Hormone Knowledge is Power

Hormones are the directors of health, enabling us to reach our personal full potential. To unlock the power of hormones and harness our hormone networks, we need to be empowered with understanding. This was the motivation for my book “Hormones, health and Human Potential: A guide to understanding your hormones to optimise your health and performance

I was one of the panel discussing hormone power at Bloomfest last week. I started by suggesting that if you are ever labelled as being “hormonal”, take this as a compliment. After all, Horme is the goddess of action and energy. We discussed how to navigate the lifetime female hormone odyssey

Female Hormone Choreography

Hormone networks are complex. Out of all the networks, those of the female hormones is the most intricate. A beautiful interactive dance of hormones occurs every menstrual cycle, following characteristic choreography. However, this hormone dance will be personal to each woman, with subtleties in timing, hormone levels and crucially individual biological response. This is why knowledge is power when it comes to female hormones. Tuning into your personal variation of hormones in terms of how you feel, takes away the mystery. This empowers you to be proactive and work with your hormones, not against them. Periods are the barometer of internal hormone health and a free monthly medical check. I mentioned the potential flash points of the menstrual cycle in terms of menstruation and the luteal phase (occurring after ovulation, in the 2 weeks or so before menstruation) and practical strategies to put in place. This area is discussed in detail in Act 1, Scene 5XX “Of Mice and Men….and Women”.

Hormonal Contraception

Hormonal contraception is often an area of confusion. It is every woman’s choice regarding her personal choice of contraception. However, in order to make an informed choice about the most suitable form, it is really important to clarify the different types available. Non hormonal options, barrier methods include condoms and the copper coil. Hormonal contraception can be divided into combined (synthetic oestradiol and progesterone) and synthetic progesterone-only options. Incidentally a hormonal contraception was trialled men, but they didn’t not like the side effects. As I explain in my book, it is really important that women (and their doctors) know that combined hormonal contraception (eg combined oral contraceptive pill) and certain types of synthetic progesterone-only options, suppress the internal production of female hormones across the board. This is why these medications are very effective contraception. This suppression of internal female hormones can be very useful for women with endometriosis and polycystic ovary syndrome (PCOS) which are conditions effectively fuelled by female hormones. However, this suppression of female hormones is absolutely not suitable for women whose periods have stopped. After writing to NICE, I am pleased to report the guidelines are now updated to advise against giving hormonal contraception to women who are not experiencing periods.

Hormone Injury

Unbalanced external lifestyle choices, rather than harnessing hormones, can cause female “hormone injury”. In my book Act 1, Scene 10 “In the Red” goes into the detail of how an imbalance in behaviours around exercise and nutrition can derail female hormone choreography. I outline practical advice of how to recover from this type of “hormone injury” and what to do to restore and reboot hormone networks and return to full health.

Graduation to Menopause and beyond

Variation in female hormone choreography occurs over the longer time scale of a woman’s lifespan. Menopause is a hot topic. Although it is great to see this being discussed, I suggest we need a more positive narrative. I prefer to talk about the graduation to menopause, rather than a decline. This stage in a woman’s life is something I cover in depth in my book in Act 2 looking through the “The Seven Ages of Man and Woman”. In some cultures, being older and wiser is revered. Menopause is something that all women will experience during their life. A point in time when the ovaries retire in their production of hormones and release of eggs.

The graduation to menopause can be the most challenging. During the perimenopause the ovaries work on an unpredictable, part time basis. The female hormone choreography works smoothly in some cycles. Other cycles there will be a mistiming and confused choreography, causing some of the typical indicators of menopause. These include changes in cycle length and nature, temperature regulation issues, labile mood and brain fog being some of the most frequent. We discussed that probably the most helpful approach for women in the workplace is to facilitate discussions, sharing experiences and putting in place practical things that are helpful for the individual: for example, having a desk fan nearby, sitting near a window. From the medical support point of view, providing the facts and practical aspects of taking HRT is something that I am very pleased to be able to provide.

The quote from the Vice President of the Royal College of Obstetrics and Gynaecologists: “Treat women as individuals, not statistics” is something that resonates when it comes to discussing how to unlock and harness the power of female hormones, throughout each woman’s personal female hormone odyssey.

Reference

Hormones, Health and Human Potential: A guide to understanding your hormones to optimise your health and performance”

Hormones, Health and Human Potential

“Hormones, Health and Human Potential” explains how hormones play a crucial role in determining health. Hormone networks provide the feedback mechanism by which our lifestyle and behaviours enable us to reach our personal potential.

Introduction


Over 2,000 years ago Hippocrates advocated that the “safest way to health” was through “the right amount of nourishment and exercise” for “every individual”. As it turns out Hippocrates was way ahead of his time in articulating the principles of personalised and preventative medicine.

Hormones as the missing link to health


Although Hippocrates understood that lifestyle and behaviours are key to health, he did not know why. We now know that hormones are the key players in this vital role. Hormones are instigators in bringing our DNA to life by determining gene expression. Hormones direct the production of proteins, in the optimal amounts and at the right time. Hormones work as networks to maintain mental and physical health.

Lifestyle factors influencing health through hormones networks


Complex internal negative feedback loops between hormones and the biological variables that they regulate, enable homeostasis for good physiological function. Challenges to homeostasis, due to our interactions with the environment are detected by the hypothalamus, which manages hormone network response. In this way there is another layer of feedback loops between lifestyle behaviours and hormones.

Well-balance lifestyle behaviours, in terms of quantity and timing, support healthy hormone network function, leading us to the “safest way to health”. Conversely, circadian misalignment, where lifestyle choices conflict between internal biochronometers, can lead to hormone dysregulation found in conditions such as metabolic syndrome.

Harnessing hormones as preventative and supportive medicine


A good balance of lifestyle factors can harness hormones as a form of supportive and preventative medicine. This is particularly relevant for type 2 diabetes mellitus and metabolic syndrome. For women, where there are physiological changes in hormones, such as occurs at menopause, attendant symptoms and impacts on long term health can be mitigated by lifestyle as part of the management of menopause. For example, exercise has been shown to have a beneficial effect on temperature regulation, metabolism, body composition, bone health and reducing the risk of breast cancer.

Athlete performance mediated by hormones


Hormones mediate the positive adaptive changes due to exercise training. Understanding these mechanisms can benefit both athletes and patients .

Imbalances in behaviours causing hormone dysregulation


Too little exercise and excess nutrition can lead to hormone dysregulation, seen in metabolic syndrome and type 2 diabetes mellitus. On the other hand, too much of a “good thing” can also cause health and performance issues in exercisers. Relative energy deficiency in sport (RED-S) can occur in exercisers of all ages and levels, where there is either an unintentional or intentional mismatch between energy intake and energy demand. Consequent low energy availability causes hormone network disruption, which in the long-term results in adverse effects on both health and performance .

Conclusions


• Hormone network function plays an important role in mental and physical health
• Hormones are influenced by our lifestyle behaviours of exercise, nutrition and sleep
• The benefits of lifestyle behaviours are derived from the positive adaptive changes driven by hormones
• Imbalances in lifestyle behaviours can cause hormone disruption leading to adverse effects on health and exercise performance

References

Keay N. Health Hormones and Human Potential. Sequoia books. 2022

McCarthy O, Pitt J, Keay N et al Passing on the exercise baton: What can endocrine patients learn from elite athletes? Clinical Endocrinology 2022 96;(6):781-792

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

Hormone Intelligence

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

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

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

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

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

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

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

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

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

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

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

References

Article St John’s College, Cambridge University

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

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

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

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

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

[6] Artificial Intelligence AI council. UK Government 2021

Energy Availability in Dancers

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

Dance v Sport

Dance and Sport…plus ça change

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

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

What’s new in dance?

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

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

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

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

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

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

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

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

References

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

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

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

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

5 www.health4performance.co.uk BASEM educational website

“Of Mice and Men….”

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

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

Mouse
“Where are the females?”

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

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

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

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

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

There are important differences between mice, men and women.

References

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

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

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

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

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

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

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

 

 

 

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

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

Slide1

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

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

Slide1

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

Authors

Nicola Keay1, Gavin Francis2

1 Department of Sport and Exercise Sciences, Durham University

2 Science4Perforamnce, London

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

References

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

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

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

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

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

Returning to Sport/Dance restoring Energy Availability in RED-S?

Although improvements are being made in raising awareness and in effective medical management of relative energy deficiency in sport (RED-S)[1, 2] what about once an athlete/dancer is “medically cleared” to return to sport/dance? What advice/support is there for athletes/dancers and their coaches/teachers? After discussions with coaches, here are some suggestions on how to achieve return to sport/dance after RED-S.

LifeSeasonDayTo recap, RED-S is a situation of low energy availability (LEA), which can lead to adverse health and performance consequences[3,4]. LEA can be a result of intentional energy restriction, which covers a spectrum of issues with eating from disordered eating to full blown clinical eating disorder. Ironically the original intention of these eating issues may have been to improve athletic performance, yet sustained LEA will ultimately lead to stagnation and deterioration in performance as found in male athletes[5].

The desire to return to full fitness can be a powerful incentive to address LEA. Nevertheless return to sport/dance needs to be carefully structured in collaboration with coaches to prevent injury and avoiding regression to the LEA state.

Structured return to training and nutrition

  • Initially focus should be on body weight strength and conditioning (S&C). Inevitably in RED-S adaptive responses to training stimuli will be dampened due to shut down of hormones networks into an energy saving mode. Once adequate EA has been established, hormone networks will be able to respond. Restoring muscle tone and working on proprioception forms a good basis to build from to mitigate injury risk. Impaired neuromuscular skills have been reported in female athletes in LEA[6], together with adverse effects of LEA on bone health increases injury risk.
  • The other reason for gradual return to training is that a routine of fuelling around training (before, during, after) needs to be established. In particular recovery nutrition within 30 minutes window to enable hormonal responses to training. Note that having this recovery nutrition does not mean reducing intake at the next meal!
  • Long endurance should be eased into after restoring muscle strength and control, in order to prevent injury. Additionally this type of training will necessitate a higher energy requirement. If adequate energy availability has only recently been restored, the balance is fragile and so too much training too soon can have negative effects. Especially if a fuelling strategy around training has not been established as described above.
  • High intensity/interval training should be the last type of training to be resumed as this places the highest stress and requires the highest energy demand on the athlete/dancer.
  • Injury, soft tissue and bone stress responses are more frequent in hormonal dysfunction of RED-S in both male and female athletes[7]. If an injury has been sustained during this period of LEA then particular emphasis needs to be on initial S&C. In the case of previous bone stress responses, multi-direction loading is key to build bone strength before resuming formal run training in athletes who are runners. Even if a bone injury has not occurred, bone turnover is one of the first systems to be adversely impacted by RED-S, so including this type of multidirectional bone loading in the initial structured return for all athletes/dancers would be beneficial.
  • Discuss with your coach a realistic, attainable goal if this will help. Maybe a low key race/event several months down the track

What to look out for

  • Don’t ignore injury niggles, illness or fatigue. Discuss with your coach and back off if necessary. This is a process, not a sprint.
  • Female athletes. You may well have experienced menstrual disruption during your time in LEA. This is a crucial training metric. Please use it! If your menstruation becomes irregular/stops this is your warning sign that your body is not ready to step up training[7]. Male coaches please reinforce this and be aware of this point. Remember Gwen Jorgensen posting her periods on Training Peaks as a training metric?
  • Flexibility in approach. Try not to put pressure on yourself to return to your previous PBs. It is important to have a plan, but you can be flexible. Everyone is different so this process of returning to sport/dance does not have a set, rigid timetable.
  • Enjoyment! Don’t forget the original reason that you started your sport/dance was for enjoyment! This is an opportunity to rediscover that joy, whether you return to competition or not.
  • “Recovery?” Does anyone fully “recover” from disordered eating/eating disorder? I don’t think so. To be a successful athlete, or indeed successful in life you need self-motivation, drive, determination. All admirable qualities, but sometimes these can get diverted to cause unhealthy eating/training patterns. So be aware that in times of stress it may be tempting to revert to old habits of under eating/over exercise to reassure yourself that you are in control.
  • Be prepared for questions: why have you been off training? Why are you not doing fully training schedule? Maybe you want to tell your team mates/friends. Maybe you don’t. That is your call.

So good luck with your return to sport/dance after RED-S, if that is what you want to do. Always discuss with you coach how to approach this.

References

1 BASEM Educational website www.health4perforamnce.co.uk

BJSM blog: Update on RED-S N Keay 2018

3, 4 IOC consensus statements on RED-S BJSM 2014 and update 2018

5 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. N Keay, G Francis, K Hind. BMJ Open in Sport and Exercise Medicine 2018

5 Reduced Neuromuscular Performance in Amenorrheic Elite Endurance Athletes.
Tornberg Å Melin A Koivula F Johansson A Skouby S et. al.Medicine and science in sports and exercise 2017 vol: 49 (12) pp: 2478-2485

6 Low Energy Availability Is Difficult to Assess but Outcomes Have Large Impact on Bone Injury Rates in Elite Distance Athletes Heikura, Ida A. Uusitalo, Arja L.T. Stellingwerff, Trent et al International Journal of Sport Nutrition and Exercise Metabolism 2018, 28, 4, 403-411

7 What’s so good about Menstrual Cycles? N Keay BJSM blog 2019

What’s so good about menstrual cycles?

Menstrual periods are a barometer of healthy hormones. The evolutionary purpose of ovulation is to reproduce. Furthermore the carefully biologically choreographed variation of hormones that occurs during an ovulatory menstrual cycle is crucial to health and athletic performance.

Why? Hormones are chemical messengers that have far reaching effects throughout the body and drive the beneficial adaptations to exercise. In the case of menstrual cycles, the fluctuations of oestrogen and progesterone are key to this process. The effects of these sex steroids go far beyond reproduction. These hormones play important roles in bone strength, cardiovascular health, optimal lipid profile and production of neurotransmitters to regulate mood. The effects of low levels of oestrogen and progesterone are well documented in menopausal women who experience loss in bone mass, risk of osteoporosis and fracture, together with an increase risk of cardiovascular disease.

Some definitions

Amenorrhoea=lack of menstrual cycles

Menarche= start of menstrual cycles

According to the Royal College of Obstetrics and Gynaecology

Primary Amenorrhoea: no onset of menstrual cycles by age 16 years.

Secondary amenorrhoea: cessation of menstrual cycles in a previously regularly menstruating woman for > 6months

Oligomenorrhoea: < 9 menstrual cycles per calendar year

Any form of amenorrhoea requires medical investigation to exclude an underlying medical condition. The most common medical causes of amenorrhoea are polycystic ovary syndrome (PCOS), prolactinoma, thyroid conditions and other endocrine conditions. Functional hypothalamic amenorrhoea (FHA) is a diagnosis of exclusion. In other words before arriving at a diagnosis of FHA [1], medical conditions that could potentially cause amenorrhoea have to be ruled out.

Screen Shot 2019-01-30 at 12.09.28

Relative energy deficiency in sport (RED-S) is a situation of low energy availability (LEA) that can be unintentional or intentional as a result of a mismatch between energy intake and energy requirement. The two sources of energy demand arise from exercise training load and maintenance of fundamental physiological function across multiple body systems [2]. In female athletes/dancers with RED-S the most obvious clinical sign is amenorrhoea as a result of FHA. In all cases of RED-S the management strategy is directed to address the underlying issue of LEA [3].

In female athletes/dancer with FHA due to RED-S, there is the possibility of pharmacological intervention based on the RED-S Clinical Assessment Tool [4]. In other words evidence from DXA of Z-score of lumbar spine < -1 and/or stress fracture. What are the most effect hormonal interventions in such cases?

What’s in a name? It is every woman’s right to choose the form of contraception she wishes to use. Hormonal contraception provides a convenient method. The combined oral contraceptive pill (OCP) contains oestrogen and progesterone to prevent ovulation. The OCP produces regular withdrawal bleeds in response to these external hormones. Progesterone-only contraception can be taken orally, via implant or delivered by an intrauterine coil and typically does not produce withdrawal bleeds. As with any medication there are potential side effects, which have to be weighed up against the benefits. Regarding the effect of hormonal contraception on bone in young menstruating women, there is evidence that such medication can impair bone health [5].

The OCP produces regular withdrawal bleeds. These are NOT menstrual periods; ovulation is prevented. Rather the OCP causes withdrawal bleeds driven by external non-physiological hormones, as opposed to internally physiologically produced hormones. This is a reason why the OCP is not recommended in FHA, as this medication will mask what is happening with internal hormones [6]. In other words the barometer of healthy hormones has been removed when taking the OCP.

Furthermore, studies show that the OCP can impact other hormone systems that play a role in bone health. The OCP is taken orally thereby producing first pass effects in the liver. These effects include induction of liver enzymes and increased production of binding proteins for hormones. Binding proteins reduce the freely available active form of hormones such insulin like growth factor 1 (IGF-1). This effect is particularly marked in those OCP with non-physiological ethinyl oestradiol. In the case of RED-S there is already a low level of active IFG-1, due to the general suppression of the hypothalamic-pituitary axis.

Therefore in addition to masking FHA, the OCP can also further decrease IGF-1 and thus compound the negative effect on bone. This has been shown to be the case in the clinical setting where the OCP was found to have no bone protective effect on bone mineral density (BMD) in women with FHA. Rather hormone replacement therapy (HRT) consisting of transdermal physiological oestrogen with cyclic micro-ionised progesterone was found to have a positive effect on BMD [7 , 8]

Therefore, if hormonal treatment is to be used in RED-S, HRT (transdermal oestradiol and cyclic micro-ionised progesterone) is best clinical practice. This decision requires careful discussion with the athlete/dancer clarifying that HRT should only be a short-term measure to protect bone health whilst the underlying issue of LEA is being resolved. Behavioural measures relating to training load, nutrition and recovery are essential to restore global hormonal function.

OCP V HRT

• What? Both provide oestrogen and progesterone, but in different forms: non-physiological v physiological

Why? Purpose of the OCP is to suppress production of endogenous female hormones and prevent ovulation. Purpose of HRT is to replace the physiological amount and form of oestrogen and progesterone

How? The OCP decreases levels of active, unbound IGF-1. Not bone protective in FHA of RED-S. HRT shown to improve BMD in FHA of RED-S

What to do? Hormonal contraception is a choice for women. In some medical conditions where there is adequate/excess oestrogen such as endometriosis or PCOS, hormonal contraception is effective in clinical management. However in the case of FHA, in particular when occurring as a consequence of LEA in RED-S there is evidence that the OCP is not bone protective and masks the clinical sign of menstruation.

The priority in managing RED-S is to address LEA. If bone protection is required, whilst addressing LEA, HRT (transdermal oestrogen and cyclic progesterone) is best clinical practice.

References

[1] Joy, E., De Souza, M. J., Nattiv, A., Misra, M., Williams, N. I., Mallinson, R. J., … Borgen, J. S. (2014). 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad. Current Sports Medicine Reports, 13(4), 219–232. https://doi.org/10.1249/JSR.0000000000000077

[2] Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., … Ljungqvist, A. (2014). The IOC consensus statement: Beyond the Female Athlete Triad-Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine48(7), 491–497. https://doi.org/10.1136/bjsports-2014-093502

[3] Mountjoy, M., Sundgot-Borgen, J. K., Burke, L. M., Ackerman, K. E., Blauwet, C., Constantini, N., … Budgett, R. (2018). IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. British Journal of Sports Medicine, 52(11), 687–697. https://doi.org/10.1136/bjsports-2018-099193

[4] Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., … Ackerman, K. (2015, April 1). Relative energy deficiency in sport (RED-S) clinical assessment tool (CAT). British Journal of Sports Medicine. BMJ Publishing Group. https://doi.org/10.1136/bjsports-2015-094873

[5] Beksinska M, Smit J, Hormonal contraception and bone mineral density. Expert Review of Obstetrics & Gynecology, 2011 vol: 6 (3) pp: 305-319

[6] Gordon, C. M., Ackerman, K. E., Berga, S. L., Kaplan, J. R., Mastorakos, G., Misra, M., … Warren, M. P. (2017). Functional hypothalamic amenorrhea: An endocrine society clinical practice guideline. Journal of Clinical Endocrinology and Metabolism102(5), 1413–1439. https://doi.org/10.1210/jc.2017-00131

[7] Ackerman, K. E., Singhal, V., Baskaran, C., Slattery, M., Campoverde Reyes, K. J., Toth, A., … Misra, M. (2018). Oestrogen replacement improves bone mineral density in oligo-amenorrhoeic athletes: A randomised clinical trial. British Journal of Sports Medicine. BMJ Publishing Group. https://doi.org/10.1136/bjsports-2018-099723

[8] Singhal, V., Ackerman, K. E., Bose, A., Torre Flores, L. P., Lee, H., & Misra, M. (2018). Impact of Route of Estrogen Administration on Bone Turnover Markers in Oligoamenorrheic Athletes and its Mediators. The Journal of Clinical Endocrinology & Metabolism. https://doi.org/10.1210/jc.2018-02143

 

 

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.

Slide1

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

 

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

Relative energy deficiency in sport (RED-S) is a clinical model that describes the potential adverse health and performance consequences of low energy availability (LEA) in male and female athletes. Identification of athletes at risk of LEA can potentially prevent these adverse clinical outcomes.

Athletes at risk of RED-S are those involved in sports where low body weight confers a performance or aesthetic advantage. In the case of competitive road cycling, being light  weight results in favourable power to weight ratio to overcome gravity when cycling uphill. How can male cyclists at risk of LEA be effectively identified in a practical manner?

Energy availability (EA) is defined as the residual energy available from dietary intake, once energy expenditure from exercise training has been subtracted. This available energy is expressed as KCal/Kg fat free mass (FFM). A value of 45 KCal/Kg FFM is roughly equivalent to basal metabolic rate, in other words the energy required to sustain health. In order to quantify EA, accurate measurements of energy intake and expenditure, and FFM assessed from dual X ray absorptiometry (DXA), need to be undertaken. However this is not practical or feasible to undertake all these measurements outside the research setting. Furthermore, methodology for assessing energy intake and expenditure is laborious and fraught with inaccuracies and subjectivity in the case of diet diaries for “free living athletes“. Even if a value is calculated for EA, this is only valid for the time of measurement and does not give any insights into the temporal aspect of EA. Furthermore, an absolute EA threshold has not been established, below which clinical symptoms or performance effects of RED-S occur.

Self reported questionnaires have been shown to be surrogates of low EA in female athletes. However there are no such sport specific questionnaires, or any questionnaires for male athletes. Endocrine and metabolic markers have been proposed as quantitative surrogate measures of EA and shown to be linked to the RED-S clinical outcome of stress fractures in runners. In female athletes the clinical sign of regular menstruation demonstrates a functioning H-P ovarian axis, not suppressed by LEA. What about male athletes? Although hypothalamic suppression of the reproductive axis due to LEA can result in low testosterone, high training loads, in presence of adequate EA, can lead to the same negative effect on testosterone concentration.

Sam

Male cyclists present a further level of complexity in assessing EA status. In contrast to runners, stress fracture will not be an early clinical warning sign of impaired bone health resulting from low EA. Furthermore cyclists are already at risk of poor bone health due to the non weight bearing nature of the sport. Nevertheless, traumatic fracture from bike falls is the main type of injury in cycling, with vertebral fracture requiring the longest time off the bike. Chris Boardman, a serial Olympic medal winner in cycling, retired in his early 30s with osteoporosis. In other words, in road cycling, the combined effect of the lack of osteogenic stimulus and LEA can produce clinically significant adverse effects on bone health.

What practical clinical tools are most effective at identifying competitive male cyclists at risk of the health and performance consequences of LEA outlined in the RED-S model? This was the question our recent study addressed. The lumbar spine is a skeletal site known to be most impacted by nutrition and endocrine factors and DXA is recognised as the “gold standard” of quantifying age matched Z score for bone mineral density (BMD) in the risk stratification of RED-S. What is the clinical measure indicative of this established and clinically significant sign of RED-S on lumbar spine BMD? Would it be testosterone concentration, as suggested in the study of runners? Another blood marker? Cycle training load? Off bike exercise, as suggested in some previous studies? Clinical assessment by interview?

Using a decision tree approach, the factor most indicative of impaired age matched (Z score) lumbar spine BMD was sport specific clinical assessment of EA. This assessment took the form of a newly developed sports specific energy availability questionnaire and interview (SEAQ-I). Reinforcing the concept that the most important skill in clinical medical practice is taking a detailed history. Questionnaire alone can lead to athletes giving “correct” answers on nutrition and training load. Clinical interview gave details on the temporal aspects of EA in the context of cycle training schedule: whether riders where experiencing acute intermittent LEA, as with multiple weekly fasted rides, or chronic sustained LEA with prolonged periods of suppressed body weight. Additionally the SEAQ-I provided insights on attitudes to training and nutrition practices.

Cyclists identified as having LEA from SEAQ-I, had significantly lower lumbar spine BMD than those riders assessed as having adequate EA. Furthermore, the lowest lumbar spine BMD was found amongst LEA cyclists who had not practised any load bearing sport prior to focusing on cycling. This finding is of particular concern, as if cycling from adolescence is not integrated with weight bearing exercise and adequate nutrition when peak bone mass (PBM) is being accumulated, then this risks impaired bone health moving into adulthood.

Further extension of the decision tree analysis demonstrated that in those cyclists with adequate EA assessed from SEAQ-I, vitamin D concentration was the factor indicative of lumbar spine BMD. Vitamin D is emerging as an important consideration for athletes, for bone health, muscle strength and immune function. Furthermore synergistic interactions with other steroid hormones, such as testosterone could be significant.

What about the effects of EA on cycling performance? For athletes, athletic performance is the top priority. In competitive road cycling the “gold standard” performance measure is functional threshold power (FTP) Watts/Kg, produced over 60 minutes. In the current study, 60 minute FTP Watts/Kg had a significant relationship to training load. However cyclists in chronic LEA were under performing, in other words not able to produce the power anticipated for a given training load. These chronic LEA cyclists also had significantly lower testosterone concentration. Periodised carbohydrate intake for low intensity sessions is a strategy for increasing training stimulus. However if this acute intermittent LEA is superimposed on a background of chronic LEA, then this can be counter productive in producing beneficial training adaptations. Increasing training load improves performance, but this training is only effective if fuelling is tailored accordingly.

Male athletes can be at risk of developing the health and performance consequences of LEA as described in the RED-S clinical model. The recent study of competitive male road cyclists shows that a sport specific questionnaire, combined with clinical interview (SEAQ-I) is an effective and practical method of identifying athletes at risk of LEA. The temporal dimension of LEA was correlated to quantifiable health and performance consequences of RED-S.

References 

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, BMJ Open in Sport and Exercise Medicine 2018

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

Fuelling for Cycling Performance Science4Performance

Pitfalls of Conducting and Interpreting Estimates of Energy Availability in Free-Living Athletes International Journal of Sport Nutrition and Exercise Metabolism 2018

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

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

Low Energy Availability Is Difficult to Assess but Outcomes Have Large Impact on Bone Injury Rates in Elite Distance Athletes International Journal of Sport Nutrition and Exercise Metabolism 2018

Treating exercise-associated low testosterone and its related symptoms The Physician and Sports Medicine 2018

Male Cyclists: bones, body composition, nutrition, performance Keay, BJSM 2018

Cyclists: Make No Bones About It Keay, BJSM 2018

Male Athletes: the Bare Bones of Cyclists

Cyclists: How to Support Bone Health?

Synergistic interactions of steroid hormones Keay BJSM 2018

Fuel for the Work Required: A Theoretical Framework for Carbohydrate Periodization and the Glycogen Threshold Hypothesis Sports Medicine 2018