Delivering personalised female hormone health through an expert report system

I am passionate about helping women improve their wellbeing and quality of life through a better understanding of their personal female hormones. But every woman is different and it takes time for me to interpret and explain her results. It has been extremely exciting to work with technology experts at Forth to create an app that enables many more women to access my medical knowledge in a personalised female hormone health report

For the past 30 years I have been working with many women who come asking questions about their female hormone health. These some of the questions often asked:

  • Am I entering the perimenopause? Should I consider HRT?
  • Am I making the best lifestyle choices for my personal hormone health?
  • How can I better understand the interaction between my hormones and my sports performance?

Women are absolutely right to be asking these important questions. The answers can help optimise physical and mental health. Women also know that lifestyle behaviour choices influence their health. The key message is that hormones are the mediators between our behaviours and our health.

Out of all the hormone networks, the female menstrual cycle is the most complex. Furthermore, the timings and levels of female hormone fluctuations are highly individual to each woman. There is also individual variation in the way that each personal female hormone network pattern interacts with behaviours and impacts wellbeing.

The gold standard for measuring the four key female hormones (Oestradiol, Progesterone, Follicle Stimulating Hormone and Luteinising Hormone) is to perform a blood test. This can be done at home using a simple capillary finger prick kit.

What is my approach to answer these questions about hormone health for an individual woman?

I start by asking about some background details, including age, menstrual history, lifestyle and wellbeing. Next, we look over the blood hormone results and I explain what these numbers mean. When I look at a set of hormone results, I scan for patterns and biological meaning. This is bit like translating a complex piece of prose written in a foreign language, but it is a language in which I am entirely fluent and conversant with all the grammar and subtle nuances, because it is the language of hormones.

After explaining the hormone patterns, we discuss how these personal patterns tie into wellbeing and what is the best course of action to optimise hormone health through lifestyle behaviours and sometimes medication, where clinically indicated. After our discussion, I write a summary letter that includes a suggested evidence-based personal action plan.

If there were a way I could make the process of delivering a personalised hormone health report more efficient, I would be able to support more women with hormone health questions. This is where artificial intelligence techniques can help.

Personalisation of health through the clinical application of artificial intelligence techniques is revolutionising health care

The Chief Medical Officer of England outlines how access to personalised medicine can be extended through the application of artificial intelligence techniques, such as machine learning[1]. This revolution in healthcare is underway. Every month I attend webinars for medical doctors run by the world leading research group based at Cambridge University to discuss the latest developments in this exciting field of clinical medical artificial intelligence[2].

Artificial intelligence (AI) [3] is somewhat of a misnomer. The “intelligence” does not come from a sterile computer; human programmers collaborate with experts to write the software. By encoding the language of hormones, the computer is able to recognise patterns and then draw upon my medical knowledge to interpret the results in a personalised report, at lightning speed.

For me, this is “intelligence augmentation”: IA rather AI.

You might wonder how a sophisticated computerised system can increase personalisation of healthcare? Even the most experienced individual doctor does not have the time or expertise to mathematically interrogate all clinical and research data in their particular field of medicine. By working closely with mathematicians, doctors can augment their clinical expertise to identify the best management and treatment for an individual. The other big advantage of mathematically modelling medical data is that it is possible to perform extensively testing, by generating lots of “virtual” patients with their medical data to feed into the system.

How can an expert report system deliver a personal female hormone health report?

The Female Hormone MappingTM system produces a personal hormone health report that is exactly what I write for a woman I see in clinic. The only difference is that this is produced in a fraction of the time it would take me to “download” my medical assessment through typing up a clinic letter[4].

The starting point to delivering a personalised female hormone health report was to work closely with a mathematician with expertise in statistics and computer science AI techniques. To help me in my interpretation of menstrual cycle hormone results, I needed graphs to show the variation of an individual’s hormone network over a menstrual cycle. This makes it easier to pick out hormone patterns and compare to a “reference” group of women matched for cycle length, who are known to be ovulating.

The process of making an expert report library

The next step was to work on an expert report system in order to access a vast library of clinic letters currently stored in my brain. This library covers all possibilities of hormone network results for women over a range of ages and activity level. The mathematical model generated an enormous range of possible graphs from “virtual” hormone blood tests from women of different ages and exercise levels. I sat for hours, days and months to harness my 30 years medical experience into how I would explain and advise a “real” woman sitting in front of me with those particular personal characteristics and results. In other words, I downloaded my medical brain.

All these medical summaries with evidence-based advice were definitely not generated by “artificial” intelligence. Rather the expert report system acts as a very efficient librarian. Presented with the request for a particular book and a specific page in the chapter, the expert librarian retrieves the exact page written by me, the author of all the books in this hormone library.

Hormonal digital fingerprint

In practical terms, a woman can now create a personalised digital fingerprint of her menstrual cycle hormone network from just two finger prick capillary blood samples taken during a cycle. Together with her personalised hormone health report, she can empower herself with insights into her hormone health in order to make informed decisions to optimise physical and mental health.

Female Hormone MappingTM is a personalised hormone health report, available at your fingertips on a mobile app, that I have developed in partnership with Forth, the health tech company where I am Chief Medical Officer. Your personalised female hormone health report provides detailed personalised clinical medical explanation, commentary and evidence-based advice written by me and delivered by an expert report system. 

As pointed out at every webinar I attend on the medical application of AI for health, AI can never replace medical doctors. Any unusual results are passed to me for review. There is also the opportunity to book in and discuss your report in further depth with me.

Furthermore, as with any medical measurement, the true value lies in monitoring trends over time. So, repeating Female Hormone MappingTM will give personal feedback on whether the advised lifestyle behavioural changes have helped with wellbeing and female hormone network function. This monitoring process directs further informed decisions about next steps for lifestyle modification, or discussion about medication where clinically indicated.

Answering the questions about personal female hormone health

This new approach in assessing female hormone networks for individual women is proving a valuable clinical tool[5]. This enables me to answer the questions that women are asking and move away from generic advice to personalised evidence-based advice. Having these personal hormone health insights empowers women to make informed, personal decisions that will help each individual attain her personal best quality of life.

References


[1]Machine learning for individualised medicine” Mihaela van der Schaar, Annual Report of the Chief Medical Officer. 2018, Chapter 10. Health 2040 – Better Health Within Reach. Accessed 2021

[2] Van der Schaar M. Revolutionising Healthcare webinars for clinicians, Cambridge University 2021

[3] Artificial Intelligence AI council. UK Government 2021

[4] Keay, N. Fingerprinting Hormones St John’s College, Cambridge University 2021

[5] Keay N. Hormone Intelligence for Female Dancers, Athletes and Exercisers. British Journal of Sports Medicine 2021

When will I reach the menopause?

What does new research into the genetics of the age of menopause reveal? How does this translate to female health in practical terms?

Biological Clock

Every woman will reach menopause around middle age. This is when ovarian responsiveness declines to the extent that ovarian hormone production is no longer sufficient for ovulation to occur.

Ovarian function

The natural age of menopause is on average 51, with a range from 45 to 55 years. About 1% of women experience primary premature ovarian insufficiency (POI), which means reduced ovarian function before the age of 40. For a tiny minority, of 0.1%, this occurs under the age of 30. POI may lead to early menopause, occurring between 40 and 45, or premature menopause occurring before 40 years of age. It is important to identify POI promptly, as a drop in ovarian hormones increases the risk of cardiovascular disease, osteoporosis and decline in cognitive function. So, replacing ovarian hormones through hormone replacement therapy (HRT) is important for long term health, especially for those women with POI[1].  Fertility may also be compromised, although the British Menopause Society stresses that, it is only when menopause is reached, that ovarian function completely stops.

What determines age of menopause?

As with the timing of many physiological processes, the natural age of menopause is thought to be determined by both genetic and environmental factors. A recent paper published in Nature[2] describes how clusters of genes can be used to provide a polygenetic score (PGS) which accounts for 10% of the variation in the age of natural menopause (as opposed to medically induced menopause). The impact of each genetic variant ranged from 3.5 weeks to 1.5 years. Whilst the PGS accounted for a very modest 10% variation in natural age of menopause, the top 1% of the PGS range corresponded to a 5-fold increase in POI compared with women with mid-range scores. The authors themselves urge caution in the clinical application of this multi genetic test approach for predicting natural age of menopause, even in those families with a family history of POI.

The PGS as an indicator of increased risk of POI, is not the novel finding of this paper. The authors state that this result is the same as that obtained through a current single gene test. The most interesting part of the research was how these genes influence the age of menopause. These specific genes code for the DNA repair system for the eggs in the ovary.

Incredibly all the eggs in the ovary are “prepared” while the female foetus is in the mother’s uterus during pregnancy. The double stranded DNA in each egg unwinds and is partially split, leaving it literally in suspended animation. These eggs have to wait another 15 to 50 years before being called upon to complete the halving of double stranded DNA. Ultimately an egg has one DNA strand when ovulated during the menstrual cycle, ready to be united with a matching single strand from a sperm. Some eggs never make the cut for ovulation.

As all the eggs were prepared in the ovaries of the female foetus, they all have the same “shelf life”. Over adult life, the shelf on which the eggs are resting metaphorically starts to tip. The DNA repair mechanisms try to keep the shelf level. However, inevitably the shelf tips over at menopause. This shelf life of eggs, contrasts with sperm in men, which are made continuously throughout adult life.

From an evolutionary perspective having a shelf life on eggs and reaching menopause is probably for the benefit of the mother and the potential baby. Although life expectancy has increased, the ageing process is something that none of us can avoid. Pregnancy, childbirth and raising a child are demanding, even more so beyond middle age. From the baby’s point of view, it is well documented that increasing maternal age increases the risk of genetic issues for the embryo. This is where genetic repair mechanisms outlined in the research paper become really important. As the DNA in the eggs in the foetal ovaries are in suspended animation, in a delicate state for the rest of the woman’s life, the DNA repair enzymes need to be on high alert to keep the eggs “fresh” and ready for ovulation.

In experiments on female mice, manipulating the two genes for DNA repair did prolong fertility and for one of these genes, also bolstered the ovarian response to hormone stimulation. However, the downside is that in the latter case this could also increase the risk of cancer. Furthermore, we do not know how manipulating maternal genetics would translate to the genetics of the offspring; nor how this genetic manipulation translates from mice to women.

Ideally it would be helpful to keep a watching brief on all factors contributing to egg health.

The missing link: female hormone networks

The authors state that their paper focused on genetics and did not consider the other key influencers of female health, fertility and definition of menopause: hormones[3]. If genetic factors account for 10% of the variation in the age of menopause, that leaves 90% unexplained. A significant proportion of the variation is likely to be due to environmental factors. Lifestyle and behavioural choices influence hormones and it is hormones that regulate gene expression in DNA.

This means that, whatever your genetic endowment, making good choices around lifestyle factors of nutrition, exercise and sleep, while avoiding negative choices like smoking, certainly helps hormone networks and therefore impacts gene expression.

Ideally a measure of dynamic hormone function would be more informative about transition to menopause. Such an approach is now possible, by combining medical and mathematical expertise through artificial intelligence techniques[4]. Quantifying ovarian responsiveness with a scoring system of female hormone network function gives a real time watching brief on female health[5]. Monitoring over time can track any decline suggesting transition to menopause.     

What can we conclude about age of menopause?

  • Menopause is a significant physical and psychological event in a woman’s life. Declining ovarian hormones pose challenges for long term health.
  • Average age of natural menopause is 51 (range 45-55 years). Early menopause occurs between 40 and 45 years of age and premature menopause under 40. Primary ovarian insufficiency (POI) is where the ovaries start to loose responsiveness before the age of 40.
  • The age of menopause is determined through a combination of genetic and environmental factors. A new research genetic test combining various genes can predict up to 10% of the variation in the natural age of menopause, leaving 90% determined by non-genetic factors. In 1% of the outlying genetic scores, this corresponded to an increased likelihood of premature ovarian insufficiency, the same as current single gene test.
  • The authors of the research urge cation that this multiple gene test is not a suitable clinical test for women, even for those with family history of POI. Nevertheless, this research sheds light on the DNA repair mechanisms that play a part in determining age of menopause.
  • This paper focused on genetics and did not discuss the hormone networks. Menopause is defined as no further menstruation when the ovaries stop producing hormones.

Practical take home points

  • You can obtain a free genetic test by asking your female family members about their age of menopause. This also opens up conversations about menopause.
  • Premature Ovarian Insufficiency does not definitively exclude the possibility of pregnancy
  • For all women, ovarian responsiveness and fertility decline after 40 years, at a variable rate.
  • Female hormone networks should be considered and can now be assessed as part of the personalised assessment of ovarian function, with medical explanation and evidence based advice. For further details
  • For medical doctors, membership of British Menopause Society provides a wealth of resources and specialist training opportunities

It is every woman’s personal choice when and if she wishes to become pregnant. Nevertheless, it is important for women to be aware of their personal female physiology. Genes are passed down through the generations, but the expression of those genes is determined hormone networks. Since lifestyle choices affect hormones, they determine to a large extent how your personal story unfolds.

References


[1] Management of the Menopause. Sixth Edition. British Menopause Society

[2] Ruth, K.S., Day, F.R., Hussain, J. et al. Genetic insights into biological mechanisms governing human ovarian ageing. Nature (2021). https://doi.org/10.1038/s41586-021-03779-7

[3] Genomic analysis identifies variants that can predict the timing of menopause. Nature 2021

[4] Keay N. Hormone Intelligence for Female Dancers, Athletes and Exercisers British Journal of Sports Medicine 2021

[5] Keay N Fingerprinting hormones St John’s College Cambridge 2021

Hormone Intelligence

Applying artificial intelligence to modelling female hormones enables women to access hormone intelligence at her fingertips

Female hormone networks form the most complex aspect of the endocrine system. The menstrual cycle depends upon a delicate web of feedback mechanisms that trigger significant changes in hormone levels. This intricate physiological process generally operates reliably, but its timing and the hormone levels are affected by internal and external factors going on in a woman’s life. This is why women differ in their experiences of menstrual cycles and why an individual woman may notice differences between cycles.

Apart from being fascinating from a physiological point of view, why is this so important from a practical point of view for women? The reason is that female hormones are not just about fertility. The ovarian hormones oestradiol (most active form of oestrogen) and progesterone have significant effects through the body. Every biological system is dependent on these hormones: bones, muscle, nervous system, including brain function, skin, the cardiovascular and digestive systems [1]. This is why female hormones impact all aspects of health: physical, mental and social [2].

The cyclical fluctuations in female hormones occurring every menstrual cycle will also change over a woman’s lifespan. Completion of puberty is marked by the start of menstrual cycles: menarche. During her adult life a woman can expect regular menstrual cycles. However, subtle hormone disruption can be missed. Although blood testing is the most accurate way of measuring all four of the key female hormones, the standard protocol of taking a blood test at one time point in the cycle, when hormones are at their most quiescent, can miss subclinical menstrual cycle hormone dysfunction.

For example, in subclinical anovulatory cycles, although a woman may experience regular menstrual periods, subtle mistiming of female hormones will not be detected with a routine single blood test. Yet this type of hormone disruption can have potential adverse consequences on health. This is particularly relevant for exercisers, athletes and dancers who are either on the brink of or recovering from low energy availability. Early identification and prevention of relative energy availability in sport (RED-S) is important for both health and exercise performance [3].

A similar situation arises for women in the perimenopause when the responsiveness of her ovaries starts to decline. This is further complicated by the fact that the decrease in ovarian hormone production is not a smooth linear process. A blood test at a single time point may not identify these changes in key female hormone networks. Although perimenopause is a natural physiological process, it can be a challenging time for women, magnified by uncertainty. All change for female hormones

Women need a new, more supportive approach, to take away uncertainty and to empower them with insights into their hormone networks.

How can a woman understand the details of her female hormone network? In theory she could take daily blood tests for the four key hormones: pituitary control hormones follicle stimulating hormone (FSH), luteinising hormone (LH) and ovarian response hormones oestradiol and progesterone. Clearly this is not practical, but it may be possible to use fewer blood tests over a cycle. Machine learning, specifically Bayesian inference, can help by optimally combining test results with background information. This background knowledge includes medical understanding of hormone networks and the characteristics of the individual woman. Machine learning can revolutionise healthcare, as outlined in the report from the Chief Medical Officer of England [4]. It is an approach widely used in modelling biological systems [5]. Artificial intelligence is an important clinical tool to support the optimisation of personalised health [6].

It has recently become possible to create a personalised digital fingerprint of a woman’s menstrual cycle hormone network from just two finger prick capillary blood samples taken during a cycle. Artificial intelligence combines deep medical and mathematical understanding of female hormone networks with the individual details of a woman’s menstrual cycle length, age and activity levels. An expert report, providing an explanation of results with actionable, evidence-based advice, can be supplemented with a personal clinical medical discussion. This gives women the long-needed opportunity to connect with their personal female hormone networks. It empowers each woman to adopt a personalised, effective and proactive approach to optimise her hormone health.

To learn more about artificial intelligence applied to female hormone networks, have at look at previous discussions and forthcoming events where I am presenting on this topic and application of this approach for female health.Presentations

To take advantage of this exciting opportunity of fingerprinting hormone networks, you can order Female Hormone Mapping™ which combines medical, mathematical and technology expertise via the Forth website (available on a discounted introductory offer for a limited time). Your personal report is delivered at your fingertips on a mobile app. You can book an appointment for a personal discussion of your report with me Female Hormones

Every woman’s hormone network fluctuations are personal to her. Every woman is an individual.

References

Article St John’s College, Cambridge University

[1] Keay, N. What’s so good about Menstrual Cycles? British Journal of Sport and Exercise Medicine 2019

[2] Keay, N. Of Mice and Men (and Women) British Journal of Sport and Exercise Medicine 2019

[3] Keay, N. Relative energy deficiency in sport (RED-S) British Journal of Sport and Exercise Medicine 2018 and British Association of Sport and Exercise educational website Health4Performance

[4] “Machine learning for individualised medicine” Mihaela van der Schaar, Chapter 10 of the 2018 Annual Report of the Chief Medical Officer. Health 2040 – Better Health Within Reach. Accessed 2021

[5] Van de Schoot, R., Depaoli, S., King, R. et al. Bayesian statistics and modelling. Nat Rev Methods Primers 1, 1 (2021). https://doi.org/10.1038/s43586-020-00001-2

[6] Artificial Intelligence AI council. UK Government 2021

All Change for Female Hormones: Menopause

Issues with body temperature regulation that can disrupt sleep; joint and muscle pain; changeable mood (from low mood, to anxiety and anger); dry, itching skin all over the body (yes, I mean everywhere!); brain fog. These are just some of the symptoms that can disrupt your life and your relationships with family and friends. There is also the accompanying increased risk of cardiovascular disease and osteoporosis.

Understanding the menopause

The underlying cause for all of these problems is not a disease process. The menopause is a normal physiological event that occurs in every woman during her life. On average the age of menopause is 51 years, however, it can occur a couple of years either side of this. In the years leading up to the menopause, the perimenopause, the ovaries start to lose responsiveness, resulting in a decline in the female ovarian hormones (oestradiol and progesterone). These reducing hormone levels can cause women to experience some of the issues above, as well as changes in the menstrual cycle. Cycles can become erratic in timing and nature, reflecting the variable rate of change in female hormone production during this stage in the female hormone journey. This perimenopause phase can vary in length, although ultimately when the ovaries shut up shop, periods cease and the ovarian hormones remain consistently low, signifying that menopause is reached.   

Whilst the menopause is a natural, expected physiological event, that does not mean that this part of a woman’s life is without challenges. Nor does this mean that women should resign themselves, or indeed accept a reduced quality of life. With increasing life expectancy, women may spend at least a third of their lives in the menopausal state. A couple of hundred years ago, even if they survived childbirth, not many women reached the age of menopause. Today, far more women than ever before will experience the consequences of low female hormones that comes with menopause, potentially for 30 years or more of their lives.

Menopause is a significant point a woman’s life from a physical and psychological point of view. Even if she has made an active decision not to have children, menopause closes the chapter on this possibility. It can also be a time of life where things are changing: “children” have grown up and are leaving home, parents are getting older and new work colleagues seem to look very young. It can seem overwhelming, when these events coincide with the seismic changes in female hormones, that are impacting physical and mental wellbeing.

Talking about the menopause

As a woman and a female doctor, having experienced all the calling points of the female hormone journey, I am passionate about explaining the complexities of hormones: how to recognise key changes in hormones and what to do from a practical point of view. Including the menopause as part of the discussion of puberty and menstrual cycles at school (for boys and girls) would mean everyone has at least heard the word “menopause” from a young age. This would help make future conversations less challenging, where “the change” is only whispered amongst our grandmothers. Certainly, when I have been invited to make presentations and speak with teenagers, they have been interested to hear to full story of hormones.

Medical doctors have an important part to play in disseminating accurate information and supporting women through this hormone journey. There are some excellent resources for both non-medically qualified and medical professionals such as the British Menopause Society and Women’s Health Concern[1], Royal College of Obstetrics and Gynaecology[2] and the NICE guidelines[3]. These include advice and current best clinical practice for everyone to peruse. Framing questions empathetically is crucial. Some may be reticent to talk about vaginal dryness. Menopause should not be a source of embarrassment; it is the expected, normal physiology of hormones. Each of us will experience this differently.

As a female doctor, with the time of my menopause approaching, I had done my due diligence on this topic. I had read in detail the excellent resources I mentioned above. Nevertheless, experiencing those symptoms listed at the start of this blog, I appreciated that this would be an even more disconcerting and indeed a very frightening experience, if I did not know that my hormones were changing in a normal and expected way. Fortunately, having done my research based on these open access resources above, I knew that hormone replacement therapy (HRT) would help as HRT improves quality of life and all-cause mortality (death from all causes).

Researching the dose and form of HRT from these resources, it made logical sense that my body would appreciate exactly the same molecular structure of hormones that I had been producing myself to date. Taking oestradiol transdermally, through the skin, avoids any entanglement with the liver. Gel was a more attractive, discrete proposition that a patch. For the progesterone component of HRT (which is a must unless you have had a hysterectomy) micronised progesterone fitted the description of being the same molecular structure as body produced. The extra bonus is that this exact, optimal form of HRT is available on the NHS in a licensed and regulated format. Having no contraindications for HRT, I was left in no doubt that this form of HRT would be what to ask my GP about.

Countering misinformation

In an editorial published in the British Medical Journal, Professor Janice Rymer, Vice President of the Royal College of Obstetrics and Gynaecology, presented unequivocal evidence about the misinformation surrounding HRT, which risks further damaging setbacks for women’s health[4].

It is tragic and bewildering that a replacement therapy that restores hormones to physiological levels and improves quality of life for women has been misrepresented. Sadly, the focus has been almost entirely on potential side effects, to the exclusion of the benefits of improving health and quality of life. After all, there seems to less reluctance giving testosterone replacement to men.

For younger women there are no qualms about giving supraphysiological doses of hormones, in non-molecular identical forms, found in many combined oral contraceptive pills to supress internal hormone production (ironically supressing oestradiol and progesterone to the low levels seen in menopause). The combined oral contraceptive pill continues to be given, in some cases, to those women with functional hypothalamic amenorrhoea (FHA), where this practice is advised against by the Endocrine Society[5].  

In conclusion I think the underlying issue is that, despite inspiring advances across many fields, there continues to be the pervasive perception that female hormones are solely about fertility. Whilst there is no denying that this is the evolutionary purpose of ovulation, female hormones are crucial to all aspects of health. This applies whatever the age of a woman.     

References


[1] British Menopause Society & Women’s Health Concern 2020 recommendations on hormone replacement therapy in menopausal women. https://thebms.org.uk/publications/consensus-statements/bms-whcs-2020-recommendations-on-hormone-replacement-therapy-in-menopausal-women/

[2] Royal College Obstetrics and Gynaecology website “Menopause and women’s health in later life” for patients

[3] National Institute of Clinical Excellence. Menopause: Diagnosis and Management Update 2019.

[4] Janice Rymer, Kate Brian, Lesley Regan. HRT and breast cancer risk. Editorial BMJ 2019;367:l5928 doi: 10.1136/bmj.l5928 (Published 11 October 2019)

[5] Gordon C, Ackerman K, Berga S et al Functional hypothalamic amenorrhea: An endocrine society clinical practice guidelineJournal of Clinical Endocrinology and Metabolism (2017) 102(5) 1413-1439

Energy Availability in Dancers

Here I discuss the findings from our recent study: Indicators and correlates of low energy availability in male and female dancers [1]. Thanks to my co authors and all the dancers who made this important study possible. I personally paid for open access to the entire paper so you and the whole dance community can read the full details.

Dance v Sport

Dance and Sport…plus ça change

There are many similarities between dancers and athletes, in terms of the physical and mental demands of training and performance. In both disciplines, training starts from a young age to hone technical skills. Dance, in particular, shares many of the challenges of aesthetic sports. In some ballets, the visual appearance of the corps de ballet is essential to the story line. In La Bayadere, the warrior sees in a dream multiple images of his true love, the dead temple dancer. In Swan Lake the corps de ballet moves like a flock of birds and in Les Sylphides the corps de ballet portrays ethereal spirits.

Furthermore, in dance and certain sports low body weight is perceived to confer a performance advantage. This is not just for aesthetics, but also to meet the technical dance demands of elevation and pointe work, where the whole of a dancer’s body weight goes through the first metatarsal joint (big toe joint). Indeed, the spotlight was on dancers in some of the early studies on the potential incidence and consequences of low energy availability [2]. However, since initial studies in dancers, the focus has been on athletes involved in sport, culminating in the International Olympic Committee (IOC) consensus statement published in 2014 on relative energy deficiency in sport (RED-S). As the name RED-S indicates, sport is the focus of this clinical syndrome describing the clinical consequences of low energy availability on health and performance [3].

What’s new in dance?

Whilst there are clearly parallels with dance and sport, there are equally some fundamental differences from cultural and organisational perspectives. Furthermore, the demands of dance have changed dramatically over just two generations. The illustration shows my grandmother from 1920s, with loose fitting costume, en pointe on two feet with a “romantic” interpretation, who was invited to join the legendary Dame Ninette De Valois and her company. This contrasts to her granddaughter (me!) at about the same age from 1980s, wearing a tight fitting, shorter length tutu, en pointe on one leg and portraying a different style of ballet.

1920s my grandmother v 1980s granddaughter (me!)

Relative Energy Deficiency in Dance
To explore the current situation of low energy availability in the dance community against the backdrop of these changes in demands, we conducted a study of dancers worldwide to assess indicators and correlates of low energy availability. Building on the sport specific energy availability questionnaire [4], we developed a dance specific version to ensure engagement with dancers [1].

The key findings from this survey of 247 dancers found that 57% of female dancers and 27% of male dancers were at risk of RED-S. Psychological factors are recognised to play a part in both the cause and consequences of RED-S. From our study of dancers a significant cluster of psychological interrelationships was found. Dancers who rated control of eating as important, also did so for control of body weight as well as expressing anxiety about missing training. In order to be a successful dancer, self-discipline and self-motivation are undoubtedly important. However, in contrast to dancers from previous generations the pervasive pressure from social media is ever increasing, alongside perceived dance specific demands of being of a certain weight to gain leading roles.

Strikingly, significant relationships were found between these psychological factors and physical and physiological indicators of low energy availability, including low body weight and menstrual dysfunction.

That is not to say that dancing is an inherently an “unhealthy” pursuit. Far from it: dance has been shown to have beneficial effects on both physical and mental wellbeing, both from a participant and an audience point of view. Dance goes beyond the dimension of physical performance, calling upon musicality, expression and acting. This is why an important message from this study is to raise awareness about misperceptions about body weight, in order to support optimal dance performance. Rather, anxiety about body weight can have negative consequences on physical and mental health, and ultimately impair dance performance. Raising awareness about low energy availability and relative energy deficiency in dance and sport was the rationale for writing the British Association of Sport and Exercise Medicine open access, educational website [5]

The other important message from this study is that early identification of aspiring male and female dancers at risk of developing the clinical consequences of relative energy deficiency in dance could be possible with a dance specific questionnaire used in this study. As with participation in sport, early identification is crucial as a proactive, preventative measure. In other words, keeping in step with the increasing demands of dance in a changing world, rather than relying on reactive measures to deal with the ensuing mental and physical injuries of relative energy deficiency in dance.

The pandemic has impacted everyone. This includes professional dancers and athletes. Whilst the return of professional athletes to some competition has been facilitated, theatres where dancers perform remain shut. These are unprecedented, challenging times for dancers. On the other hand, this does offer the opportunity to plan for ways to ensure future generations of healthy dancers with sustainable careers.

References

1 Keay N, Overseas A, Francis G. Indicators and correlates of low energy availability in male and female dancers BMJ Open Sport & Exercise Medicine 2020;6:e000906. doi: 10.1136/bmjsem-2020-000906

2 Keay N, Fogelman I, Blake G Bone mineral density in professional female dancers. British Journal of Sports Medicine 1997;31:143-147

3 Keay N, Francis G Infographic. Energy availability: concept, control and consequences in relative energy deficiency in sport (RED-S) British Journal of Sports Medicine 2019;53:1310-1311.

4 Keay N, Francis G, Hind K Low energy availability assessed by a sport-specific questionnaire and clinical interview indicative of bone health, endocrine profile and cycling performance in competitive male cyclists BMJ Open Sport & Exercise Medicine 2018;4

5 www.health4performance.co.uk BASEM educational website

Online Courses for High Performing Female Athletes

Courses for Coaches and Athletes

Coaching High Performing Female Athletes

Training as a High Performing Female Athlete

Increasing numbers of women are participating in exercise and sport. However this has not been matched by female specific research, education and implementation of practical strategies to optimise female health and performance.

Does this matter? Absolutely as there are crucial physiological differences between females and males. To date the majority of clinical medicine, sport science and coaching strategies are based on a blueprint for men.

The result is that female athletes are at risk of not optimising their health and therefore unable to reach their personal full athletic potential.

The most obvious and important difference between men and women on a medical and physiological basis is that women have menstrual cycles, where there are considerable fluctuations of female hormones. So any discussion of exercise training, nutrition and recovery for female athletes has to factor in this fundamental physiological process.

I have developed a suite of courses to support female athletes and their coaches in their quest to optimise health and performance. These courses provide up-to-date, evidence-based information and practical strategies. The objective is to help female athletes become resilient and sustainable athletes in the long term, enabling each individual to to achieve her personal full potential.

There are 2 courses:

Course for coaches working with high performing female athletes from puberty and beyond, across all sports. This course is endorsed by the British Association of Sport and Exercise Medicine. The course includes lectures, interviews with an Olympic coach and a former international female athlete, quizzes and resources. The material covers female physiology; practical strategies of training, nutrition and recovery to optimise health and performance; warning signs to look out for in the case of imbalances, with particular reference to relative energy deficiency in sport (RED-S). Successful completion of he course and reaching pass mark for the quizzes results in a certificate of completion. Link to coach course

Course for high performing female athletes covers female physiology from puberty onwards; training schedule strategies covering training load, nutrition and recovery; risk of relative energy deficiency in sport (RED-S): what to look out for and what to do. There are also interviews with an Olympic coach and a former international female athlete. Link to athlete course

Coach Course Endorsed by BASEM

References

N. Keay “Of Mice and Men” British Journal of Sport Medicine 2019

Thyroid Function in Athletes and Dancers

Now is a good time to revisit a topic discussed in a previous BJSM blog (1), to coincide with guidelines on the management of thyroid disease released by National Institute of Clinical Excellence (NICE) in November 2019 (2) and summarised in the British Medical Journal (BMJ) last month (3).

It has transpired that athletics coach Alberto Salazar facilitated the clinically inappropriate prescription of thyroxine to some of his euthyroid athletes. Thyroxine is not on the World Anti-Doping Agency’s (WADA) banned list, nevertheless as we shall discuss below, administering thyroxine to those with normal thyroid function potentially can have adverse consequences on health and performance. Salazar was banned for four years on the grounds outlined by United States Anti Doping Agency (USADA) (4), falling into three areas: use of a prohibited method (with infusion in excess of the limit), tampering with the doping control process, and trafficking of testosterone.

Recap of thyroid axis

In common with many endocrine axes, the thyroid axis works on a negative feedback loop mechanism to maintain homeostasis of circulating levels of the response hormone thyroxine (T4) in the normal range. TSH (thyroid stimulating hormone) is the control hormone released by the pituitary gland. TSH acts on the thyroid gland to release T4, which in turn is converted peripherally to the more active T3. As with all biological homeostatic mechanisms, there is some physiological variation within the normal range for an individual. Significant changes, beyond that expected from biological and analytical variation can be calculated using the system recently described in BMJ (5).

Screen Shot 2020-03-12 at 17.44.37

Significant patterns in thyroid function

Consecutively raised TSH levels, with paired levels of T4 below the normal range indicate primary hypothyroidism. Conversely, levels of TSH below the normal range with paired levels of T4 above the upper end of the normal range indicate an overactive thyroid. If the situation were that clear-cut, then this would be a very short blog. Needless to say, there are some situations requiring careful scrutiny. Subclinical hypothyroidism is the situation where TSH is raised above the upper end of the normal range, yet T4 remains in range. According to NICE guidelines thyroxine treatment is indicated where TSH >10 mlU/L on 2 occasions, 3 months apart OR in someone under 65 years of age, where TSH is raised above the reference range (but lower than 10 mlU/L) on 2 occasions, 3 months apart AND accompanied by symptoms of hypothyroidism. Furthermore, NICE advises that any treatment with thyroxine should be such that TSH is maintained in the normal range and NOT cause suppression of TSH, nor symptoms of thyrotoxicosis. Based on this clinical criteria, some athletes under Salazar were reportedly treated inappropriately with thyroxine. In other words, even when TSH was in the normal range and the athletes were in euthyroid status, in the absence of an indication of subclinical hypothyroidism, it appears that thyroxine was given in the belief that this might aid with maintaining low body weight, which could be a performance advantage. Nevertheless, WADA does not consider thyroxine to confer a performance advantage, which is why this hormone is not on the banned list.

Screen Shot 2020-03-12 at 17.44.23However, treatment with thyroxine, which is not warranted on clinical grounds, can potentially have adverse effects on health, for example, increased risk of cardiac arrhythmias. Moreover, it is well documented that thyrotoxicosis is a risk factor for bone fracture in the long term. In the short term, stress fractures in athletes are recognised as a consequence of low energy availability (6), which is the underlying aetiology of relative energy deficiency in sport (RED-S) (7). Increased metabolic rate as a consequence of endogenous or exogenous excess thyroxine could theoretically lead to a situation of unintentional low energy availability and the adverse clinical sequalae of RED-S.

“Non thyroidal illness”/ “sick euthyroid”

This is characterised by low-end range TSH and T4. In other words, the negative feedback loop to maintain hormone homeostasis is not functionally normally. This situation is seen in functional hypothalamic-pituitary-endocrine gland suppression: for example, in athletes and dancers with the clinical syndrome of RED-S. In female athletes RED-S often presents as functional hypothalamic amenorrhoea, with low FSH and LH (in the presence of normal prolactin) and low oestrogen. As part of the adaptive response to the situation of low energy availability, metabolic rate is down-regulated to “save energy” (8) characterised by low-end range TSH, T4 and T3 (9). In such a situation, giving exogenous thyroxine will override this physiological response to down regulate metabolic rate and potentially increase energy deficit.

The psychological and physical pressures experienced by athletes and dancers can sometimes have reversible impacts on the hypothalamic-pitutary-thyroid axis, as seen in RED-S. On the other hand, athletes and dancers can also experience medical conditions, which impact this endocrine axis requiring appropriate treatment in line with medical guidelines. The recognition of these different situations provides insights and a deeper understanding of overall endocrine function in this athletic population.

References

1 Keay N. Fatigue, sport performance and hormones….more on the endocrine system. Posted on May 25, 2017 by BJSM

2 Thyroid disease: assessment and management NICE guideline [NG145]Published date: November 2019

3 Thyroid disease assessment and management: summary of NICE guidance BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m41 (Published 29 January 2020) Cite this as: BMJ 2020;368:m41

4 AAA Panel Imposes 4-Year Sanctions on Alberto Salazar and Dr. Jeffrey Brown for Multiple Anti-Doping Rule Violations September 2019 USAD 

5 Your results may vary: the imprecision of medical measurements BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m149 (Published 20 February 2020) Cite this as: BMJ 2020;368:m149

6 Heikura I, Uusitalo A, Stellingwerff T et al Low Energy Availability Is Difficult to Assess but Outcomes Have Large Impact on Bone Injury Rates in Elite Distance Athletes. International Journal of Sport Nutrition and Exercise Metabolism 2018; 28 (4), 403-11

7 Keay N. 2018 UPDATE: Relative Energy Deficiency in Sport (RED-S) Posted on May 30, 2018 by BJSM

8 Staal S, Sjödin A, Fahrenholtz I Low RMR ratio as a Surrogate Marker for Energy Deficiency, the Choice of Predictive Equation Vital for Correctly Identifying Male and Female Ballet Dancers at Risk International Journal of Sport Nutrition and Exercise Metabolism 2018

9 Ihle R, Loucks A Dose-response relationships between energy availability and bone turnover in young exercising women Journal of Bone and Mineral Research (2004) 19(8) 1231-1240

“Of Mice and Men….”

“We need to treat individual women, not statistics” was the concluding sentence of an insightful BMJ Editorial 2019 [1]

However, as Caroline Criado Perez points out in her recent, science prizing-winning book, Invisible Women, in many instances there are no scientific or medical statistics on women[2].

Mouse
“Where are the females?”

The efficacy of drugs is predominately initially tested in vivo on male cells. So at inception, potentially many medications, which might have been effective in females are discarded at the earliest stage of research, because no effects are observed in male cells. The trend of the default male organism in research follows through into animal experimentation on male mice. Although animal models may not be entirely predictive of effects in humans, certainly the effects in female humans will be even less certain. Does it matter that research is conducted predominately on male tissue, male organisms and men? Thalidomide, specifically one of the optimal isomers, is a drug that had devastating teratogenic effects when taken by women. Indeed, a wide range of potential sex differences in the effects and metabolism of drugs has been reported. Furthermore the action of drugs, including adverse effects, can vary according the phases of the menstrual cycle, due to variations in circulating sex steroids. For example, certain drugs are likely cause arrhythmia in the follicular phase of the menstrual cycle[3]. Yet the effect of many drugs in females is not well understood, as research had not included females, let alone women in different phases of the menstrual cycle.

Why is research focused on males? There is an argument that the menstrual cycle in females is “too complicated” or including women in a study at difference phases of the menstrual cycle “will interfere with results”. Menstrual cycles have been around since women evolved, so this is not a phenomenon that is going to go away anytime soon. Therefore, welcoming the complexity of the intricate choreography of hormones during the menstrual cycle and during the lifetime of a women, is a more constructive approach. Certainly a more acceptable scientific approach is where the objective is to elucidate similarities and differences between men, rather than excluding the female half of the population and assuming no differences in physiology and metabolism exist. Furthermore there are differences between individual women. Individual women will be impacted by fluctuations of hormones during the menstrual cycle in different ways, depending on varying tissue sensitivities to steroids between individuals.

This concept is especially important in sports science where the vast majority of studies are conducted in males. As I outlined in my presentation recently at Barça Innovation Hub, before discussing external factors (training load, nutrition, recovery), researched in males, for female athletes is is vital to take into account internal bio-chronometers[4]. Circadian misalignment leads to suboptimal health and performance[5]. For female athletes, the most important cyclical variation of hormones during the menstrual cycle. Furthermore, these periodic changes in hormones have individual effects. Only when these are recognised can external factors be integrated with internal periodicity. In other words by taking account of individual internal variations, this makes it possible to provide personalised advice. Tracking menstrual cycles provides an important training metric as menstrual cycles are a barometer of healthy hormones[6]. As it becomes easier to track personal health and performance data on a daily basis, both researchers and individual women can gain a better understanding of how female physiology varies over the menstrual cycle. Optimising health and performance for the individual female athlete, makes for a stronger team.

What about in the clinical medical setting? I recently attended an excellent update on acute medicine for medical doctors. An eminent cardiologist presented a series of case studies, including a woman who started experiencing symptoms in the morning, which both she and doctors thought were due to indigestion. Eventually when this “indigestion” had not settled by later afternoon, she attended A&E. She had suffered an extensive myocardial infarction (heart attack). The cardiologist explained that even though she went to a hospital with an on-site primary percutaneous coronary intervention facility, unfortunately due to the long delay in presenting to hospital, the heart muscle had died. The opportunity had been missed to take her into the catheterisation laboratory to restore blood flow and function to the cardiac muscle. He outlined how this delay in diagnosis would have a big impact on her future quality of life and life span. Unfortunately this is not an isolated case. Women are far more likely to be misdiagnosed as not having acute coronary syndrome, when in fact they are indeed suffering a “heart attack”. Why is this? The “typical” presentation of myocardial infarction of central crushing chest pain with radiation to left neck and arm, disseminated to the public and medical students, is in fact only typical for men. Women present with “atypical” symptoms, in other words atypical for men[7]

Even where female specific statistics do exist, the emphasis should be on considering the individual woman in clinical context. The recent BMJ editorial on HRT emphasised providing women with high quality, unbiased information on which women can weigh up their personal risk/benefit outcomes from HRT. As, each woman can experience changes in hormones differently, including those occurring at the menopause; so the emphasis should be on an individual woman’s quality of life rather than epidemiological statistics[1].

There are important differences between mice, men and women.

References

[1] Rymer J, Brian, K, Regan L. HRT and breast cancer risk. BMJ Editorial 2019. dx.doi. org/10.1136/bmj.l5928

[2] Caroline Criado Perez. Royal Society Book Prize. Invisible Women. Publisher Chatto & Windus 2019

[3] Soldin O, Chung S, Mattison D. Sex Differences in Drug Disposition. Journal of Biomedicine and Biotechnology 2011, Article ID 187103 doi:10.1155/2011/187103

[4] N. Keay “Dietary periodisation for female football players” Barca Innovation Hub conference, Camp Nou, Barcelona, 9 October 2019

[5] N.Keay, Internal Biological Clocks and Sport Performance BJSM 2017

[6] N.Keay, What’s so good about Menstrual Cycles? BJSM 2019

[7] Khamis R, Ammari T, Mikhail G. Gender differences in coronary heart disease. Education in Heart. Acute coronary syndromes. BMJ Heart http://dx.doi.org/10.1136/heartjnl-2014-306463

 

 

 

RED-S Research: Bones and Ballet

BJSM Blog 26/8/2019

Dr Nicky Keay

BJSMThere are many areas of RED-S (relative energy deficiency in sport) that are currently being researched. Whilst there is animated discussion about scientific evidence for energy availability thresholds in men and women, in the clinical setting what are the most effective ways to identify and support these athletes and dancers at risk of the health and performance consequences of RED-S?

Bone stress injuries, including stress fractures and other complications of suboptimal bone heath such as compression fractures are some of the most clinically significant sequalae of low energy availability described in the RED-S (relative energy deficiency in sport) clinical model[i]. Suboptimal bone health with associated recurrent stress fractures can be career ending for athletes and dancers.

Therefore early identification of those with suboptimal bone health is crucial. In terms of identifying athletes/dancers at risk of developing bone health consequences due to RED-S, a sport specific questionnaire in male cyclists has been demonstrated to be effective[ii]. The purpose of identifying those at risk of suboptimal bone health is in order to put in place interventions, to prevent progression, and in some cases, improve bone health. Evidence for positive outcomes of these behavioural interventions are reported in male cyclists[iii].

Currently bone mineral density (BMD) is measured using DXA (dual X ray absorptiometry), which although low in dose, nevertheless involves ionising radiation. This limits the frequency of measurement, although bone is metabolically active and often one of first systems to change in response to low energy availability[iv]. The new technology of R.E.M.S. (Radiofrequency Echographic Multi Spectrometry) involves totally safe ultrasound. Furthermore this technology provides information on bone microarchitecture. Currently assessment of bone microarchitecture is only possible with pQCT (peripheral quantitative computerised tomography), which is not only involves a high radiation dose, furthermore is limited to assessment of peripheral skeletal sites. Although BMD is undoubtedly an important factor in determining bone health, nevertheless bone strength and structure also plays an important part.

Therefore the main objective of a forthcoming study[v] is to establish the effectiveness of identifying those at risk of suboptimal bone health with this new specialised ultrasound based technology and correlate with questionnaire and blood markers in both athletic and non athletic populations.

Ballet and other Dance forms

RED-S is more prevalent in sports where being of low body weight confers a performance or aesthetic advantage. Although dance is not a sport, nevertheless this type of activity requires low body weight from both a performance and aesthetic point of view for both male and female dancers. Dance training often starts at a young age[vi] and as with early sport specialisation, there is an increased risk of developing low energy availability during this time of high-energy demand for growth and development[vii]. So much so, that this situation can have a negative impact on accumulation of peak bone mass and adverse potential long-term effects[viii].

Although there is a validated questionnaire LEAF-Q[ix] for assessing low energy availability in female athletes, this excludes half the population and is not sport specific. A questionnaire-based study amongst female athletes was found to be effective at identifying and quantifying the clinical consequences of low energy availability[x]. Our recent study of competitive male road cyclists found that a sport specific energy availability questionnaire combined with interview (SEAQ-I)[xi] was the measured factor most effective in indicating low BMD of the lumbar spine. BMD of the lumbar spine is a quantifiable measure of chronic low energy availability. Other objective measures of low energy availability include indicators of endocrine function. In women menstrual function and in men testosterone, which in turn are clinked to the clinical outcome of impaired bone health and stress fracture in runners[xii]

To date there is a dearth of sport specific questionnaires to assess low energy availability and none that are dance specific. Dance involves both male and female and is certainly a type of activity where individuals are at risk of low energy availability and the clinical consequences of RED-S. Therefore the aim of the current dance study is to use a dance specific energy availability questionnaire (DEAQ)[xiii] to asses awareness, risk factors and consequences of low energy availability and RED-S.

References

[i] Mountjoy M, Sundgot-Borgen J, Burke L et al. IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update British Journal of Sports Medicine 2018; 52(11): 687-697 DOI: 10.1136/bjsports-2018-099193

[ii] Keay N, Francis G, Hind K. Low energy availability assessed by a sport-specific questionnaire and clinical interview indicative of bone health, endocrine profile and cycling performance in competitive male cyclists BMJ Open Sport and Exercise Medicine 2018; 4(1) DOI: 10.1136/bmjsem-2018-000424

[iii] Keay N, Francis G, Entwistle I et al. Clinical evaluation of education relating to nutrition and skeletal loading in competitive male road cyclists at risk of relative energy deficiency in sports (RED-S): 6-month randomised controlled trial BMJ Open Sport and Exercise Medicine 2019; 5(1) DOI: 10.1136/bmjsem-2019-000523

[iv] Professor Louise Burke presenting at annual ISENC conference Newcastle 2018

[v] Assessment of Echographic Technology in Measuring Bone Health in the Clinical Setting

[vi] N. Keay. Dancing through adolescence British Journal of Sports Medicine 1998 DOI: 10.1136/bjsm.32.3.196

[vii] N. Keay. The modifiable factors affecting bone mineral accumulation in girls: The paradoxical effect of exercise on bone Nutrition Bulletin 2000 DOI: 10.1046/j.1467-3010.2000.00051.x

[viii] N. Keay, G.Blake, I. Fogleman.  Bone mineral density in professional female dancers British Journal of Sports Medicine 1997; 31(2): 143-147

DOI: 10.1136/bjsm.31.2.143

[ix] Melin A, Tornberg Å, Skouby S et al. The LEAF questionnaire: A screening tool for the identification of female athletes at risk for the female athlete triad British Journal of Sports Medicine 2014: 48 (7)

[x] K. Ackerman, B. Holtzman et al. Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport British Journal of Sports Medicine 2018; 53(10) 628-633

DOI: 10.1136/bjsports-2017-098958

[xi] N. Keay, G. Francis, K. Hind. Low energy availability assessed by a sport-specific questionnaire and clinical interview indicative of bone health, endocrine profile and cycling performance in competitive male cyclists BMJ Open Sport and Exercise Medicine 2018 4(1) DOI: 10.1136/bmjsem-2018-000424

x Heikura I, Uusitalo A, Stellingwerff T et al. Low energy availability is difficult to assess but outcomes have large impact on bone injury rates in elite distance athletes, International Journal of Sport Nutrition and Exercise Metabolism 2018; 28(4): 403-411 DOI: 10.1123/ijsnem.2017-0313

[xiii] DEAQ Dance Energy Availability Questionnaire on line with ethical approval from Durham University

Energy Availability: Concept, Control and Consequences in relative energy deficiency in sport (RED-S)

Relative energy deficiency in sport (RED-S) is an issue of increasing concern in sports and exercise medicine. RED-S impact exercisers of all levels and ages, particularly where low body weight confers a performance or aesthetic advantage. Key to mitigating adverse health and performance consequences of RED-S is supporting athletes and dancers to change behaviours. These infographics aim to assist clinicians in communicating the concepts to exercisers and in implementing effective management of athletes in their care[1].

Slide1

Figure 1 illustrates the concept of energy availability (EA) in RED-S. Preferentially energy derived from dietary intake covers the demands of training and the remaining energy, EA, is, quantified in Kcal/Kg of fat free mass[2]. In Figure 1, the central bar illustrates adequate EA in an athlete where energy intake is sufficient to cover the demands of training and fundamental life processes to maintain health. Conversely, low energy availability (LEA) is a situation of insufficient EA to cover basic physiological demands. LEA leads to the adverse consequences of RED-S[3]. LEA can arise unintentionally or intentionally, due to a mismatch between energy intake and energy requirement. In Figure 1 the bar on the left shows LEA resulting from reduced energy intake with maintained training load. On the right, LEA is a consequence of increased training load with maintained energy intake.

Figure 2 illustrates that EA is under the control of an athlete[4]. The three behaviours relating to training, nutrition and recovery determine EA. Integrated periodisation of these behaviours results in optimal health and performance. Conversely, an imbalance in these behaviours results in suboptimal functionally. LEA in the case of high training loads relative to nutritional intake. Thus, this figure reinforces the important point in the IOC statements on RED-S that psychological factors which determine these behaviours are key in both the development, continuation and management of RED-S[2,3].

Slide1

Figure 2 also shows the temporal, synergistic effect of these behaviours to ensure a fully functioning endocrine system. Hormones are key for health and to drive positive adaptations to exercise, to improve athletic performance. Thus hormones can be informative in tracking the response of an individual to these three input variables. Furthermore, endocrine markers relate to the RED-S clinical outcome of stress fracture in athletes, being more reliable as objective, quantifiable indicators of EA than numerical calculation of EA from direct assessment[5].

Authors

Nicola Keay1, Gavin Francis2

1 Department of Sport and Exercise Sciences, Durham University

2 Science4Perforamnce, London

Br J Sports Med 2019;0:1–2. doi:10.1136/bjsports-2019-100611

References

1 http://health4performance.co.uk (accessed 21/01/2019) Health4Performance Educational BASEM website raising awareness of RED-S Working group on RED-S British Association of Sport and Exercise Medicine 2018

2 Mountjoy M, Sundgot-Borgen J, Burke L et al. IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update Br J Sports Med2018;52(11):687-697

3 Mountjoy M, Sundgot-Borgen J, Burke L et al. The IOC consensus statement: beyond the Female Athlete Triad–Relative Energy Deficiency in Sport (RED-S). Br J Sports Med2014;48(7):491-7

4 Burke L, Lundy B, Fahrenholtz L et al, & Melin. Pitfalls of conducting and interpreting estimates of energy availability in free-living athletes. International Journal of Sport Nutrition and Exercise Metabolism2018; 28(4):350–363. https://doi.org/10.1123/ijsnem.2018-0142

5 2Heikura I, Uusitalo A, Stellingwerff T et al. Low energy availability is difficult to assess but outcomes have large impact on bone injury rates in elite distance athletes. International Journal of Sport Nutrition and Exercise Metabolism2018; 28(4):403–411. https://doi.org/10.1123/ijsnem.2017-0313