Raising Awareness of RED-S in Male and Female Athletes and Dancers

Health4Performance is a recently developed BASEM open access educational resource

This is a world premier: a resource developed for and by athletes/dancers, coaches/teachers, parents/friends and healthcare professionals to raise awareness of Relative Energy Deficiency in Sport (RED-S)

What?

Optimal health is required to attain full athletic potential. Low energy availability (LEA) can compromise health and therefore impair athletic performance as described in the RED-S clinical model.

Dietary energy intake needs to be sufficient to cover the energy demands of both exercise training and fundamental physiological function required to maintain health. Once the energy demands for training have been covered, the energy left for baseline “housekeeping” physiological function is referred to as energy availability (EA). EA is expressed relative to fat free mass (FFM) in KCal/Kg FFM.  The exact value of EA to maintain health will vary between genders and individuals, roughly equivalent to resting metabolic rate of the individual athlete/dancer. LEA for an athlete or dancer will result in the body going into “energy saving mode” which has knock on effects for many interrelated body systems, including readjustment to lower the resting metabolic rate in the longer term. So although loss in body weight may be an initial sign, body weight can be steady in chronic LEA due to physiological energy conservation adaptations. Homeostasis through internal biological feedback loops in action.

The most obvious clinical sign of this state of LEA in women is cessation of menstruation (amenorrhea). LEA as a cause of amenorrhoea is an example of functional hypothalamic amenorrhoea (FHA). In other words, amenorrhoea arising as a result of an imbalance in training load and nutrition, rather than an underlying medical condition per se, which should be excluded before arriving at a diagnosis of FHA. All women of reproductive age, however much exercise is being undertaken, should have regular menstrual cycles, which is indicative of healthy hormones. This explains why LEA was first described as the underlying aetiology of the female athlete triad, as women in LEA display an obvious clinical sign of menstrual disruption. The female athlete triad is a clinical spectrum describing varying degrees of menstrual dysfunction, disordered nutrition and bone mineral density. However it became apparent that the clinical outcomes of LEA are not limited to females, nor female reproductive function and bone health in female exercisers. Hence the evolution of the clinical model of RED-S to describe the consequences of LEA on a broader range of body systems and including male athletes.

A situation of LEA in athletes and dancers can arise unintentionally or intentionally. In the diagram below the central column shows that an athlete where energy intake is sufficient to cover the demands from training and to cover basic physiological function. However in the column on the left, although training load has remained constant, nutritional intake has been reduced. This reduction of energy intake could be an intentional strategy to reduce body weight or change body composition in weight sensitive sports and dance.  On the other hand in the column on the right, training load and hence energy demand to cover this has increased, but has not been matched by an increase in dietary intake. In both these situations, whether unintentional or intentional, the net results is LEA, insufficient to maintain health. This situation of LEA will also ultimately impact on athletic performance as optimal health is necessary to realise full athletic potential.

EnergyBalance

Although LEA is the underlying aetiology of RED-S, there are many methodological and financial issues measuring LEA accurately in “free living athletes“. In any case, the physiological response varies between individuals and depends on the magnitude, duration and timing of LEA. Therefore it is more informative to measure the functional responses of an individual to LEA, rather than the value calculated for EA. As such, Endocrine markers provide objective and quantifiable measures of physiological responses to EA. These markers also reflect the temporal dimension of LEA; whether acute or chronic. In short, as hormones exert network effects, Endocrine markers reflect the response of multiple systems in an individual to LEA. So by measuring these key markers, alongside taking a sport specific medical history, provides the information to build a detailed picture of EA for the individual, with dimensions of time and magnitude of LEA. This information empowers the athlete/dancer to modify the 3 key factors under their control of training load, nutrition and recovery to optimise their health and athletic performance.

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Why?

Who is at risk of developing RED-S? Any athlete involved in sports or dance where being light weight confers a performance or aesthetic advantage. This is not restricted to elite athletes and dancers. Indeed the aspiring amateur or exerciser could be more at risk, without the benefit of a support team present at professional level. Young athletes are at particular risk during an already high energy demand state of growth and development. Therefore early identification of athletes and dancers at risk of LEA is key to prevention of development of the health and performance consequences outlined in the RED-S clinical model. Although there is a questionnaire available for screening for female athletes at risk of LEA, more research is emerging for effective and practical methods which are sport specific and include male athletes.

How?

Early medical input is important as RED-S is diagnosis of exclusion. In other words medical conditions per se need to be ruled out before arriving at a diagnosis of RED-S.  Prompt medical review is often dependent on other healthcare professionals, fellow athletes/dancers, coaches/teachers and parents/friends all being aware and therefore alert to RED-S. With this in mind, the Health4Performance website has areas for all of those potentially involved,  with tailored comments on What to look out for? What to do? Ultimately a team approach and collaboration between all these groups is important. Not only in identification of those at risk of LEA, but in an integrated support network for the athlete/dancer to return to optimal health and performance.

References

Heath4Performance BASEM Educational Resource

Video introduction to Health4Performance website

2018 UPDATE: Relative Energy Deficiency in Sport (RED-S) BJSM 2018

What is Dance Medicine? BJSM 2018

Identification and management of RED-S Podcast 2018

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 Keay, Francis, Hind. BJM Open Sport and Exercise Medicine 2018

How to Identify Male Cyclists at Risk of RED-S? 2018

Pitfalls of Conducting and Interpreting Estimates of Energy Availability in Free-Living Athletes IJSNM 2018

Low Energy Availability Is Difficult to Assess but Outcomes Have Large Impact on Bone Injury Rates in Elite Distance Athletes IJSNM 2017

The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad BJSM 2013

IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update BJSM 2018

 

What is Dance Medicine?

Traditionally dance medicine has been somewhat the poor relation of sports medicine. Why is this the case? There is no doubt that dancers, of whatever genre, require the physical and psychological attributes of athletes. However, dance involves an additional artistic component where ultimately performance on stage is judged not according to a score card as in aesthetic sports, rather on the ability of the dancers to forge an emotional connection with the audience.

As with athletes, injuries are always an important topic for dancers: how to recognise the aetiology of injuries and thus develop prevention strategies. Dance UK have published two reports on national enquiries into the health of dancers. Dance UK has now evolved into the organisation One Dance which includes the National Institute of Dance Medicine and Science (NIDMS). One Dance provides delivery of the Healthier Dancer Programme (HDP) whose talks regularly engage 1500+ dancers and dance professionals per year and which will be a part of the One Dance UK conference at the end of November, an overarching event for the entire dance sector. One Dance holds a list of healthcare professionals with experience and expertise in dance. One Dance is an especially an important resource for independent dancers who will not have access to the provision for those working in larger dance companies.

However, beyond injury management, there are important aspects of the health of dancers which need to be considered, highlighted in an information booklet “Your body, Your risk” from Dance UK. The female athlete triad is well established as a clinical spectrum comprising of disordered eating, menstrual dysfunction and impaired bone health. Indeed impaired bone mineral density many persist even after retirement in female dancers. The recent evolution of the female athlete triad into relative energy deficiency in sports (RED-S) provides an important clinical model. RED-S includes male athletes/dancers, involves multiple body systems and crucially, evidence of detrimental effects on athletic performance is being researched and described. In other words RED-S is not restricted to female dancers/athletes with bone stress injuries.

BalletDials
Integrated periodisation of training, nutrition and recovery support perforamnce

The fundamental cause of RED-S is low energy availability where nutritional intake is insufficient to cover energy requirements for training and resting metabolic rate. In this situation the body goes into energy saving mode, which includes shut down of many hypothalamic-pituitary axes and hence endocrine network dysfunction. As hormones are crucial to backing up adaptations to exercise training, dysfunction will therefore have an effect not just on health, but on athletic performance. In dance, neuromuscular skills and proprioception are key for performance. Hence, of concern is that these skills are adversely impacted in functional hypothalamic amenorrhoea, which together with impaired bone health from RED-S, greatly increases injury risk.

Low energy availability can arise in dance and sport where low body weight confers an aesthetic and/or performance advantage. There is no doubt that being light body weight facilitates pointe work in female dancers and ease of elevation in male dancers. Thus, low energy availability can occur intentionally in an effort to achieve and maintain low body weight. Low energy availability can also be unintentional as a result of increased expenditure from training, rehearsal and performance demands and the practicality of fuelling. This situation is of particular concern for young dancers in training, as this represents a high energy demand state, not just for full time training, additionally in terms of energy demands for growth and development, including attainment of peak bone mass.

Despite the significance of RED-S in terms of negative consequences on health and performance, as outlined by the IOC in the recent consensus update, further work is required in terms of raising awareness, identification and prevention. Fortunately these issues are being addressed with the development of an online educational resource on RED-S for athletes/dancers, their coaches/teachers/parents and healthcare professionals which is backed by British Association of Sport and Exercise Medicine (BASEM) and with input from One Dance and NIDMS. In terms of research to facilitate the proliferation of evidence base in dance medicine, One Dance lists calls for research, whilst NHS NIDMS clinics provide access to clinical dance medicine. The importance of the application of this growing field of dance medicine and science for the health and performance of dancers was recently outlined in an article “Raising the barre: how science is saving ballet dancers“.

On the international stage, the International Association for Dance Medicine & Science (IADMS) strives to promote an international network of communication between dance and medicine. To this end, IADMS will hold its 28th Annual Conference in Helsinki, Finland from October 25-28, 2018. In addition to extensive discussion of dance injuries, there will be presentations on “Sleep and Performance” and “Dance Endocrinology”.

So maybe Dance Medicine and Science is not so much the poor relation of Sports Medicine, rather showing the way in terms of integrating input between dancers, teachers and healthcare professionals to optimise the health of dancers and so enable dancers to perform their full potential.

References

Presentations

Fit to Dance? Report of National inquiry into dancers’ health.

Fit to Dance 2 Dance UK

One Dance

Your body your risk. Dance UK

Fit but fragile. National Osteoporosis Society

Bone mineral density in professional female dancers N. Keay, BJSM

2018 UPDATE: Relative Energy Deficiency in Sport (RED-S) Dr N Keay BJSM 2018

Reduced Neuromuscular Performance in Amenorrheic Elite Endurance Athletes Medicine and Science in Sports & Exercise 2017

Dancing through Adolescence Dr N Keay BJSM

Healthy Hormones Dr N Keay BASEM 2018

Dancers, Periods and Osteoporosis, Keay N, Dancers, Periods and Osteoporosis, Dancing Times, September 1995, 1187-1189

A study of Dancers, Periods and Osteoporosis, Keay N, Dance Gazette, Issue 3, 1996, 47

Raising the barre: how science is saving ballet dancers The Guardian 2018

International Association for Dance Medicine and Science Medicine & Science in Sports and Exercise

 

 

Cumulative Endocrine Dysfunction in Relative Energy Deficiency in Sport (RED-S)

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Unfortunately I continue to see athletes, both male and female, whose health and athletic performance is hampered due to Relative Energy Deficiency in Sports (RED-S). There have been some high profile athletes who have been very open about how RED-S has affected them, alerting younger athletes to potential pitfalls.

Does this issue warrant highlighting? Yes! The athletes I see and those that speak out are only just the tip of the iceberg. In a study of exercising females, half were found to have subtle menstrual hormone disruption such as luteal phase deficit or anovulation. A third were amenorrhoeic, with no periods at all. All women of reproductive age, whether an athlete or not, should have regular periods, otherwise there are potential serious health and performance sequaelae. However studies in both the USA and Australia have revealed that the majority of young exercising women are not aware of the link between menstrual disruption and deleterious, potentially irreversible effects on bone health.

The impact of non-integrated periodisation of training, nutrition and recovery has evolved since the early description of the female athlete triad. The constellation of amenorrhoea, disordered eating and osteoporosis is now considered to be a clinical spectrum. In turn the female athlete triad is part of a much broader picture of RED-S, which includes adverse multi-system effects beyond bone health and is also seen in male athletes.

Although an athlete may appear healthy, what are the underlying Endocrine disruptions occurring in RED-S that ultimately will impede both optimal health and performance to full potential? In general, female exercisers are more susceptible to internal and external perturbations as the female Endocrine system is more finely balanced than in males. Nevertheless, in a study of male athletes, in the short time period after completing a training session, bone turnover was adversely affected, with an increase in markers of resorption relative to formation, if an athlete did not refuel rapidly with protein and carbohydrate. In the now classic research by Loucks, 5 days of manipulated energy restricted availability, via dietary intake and exercise output, caused disruption in LH pulsatility in previously eumenorrhoeic women. From this research and subsequent studies, not only is the reproductive axis disrupted with reduced energy availability, in addition hypothalamus-pituitary-thyroid (decreased T3) and adrenal axes (increased cortisol) and decreased IGF1 due to relative GH resistance are all disrupted. These interactive hormonal dysfunctions occur even before reduction in sex steroids. A recent study demonstrated that beyond the average energy availability over a 24 hour time window, within day energy deficits in terms of duration and magnitude are associated with a greater degree of disruption of Endocrine and metabolic markers, in particular decreased oestradiol and increased cortisol. So consistency of nutrition, not only during a training season but from day to day is vital.

Although energy availability is the crucial factor in the pathophysiology of RED-S, measuring this is not practical for all athletes in terms of accuracy and cost. Clinical menstrual status in female athletes and basic Endocrine markers are proposed as being more reliable and accessible. The Endocrine system is very sensitive to internal and external perturbations, as described above, and presages performance consequences of RED-S, such as injury. An important starting point is for all female athletes is to ask themselves: are my periods regular? This is also a vital question that coaches and parents need to consider for athletes in their care. If the answer is no, then this needs to be assessed, ideally by those with experience in Sports Endocrinology.

Why are these clinical and biochemical markers of Endocrine dysfunction important for athletes? Essentially there are significant health and performance implications for athletes. As outlined in the stories of female athletes, by the time career limiting stress fractures become obvious, typically in early twenties, the Endocrine system has been in disarray for a significant time. Long term, irreversible poor bone health and adverse body composition have been established.

In my opinion, emphasis should be placed on the positive outcome of integrating periodised training, nutrition and recovery to support a functional Endocrine system and therefore optimal health and ability to reach full athletic potential. For example for female athletes, competing in sports where low body mass confers a performance advantage, such as ballet, gymnastics and road cycling, finely tuned neuromuscular skills are essential to reach maximal potential and minimise injury risk. Yet these are the athletes most at risk of developing RED-S, with consequential adverse effects on menstrual cycles, endogenous oestrogen secretion and neuromuscular function.

Rather than reading headlines about the concerning health issues amongst athletes, more guidance for athletes and those working with them, on the warning signs and how to combat RED-S are needed so that athletes can reach their full potential and the headlines become about athlete achievements.

For more discussion on the Endocrine and Metabolic aspects of Sport and Exercise Medicine, all members of multi-disciplinary team working with athletes, including athletes and coaches are welcome to the BASEM Spring Conference

BAsem2018_SpringConf_BJSM

References

Relative Energy Deficiency in Sports (RED-S) Practical considerations for endurance athletes

British middle-distance runner Bobby Clay is struggling with osteoporosis but wants her experience to act as a lesson for fellow young athletes Athletics Weekly 2017

In a special AW report, former English Schools champion Jen Walsh reveals the devastation that the female athlete triad can wreak Athletics Weekly 2017

Optimal Health: Especially Young Athletes! Part 3 – Consequences of Relative Energy Deficiency in Sports BASEM 2017

Prevalence High prevalence of subtle and severe menstrual disturbances in exercising women: confirmation using daily hormone measures. Human Repro 2010

Energy deficiency, menstrual disturbances, and low bone mass: what do exercising Australian women know about the female athlete triad? Int J Sport Nutr Exerc Metab. 2012

Female adolescent athletes’ awareness of the connection between menstrual status and bone health J Pediatr Adolesc Gynecol. 2011

Optimal health: including female athletes! Part 1 Bones BJSM 2017

Optimal Health: For All Athletes! Part 4 – Mechanisms BASEM 2017

Optimal health: including male athletes! Part 2 Relative Energy Deficiency in sports BJSM 2017

Sports Endocrinology – what does it have to do with performance? BJSM 2017

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

Luteinizing hormone pulsatility is disrupted at a threshold of energy availability in regularly menstruating women JCEM 2003

Within-day energy deficiency and reproductive function in female endurance athletes Scandinavian Journal of Science and medicine in Sports 2017

Low Energy Availability is Difficult to Assess But Outcomes Have Large Impact on Bone Injury Rates in Elite Distance Athletes Sports Nutrition and Exercise Metabolism 2017

Body Composition for Health and Sports Performance

Reduced Neuromuscular Performance in Amenorrheic Elite Endurance Athletes Medicine & Science in Sports & Exercise 2017

Conferences in Sport/Dance, Exercise Science and Medicine 2018

Conferences for the New Year:

BAsem2018_SpringConf_BJSM

If you are interested in any aspects of Sport/Dance, Exercise and Lifestyle Medicine here are some suggestions:

British Association of Sport and Exercise Medicine Spring Conference 22 March 2018 “Health, Hormones and Human Performance” Covering the Endocrine and Metabolic aspects of Sport, Dance, Exercise Science and Medicine. From the elite athlete to the reluctant exerciser. Aimed at all those members of the multidisciplinary team working with athletes/dancers, plus athletes/dancers and their coaches/teachers.

CPD points awarded from Faculty of Sports and Exercise Medicine FSEM

BASES British Association of Sport and Exercise Sciences CPD awarded

British Journal of Sports Medicine Quality International Education Approved

CPD points from Royal College of Physicians

CPD from REP-S

 

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Why? The balance and timing of exercise, nutrition and recovery is key to optimising health and all aspects of human performance. Intricate network interactions between the Endocrine system and metabolic signalling pathways drive these positive adaptations. However, non-integration of these lifestyle factors can disrupt signalling feedback pathways and predispose to maladaptation and potentially disease states.

What? Discussion, led by experienced clinicians and researchers will cover:

· Key role of Sports Endocrinology in health and performance

· Effects of exercise modalities on body composition and bone health

· Machine learning in interpreting biochemical & metabolomic patterns

· Endocrine & metabolic markers in assessing health & training status

· Gut metabolism in supporting health and performance

· Exercise as crucial lifestyle factor in pre-existing metabolic dysfunction

Who? This conference is relevant to all members of multidisciplinary teams supporting both reluctant exercisers and elite athletes. Medics, researchers, physiologists, physiotherapists, nutritionists, psychologists, coaches, athletes. All welcome.

Health, Hormones and Human Performance will be a conference of interest to all those involved with aspiring and elite athletes, including dancers (National Institute of Dance Medicine and Science NIDMS) and those supporting reluctant exercisers through Lifestyle Medicine.

Latest news from BASEM. Interview with BASEM Today Issue 41 – Winter 2017

 

Wales Exercise Medicine Symposium by Cardiff Sports & Exercise Medicine Society 27/1/18. This includes Dr Peter Brukner, founder of the Olympic Sports Medicine Park in Melbourne, and an afternoon session discussing the female athlete through the lifespan. CPD points applied for from the Royal College of Physicians, the Faculty of Sports and Exercise Medicine, REPs and the Royal College Of General Practitioners.

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Women in Sport and Exercise Conference 2018  13-14 June Organised by The Women in Sport and Exercise Academic Network and attracting British Association of Sport and Exercise Sciences (BASES) CPD points.

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Medically young, older athletes

Spot the differences?

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You don’t have to be a Radiologist to see that there are some differences between the two X-rays above. Both are from adults of the same age 51 years. Female on left as you look at screen and male on right. In both cases, these adults would be described as “medically young”. Always physically active and reasonably accomplished as athletes in their respective sport disciplines. Never smoked, never overweight, good nutrition.

As discussed at the recent conference at the Royal Society of Medicine (RSM) on “Sports Injuries and Sports Orthopaedics” in the session on the “Ageing Athlete”, there are challenges for athletes in Masters’ age groups, including mechanical joint issues associated with increasing age.

Looking at the male X-ray on right there is small gap between femoral head (ball-like structure) and acetabulum (socket in which femoral head lies). This gap is where the articular cartilage reduces friction between articulating surfaces of this ball and socket joint. In contrast in female X-ray on left of screen, this gap is reduced as cartilage has been worn away so that on right hip (left as you look at screen) bone is grinding on bone. Ouch!

Look again at the femoral heads (ball like structures). In the male these have smooth contours and are symmetrical on both sides. In contrast, in the female there is marked asymmetry with squashed appearance on right side (left of screen) of the femoral head with honeycomb appearance suggesting that there is cyst formation and impaction into socket of joint. This results in shorter leg and weakness of the bone architecture so more likely to compress further. Strangely the blood supply to femoral head is retrograde, meaning it flows backwards from origin of supplying blood vessel to provide vital nutrients to bone, which is a living tissue. If this blood supply is disrupted then the bone dies (avascular necrosis) and become more fragile. The femoral neck (slim area below femoral head) where blood supply courses, has been telescoped down and looks stubby compared to opposite side in female.

Although in the female, the right hip aches and is stiff, it is actually the left hip (right as you look at screen) that hurts more, both at rest and when trying to exercise. Why? If you look carefully on the upper boarder of acetabulum (socket) you will see small cysts. I imagine that pain is caused when the synovial fluid (lubricating fluid) in joint is forced into exposed bone, in hydraulic action especially when moving the hip joint.

So what to do? Total hip replacement (THR) is the only feasible option for the female above, due to extensive damage to the hip joints. Why are some people more prone to this type of joint damage? Apart from underlying medical pathologies that damage joints, the nature of some types of exercise can contribute. For example Ballet is demanding on the hip joint in terms of range of movement and load bearing. The individual can also be predisposed in biomechanical terms to joint issues: in the female X-ray above the femoral head is more exposed than the male.

Although the perception is that THR is more for the elderly wishing to be able to walk to the shops, with improvements in materials and technology used in hip protheses, there are examples of young athletes successfully returning to previous pre-operative levels of exercise training without pain. Recently a 28 year old male soloist dancer of the Paris Opera Ballet had a THR and returned to professional dancing. The medically young athlete will probably have the required motivation and physical ability to rehab effectively. A house in the south of France with private pool and climate for rehab outside would certainly add to motivation. Nevertheless, return to dancing at a professional level in a top level Ballet company after THR is remarkable as classical dance requires a unique combination of outstanding strength, control, proprioception and flexibility. At the conference at the RSM, during the lecture on “Can I run after my hip replacement?” hip replacements in the medically young, active population were reported to have good success rate with athletes able to return to previous level of sport with predicted lifespan of replacement of up to 25 years. Of course every individual athlete should weigh up the pros and cons. Taking up a new impact sport would probably not be sensible. Delaying surgery too long, apart from increasing pain, can compromise biomechanics and therefore replacement outcome. On the other hand, any operation carries a risk, however small and THR requires extensive rehabilitation in order to return to sport.

Deciding on the timing of THR in medically young, older athlete is not straight forward, especially if considering your own hips. Ultimately in such a person, the decision to go for surgery is based on quality of life and limitation to current sport activity, combined with the desire to return to previous level of activity, without the pain. What would you do?

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

Successful Ageing Dr N. Keay, British Association of Sport and Exercise Medicine 2017

Conference: Sports Injuries and Sports Orthopaedics, Royal Society of Medicine, 18/1/17, Session “The Ageing athlete”. Including lectures on: “Can I run after my hip replacement? Current recommendations for impact exercise following joint replacement” Mr Konan and “Managing acute injuries in worn joints” Mr Oussedik

 

 

 

Optimal health: especially young athletes! Part 3 Consequences of Relative Energy Deficiency in sports

In my previous blogs I have described the adverse effects of Relative Energy Deficiency in sports (RED-S) in both female and male athletes both in terms of current health and sport performance and potential long term health problems. What about young aspiring athletes? There is concern that early sport specialisation, imbalances in training not covering the full range of the components of fitness, together with reduced sleep, all combine to increase injury risk. Young athletes are particularly vulnerable to developing RED-S during a period of growth and development accompanied by a high training load.

Sufficient energy availability and diet quality, including micronutrients, is especially important in young athletes. To investigate further I undertook a three year longitudinal study involving 87 pre- and post-pubertal girls, spread across control pupils at day school together with students in vocational training in both musical theatre and ballet streams. There was a gradation in hours of physical exercise training per week ranging from controls with least, followed by musical theatre, through to ballet stream with the most.

In all girls dietary, training and menstrual history were recorded and collected every six months. At the same visit anthropometric measurements were performed by an experienced Paediatric nurse and bloods were taken for Endocrine markers of bone metabolism and leptin. Annual DEXA scans measured body composition, total body bone mineral density (BMD) and BMD at lumbar spine (including volumetric) and BMD at femoral neck.

The key findings included a correlation between hours of training and the age of menarche and subsequent frequency of periods. In turn, any menstrual dysfunction was associated with low age-matched (Z score) BMD at the lumbar spine. There were significant differences between groups for age-matched (Z score) of BMD at lumbar spine, with musical theatre students having the highest and ballet students the lowest. There were no significant differences in dietary intake between the three groups of students, yet the energy expenditure from training would be very different. In other words, if there is balance between energy availability and energy expenditure from training, resulting in concurrent normal menstrual function, then such a level of exercise has a beneficial effect on BMD accrual in young athletes, as demonstrated in musical theatre students. Conversely if there is a mismatch between energy intake and output due to high training volume, this leads to menstrual dysfunction, which in turn adversely impacts BMD accrual, as shown in the ballet students.

I was fortunate to have two sets of identical twins in my study. One girl in each twin pair in the ballet stream at vocational school had a twin at a non-dance school. So in each twin set, there would be identical genetic programming for age of menarche and accumulation of peak bone mass (PBM). However the environmental influence of training had the dominant effect, as shown by a much later age of menarche and decreased final BMD at the lumbar spine in the ballet dancing girl in each identical twin pair.

After stratification for months either side of menarche, the peak rate of change for BMD at the lumbar spine was found to be just before menarche, declining rapidly to no change by 60 months post menarche. These findings suggest that optimal PBM and hence optimal adult BMD would not be attained if menarche is delayed due to environmental factors such as low energy density diet. If young athletes such as these go on to enter professional companies, or become professional athletes then optimal, age-matched BMD may never be attained as continued low energy density diet and menstrual dysfunction associated with RED-S may persist. Associated low levels of vital hormones such as insulin like growth factor 1 (IGF-1) and sex steroids impair bone microarchitecture and mineralisation. Thus increasing risk of injury such as stress fracture and other long term health problems. The crucial importance of attaining peak potential during childhood and puberty was described at a recent conference at the Royal Society of Medicine based on life course studies. For example, delay in puberty results in 20% reduction of bone mass.

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It is concerning that RED-S continues to occur in young athletes, with potential current and long term adverse consequences for health. Young people should certainly be encouraged to exercise but with guidance to avoid any potential pitfalls where at all possible. In my next blog I will delve into the Endocrine mechanisms involved in RED-S: the aetiology and the outcomes.

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

Optimal Health: including female athletes! Part 1 Bones Dr N. Keay, British Journal of Sport Medicine

Optimal health: including male athletes! Part 2 Relative Energy Deficiency in sports Dr N. Keay, British Journal of Sport Medicine 4/4/17

Keay N. The modifiable factors affecting bone mineral accumulation in girls: the paradoxical effect of exercise on bone. Nutrition Bulletin 2000, vol 25, no 3. 219-222.

Keay N The effects of exercise training on bone mineral accumulation in adolescent girls. Journal of Bone and Mineral Research. Vol 15, suppl 1 2000.

Keay N, Frost M, Blake G, Patel R, Fogelman I. Study of the factors influencing the accumulation of bone mineral density in girls. Osteoporosis International. 2000 vol 11, suppl 1. S31.

New S, Samuel A, Lowe S, Keay N. Nutrient intake and bone health in ballet dancers and healthy age matched controls: preliminary findings from a longitudinal study on peak bone mass development in adolescent females, Proceedings of the Nutrition Society, 1998

Keay N, Dancing through adolescence. Editorial, British Journal of Sports Medicine, vol 32 no 3 196-7, September 1998.

Bone health and fractures in children. National Osteoporosis Society

Lifetime influences on musculoskeletal ageing and body composition. Lecture by Professor Diana Kuh, Director of MRC Unit for Lifelong Healthy Ageing, at Royal Society of Medicine, conference on Sports Injuries and sports orthopaedics. 17/1/17

Relative Energy Deficiency in sport (REDs) Lecture by Professor Jorum Sundgot-Borgen, IOC working group on female athlete triad and IOC working group on body composition, health and performance. BAEM Spring Conference 2015.

Health and fitness in young people

Optimal health: including female athletes! Part 1 Bones

webmd_rm_photo_of_porous_bonesIt is hard to dispute that women are underrepresented in medical research and certainly there are not many studies that include female athletes. Does this matter? After all whatever your gender the same physiological and metabolic processes occur. However the Endocrine system is where there are distinct differences in sex steroid production, which in turn have different responses in multiple target cells.

Although studies on changes in exercise performance in response to various dietary interventions and training regimes are often very interesting and well described, I am left feeling slightly uneasy when the subjects are all males. The cause for my concern is that the female hypothalamus-pituitary-ovarian axis is a particularly sensitive system with complex feedback loops and interacting networks.

Menstrual disturbance is not unusual amongst women in sport/dance where low body weight is an advantage. When a ballet dancer performs pointe work, putting full body weight through the big toe is hard enough, without extra load! Some women might consider it a convenience to be spared the hassle of menstruation. At age 24, I was perfectly fine never having had a period (primary amenorrhoea), or so I thought, being no more tired than other hospital medical colleagues working full time, studying for postgraduate medical exams and also involved in exercise training.

While working as a SHO at Northwick Park Hospital, I volunteered to be included in a study at the British Olympic Medical Association. The study was of female lightweight rowers and ballet dancers to look at VO2 max, percentage body fat and bone mineral density (BMD). I had been doing Ballet intensively (and obsessively) from a very young age, together with restricted fat and carbohydrate intake. Sounds a familiar scenario? Although I looked perfectly healthy (and I did not fit into a clinical condition requiring treatment), worked and danced well, my bone density was worryingly low. So if you are a female doing weight-bearing exercise or resistance training which loads the skeleton, these activities promoting osteogenesis will be negated if you are not ovulating and producing adequate oestrogens. The female athlete triad composed of disordered eating, amenorrhoea and low BMD was originally described by Drinkwater in 1984. However, once pathological states causing amenorrhoea have been excluded, in medical terms the female athlete triad did not necessarily constitute a disease state requiring intervention, rather subset of the “normal population”.

How significant is having low BMD compared to the age-matched population during your 20s? Could this even be viewed as a reversible adaptation to training, reflected in site specific differences in BMD according to sport? After all, when female athletes retire with decreased training “stress” and more “relaxed” diet, menses often resume and therefore does BMD also improve? This was the question I sought to answer in my study on 57 premenopausal retired professional dancers. Even with return of menses, if these athletes had experienced previous amenorrhoea of more than 6 month duration, then bone loss was irrecoverable. Current low BMD was also correlated to lowest body weight (independent of amenorrhoea) during dance career and later age of menarche. There did not appear to be any protective effect of being on the oral contraceptive pill. Constructing a model of BMD using multiple regression 33.6% of total variation in z (age matched) score for BMD at lumbar spine was accounted for by duration of amenorrhea, age at menarche and lowest body weight during dance career. So “athletic” hypothalamic amenorrhea rather than being a reversible, adaptive response has long term, irreversible effects on BMD.

Apart from bone metabolism, what other systems are impacted by mismatch of energy intake and expenditure in overtly healthy athletes? Are the endocrine and metabolic systems in male athletes also affected by subtle imbalances in training energy expenditure and dietary intake? What about young athletes? In my next blog I will explore the rationale behind the original female athlete triad now being described as part of Relative Energy Deficiency in sports (RED-S). The implications for current health and sports performance, as well as long term health in both adult men and women and young athletes.

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, Fogelman I, Blake G. Bone mineral density in professional female dancers. British Journal of Sports Medicine, vol 31 no2, 143-7, June 1997.

Keay N. Bone mineral density in professional female dancers. IOC World Congress on Sports Sciences. October 1997.

Keay N, Bone Mineral Density in Professional Female Dancers, Journal of Endocrinology, November 1996, volume 151, supplement p5.

Keay N, Bone Mineral Density in Female Dancers, abstract Clinical Science, Volume 91, no1, July 1996, 20p.

Keay N, Dancers, Periods and Osteoporosis, Dancing Times, September 1995, 1187-1189

Keay N, A study of Dancers, Periods and Osteoporosis, Dance Gazette, Issue 3, 1996, 47

Fit to Dance? Report of National inquiry into dancers’ health

Fit but fragile. National Osteoporosis Society

Your body your risk. Dance UK

From population based norms to personalised medicine: Health, Fitness, Sports Performance British Journal of Sport Medicine 22/2/17

Optimal Health: Including Male Athletes! Part 2 – REDs Dr N. Keay, British Association Sport and Exercise Medicine

Optimal health: especially young athletes! Part 3 Consequences of Relative Energy Deficiency in sports Dr N. Keay, British Association Sport and Exercise Medicine

Optimal health: for all athletes! Part 4 Mechanisms Dr N. Keay, British Association Sport and Exercise Medicine

Ballet for Injury Prevention

 

Ballet is an excellent way for people of all ages to improve mobility and build strength.

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Barnes Studio

Furthermore, if athletes take Ballet classes then this can aid in injury prevention. Ballet incorporates all the elements of a balanced training session improving core strength, muscle tone, muscle dynamics, flexibility, neuromuscular skills and proprioception. Taking Ballet class also provides an interesting challenge both mentally and physically as described in amina sana corpore sano. Ballet offers something different to the usual strength and conditioning training sessions taken by athletes.

Development of neuromuscular skills is vital for young people not only for physical fitness and enabling sports performance, but to enhance cognitive ability, both in short and long term.

The American Academy of Orthopaedic Surgeons recommend that if you are tempted to try Ballet, make sure you go to a class where the teacher can ensure you learn proper technique. I teach Ballet, backed up with my experience in sport medicine and Pilates, in small class setting for individual attention and correction. Whatever your previous dance experience or current level of fitness: are you ready for the challenge and some fun?

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

Ballet

Stories

Anima sana corpore sano

Young people: neuromuscular skills for sports performance

AAOS

Amina Sana in Corpore Sano

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Barnes Studio

Why not give both your body and brain a workout simultaneously? Recall sequences of steps and translate into movement with musicality and expression. Challenge mind and body by taking a Ballet class. Develop and maintain a healthy mind in a healthy body.

A healthy mind in a healthy body: the WHO (World Health Organisation) defines health as a positive state, incorporating the elements of physical, mental and social health, not simply the absence of disease.

Medical evidence demonstrates that exercise is beneficial for the cardio vascular, respiratory, metabolic, endocrine and musculoskeletal systems. It also enhances wellbeing, through the release of endorphins.

Longer term interaction of physical and mental health is now being reported more in scientific journals and the press. Exercise has a long term positive effect on mental health. Exercise is a modifiable lifestyle factor that can decrease the risk of cognitive decline by 18-30%. The mechanism is thought to be related to blood flow to areas of the brain associated with memory.

Ballet is recommended by American Academy of Orthopaedic Surgeons as an injury prevention strategy for athletes as improves neuromuscular skills, proprioception, muscle tone and muscle dynamics.

Ballet

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

http://gpcpd.walesdeanery.org/index.php/welcome-to-motivate-2-move

http://www.businessinsider.com/master-athletes-stopped-exer…

Ballet for Injury Prevention