Category: Principles

Body Composition for Health and Sports Performance

9 December 2017
Screen Shot 2017-12-02 at 15.03.23
Body Composition from DEXA scan

Focusing on changes in body weight and body mass index (BMI) alone, as outcome measures of lifestyle interventions, ignores the beneficial multi-system and psychological effects of lifestyle medicine, in particular exercise. This includes advantageous changes in body composition for health and performance.

Why is body composition important? Because not all weight is equal in terms of tissue composition and distribution. To support optimal health, favourable levels of lean mass  versus fat mass decreases the risk of sarcopenia, associated bone loss and metabolic syndrome. For athletes, high lean mass coupled with low fat mass is related to improved athletic performance, especially in disciplines where strength to weight ratio a major consideration and/or those disciplines such as gymnastics and ballet where an aesthetic component confers a performance advantage.

The range of methods for measuring body composition have advantages and disadvantages in terms of accuracy, accessibility and expense. Although accurate in experienced hands, skin fold measurements are limited to giving a measure of subcutaneous fat. Impedance scales have the advantage of giving a measure of both total and visceral fat percentage, however accuracy is dependent on hydration status, amongst other variable factors. Dual-Energy X-Ray Absorptiometry (DEXA) scan is the “gold standard” for measuring body composition to include bone, lean and fat: both total and visceral. DEXA scan is relatively inexpensive and very low radiation dose compared to traditional X ray or computerised tomography (CT). This method of assessing body composition during training seasons is used by some professional sports teams. The illustration above shows a trained male with total fat in the athletic range. Although simple to measure, BMI does not accurately reflect body composition. All methods of assessing body composition can potentially have role in monitoring changes, for example over training seasons, and trends for individuals rather than relying on the absolute values of metrics measured.

How to go about optimising body composition? Combined exercise and nutritional strategies trigger and reinforce favourable metabolic and Endocrine signalling pathways. The detail of these lifestyle strategies will depend on the clinical context and the objectives of the individual: ranging from a sedentary person trying to improve health and well being, to an athlete aiming to improve sport performance. In all scenarios protein intake is an important factor in supporting lean mass, alongside tailored exercise/training. Temporal considerations for optimising body composition in athletes include the age of the athlete and targeting key competitions during a training cycle and in long term over athletic career. Ultimately optimising body composition has to translate to improved athletic performance for the endurance athlete. So aiming for “high quality weight loss” with retention or even improved lean mass, is more likely to support performance, rather than focusing on fat mass loss in isolation, which may occur in any case as a secondary consequence of integrated periodised training, nutrition and recovery. Striving for weight loss and reduced fat mass without careful monitoring and attention to effects on performance, can run the risk of athletes developing relative energy deficiency in sports (RED-S). Female athletes with functional hypothalamic amenorrhoea have been shown to decreased levels not only of lean and fat mass, but in addition reduced metabolically active brown fat and the associated hormone isirin which promotes fat “browning” and impacts bone mineralisation. In addition, there are differences between male and female athletes to be considered in terms of body composition and cycling performance.

From middle-age, both lean mass and bone mineral density (BMD) decline: sarcopenia and bone health intertwined. In order to mitigate against these changes, resistance exercise is particularly beneficial to stimulate muscle and load the skeleton and for metabolic and cognitive benefits. BMI is particularly misleading as a metric to assess risk of disease in menopausal women. Rather, the finer detail of body composition, for example visceral fat area, is more informative in terms of metabolic and psychological health.

Body composition is a more reliable indicator of health than body weight or BMI. Nevertheless body composition in isolation is not the sole determinant of health and performance. Rather body composition is just one of many multi-system effects mediated by integrated metabolic and Endocrine signalling pathways. These network effects are driven by lifestyle factors including exercise, nutrition and recovery, to determine health and sports performance.

For more discussion and debate on the role of body composition for health and performance BASEM Spring Conference 2018 6 CPD points from FSEM and BJSM approved for international education

BAsem2018_SpringConf_BJSMFSEM_CPD_AwardScreen Shot 2017-12-12 at 14.47.15

References

Challenging those hard to shift, big fat obesity risks BMJ 2017; 359: j5303 British Journal of Medicine 2017

Lifestyle Choices for optimising health: exercise, nutrition, sleep British Journal of Sport Medicine 2107

One road to Rome: Exercise British Journal of Sport Medicine 2107

Current Status of Body Composition Assessment in Sport Review and Position Statement on Behalf of the Ad Hoc Research Working Group on Body Composition Health and Performance, Under the Auspices of the I.O.C.Medical Commission

International society of sports nutrition position stand: diets and body composition Journal of the International Society of Sports Nutrition 2017
Case-Study: Body Composition Periodization in an Olympic-Level Female Middle-Distance Runner Over a 9-Year Career International Journal of Sport Nutrition and Exercise Metabolism 2017

Body composition assessment of English Premier League soccer players: a comparative DXA analysis of first team, U21 and U18 squads Journal of Sports Sciences

Protein Recommendations for Weight Loss in Elite Athletes: A Focus on Body Composition and Performance International Journal of Sport Nutrition and Exercise Metabolism 2017

Optimal Health: For All Athletes! Part 4 – Mechanisms British Association for Sport and Exercise Medicine 2017

Effect of Chronic Athletic Activity on Brown Fat in Young Women Plos One 2106

Irisin levels are lower in young amenorrheic athletes compared with eumenorrheic athletes and non-athletes and are associated with bone density and strength estimates Plos One

Kings and Queens of the Mountains Science4Performance

Low bone mineral density in middle-aged women: a red flag for sarcopenia Menopause 2017

Resistance training – an underutilised drug available in everybody’s medicine cabinet BJSM 2017

Benefits of resistance training in physically frail elderly: a systematic review Ageing Clinical and Experimental Research 2017

Is BMI a valid measure of obesity in postmenopausal women? Menopause 2017

Association of visceral fat area with the presence of depressive symptoms in Chinese postmenopausal women with normal glucose tolerance Menopause 2017

 

 

 

Health and Performance during Lifespan: latest research

16 November 2017

LifeSeasonDay

Your lifespan depends on genetic and key lifestyle choices

Lifespan is dependent on a range of genetic factors combined with lifestyle choices. For example a recent study reported that an increase in one body mass index unit reduced lifespan by 7 months, whilst 1 year of education increased lifespan by 11 months. Physical activity was shown to be a particularly important lifestyle factor through its action on preventing age-related telomere shortening and thus reducing of cellular ageing by 9 years. Nevertheless, even though males and females have essentially identical genomes, genetic expression differs. This results in different disease susceptibilities and evolutionary selection pressures. More studies involving female participants are required!

Circadian clock

Much evidence is emerging about the importance of paying respect to our internal biological clocks when considering the timing of lifestyle factors such as eating, activity and sleep. For example intermittent fasting, especially during the night, and time restricted eating during the day enables metabolic flexibility. In other words, eating within a daylight time window will support favourable metabolism and body composition. No midnight snacks!

For athletes, even more care needs be given to timing of nutrition to support athletic performance. In the short term there is evidence that rapid refuelling after training with a combination of carbohydrate and protein favours a positive balance of bone turnover that supports bone health and prevents injury in the longer term. Periodised nutrition over a training season, integrated with exercise and recovery, is important in order to benefit from training adaptations and optimise athletic performance.

Protein intake in athletes and non athletes

Recovering from injury can be a frustrating time and some athletes may be tempted to reduce food intake to compensate for reduced training. However, recommendations are to maintain and even increase protein consumption to prevent a loss of lean mass and disruption of metabolic signalling. In the case of combined lifestyle interventions, such as nutrition and exercise aimed at reducing body weight, these should be directed at improving body composition. Adequate protein intake alongside exercise will maintain lean mass in order to minimise the risk of sarcopenia and associated bone loss which can occur during hypocaloric regimes. Good protein intake is important for bone health to support bone mineral density and reduce the risk of osteoporosis and fracture.

Adolescent Athlete

In the young athlete, integrated periodisation of training, nutrition and recovery is of particular importance, not only to support health and performance, but as an injury prevention strategy.  Sufficient sleep and nutrition to match training demands are key.

Differences between circadian phenotype and performance in athletes

For everyone, whether athlete or reluctant exerciser, balancing and timing key lifestyle choices of exercise, nutrition and sleep are key for optimising health and performance. However there are individual differences when it comes to the best time for athletes to perform, according to circadian phenotype/chronotype. In other words personal biological clocks which run on biological time. An individual’s performance can vary by as much as 26% depending on the time of day relative to one’s entrained waking time.

Later in Life

Ageing can be can be confused with loss of fitness and ability to perform activities of daily living. Although a degree of loss of fitness does occur with increasing age, this can be prevented to a certain degree and certainly delayed with physical activity. Exercise attenuates sarcopenia, which supports bone mineral density with the added benefit of improved proprioception, helping to reduce risk of falls and potential fracture; not to mention the psychological benefits of exercise.

 

For more discussion on Health Hormones and Human Performance come to British Association of Sport and Exercise Medicine Spring Conference 

BAsem2018_SpringConf_BJSM

References

Genome-wide meta-analysis associates HLA-DQA1/DRB1 and LPA and lifestyle factors with human longevity Nature Communications 2017

Physical activity and telomere length in U.S. men and women: An NHANES investigation Preventive Medicine 2017

The landscape of sex-differential transcriptome and its consequent selection in human adults BMC Biology 2017

Temporal considerations in Endocrine/Metabolic interactions Part 1 British Journal of Sport and Exercise Medicine, October 2017

Flipping the Metabolic Switch: Understanding and Applying the Health Benefits of Fasting Obesity 2017

Temporal considerations in Endocrine/Metabolic interactions Part 2 British Journal of Sport and Exercise Medicine, October 2017

Time-restricted eating may yield moderate weight loss in obesity Endocrine Today 2017

The Effect of Postexercise Carbohydrate and Protein Ingestion on Bone Metabolism Translational Journal of the American College of Sports Medicine 2017

Periodized Nutrition for Athletes Sports Medicine 2017

Internal Biological Clocks and Sport Performance British Journal of Sport and Exercise Medicine, October 2017

Nutritional support for injuries requiring reduced activity Sports in Science Exchange 2017

Balance fat and muscle to keep bones healthy, study suggests NTU October 2017

Dietary Protein Intake above the Current RDA and Bone Health: A Systematic Review and Meta-Analysis Journal of the American College of Nutrition 2017

Too little sleep and an unhealthy diet could increase the risk of sustaining a new injury in adolescent elite athletes Scandinavian Journal of Medicine & Science in Sports

Sleep for health and sports performance British Journal of Sport and Exercise Medicine, 2017

The impact of circadian phenotype and time since awakening on diurnal performance in athletes Current Biology

Successful Ageing British Association of Sport and Exercise Medicine 2017

Focus on physical activity can help avoid unnecessary social care BMJ October 2017

Biochemical Pathways of Sarcopenia and Their Modulation by Physical Exercise: A Narrative Review Frontiers in Medicine 2017

 

Lifestyle Choices

18 October 2017
Slide1
Lifestyle Choices: Exercise, Nutrition, Sleep

Lifestyle factors of exercise, nutrition and sleep are vital for optimising health. In the illustration shown, ideally we should be in the green zone representing a balance between these lifestyle factors. Slipping into the peripheral red zone represents an imbalance: either too much or too little of any of these three elements. In particular exercise is of paramount importance being the most effective way of producing beneficial, multi-system effects mediated via the Endocrine system to optimise health and playing an important role in chronic disease prevention. However, it is not just a matter of what, but when: timing is crucial in integrating lifestyle factors with internal biological clocks. Beyond these guiding principles, personal preference and choice is emerging as being just as important as the lifestyle factor itself.

In a fascinating study, 58 participants were given either a prescribed exercise session, or a choice of exercise. Afterwards the participants were presented with a choice of foods, which they believed was simply as way of thank you for taking part in the exercise study. Post exercise, in those given no choice exercise, higher energy intake of food was consumed with larger proportion of “unhealthy” food compared to choice exercise group. The choice exercise group reported greater value and enjoyment of the exercise session. Thus autonomous choice of exercise not only provides positive reinforcement of exercising, but subsequent food choice is improved.

This concept of facilitating self determination, particularly when it comes to exercise was explored at the the recent annual British Association of Sport and Exercise conference. “Practicalities of intervention design, adherence and motivation” was presented by Dr Carly McKay from Bath University, who described how empowering people to make choices is far more likely to mean they will adhere to those lifestyle options that will optimise health.

What about the optimal timing of exercise which might improve motivation and performance? Well this depends on the context and what you are trying to achieve. In the case of training for competition and competition itself, optimal performance tends to be early evening, providing the most favourable hormonal milieu. Although in theory the morning diurnal release of cortisol might help with exercise, the downside is that this may interfere with blood glucose regulation. Furthermore, focusing on just one hormone in the Endocrine system, rather than the integrated function of the hypothalamic-pituitary axis could be misleading. Although due respect should be paid to internal biological clocks, to prevent circadian misalignment between internal pacemakers and external factors; equally becoming too obsessive about sticking to a rigid schedule would psychologically take away that essential element of choice. Practicality is a very important consideration and a degree of flexibility when planning the timing of exercise. For example, my choice of cardiovascualar exercise is swimming, which I fit in according to work commitments and when public lane swimming is available. Fortunately whilst at the BASEM conference in Bath, these practical conditions were met during the lunch break to take advantage of the 50m pool at Bath University. Pragmatic, not dogmatic when it comes to timing of exercise.

Timing of nutrition post exhaustive exercise is an important factor in supporting bone health. Immediate, rather than delayed refuelling with carbohydrate and protein is more advantageous in the balance of bone turnover markers; favouring formation over resorption. In the longer term, prolonged low energy availability as in the situation of relative energy deficiency in sport (RED-S) has a potentially irreversible adverse effect on bone health. In terms of the timing of meals, not eating too close to going to sleep, ideally 2 hours before melatonin release, is best for metabolic health.

Backing up the lifestyle choices of exercise and nutrition is sleep. Timing, duration and quality of sleep is essential for many aspects of health such as hormonal release of growth hormone, functional immunity and cognitive function. Certainly it is well recognised that shift workers, with circadian misalignment: disturbed sleep patterns relative to intrinsic biological clocks, are more at risk of developing cardio-metabolic disease.

In summary, a prescriptive approach to lifestyle factors could be counter productive. Discussing options and encouraging individuals to make their own informed and personal choices is far more likely to enable that person to take responsibility for their health and adhere to changes in lifestyle that are beneficial for their health. Having worked in hospital based NHS diabetic clinics for many years, I appreciate that supporting reluctant exercisers is not always an easy task. Equally it can be difficult to distinguish between the effects of ageing and loss of fitness. However, this does not mean that this supportive and inclusive approach should be abandoned. Rather, encouraging people to participate in decision making that they feel leads to options that are realistic and beneficial, is the approach most likely to work, especially in the long term.

“If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.”
— Hippocrates

For more discussion on Health Hormones and Human Performance come to British Association of Sport and Exercise Medicine Spring Conference 

BAsem2018_SpringConf_BJSM

References

Presentations

One road to Rome: Exercise Dr N. Keay, British Journal of Sports Medicine 2017

Endocrine system: balance and interplay in response to exercise training Dr N. Keay 2017

Temporal considerations in Endocrine/Metabolic interactions Part 1 Dr N. Keay, British Journal of Sports Medicine 2017

Temporal considerations in Endocrine/Metabolic interactions Part 2 Dr N. Keay, British Journal of Sports Medicine 2017

Internal Biological Clocks and Sport Performance Dr N. Keay, British Association of Sport and Exercise Medicine 2017

Providing Choice in Exercise Influences Food Intake at the Subsequent Meal Medicine & Science in Sports & Exercise October 2017

BASEM/FSEM Annual Conference 2017, Assembly Rooms, Bath

Addiction to Exercise – what distinguishes a healthy level of commitment from exercise addiction? Dr N. Keay, British Journal of Sports Medicine 2017

The Effect of Postexercise Carbohydrate and Protein Ingestion on Bone Metabolism Translational Journal of the American College of Sports Medicine October 2017

Optimal Health: For All Athletes! Part 4 – Mechanisms Dr N. Keay, British Association of Sport and Exercise Medicine 2017

Sleep for health and sports performance Dr N. Keay, British Journal of Sports Medicine 2017

Focus on physical activity can help avoid unnecessary social care British Medical Journal October 2017

Internal Biological Clocks and Sport Performance

5 October 2017

A Nobel Prize was awarded this week to researchers who uncovered the molecular mechanisms controlling circadian rhythm: our internal biological clock.

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Circadian Hormone Release

These mechanisms rely on negative feedback loops found in many biological systems where periodicity of gene expression is key, such as the Endocrine system. Internal biological clocks allow for anticipation of the requirements from body systems at different times of the day and the ability to adapt to changes in external lifestyle factors. What is the clinical significance of biochronometers?

The importance of integration of lifestyle factors, such as timing of eating, activity and sleep with our internal biological clocks is revealed in situations of circadian misalignment that lead to suboptimal health and disease states in the longer term.

Consideration of our biochronometers is especially important for athletes in order to synchronise periodised training, nutrition and recovery and thus optimise health and sports performance.

Athletic Performance Performance in a cycle time trial was found to be better in the evening, rather than the morning, proposed to be due to a more favourable endogenous hormonal and metabolic internal milieu. Certainly there were some disgruntled swimmers at an international event, when the usual pattern of morning heats and evenings finals was switched, to accommodate television viewing spectators.

Female athletes: menstrual cycle/training season Women have an extra layer of endogenous biological periodicity in the form of the menstrual cycle controlled by temporal changes of hormone release in the hypothamalmus-pituitary-ovarian Endocrine axis. Changes in external factors of training load, nutrition and recovery are detected by the neuroendocrine gatekeeper, the hypothalamus, which produces an appropriate change in frequency and amplitude of GnRH (gonadotrophin releasing hormone), which in turn impacts the pulsatility of LH (lutenising hormone) release from the pituitary and hence the phases of the menstrual cycle, in particular ovulation. Even short term reduction of energy availability in eumenorrhoeic female athletes can inhibit LH pulsatility frequency and release of other hormones such as IGF1. Disrupted release of sex steroids and IGF1 has a negative effect on bone turnover: increased resorption and decreased formation. Active females have been found more susceptible to reduction in energy availability impacting bone metabolism than their male counterparts.

Another consequence of the phasic nature of the menstrual cycle relating to external factors such as exercise, is that injury risk could be linked to changes in the expression of receptors for for sex steroids oestrogen and progesterone in skeletal muscle. Certainly during pregnancy and the post partum period, relaxin hormone increases the laxity of soft tissues, such as ligaments, and hence maintenance stretching, rather than seeking to increase flexibility, is recommended to prevent injury, .

In order to produce desired temporal adaptive changes in response to exercise training, signalling pathways mediated by reactive oxidative species and inflammatory markers are stimulated in the short term, with supportive Endocrine interactions in the longer term. However, an over-response can impair adaptive changes and impact other biological systems such as the immune system. This maladaptive response could occur as a result of non-integrated periodisation of training, nutrition and recovery in athletes and, in the case of female athletes, oral contraceptive pill use has been implicated, as this effectively imposes a medical menopause, preventing the phasic release of endogenous hormones.

Considering a longer time scale, such as a training season, female athletes were found to have a more significant fall ferritin during than male athletes. Low normal iron does not necessarily correlate to iron deficiency anaemia, but low levels in athletes can impact bone health. Supplementation with vitamin C to improve absorption may help, although iron overload can have deleterious effects. As training intensity increases as the season progresses, six monthly haematological reviews for female athletes were recommended in this study.

Changes in set point feedback Feedback control of the Endocrine system, for example the hypothalamic-pituitary-thyroid axis is dynamic: both anticipatory and adaptive, depending on internal and external inputs. However, presentation of a prolonged stimulus can result in maladaptation in the longer term. For example, disruption of signalling pathways leading to hyperinsulinaemia results in insulin resistance, which represents the underlying pathophysiological mechanism of obesity and the metabolic syndrome. In other words a situation of tachyphylaxis, where prolonged, repeated stimulus over time results in insensitivity to the original stimulus. This also applies to the nature of exercise training over a training season and diets that exclude a major food type: temporal variety is key.

Lifespan (prematurity, ageing) Changes during the lifespan represent an important biochronometer. Premature and small-for-dates babies are at risk of long term metabolic and Endocrine dysfunction, potentially due to intrauterine reprogramming of the hypothalamic-pituitary axis. At the other end of the biological time scale, with advancing age, DNA methylation and changes in epigenetic expression occur. It has been suggested that this age related methylation drift could be delayed with calorie restriction. Melatonin, a key player in intrinsic biological time keeping has been proposed to attenuate bone resorption by reducing relative oxidative stress. This would potentially explain why shift workers with disrupted sleep patterns are reported to be at risk not only of metabolic dysfunction, but also impaired bone health. Disrupted sleep patterns are a concern for athletes, especially those whose training and competition schedule involve frequent international travel across time zones.

In summary, respecting your internal biological clocks and integrating your lifestyle and your training, nutrition and recovery with these intrinsic pacemakers in mind will optimise health and performance.

For further discussion BASEM annual conference 22/3/18: Health, Hormones and Human Performance

Presentations

References

The Nobel Prize in Physiology or Medicine 2017

Circadian clock control of endocrine factors Nat. Rev. Endocrinol

Temporal considerations in Endocrine/Metabolic interactions Part 1 Dr N. Keay, British Journal of Sports Medicine 2017

Temporal considerations in Endocrine/Metabolic interactions Part 2 Dr N. Keay, British Journal of Sports Medicine 2017

Athletic Fatigue: Part 2 Dr N. Keay 2017

Effect of Time of Day on Performance, Hormonal and Metabolic Response during a 1000-M Cycling Time Trial Plos One 2017

Optimal Health: For All Athletes! Part 4 – Mechanisms Dr N. Keay, British Association of Sport and Exercise Medicine 2017

Effects of reduced energy availability on bone metabolism in women and men Bone 2017

Expression of sex steroid hormone receptors in human skeletal muscle during the menstrual cycle Acta Physiol (Oxf). 2017

Endocrine system: balance and interplay in response to exercise training

Kynurenic acid is reduced in females and oral contraceptive users: Implications for depression Science Direct 2017

Oxidative Stress in Female Athletes Using Combined Oral Contraceptives Sports Medicine

Iron monitoring of male and female rugby sevens players over an international season J Sports Med Phys Fitness. 2017

Thyroid Allostasis–Adaptive Responses of Thyrotropic Feedback Control to Conditions of Strain, Stress, and Developmental Programming Frontiers in Endocrinology 2017

Stress- and allostasis-induced brain plasticity Annu Rev Med

Optimising Health and Athletic Performance Dr N. Keay 2017

Long-term metabolic risk among children born premature or small for gestational age Nature Reviews Endocrinology 2017

Caloric restriction delays age-related methylation drift Nature Communications 2017

Melatonin at pharmacological concentrations suppresses osteoclastogenesis via the attenuation of intracellular ROS Osteoporosis International 2017

Sleep for health and sports performance Dr N. Keay, British Journal of Sports Medicine 2017

 

Optimising Health and Athletic Performance

20 September 2017

FactorsWordCloud4

In order to improve sports performance, athletes periodise their training, nutrition and recovery within the context of a training season. For those not in exercise training, these controllable lifestyle factors correspond to exercise, diet and sleep, which require modification during the lifespan. In old money, this was called preventative medicine. Taking this a step further, rather than preventing disease, this proactive, personalised approach optimises health. Health should be a positive combination of physical, mental and social well being, not simply an absence of illness.

Failure to balance these lifestyle factors in an integrated fashion leads to negative outcomes. An athlete may experience maladaptation, rather than the desired adaptations to exercise training. For non-athletes an adverse combination of lifestyle factors can lead to suboptimal health and a predisposition to developing chronic disease.

What are the fundamental pathophysiological mechanisms involved in the aetiology of the clinical spectrum of suboptimal health, suboptimal sports performance and chronic disease?

Inflammation A degree of systemic inflammation and oxidative stress induced by exercise training is required to drive desired adaptations to support improved sport performance. However, prolonged, elevated levels of inflammation have adverse effects on health and underpin many chronic disease states. For example, inflammation is a contributing pathophysiological factor in the development of atherosclerosis and atherothrombosis in cardiovascular disease. What drives this over-response of the inflammatory process? Any combination of adverse lifestyle factors. Adipose tissue has an Endocrine function, releasing a subgroup of cytokines: adipokines which have peripheral and central signalling roles in energy homeostasis and inflammation. In a study of Belgian children, pro-inflammatory energy related biomarkers (high leptin and low adiponectin) were associated with decreased heart rate variability and hence in the long term increased risk of cardiovascular disease. For those with a pre-existing chronic inflammatory condition, response to treatment can be optimised with personalised lifestyle interventions.

Metabolism Non-integrated lifestyle factors can disrupt signalling pathways involved in glucose regulation, which can result in hyperinsulinaeamia and insulin resistance. This is the underlying pathological process in the aetiology of metabolic syndrome and metabolic inflexibility. Non-pharmacological interventions such as exercise and nutrition, synchronised with endogenous circadian rhythms, can improve these signalling pathways associated with insulin sensitivity at the mitochondrial level.

Intriguingly, evidence is emerging of the interaction between osteocalcin and insulin, in other words an Endocrine feedback mechanism linking bone and metabolic health. This is reflected clinically with increased fracture risk found amongst type 2 diabetics (T2DM) with longer duration and higher HbA1C.

Hormone imbalance The hypothalamus is the neuroendocrine gatekeeper of the Endocrine system. Internal feedback and external stimuli are integrated by the hypothalamus to produce an appropriate Endocrine response from the pituitary gland. The pathogenesis of metabolic syndrome involves disruption to the neuroendocrine control of energy homeostasis with resistance to hormones secreted from adipose tissue (leptin) and the stomach (ghrelin). Further evidence for the important network effects between the Endocrine and metabolic systems comes from polycystic ovarian syndrome (PCOS). Although women with this condition typically present to the Endocrine clinic, the underlying aetiology is metabolic dysfunction with insulin resistance disrupting the hypothamic-pituitary-ovarian axis. The same pathophysiology of disrupted metabolic signalling adversely impacting the hypothalamic-pituitary-gonadal axis also applies to males.

In athletes, the exact same signalling pathways and neuroendocrine systems are involved in the development of relative energy deficiency in sports (RED-S) where the underlying aetiology is imbalance in the periodisation of training load, nutrition and recovery.

Gastrointestinal tract In addition to malabsorption issues such as coeliac disease and non-gluten wheat sensitivity, there is emerging evidence that the composition and diversity of the gut microbiota plays a significant role in health. The microbiome of professional athletes differs from sedentary people, especially at a functional metabolic level. Conversely, an adverse gut microbiome is implicated in the pathogenesis of metabolic dysfunction such as obesity and T2DM, via modulation of enteroendocrine hormones regulating appetite centrally and insulin secretion peripherally.

Circadian disregulation As previously discussed, it is not just a question of what but WHEN you eat, sleep and exercise. If there is conflict in the timing of these lifestyle activities with internal biological clocks, then this can disrupt metabolic and endocrine signally. For example, in children curtailed sleep can impact glucose control and insulin sensitivity, predisposing to risk of developing T2DM. Eating too close to the onset of melatonin release in the evening can cause adverse body composition, irrespective of what you eat and activity levels. In those with pre-existing metabolic dysfunction, such as PCOS, timing of meals has an effect on insulin levels and hence reproductive Endocrine function. The immune system displays circadian rhythmicity which integrated with external cues (for example when we eat/exercise/sleep) optimises our immune response. For athletes competing in high intensity races, this may be more favourable in terms of Endocrine and metabolic status in the evening.

Psychology Psychological stress impacts the key pathophysiological mechanisms outlined above: metabolic signalling, inflammation and neuroendocrine regulation, which contribute to Endocrine and metabolic dysfunction. Fortunately stress is a modifiable lifestyle risk factor. In the case of functional hypothalamic amenorrhoea (where nutrition/exercise/sleep are balanced), psychological intervention can reverse this situation.

Conclusion Putting this all together, if the modifiable lifestyle factors of exercise, nutrition, sleep are optimised in terms of composition and timing, this improves metabolic and Endocrine signalling pathways, including neuroendocrine regulation. Preventative Medicine going beyond preventing disease; it optimises health.

BASEM annual conference 22/3/18: Health, Hormones and Human Performance

Presentations

References

Athletic Fatigue: Part 2 Dr N. Keay

From population based norms to personalised medicine: Health, Fitness, Sports Performance Dr N. Keay, British Journal of Sports Medicine 2017

Endocrine system: balance and interplay in response to exercise training Dr N. Keay

Saturated fat does not clog the arteries: coronary heart disease is a chronic inflammatory condition, the risk of which can be effectively reduced from healthy lifestyle interventions British Journal of Sports Medicine 2017

Longitudinal Associations of Leptin and Adiponectin with Heart Rate Variability in Children Frontiers in Physiology 2017

A Proposal for a Study on Treatment Selection and Lifestyle Recommendations in Chronic Inflammatory Diseases: A Danish Multidisciplinary Collaboration on Prognostic Factors and Personalised Medicine Nutrients 2017

Assessment of Metabolic Flexibility by Means of Measuring Blood Lactate, Fat, and Carbohydrate Oxidation Responses to Exercise in Professional Endurance Athletes and Less-Fit Individuals Sports Medicine 2017

Skeletal muscle mitochondria as a target to prevent or treat type 2 diabetes mellitus Nature Reviews Endocrinology

Insulin and osteocalcin: further evidence for a mutual cross-talk Endocrine 2017

HbA1c levels, diabetes duration linked to fracture risk Endocrine Today 2017

The cellular and molecular bases of leptin and ghrelin resistance in obesity Nature Reviews Endocrinology 2017

Metabolic and Endocrine System Networks Dr N. Keay

Adiponectin and resistin: potential metabolic signals affecting hypothalamo-pituitary gonadal axis in females and males of different species Reproduction 2017

Optimal Health: For All Athletes! Part 4 – Mechanisms Dr N. Keay, British Association of Sport and Exercise Medicine 2017

Ubiquitous Microbiome: impact on health, sport performance and disease Dr N. Keay

The microbiome of professional athletes differs from that of more sedentary subjects in composition and particularly at the functional metabolic level Gut. BMJ

Interplay between gut microbiota, its metabolites and human metabolism: Dissecting cause from consequence Trends in Food Science & Technology 2016

Temporal considerations in Endocrine/Metabolic interactions Part 1 Dr N. Keay, British Journal of Sports Medicine 2017

Temporal considerations in Endocrine/Metabolic interactions Part 2 Dr N. Keay, British Journal of Sports Medicine 2017

Sleep Duration and Risk of Type 2 Diabetes Paediatrics 2017

Later circadian timing of food intake is associated with increased body fat Am J Clin Nutr. 2017

Effects of caloric intake timing on insulin resistance and hyperandrogenism in lean women with polycystic ovary syndrome Clin Sci (London)

Immunity around the clock Science

Effect of Time of Day on Performance, Hormonal and Metabolic Response during a 1000-M Cycling Time Trial PLOS

Type 2 diabetes mellitus and psychological stress — a modifiable risk factor Nature Reviews Endocrinology 2017

Recovery of ovarian activity in women with functional hypothalamic amenorrhea who were treated with cognitive behaviour therapy Fertil Steril

 

Athletic Fatigue: Part 2

3 September 2017

A degree of athletic fatigue following a training session, as described in part 1, is required to set in motion mechanisms to drive beneficial adaptations to exercise. At what point does this process of functional over-reaching tip into non-functional over-reaching denoted by failure to improve sports performance? Or further still along the spectrum and time scale, the chronic situation of overtraining and decrease in performance? Is this a matter of time scale, or degree, or both?

Slide1
Integrated Periodisation of Training Load, Nutrition and Recovery keeps an individual on the green plateau, avoiding descent into the red zone, due to an excess or deficiency

Determining the tipping point between these fatigue situations is important for health and performance. A first step is always to exclude underlying organic disease states, be these of Endocrine, systemic inflammatory or infective aetiologies. Thereafter the crucial step is to assess whether the periodisation of training, nutrition and recovery are integrated over a training block and in the longer term over a training season.

What about the application of Endocrine markers to monitor training load? Although the recent studies described below are more applicable to research scenarios, they give some interesting insights into the interactive networks effects of the Endocrine system and the multifactorial nature of fatigue amongst individual athletes.

In the short term, during a 2 day rowing competition, increases in wakening salivary cortisol were noted followed by return towards baseline in subsequent 2 day recovery. Despite individual variability with salivary cortisol measurement, this does at least offer a noninvasive way to adjust training loads around competition time for elite athletes.

Over an 11 day stimulated training camp and recovery during the sport specific preparatory phase of the training season, blood metabolic and Endocrine markers were measured. In the case of an endurance based training camp in cyclists, a significant increase in urea (due to protein breakdown associated with high energy demand training) and decrease in insulin-like growth factor 1 (IGF1) from baseline were noted. Whereas for the strength-based athletes for ball sports, an increase in creatine kinase (CK) was seen, as a result of muscle damage. This study demonstrates how different markers of fatigue are specific to sport discipline and mode of training. Large inter-individual variability existed between the degree of change in markers and degree of fatigue.

In the longer term, for the case of overtraining syndrome potential Endocrine markers have been reviewed. Whilst basal levels of most measured hormones remained stable, a blunted submaximal exercise response of growth hormone (GH), prolactin and ACTH could be indicative of developing overtraining syndrome. Whilst this review is interesting, dynamic testing is not a practical approach and these findings are not specific to over training. Rather this blunted dynamic exercise response would indicate relative suppression of the neuroendocrine hypothalamic-pituitary axis which could potentially involve other stressors such as inadequate sleep or poor nutrition. Although basal levels may lie “within the normal range”, if both pituitary derived stimulating hormone and end endocrine gland hormone concentrations fall in the lower end of the normal ranges (eg low end of range TSH and T4) this is consistent with mild hypothalamic suppression observed over the range of training and fatigue conditions (functional/non-functional and overtraining) and/or Relative Energy Deficiency in Sports (RED-S).

Although the studies above are of research interest, non invasive monitoring, specific to an athlete is more practical for monitoring the effects of training. Several useful easily measurable metrics can give clues: resting heart rate, heart rate variability, power output. Tools on Strava and Training Peaks provide practical insights in monitoring training effectiveness via these metrics. A range of mobile apps makes it ever easier to augment a personal training log to include these training metrics, along with feel, sleep and nutrition. Such a log provides feedback on health and fitness for the individual athlete, in order to personalise training plans. Certainly adding the results from any standard basal blood tests will also help add to the picture, along the lines of building a longitudinal personal biological passport. After all, “normal ranges” are based on the general population, of which top level athletes may represent a subgroup. The more personalised the metics recorded over a long time scale, the more sensitive and useful the process to guide improvement in sport performance.

Context is key when considering athletic fatigue: temporal considerations and individual variation. Certainly the interactive network effects of the Endocrine system are important in determining the degree of adaptation to exercise and therefore sports performance. However the Endocrine system acts in conjunction with many other systems (metabolic, immune and inflammatory), in determining the effectiveness of training in improving sports performance. So it is not surprising that one metric or marker in isolation is not predictive of fatigue status in individual athletes.

For more discussion on Health, Hormones and Human Performance come to the British Association of Sport and Exercise Medicine annual conference

Presentations

References

Athletic Fatigue: Part 1

Endocrine system: balance and interplay in response to exercise training

Temporal considerations in Endocrine/Metabolic interactions Part 1

Fatigue, sport performance and hormones..more on the endocrine system Dr N Keay, British Journal of Sports Medicine 2017

Sport Performance and RED-S, insights from recent Annual Sport and Exercise Medicine and Innovations in Sport and Exercise Nutrition Conferences Dr N Keay, British Journal of Sports Medicine 2017

Capturing effort and recovery: reactive and recuperative cortisol responses to competition in well-trained rowers British Journal of Sports Medicine

Blood-Borne Markers of Fatigue in Competitive Athletes – Results from Simulated Training Camps Plos One

Hormonal aspects of overtraining syndrome: a systematic review BMC Sports Science, Medicine and Rehabilitation 2017

Clusters of Athletes – A follow on from RED-S blog series to put forward impact of RED-S on athlete underperformance Dr N Keay, British Association of Sport and Exercise Medicine 2017

Strava Fitness and Freshness Science4Performance 2017

From population based norms to personalised medicine: Health, Fitness, Sports Performance Dr N Keay, British Journal of Sports Medicine 2017

Sports Endocrinology – what does it have to do with performance? Dr N Keay, British Journal of Sports Medicine 2017

Athletic Fatigue: Part 1

1 September 2017

Interpreting athletic fatigue is not easy. Consideration has to be given to context and time scale. What are the markers and metrics that can help identify where an athlete lies in the optimal balance between training, recovery and nutrition which support beneficial adaptations to exercise whilst avoiding the pitfalls of fatigue and maladaptation? This blog will discuss the mechanisms of athletic fatigue in the short term.

Screen Shot 2017-08-30 at 09.17.58
Proposed causes of fatigue dependent on duration and intensity of training session

In the short term, during an endurance training session or race, the temporal sequence of athletic fatigue depends on duration and intensity. It is proposed that below lactate threshold (LT1), a central mechanism governs: increasing central motor drive is required to maintain skeletal muscular power output until neuromuscular fatigue cannot be overcome. From lactate threshold (LT1) to lactate turn point (LT2), a combination of central and peripheral factors (such as glycogen depletion) are thought to underpin fatigue. During high intensity efforts, above LT2 (which correspond to efforts at critical power), accumulation of peripheral metabolites and inability to restore homeostasis predominate in causing fatigue and ultimately inability to continue, leading to “task failure”. Of course there is a continuum and interaction of the mechanisms determining this power-duration relationship. As glycogen stores deplete this impacts muscle contractility by impairing release of calcium from the sarcoplasmic reticulum in skeletal muscle. Accumulation of metabolites could stimulate inhibitory afferent feedback to central motor drive for muscle contraction, combined with decrease in blood glucose impacting central nervous system (CNS) function.

Even if you are a keen athlete, it may not be possible to perform a lactate tolerance or VO2 max test under lab conditions. However a range of metrics, such as heart rate and power output, can be readily collected using personalised monitoring devices and then analysed. These metrics are related to physiological markers. For example heart rate and power output are surrogate markers of plasma lactate concentration and thus can be used to determine training zones.

A training session needs to provoke a degree of training stress, reflected by some short term fatigue, to set in motion adaptations to exercise. At a cellular level this includes oxidative stress and exerkines released by exercising tissues, backed up by Endocrine responses that continue to take effect after completing training during recovery and sleep. Repeated bouts of exercise training, followed by adequate recovery, result in a stepwise increase in fitness. Adequate periodised nutrition to match variations in demand from training also need to be factored in to prevent the Endocrine system dysfunction seen in Relative Energy Deficiency in Sports (RED-S), which impairs Endocrine response to training and sports performance. Integrated periodisation of training/recovery/nutrition is essential to support beneficial multi-system adaptations to exercise on a day to day time scale, over successive training blocks and encompassing the whole training and competition season. Psychological aspects cannot be underestimated. At what point does motivation become obsession?

In Part 2 the causes of athletic fatigue over a longer time scale will be discussed, from training blocks to encompassing whole season.

For more discussion on Health, Hormones and Human Performance come to the British Association of Sport and Exercise Medicine annual conference

Presentations

References

Endocrine system: balance and interplay in response to exercise training

Power–duration relationship: Physiology, fatigue, and the limits of human performance European Journal of Sport Science 2016

Strava Ride Statistics Science4Performance 2017

Sleep for health and sports performance Dr N Keay, British Journal of Sports Medicine 2017

Relative Energy Deficiency in Sports (RED-S) Practical Considerations for Endurance Athletes

Sports Endocrinology – what does it have to do with performance? Dr N Keay, British Journal of Sports Medicine 2017

Optimal Health: For All Athletes! Part 4 – Mechanisms Dr N Keay, British Association of Sport and Exercise Medicine 2017

Addiction to Exercise – what distinguishes a healthy level of commitment from exercise addiction? Dr N Keay, British Journal of Sports Medicine 2017

 

 

One road to Rome: Metabolic Syndrome, Athletes, Exercise

20 July 2017

One road to Rome

Metabolic syndrome comprises a cluster of symptoms including: hypertension, dyslipidaemia, fatty liver disease and type 2 diabetes mellitus (T2DM).

The underlying pathological process is insulin resistance which distorts metabolism. Temporal and mechanistic connections have been described between hyperinsulinaemia, obesity and insulin resistance. Insulin levels rise, potentially stimulated by excess intake of refined carbohydrates and in addition the metabolic actions of insulin are attenuated on target tissues such as the liver, skeletal muscle and adipose tissue. At a cellular level, inflammatory changes play a part in this metabolic dis-regulation. Mitochondrial action in skeletal muscle is impaired, compromising the ability to oxidise fat as a substrate, thus resulting in muscle glycolysis and a consequent rise in blood lactate.

Although much attention has been focused on restricting calories and treating elevated lipids with medication (statins), evidence is now emerging that this does not have the anticipated effect of reducing mortality from cardiovascular disease. In addition, it has been proposed that the gut microbiota plays a pivotal role in metabolism, inflammation and immunity.

Metabolic syndrome usually conjures an image of an overweight person with or on the verge of developing T2DM. However there is an interesting group of slim people who are also are at risk of developing metabolic syndrome due to insulin resistance. The majority of women with polycystic ovary syndrome (PCOS) present with menstrual disturbance of some description. However not all display the textbook characteristics of Stein-Leventhal syndrome (overweight, hirsute and with skin problems). There is in fact of spectrum of clinical phenotypes ranging from the overweight to the slim. In all phenotypes of PCOS, the crucial uniting underlying metabolic disturbance is insulin resistance. The degree of insulin resistance has been shown to be related to adverse body composition with increased ratio of whole body fat to lean mass.

Although this confuses the picture somewhat, it also simplifies the approach. In all cases the single most important lifestyle modification is exercise.

Exercise improves metabolic flexibility: the ability to adapt substrate oxidation to substrate availability. Endurance exercise training amongst athletes results in improved fat oxidation and right shift of the lactate tolerance curve. Conversely metabolic inflexibility associated with inactivity is implicated in the development of insulin resistance and metabolic syndrome.

What about nutritional strategies that might improve metabolic flexibility? Ketogenic diets can either be endogenous (carbohydrate restricted intake) or exogenous (ingestion of ketone esters and carbohydrate). Low carbohydrate/high fat diets (terms often used interchangeably with all types of ketogenic diets) have been shown to improve fat oxidation and potentially mitigate cognitive decline in older people.

However, in the case of athletes, the benefits do not necessarily translate to better performance. Despite reports of such diets enhancing fat oxidation and favourable changes in body composition, a recent study demonstrates that this, in isolation, does not translate into improved sport performance. A possible explanation is the oxygen demand of increased oxidation of fat needs to be supported by a higher oxygen supply. The intermediate group of endurance athletes in this study, on the periodised carbohydrate intake, fared better in performance terms. Another recent study confirmed that a ketogenic diet failed to improve the performance of endurance athletes, in spite of improving fat metabolism and body composition. Despite small numbers, this warrants particular mention as the majority of participants were women, who are in general very underrepresented in scientific studies.

In all likelihood, the reason that these type of diets (ketogenic, high fat/low carb: not always well defined!) did not improve sport performance is that only one aspect of metabolism was impacted and quantified. Although fat oxidation, modified via dietary interventions, is certainly an important component of metabolism, the impact on the interactive network effects of the Endocrine system should be evaluated in the broader context of circadian rhythm. For athletes this goes further, to include integrated periodisation of nutrition, training and recovery to optimise performance, throughout the year.

In addition to dietary interventions, medical researchers continue to explore the use of exercise mimetics and metabolic modulators, to address metabolic syndrome. Unfortunately, some have sought their use as a short cut to improved sport performance. Many of these substances appear on the WADA banned list for athletes. However the bottom line is that it is impossible to mimic, either through a dietary or pharmacological intervention, the multi-system, integrated interplay between exercise, metabolism and the Endocrine system.

Only one road to Rome!

Whatever your current level of activity, whether reluctant exerciser or athlete, the path is the same to improve health and performance. This route is exercise, supported with periodised nutrition and recovery. Exercise will automatically set in motion the interactive responses and adaptations of your metabolic and Endocrine systems.

For further discussion on Endocrine and Metabolic aspects of SEM come to the BASEM annual conference 22/3/18: Health, Hormones and Human Performance

References

Insulin action and resistance in obesity and type 2 diabetes Nature Medicine 2017

Inflammation: Why and How Much? Dr N. Keay, British Association of Sport and Exercise Medicine

The cholesterol and calorie hypotheses are both dead — it is time to focus on the real culprit: insulin resistance Clinical Pharmacist 2017

Skeletal muscle mitochondria as a target to prevent or treat type 2 diabetes mellitus Nature Reviews Endocrinology 2016

The essential role of exercise in the management of type 2 diabetes Cleveland Clinic Journal of Medicine 2017

β cell function and insulin resistance in lean cases with polycystic ovary syndrome Gynecol Endocrinol. 2017

The many faces of polycystic ovary syndrome in Endocrinology. Conference Royal Society of Medicine 2017

Association of fat to lean mass ratio with metabolic dysfunction in women with polycystic ovary syndrome Hum Reprod 2014

Sedentary behaviour is a key determinant of metabolic inflexibility Journal of physiology 2017

International society of sports nutrition position stand: diets and body composition J Int Soc Sports Nutr. 2017

A cross-sectional comparison of brain glucose and ketone metabolism in cognitively healthy older adults, mild cognitive impairment and early Alzheimer’s disease Exp Gerontol. 2017

Low carbohydrate, high fat diet impairs exercise economy and negates the performance benefit from intensified training in elite race walkers J Physiol. 2017

Ketogenic diet benefits body composition and well-being but not performance in a pilot case study of New Zealand endurance athletes J Int Soc Sports Nutr. 2017

Sports Endocrinology – what does it have to do with performance? Dr N. Keay, British Journal of Sports Medicine 2017

Hormones and Sports Performance

Endocrine system: balance and interplay in response to exercise training

 

Endocrine system: balance and interplay in response to exercise training

12 June 2017

The process of homeostasis maintains a steady internal milieu. So how is it possible for adaptations to occur? What are the internal mechanisms that determine a good outcome versus a negative one?

Changes in the external environment, such as exercise training, challenge homeostasis, producing spatial and temporal responses in the internal environment. These cause interactions between muscle, bone and gut, modulated by the Endocrine system. The degree and nature of these responses dictate whether a positive adaptation occurs. An excessive response, or a response not in tune with the networks of the Endocrine system, can hinder adaptation or produce a maladaptive response. The balance and interplay of internal responses are crucial in determining the outcome to exercise training in the individual.

F=MA

Local responses in exercising tissues

Exercising tissues release exerkines (metabolites, nucleic acids, peptides) which are packaged in exosomes and microvesicles. The content of these vesicle packages increases with intensity of endurance exercise in a dose-dependent manner. These exerkines have autocrine and paracrine effects, which modulate systemic adaptations to endurance exercise in the tissues themselves and those in the vicinity.

The range of these molecular responses from exercising tissues has been identified applying multi-omics (epigenomic, transcriptomic and proteomic analyses). Furthermore variance in trainability has been shown to be correlated with the integrated responses of tissue molecular signalling pathways to endurance exercise.

In a similar manner, the degree of inflammatory response and production of reactive oxygen and nitrogen species (RONS) to exercise mediate favourable adaptations. Inter-individual variations in redox status has been shown to determine the ability to adapt to exercise training. However, unlimited increase in response does not necessarily produce a better outcome. An over response to exercise in these signalling pathways, hinders adaptation.

Exercise promotes bone adaptation in terms of bone material, structure and muscle action. Paracrine crosstalk occurs between muscle and bone. Muscle myokines and insulin like growth factor 1 (IGF1) favour bone formation, whilst inflammatory molecules, such as interleukin 6 (Il-6) released during muscle contractions, favour bone reabsorption. The balance between these opposing processes determines whether bone remodelling is effective, or whether bone stress reactions occur over a pathological continuum. These responses and adaptations occur on the background of lifespan Endocrine environment, which impacts the outcome.

Gut microbiota

The gut microbiota support the regulation of inflammation at the local and systemic level. Furthermore the communication between the gut microbiota and mitochondria has been described as an important interaction in facilitating adaptive responses to exercise. Mitochondria are organelles crucial for production of ATP, as well as RONS. The gut microbiota are involved in mitochondrial biogenesis by regulating key mitochondrial transcriptional factors and enzymes . Furthermore, the metabolites of the gut microbiota such as short chain fatty acids, modulate the inflammatory effects of mitochondrial oxidative stress. Conversely genetic variants in the mitochondrial genome could impact mitochondrial function and thus the gut microbiota in terms of composition and activity.

The gut microbiota have a role in regulating intestinal permeability. Leaky gut is where epithelial integrity is lost at the tight junctions between cells in the gut lining. Leaky gut can occur in gut dysbiosis and also following endurance exercise where re-perfusion injury produces acute hyper-permeability. In these instances, increased gut permeability augments the antigen load and causes increased systemic inflammation and potentially can trigger autoimmune disease. This demonstrates that an excessive inflammatory response to exercise can hinder positive adaptation

Metabolic adaptations

Metabolic flexibility, the ability to respond and adapt to changes in metabolic demand, is enhanced with exercise training through these autocrine, paracrine and Endocrine mechanisms. Metabolic flexibility supports energy availability and fuel selection during exercise. Exercise mimetics, such as artificial metabolic modulators, have been reported to up-regulate gene expression to shift metabolism to fat oxidation in exercising muscle. This would potentially extend the limit of endurance exercise. However this “short cut” to adaptation favouring improved sport performance is illegal, with such molecular ligands on the World Anti-Doping Agency (WADA) banned list.

Hierarchy of control

There is a hierarchy of control in modulating multi-system adaptations to exercise. The Endocrine system is key. Exercise per se produces an Endocrine response, for example exercise is a key stimulus for growth hormone release via the hypothalamus, the neuroendocrine gatekeeper. Growth hormone supports the anabolic response to exercise. In addition, the Endocrine milieu during the lifespan has an impact on response and adaptations to exercise. Any disruption in the Endocrine system hinders adaptive changes. Endocrine dysfunction may occur as a result of non-integrated periodisation of exercise/nutrition and recovery as seen in relative energy deficiency in sports (RED-S). Dysfunction can also occur due to an Endocrine pathology.

Conclusion

Changes in external stimuli, such as exercise and nutrition, produce internal responses on autocrine, paracrine and Endocrine levels. These molecular signalling pathways drive adaptive changes through integrated, network effects. However any imbalances in these interactive responses can hinder desired adaptive changes and even result in negative maladaptive outcomes to exercise training.

For further discussion on Endocrine and Metabolic aspects of SEM come to the BASEM annual conference 22/3/18: Health, Hormones and Human Performance

References

Keay N, Logobardi S, Ehrnborg C, Cittadini A, Rosen T, Healy ML, Dall R, Bassett E, Pentecost C, Powrie J, Boroujerdi M, Jorgensen JOL, Sacca L. Growth hormone (GH) effects on bone and collagen turnover in healthy adults and its potential as a marker of GH abuse in sport: a double blind, placebo controlled study. Journal of Endocrinology and Metabolism. 85 (4) 1505-1512. 2000.

Sport Endocrinology presentations

Sports Endocrinology – what does it have to do with performance? Dr N.Keay, British Journal of Sport Medicine

Balance of recovery and adaptation for sports performance Dr N.Keay, British Association of Sport and Exercise Medicine

Inflammation: Why and How Much? Dr N.Keay, British Association of Sport and Exercise Medicine

Clusters of Athletes – A follow on from RED-S blog series to put forward impact of RED-S on athlete underperformance  Dr N.Keay, British Association of Sport and Exercise Medicine

Optimal Health: For All Athletes! Part 4 – Mechanisms Dr N.Keay, British Association of Sport and Exercise Medicine

The potential of endurance exercise-derived exosomes to treat metabolic diseases Nature Reviews Endocrinology

Exosomes as Mediators of the Systemic Adaptations to Endurance Exercise Cold Spring Harbor Perspectives in Medicine

Genomic and transcriptomic predictors of response levels to endurance exercise training
Journal of Physiology

Adaptations to endurance training depend on exercise-induced oxidative stress: exploiting redox inter-individual variability Acta Physiologica

Mechanical basis of bone strength: influence of bone material, bone structure and muscle action Journal of Musculoskeletal and Neuronal Interactions

The Crosstalk between the Gut Microbiota and Mitochondria during Exercise Frontiers in Physiology

Leaky Gut As a Danger Signal for Autoimmune Diseases Frontiers in Immunology

Metabolic Flexibility in Health and Disease Cell Metabolism

Hormones and Sports Performance

PPARδ Promotes Running Endurance by Preserving Glucose Cell Metabolism

 

Fatigue, Sport Performance and Hormones…

2 May 2017

How do you feel on Monday morning, when the alarm wakes you at 7am with a day of work ahead after the weekend? A bit tired, slightly lethargic, sluggish, maybe a little bit down, perhaps a few regrets about somewhat too much alcohol/food over weekend, frustrated that the exercise training schedule didn’t go according to plan?sleep

There are many causes of fatigue and sport underperformance: Endocrine, immunological, infective, metabolic, haematological, nutritional, digestive, neoplastic….. The adrenal gland in the Endocrine system in particular has come in for some bad press recently.

Adrenal woes

Undoubtedly the adrenal glands have a case to answer. Situated above the kidneys these Endocrine glands produce glucocorticoids, mineralocorticoids, androgens from the adrenal cortex and from the adrenal medulla adrenaline. Glucocorticoids (e.g. cortisol) have a metabolic function to maintain energy homeostasis and an immune function to suppress inflammation. Mineralocorticoids (e.g. aldosterone) maintain electrolyte and water balance. As mineralocorticoids and glucocorticoids are similar biological steroid molecules, there is some degree of overlap in their actions.

Addison’s disease and Cushing’s disease are serious medical conditions, corresponding respectively to under or over production by the adrenal glands of steroid hormones. Someone presenting in Addisonian crisis is a medical emergency requiring resuscitation with intravenous hydrocortisone and fluids. Conversely those with Cushing’s can present with hypertension and elevated blood glucose. Yet, apart from in the extremes of these disease states, cortisol metrics do not correlate with clinical symptoms. This is one reason why it is unwise and potentially dangerous to stimulate cortisol production based on clinical symptoms. Inappropriate exogenous steroid intake can suppress normal endogenous production and reduce the ability to respond normally to “stress” situations, such as infection. This is why the prescription of steroids, for example to reduce inflammation in autoimmune disease, is always given in a course of reducing dose and a steroid alert card has to be carried. Athletes should also be aware that exogenous steroid intake is a doping offence.

However, what is the “normal” concentration for cortisol? Well, for a start, it depends what time of day a sample is taken, as cortisol is produced in a circadian rhythm, with highest values in the morning on waking and lowest levels about 2/3am. Nor is this temporal periodicity of production the only variable, there are considerations such as tissue responsiveness and metabolism (break down) of the hormone. On top of these variables there are other inputs to the feedback control mechanism, which can in turn influence these variables. In other words, focusing on the steroid hormone production of the adrenal gland in isolation, could overlook underlying hypothamalmic-pituitary-adrenal (H-P-A) axis dysfunction and indeed wider issues.

Much maligned thyroid

That is not end of the possible causes of fatigue and sport underperformance: the H-P-A axis is just one of many interrelated, interacting Endocrine systems. There are many neuroendocrine inputs to the hypothalamus, the gate keeper of the control of the Endocrine system. Furthermore there are network interaction effects between the various Endocrine control feedback loops. For example cortisol towards the top end of “normal” range can impede the conversion at the tissue level of thyroxine (T4) to the more active triiodothyronine (T3) by enzymes which require selenium to function. Rather T4 can be converted to reverse T3 which is biologically inactive, but blocks the receptors for T3 and thus impair its action. This in turn can interfere with the feedback loop controlling thyroid function (hypothalamic-pituitary-thyroid axis). The physiological ratio of T4 to T3 is 14:1, which is why supplementation with desiccated thyroid is not advisable with ratio of 4:1. There are other processes which can crucially interfere with this peripheral conversion of T4 to T3, such as inflammation and gut dysbiosis, which can occur as result of strenuous exercise training. So what might appear to be a primary thyroid dysfunction can have an apparently unrelated underlying cause. Indeed amongst highly trained athletes thyroid function can show an unusual pattern, with both thyroid stimulating hormone (TSH) and T4 at low end of the “normal “range, thought to be due to resetting of the hypothalamic-pituitary control signalling system. This highlights that the “normal” range for many hormones comprises subsets of the population and in the case of TSH, the “normal” range is not age adjusted, despite TSH increasing with age. As described by Dr Boelaert at recent conferences, there is certainly no medical justification for reports of some athletes in the USA being given thyroxine with TSH>2 (when the normal range is 0.5-5mU/l). Although thyroxine is not on the banned list for athletes, it could have potentially serious implications for health due to its impact on the Endocrine system as a whole.

Endocrine system interactions

SportsEndocrinologyWordCloud

Symptoms of fatigue are common to many clinical conditions, not just dysfunction in an Endocrine control axis in isolation, nor even the network interactive effects of the Endocrine system in isolation. For example, the impact of nutrition relative to training load produces a spectrum of clinical pictures and Endocrine disturbances seen in Relative Energy Deficiency in Sport (RED-S) in terms of health and sport performance.

Underlying mechanisms of Endocrine dysfunction

There may be predisposing factors in developing any clinical syndrome, the usual suspects being inflammation: whether infective, dysbioses, autoimmune; nutritional status linked with endocrine status;  training load with inadequate periodised recovery to name a few….

For further discussion on Endocrine and Metabolic aspects of SEM come to the BASEM annual conference 22/3/18: Health, Hormones and Human Performance

References

From population based norms to personalised medicine: Health, Fitness, Sports Performance British Journal of Sport Medicine 2017

Sports Endocrinology – what does it have to do with performance? British Journal of Sport Medicine 2017

Advanced Medicine Conference, Royal College of Physicians, London 13-16 February 2017, Endocrine session: Dr Kristien Boelaert, Dr Helen Simpson, Professor Rebecca Reynolds

Subclinical hypothydroidism in athletes. Lecture by Dr Kristeien Boelaert, British Association of Sport and Exercise Medicine Spring Conference 2014. The Fatigued Athlete

Sport Performance and RED-S, insights from recent Annual Sport and Exercise Medicine and Innovations in Sport and Exercise Nutrition Conferences British Journal of Sport Medicine 2017

Relative Energy Deficiency in Sport CPD module British Association of Sport and Exercise Medicine 2017

Sleep for health and sports performance British Journal of Sport Medicine 2017

Inflammation: why and how much? British Association of Sport and Exercise Medicine 2017

Clusters of athletes British Association of Sport and Exercise Medicine 2017

Enhancing Sport Performance: Part 1 British Association of Sport and Exercise Medicine 2017

Balance of recovery and adaptation for sports performance British Association of Sport and Exercise Medicine 2017

Annual Sport and Exercise Medicine Conference, London 8/3/17 Gut Dysbiosis, Dr Ese Stacey

Adrenal fatigue does not exist: a systematic review BMC Endocrine Disorders. 2016; 16(1): 48.

A Controversy Continues: Combination Treatment for Hypothyroidism Endocrine News, Endocrine Society April 2017