observational study aimed to determine the prevalence of LEA and associated RED-S health and performance outcomes among Kho-Kho players. Methods Fifty-two male national-level Kho-Kho players aged 16-31 years were assessed for energy availability, bone mineral density (BMD), sleep quality, disordered eating, selected metabolic (hemoglobin, blood glucose, etc.) and performance outcomes (agility, speed, and power) as per RED-S risk assessment tool. Differences across the low EA (≤ 25 kcal/ kg fat-free mass) and Optimal EA (> 25 kcal/ kg fat-free mass) groups were evaluated using the Independent Samples t test and the chi-square test. Results Low EA among athletes was associated with lower z-scores for BMD, sleep quality and agility, compared to athletes with optimal EA. At least one moderate-to-high RED-S risk outcome was prevalent among 98% of the Kho-Kho players, irrespective of EA. Most athletes exhibited a lower EAT score and disordered eating outcomes, with no significant differences across groups. Conclusion The male Kho-Kho players showed a prevalence of low EA that can be due to higher training loads and unintentional under-eating, not related to an eating disorder. The players also exhibited higher RED-S risk outcomes; however, it was irrespective of low EA.
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Affiliation(s)
- Kommi Kalpana
- Faculty of Sports, Manav Rachna International Institute of Research and Studies, Delhi-NCR, India
| | | | - Gulshan Lal Khanna
- Faculty of Sports, Manav Rachna International Institute of Research and Studies, Delhi-NCR, India
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Fleischer SH, Freire AK, Brown K, Creer A, Eggett DL, Fullmer S. Association of Short-Term Changes in Menstrual Frequency, Medication Use, Weight and Exercise on Bone Mineral Density in College-Aged Women. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10363. [PMID: 36011999 PMCID: PMC9408413 DOI: 10.3390/ijerph191610363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 06/15/2023]
Abstract
To evaluate if experiencing a short-term exposure (18-months) to factors such as menstrual irregularities, dieting, changes in exercise or body weight, and medication usage is associated with bone mineral density (BMD) in college-aged females. A retrospective survey assessing health behaviors during a recent 18-month time period and a DXA scan were completed in 641 females. A total of 45.5% of participants reported amenorrhea during the 18-month time period. Those who experienced amenorrhea had lower femoral neck BMD (p = 0.018), trochanter (p = 0.018) and spine BMD (p = 0.022) compared to eumenorrheic women. Lifetime oral contraceptive usage longer than six months was negatively associated with BMD at femoral neck (p = 0.018) and total hip (p = 0.021). Women who lost weight trended towards having the lowest BMD at all sites compared to women who gained weight. Following a very-low calorie diet during the time period was negatively correlated with spine BMD (p = 0.001). Time spent in vigorous and very vigorous activity was weakly correlated with some hip BMD sites but time spent in extremely vigorous activity was not. In conclusion, females who experienced weight loss, amenorrhea, or a very low-calorie diet within an 18-month period of time in young adulthood had lower BMD. Additionally, oral contraceptive usage for longer than six months during their lifetime was associated with lower BMD.
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Affiliation(s)
- Stacie H. Fleischer
- Department of Nutrition, Dietetics and Food Science, College of Life Sciences, Brigham Young University, Provo, UT 84602, USA
| | - Annalisa K. Freire
- Department of Nutrition, Dietetics and Food Science, College of Life Sciences, Brigham Young University, Provo, UT 84602, USA
| | - Katie Brown
- Department of Nutrition, Dietetics & Food Sciences, College of Agriculture and Applied Sciences, Utah State University, Logan, UT 84322, USA
| | - Andrew Creer
- Department of Statistics, College of Physical and Mathematical Sciences, Brigham Young University, Provo, UT 84602, USA
| | - Dennis L. Eggett
- Department of Exercise Science & Outdoor Recreation, College of Science, Utah Valley University, Orem, UT 84058, USA
| | - Susan Fullmer
- Department of Nutrition, Dietetics and Food Science, College of Life Sciences, Brigham Young University, Provo, UT 84602, USA
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Abstract
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.
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50
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Hattori S, Aikawa Y, Omi N. Female Athlete Triad and Male Athlete Triad Syndrome Induced by Low Energy Availability: An Animal Model. Calcif Tissue Int 2022; 111:116-123. [PMID: 35522259 DOI: 10.1007/s00223-022-00983-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/11/2022] [Indexed: 12/01/2022]
Abstract
Energy availability (EA) is defined the difference in energy intake and exercise energy expenditure. Reduction of EA (i.e. Low energy availability, LEA) often causes abnormalities of reproduction system and drastic bone loss in some female athletes, the phenomenon is called as female athlete triad. More than ever before, it is considered a serious problem, the reason of these are (1) the syndrome occurred in female athletes but also male athletes, (2) LEA is leads to dysfunction of various organs other than reproductive system (Relative energy deficiency in sport, RED-S). On the other hand, we have focused on this syndrome and have proposed novel insights into the physiological effects of LEA on bone and solutions through nutritional treatment by recreating it in animal models. In this review, we will summarize the epidemiological and physiological perspectives of these diseases from historical background to recent findings, and introduce the usefulness of using animal models to explore mechanisms and treatments.
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Affiliation(s)
- Satoshi Hattori
- Faculty of Health and Sport Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8572, Japan
| | - Yuki Aikawa
- Department of Science of Living, Tsu City College, 157 Isshinden-nakano, Tsu, Mie, 514-0112, Japan
| | - Naomi Omi
- Faculty of Health and Sport Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8572, Japan.
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