Healthy Hormones

Is your training in tune with your hormones and nutrition to optimise your athletic performance?

Hormones are internal chemical messengers regulating all aspects of your health and athletic performance. Discussed at recent BASEM conference “Health Hormones and Human Performance”

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Bone health can be at risk if hormone status not optimal

How? To enable your hormones to do the best job they can for your health and sport performance, you need to find a balance between what, how much and when you train, eat and sleep. In the diagram below, this represents staying on the healthy green plateau. Too much, or too little of any of these choices can lead to imbalances and tipping off the green plateau into the red, less healthy peripheries.

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Integrated periodisation of training, nutrition and recovery for optimal health and performance (Keay, BJSM 2017)

What? Imbalances between training load, nutrition and recovery can cause problems in the Endocrine system: the whole network of hormone interactions throughout your body. The bottom line is that if insufficient energy is provided through nutrition to cover both your training demands and the “housekeeping” activities within the body to keep you alive, then your body goes into energy saving mode. This situation is called relative energy deficiency in sports (RED-S) and has the potential to adversely impact one or more of the important systems in your body vital for optimal health and performance.

RED-S has evolved from the female athlete triad described in 1980s by Barbara Drinkwater in NEJM, where although female runners were consuming same dietary intake, those with higher training load were more likely to have menstrual dysfunction and low bone mineral density. Since this original description it has become obvious that the reproductive axis is just one of several hormone networks to be impacted by low energy availability and that RED-S also impacts the other half of the population: men.

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Potential Multisystem effects of RED-S (IOC statement BJSM 2014)

Why? Suboptimal levels of energy availability to support health and performance can arise unintentionally, for example with increased training loads and/or times of growth and development in young athletes. Intentionally restrictive eating patterns can also be the cause of RED-S, particularly in sports/dance where low body weight confers a performance or aesthetic advantage. It is an indisputable fact that in order cycle up a mountain you need to overcome gravity and produce high watts/kg. Equally it is pretty impossible to do pointe work, let alone 32 fouttées en tournant en pointe unless you are a lightweight dancer. However if this at the expense of disrupting your hormones, then the advantage of being low body weight will be lost.

How to know? How to know if you, a teammate or a fellow athlete is at risk of RED-S? If you are a female athlete then your hormones are in balance if you are having regular periods (this does not include withdrawal bleeds as result of being on the oral contraceptive pill). Any woman of reproductive age from 16 years to the menopause should have regular periods (unless pregnant). Regular menstruation acts as the barometer of healthy hormones in women. If this is not the case, whether you are an athlete or not, you need to get this checked out medically to exclude underlying medical conditions. Having excluded these, then you need to review the integrated periodisation of training, nutrition and recovery. In male athletes there is not such an obvious sign that your hormones are at healthy levels. However recurrent injury/illness/fatigue can be warning signs. The diagram below shows all the potential adverse effects of RED-S on performance. Be aware that you do not have to have all, or indeed be aware of any of these effects if you develop RED-S.

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Potential Performance effects of RED-S (IOC statement BJSM 2014)

So What? If you are an athlete/dancer, you may be thinking that none of this applies to you. You are feeling and performing fine. Maybe you have not yet experienced any of the detrimental effects of RED-S. However, you will never know how good an athlete you could be and whether you truly are performing to your full potential unless you put yourself in the best position in terms of your hormones to achieve this goal.

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Suboptimal performance as result of RED-S (Keay, BJSM 2017)

Key Points

• Insufficient nutrition intake (quantity and quality), whether intentional or not, results in RED-S and multiple hormonal disruptions

• RED-S has detrimental health and athletic performance consequences in both the short and the long term

• Some consequences of RED-S are irreversible for example poor bone health, unless intervention is swift

Check points

• Are you suffering with frequent injuries/fatigue/illness over last 3 months or more?

• Female athletes: if 16 years or older have your periods not started? Have you missed more than 3 consecutive periods?

If yes to any of above, seek medical advice from someone with experience Sports Endocrinology. Now! The longer you leave the situation the harder it will be to rectify. Initially underlying Endocrine conditions per se have to be ruled out. RED-S is a functional dysfunction of the Endocrine system, so a diagnosis of exclusion. Having established RED-S as the diagnosis, monitoring Endocrine markers can be very helpful as these are examples of objective metrics in monitoring energy availability and therefore response to optimising integrated periodisation of nutrition, training and recovery.

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Integrated periodisation of key training factors support healthy hormones to drive improvements in performance

What to do? Don’t ignore! Although you may think you are fine, if your hormones are not working for you, then you will never reach your full potential as an athlete/dancer. For female athletes having regular periods means your hormones are in healthy ranges and this is normal. Not starting and/or missing periods is not healthy, for any woman.

For both male and female athletes, if you are experiencing recurrent injury, fatigue or illness, you need to get this checked out. There may be a simple explanation such as viral infection, low vitamin D or iron. However it may be that the underlying reason is due to hormone issues.

If you are an athlete, coach, teacher or parent and concerned that you/an athlete in your care has not got the balance right to optimise health and athletic performance, then a 3 way discussion will help and support the decision to seek medical advice as appropriate.

References

Lifestyle Choices for optimising health: exercise, nutrition, sleep Keay, BJSM 2017

Optimal health: including female athletes! Part 1 BJSM 2017

Optimal health: including male athletes! Part 2 BJSM 2017

Optimal Health: Especially Young Athletes! Part 3 BASEM 2017

Optimal Health: For All Athletes! Part 4 BASEM 2017

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

Cumulative Endocrine Dysfunction in Relative Energy Deficiency in Sport (RED-S) BJSM 2018

Presentation at BASEM conference “Health, Hormones and Human Performance”

 

Health, Hormones and Human Performance Part 1

How hormones determine health and athletic performance

Endocrine and Metabolic aspects of Sports and Exercise Medicine are crucial determinants of health and human performance, from reluctant exerciser through to elite athlete and professional dancer. This is what I set out to demonstrate as the chair of the recent British Association of Sport and Medicine conference, with insightful presentations from my colleagues whom I had invited to share their research and practical applications of their work. The audience comprised of doctors with interest in sport and exercise medicine, representatives from the dance world, research scientists, nutritionists, physiotherapists, coaches and trainers. In short, all were members of multi-disciplinary teams supporting aspiring athletes. The importance of the conference was reflected in CDP awards from FSEM, BASES, Royal College of Physicians (RCP), REP-S and endorsement for international education from BJSM and National Institute of Dance Medicine and Science (NIDMS).

Exercise is a crucial lifestyle factor in determining health and disease. Yet we see an increasing polarisation in the amount of exercise taken across the general population. At one end of the spectrum, the increasing training loads of elite athletes and professional dancers push the levels of human performance to greater heights. On the other side of the spectrum, rising levels of inactivity, in large swathes of the population, increase the risk of poor health and developing disease states. Which fundamental biological processes and systems link these groups with apparently dichotomous levels of exercise? What determines the outcome of the underlying Endocrine and metabolic network interactions? How can an understanding of these factors help prevent sports injuries and lead to more effective rehabilitation? How can we employ Endocrine markers to predict and provide guidance towards beneficial outcomes for health and human performance?

If you weren’t able to come and participate in the discussion, these are some topics presented. My opening presentation (see video below) set the scene, outlining why having an optimally functioning Endocrine system is fundamental to health and performance. Conversely, functional disruption of Endocrine networks occurs with non integrated periodisation of the three key lifestyle factors of exercise/training, nutrition and recovery/sleep, which can lead to adverse effects on health and athletic performance.

In the case of an imbalance in training load and nutrition, this can manifest as the female athlete triad, which has now evolved into relative energy deficiency in sports (RED-S) in recognition of the fact that Endocrine feedback loops are disrupted across many hormonal axes, not just the reproductive axis. And, significantly, acknowledging the fact that males athletes can also be impacted by insufficient energy availability to meet both training and “housekeeping” energy requirements. Why and how RED-S can affect male athletes, in particular male competitive road cyclists, was discussed, highlighting the need for further research to investigate practical and effective strategies to optimise health and therefore ultimately performance in competition.

A degree of overlap and interplay exists between RED-S (imbalance in nutrition and training load), non functional over-reaching and over-training syndrome (imbalances in training load and recovery). Indeed research evidence was presented suggesting that RED-S increases the risk of developing over-training syndrome. In these situations of functional disruption of the Endocrine networks, underlying Endocrine conditions per se should be excluded. Case studies demonstrated this principle in the diagnosis of RED-S. This is particularly important in the investigation of amenorrhoea. All women of reproductive age, whether athletes or not, should have regular menstruation (apart from when pregnant!), as a barometer of healthy hormones. Indeed, since hormones are essential to drive positive adaptations to exercise, healthy hormones are key in attaining full athletic potential in any athlete/dancer, whether male or female. Evidence was presented from research studies for the role of validated Endocrine markers and clinical menstrual status in females as objective and quantifiable measures of energy availability and hence injury risk in both male and female athletes.

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Triumvirate of external factors impacting Endocrine system and hence performance

Alongside training metrics, if female athletes recorded menstrual pattern (as Gwen Jorgensen recently showed on her Training Peaks) and all athletes kept a biological passport of selected Endocrine markers; this could potentially identify at an early stage any imbalances in the triumvirate of training load, nutrition and recovery. Pre-empting development of RED-S or over-training syndrome, supports the maintenance of healthy hormones and hence optimal human performance.

Look out for presentations from speakers which will be uploaded on BASEM website shortly.

References

Video of presentation on the Endocrine and Metabolic Aspects of Sports and Exercise Medicine BASEM conference “Health, Hormones and Human Performance”

Study of hormones, body composition, bone mineral density and performance in competitive male road cyclists Investigation of effective and practical nutrition and off bike exercise interventions

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

 

 

 

Cyclists: Make No Bones About It

Competitive cyclists are potentially at risk of suboptimal bone health. Although cycling is excellent for cardiovascular fitness, this type of non skeletal loading exercise does not mechanically stimulate osteogenesis (bone formation). This situation of low mechanical osteogenic stimulus to build bone can be compounded by restrictive eating patterns and associated hormone dysfunction of relative energy deficiency in sports (RED-S).

In a recent pilot study 7/10 competitive cyclists (Cat 2 and above) had low age-matched bone mineral density (BMD) in the lumbar spine. This is comparable to another study where 15/28 male cyclists training over eight hours a week were found to have low BMD for their age and were therefore at risk of low trauma fracture. However, cyclists with a lower training volume (Cat 4) did not fair so badly in terms of BMD, due to higher body mass index (BMI) and fat mass. Although greater body mass mechanically loads the skeleton, the downside is that you need to generate more power to get up a hill.

Why is cycling unique compared to other sports where an important adaptation to training is to improve, not impair, bone health? What are the practical solutions to prevent this potential negative effect of cycle training?

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Site Specific Effects on Bone Mineral Density

The illustration shows how different sports exert site specific effects on the bone mineral density of the skeleton. In general terms, hip femoral neck BMD is more dependent on mechanical loading osteogenic stimuli, whereas lumbar spine BMD is more dependent on nutritional and Endocrine status.

What are the most effective mechanical osteogenic stimuli? Evidence from animal models demonstrates that bone responds to exercise that is dynamic, non-repetitive and unpredictable. Load and repetitions are not such important factors. This is shown in a study of track and field athletes, where sprinters were found to have higher BMD at load bearing sites of the skeleton than long distance runners due to a local loading effect rather than a systemic effect associated with repetitive loading nature of longer distance running. The other important consideration is that sprinters and rugby players tend to weigh more with higher lean mass than distance runners, providing higher skeletal loading forces. These differences in anthropometric and body composition metrics are also associated with different nutritional and Endocrine status.

In contrast to sports involving running, rowing creates a mechanical osteogenic stimulus that is directed through the lumbar spine, resulting in an associated increase in BMD at this site. This site specific effect of rowing can prevent bone loss at the lumbar that would be anticipated with rowers experiencing RED-S.

Swimming and cycling are similar in that both these types of exercise do not provide mechanical skeletal loading osteogenic stimulus. However the consequences on BMD, particularly at the lumbar spine, can be compounded in cycling by the performance advantage of low body mass and therefore potential of restrictive nutrition and consequent effect on Endocrine status: factors which impact bone health.

In the recent pilot study of competitive cyclists, although 7/10 had below average for age lumbar spine BMD, those with stronger bones had a previous history of other sports that improve BMD at this site: namely rugby and rowing, together with the cyclist doing concurrent and consistent weight training throughout the season. These findings were consistent with a study where male riders who had undertaken pre-season weight training had better BMD than riders who had not. Cumulative skeletal loading over a lifetime determines BMD. However, the skeletal system is dynamic and as with any training adaptation, any beneficial effects of skeletal loading exercise are reversible if not maintained throughout the lifespan.

Typically, the objective of off-bike strength and conditioning (S&C) is aimed at producing higher watts on the bike. Some strengthening exercises may, as by product, produce an osteogenic stimulus indirectly by muscle pulling on bone. Should off-bike work include specific mechanical axial skeletal loading exercises that are continued throughout the season? Skeletal loading exercises for cyclists would have to be effective and practical, not requiring access to gym and possible to fit into training schedule throughout the season. This will be investigated in an forthcoming study of competitive male cyclists.

In meantime there will be more discussion on “Health, Hormones and Human Performance” at the BASEM conference 22 March. All welcome, including athletes and coaches, alongside healthcare professional working with athletes.

References

Male Cyclists: bones, body composition, nutrition, performance

Cycling and bone health: a systematic review BMC Medicine 2012

Male Athletes: the Bare Bones of Cyclists

Comparisons of Bone Mineral Density Between Recreational and Trained Male Road Cyclists Clinical Journal of Sport Medicine 2016

Longitudinal Assessment of Bone Mineral Density and Body Composition in Competitive Cyclists Journal of Strength and Conditioning Research 2017

Kings and Queens of the Mountains Science4Perforamnce

Inhibition of osteopenia by low magnitude, high-frequency mechanical stimuli Drug Discovery Today 2001

Bone density and neuromuscular function in older competitive athletes depend on running distance Osteoporosis International 2012

Menstrual state and exercise as determinants of spinal trabecular bone density in female athletes BMJ 1990

Male Athletes: the Bare Bones of Cyclists

Resistance Training Is Associated With Higher Lumbar Spine and Hip Bone Mineral Density in Competitive Male Cyclists Journal of Strength and Conditioning Research 2018

A meta-analysis of brief high-impact exercises for enhancing bone health in premenopausal women  Osteoporosis International 2012

Jumping Improves Hip and Lumbar Spine Bone Mass in Prepubescent Children: A Randomized Controlled Trial JBMR 2001

Longitudinal Changes in Bone Mineral Density in Male Master Cyclists and Nonathletes The Journal of Strength & Conditioning Research 2011