health – Dr Nicky Keay

“Sleep is the chief nourisher in life’s great feast”

17 January 2023

Macbeth, Shakespeare

At the start of every year there is always a lot of talk about refraining from certain activities like drinking alcohol, advice about eating a particular way, or recommendations to do certain types/amount of exercise. Trends in these lifestyle choices may come and go, but there is one behaviour that remains constant to achieve optimal health. Sleep.

In my book “Hormones, Health and Human Potential: A guide to understanding your hormones to optimise your health and performance” I discuss how our lifestyle choices and behaviours around sleep, exercise and nutrition influence hormone networks and consequently our health.

Illustration from “Hormones, Health and Human Potential”

Sleep for hormone health

Why is sleep such an essential component for health? Although being asleep is a physical state of inactivity, it is when many hormone networks are at their most active. For example, one of the main stimuli for growth hormone (GH) release is sleep. Despite its name, GH is not just about growth in children. All adults continue to produce GH and this is an important anabolic (tissue building) hormone. GH maintains a healthy body composition: favouring muscle over fat deposition. GH also plays a role in bone health.

Sleep for fitness

Another stimulus for GH release is exercise. However, you don’t get fitter in real time while you exercise. You get fitter when you are asleep. After stopping exercise and during sleep these two combined stimuli for GH release drive the positive adaptations to exercise. Sleep enables you to become citius, altius, fortius.

Sleep for sex steroid hormone networks

Sleep is also essential for other hormone networks, such as those of the reproductive axis, in both men and women. Studies show that men who have reduced sleep tend to have lower levels of testosterone and poorer bone health. Essentially if you do not have sufficient quality and quantity of sleep this has a negative effect on many aspects of both physical and mental health.

Sleep for metabolic health

Hormones that control appetite and satiety are linked with the sleep/wake cycle. People who have disrupted sleep patterns are more likely to struggle with blood glucose and weight control.

Timing of sleep

The timing of sleep is also important. Hormone networks run on a variety of internal biological clocks, known as biochronometers. The trick is to try and synchronise the timing of your behaviours with these internal biochronometers. If you have an “scheduling conflict” between external and internal clocks, this leads to a situation of circadian misalignment. Circadian misalignment can lead to many adverse consequences on mental and physical health, including metabolic and cardiovascular health. This negative combination can lead to metabolic syndrome which increases the risk of type 2 diabetes mellitus, cardiovascular disease and high blood pressure.

Consequences of disrupted sleep patterns

Shift workers, for example junior doctors, are at risk of developing circadian misalignment. Disrupted sleep patterns, clashing with internal hormone timing becomes a vicious circle. Poor sleep interferes with the diurnal variation of cortisol, which peaks as an awakening response. Disruption of this cortisol awakening response can disrupt subsequent night sleeping.

A degree of circadian entrainment is possible. In other words, our hormone clocks can adapt to slight changes in sleeping patterns. For example, getting up early for exercise training. It is also possible to reset internal biological clocks, as we do after a long-haul flight. This is because in our brain we have a biological light sensor which has direct communication with the manager of the hormone orchestra, conveniently situated in very close proximity in the brain. The timing of daily hormone release can be reset to correspond with local night and day timing. This contrasts to the situation of doing shift work, where you are continuously in conflict with night/day timing and internal hormone clocks.

Top tips for sleep to optimise hormone health

So, if there is one behaviour that you are going to improve this year, it should be sleep.

Sleep hygiene is the term used to cover strategies to ensure a good night’s sleep. One of the tops tips is to try and go to bed at a regular time, before midnight. A recent study shows that is these hours before midnight that are particularly valuable for hormone health. In fact, it is useful to set an alarm for going to bed.

Another strategy to help sleep is finding a bedtime “wind down” routine that suits you. For example, reading or listening to music. Looking at mobile electronic devices is not one of these. The reason being that the light emitted from these devices prevents the production of the sleep hormone melatonin.

When it comes to hormone health, sleep is indeed the chief nourisher. Sleep and other lifestyle choices to harness hormones for optimal health, through life, are explored in detail in “Hormones, Health and Human Potential: A guide to understanding your hormones to optimise your health and performance”.

Next steps

“Hormones, Health and Human Potential: A guide to understanding your hormones to optimise your health and performance” is available in paperback and Kindle (illustrations in colour) from Amazon and direct from Sequoia books (ship overseas)

Hormone Health advisory appointments are available

Presentations and workshops

Excess is a Fatal Thing. Nothing Succeeds like Moderation

1 January 2023

Oscar Wilde quipped that “Moderation is a fatal thing. Nothing succeeds like excess.” However, when it comes to enjoying a healthy lifespan, nothing succeeds like moderation.

**Harnessing Hormones through Lifestyle Choices for Health**

Personalising Health through Lifestyle

Hippocrates advocated that giving each individual just the right amount of exercise and nourishment, not too little and not too much, is the safest way the health. Although Hippocrates is often known as the father of medicine, more accurately he could be described as the father of health. Health being not just the absence of disease, rather the positive combination of physical, mental and social health.

In ancient Greek times it was not known why moderation, of nutrition and exercise surely lead to health. As I describe in “Hormones, Health and Human Potential” it is the interactions of these behaviours with our hormone networks that maintain internal harmony known as homeostasis. Homeostasis is equilibrium of the internal environment to support all physiological processes for health. Hormone networks can adapt and withstand a certain degree of external excess in the form of too much or too little nutrition or exercise. However there comes a critical point, personal for each individual, where continued excess of unbalanced behaviours will tip over into adverse effects on health. Incidentally in this situation it is not hormones that become unbalanced, rather unbalanced behaviours have forced hormone networks into extensive adaptive changes.

Rebalancing Lifestyle Choices

There are certainly ever emerging challenges for attaining just the right amount and timing of each lifestyle choice around nutrition and exercise. Everyone likes a “quick fix”: apart from your hormones and your health. This is why New Year’s resolutions around extreme dieting or exercise at either end of the spectrum don’t lead to long term benefits. Another problem is that it is difficult to override in-build “safety” mechanisms, so it is challenging psychologically to stick to original intentions. Your body and millions of years of evolution knows best. This can leave you deflated and demotivated. You can’t stick to your plan and this plan does not bring the success you expected. What are the ways to set you on the surest path for optimal heath?

Lifestyle choices for 2023

Exercise

There are two very important factors in your choice of exercise. Firstly, that this is something you personally enjoy. Studies show that those who chose exercise that they enjoy are more likely to keep exercising and make healthy food choices. My personal favourite is taking a ballet class with my excellent teacher and friends of many years. Dance also covers the second important point about exercise choice in that it should involve different types of fitness. I see many people just focusing on a cardiovascular type of exercise, neglecting strength, flexibility and neuromuscular skills. However, if ballet is not your thing, then choose your exercise types wisely for enjoyment and to cover all bases of fitness.

Nutrition

Nutrition is very similar to exercise in that food choices should cover all the nutritional requirements for the individual and not neglect the enjoyment element of eating. Trying to adhere rigidly to any type of diet that does not encompass these elements will not end well for health in the long run. I see a lot of exercisers who end up in unintentional or intentional low energy availability with associated adaptative down regulation of hormones, which can be challenging to rectify. At the other end of the spectrum, for those who maybe have favoured energy intake over energy expenditure, the type of weight reduction diets that purport to give rapid weight loss, can often be counterproductive in the long term. If it sounds too good to be true, it probably is.

Sleep

“Sleep is the chief nourisher in life’s great feast”. Although Shakespeare did not realise at the time of writing “Macbeth”, sleep certainly is the chief nourisher when it comes to hormones. Many hormone biological clocks, biochronometers, are set according to our sleep patterns with recent research showing that lack of sleep adversely impacts hormone health for men and women. So aiming for good sleep patterns is something relatively straight forward and actionable to support health.

Stress management

We often have our own personal responses to “stress”. This could be responding through an excess of behaviour at either end of spectrum: eating and/or exercising too little or too much. Especially when combined with disrupted sleep patterns, this creates the perfect storm for challenging hormone health. This vicious circle can become a repeating pattern of response to “stress”. I put “stress” in inverted commas intentionally, because “stress” is our personal interpretation of external stressors. We each have our own interpretation of events and our personal response.

For this reason, “stress” management strategies are a personal choice. Identifying your personal triggers for deviating away from balanced behaviours is an important starting point. Then noting what tends to be your typical response is to these triggers. Can you explore more helpful ways to deal with your personal triggers? Is this listening to music, reading, mediation, meeting with friends or as Hippocrates advised going for a walk? I often see people (including myself) who have tendency to over exercise when confronted with stress provoking situations. So, in this case, going for more walks wouldn’t be the best option. Make sure your strategies are personal to you.

Moderation for Optimal Health 2023

The top tip for optimal health in 2023 and beyond is to aim for moderation and balance across the key lifestyle choices of exercise, nutrition and sleep. Combined with your personal stress management strategies to avoid too much or too little of any of these behaviours, this is the surest way to health as Hippocrates advised. If you do need to modify or fine tune your choices, making small changes that you can sustain over the whole year and beyond will bring success in health.

Next steps

“Hormones, Health and Human Potential: A guide to understanding your hormones to optimise your health and performance” is available in paperback and Kindle (illustrations in colour) from Amazon and direct from Sequoia books (ship overseas)

Hormone Health advisory appointments are available

Presentations and workshops

Subclinical Ovulatory Disturbances

20 December 2022

Adaptation of menstrual cycle hormones

In my book “Hormones, Health and Human Potential”, I really enjoyed writing the chapter 5XX “Of Mice and men….and Women!” Celebrating Horme the goddess of effort, energy and action. However, there are some instances where even this formidable goddess is challenged and adaptations are required[1].

Challenges to menstrual cycle hormones

Menstrual cycle hormone choreography is as beautiful as it is complex. Generally, this repeating motif follows the score faithfully during a woman’s reproductive years. However, when external stressors become too great, then menstrual hormone fluctuations respond and adapt.

A single stressor, for example financial concerns or a life event can impact hormones and disrupt menstrual cycles on a short time scale of a handful of cycles. However, a combination of stressors can have a synergistic effect on disrupting female hormone networks. Additive stressors over a long-time scale are known as an allostatic load. A high allostatic load causes a more extensive adaptation of female hormones[2]. For example, a high level of stress from intense exercise training together with metabolic stress from insufficient food intake can result in total suppression of menstrual cycle hormone fluctuation and cessation of periods (amenorrhoea) found in relative energy deficiency in sport (RED-S).

Unbalanced behaviours

Although “hormone imbalance” is a popular phrase, this has no medical meaning. This misleading phrase does a massive disservice to Horme and to millions of years of evolution in fine-tuning the most intricate hormone network. It is not the hormone network that has become “unbalanced”, rather it is our unbalanced behaviours and/or management of external stressors that have caused hormones to adapt and change appropriately. On a positive note, understanding hormones empowers us to nurture and harness our hormones through our lifestyle choices.

Spectrum of female hormone adaptation

There is a graded response of female hormones to external stressors, depending on the number and the time scale of these. A cumulative combination of stressors results in a high allostatic load which causes amenorrhoea. Physiological causes of amenorrhoea must be excluded: pregnancy and menopause; as should medical causes such as prolactinoma and polycystic ovary syndrome (PCOS).

The type of amenorrhoea occurring as an adaptive response to a high allostatic load is functional hypothalamic amenorrhoea (FHA). This means that the neuroendocrine gatekeeper in the brain, the hypothalamus, has taken the executive decision to suspend female hormone fluctuations, in order to conserve resources to deal with the stressful situation. From an evolutionary point of view this is not the time for the high demand state of pregnancy. The good news is that being an adaptive functional response, FHA is reversible if the underlying cause is addressed.

Tip of the iceberg

Amenorrhoea is a very obvious clinical sign. Similarly, oligomenorrhoea (less than 9 periods per calendar year). However, these menstrual disruptions are just the tip of the iceberg. Less obvious are the subclinical ovulatory disturbances (rather unflatteringly referred to as SODs). This is where a women may experience a menstrual period, but the full repertoire of female hormone fluctuation has not occurred. Specifically, progesterone has not increased to levels that would be expected in the luteal phase of the cycle (second half of the cycle). If ovulation has occurred, then the remnant of the egg follicle in the ovary forms the corpus luteum which secretes progesterone. Progesterone increases resting metabolic rate and energy demand. So, keeping progesterone low is a good adaptive response to high allostatic load by keeping energy demand low.

If subclinical ovulatory disturbances are an adaptive physiological response, does this matter for a woman’s health? The answer is yes. Oestradiol (the most active form of oestrogen) often takes the limelight when it comes to positive effects on bone, soft tissue, cardiovascular, and neurological health. However, evidence is emerging that progesterone plays an equally important supporting role in these areas of health. For this reason, it is important to identify these elusive disturbances in menstrual hormone choreography.

How to detect subclinical ovulatory disturbances

As I discuss in my book in the chapter “Hormone Supermodels”, applying artificial intelligence (AI) techniques to modelling menstrual cycle hormones can help in identifying subtleties in hormone disruption. This is a fast-moving field and even since publishing on this topic, further advances are being made as more data is emerging and employment of different mathematical techniques, with reduction in the number of samples required. Monitoring temperature change as surrogate for indicating adequate progesterone levels during the luteal phase is a non invasive way of monitoring menstrual cycle hormone function. Personalisation of female hormone health is on the move. Nevertheless, the cornerstone of any medical AI focused on hormones is the medical doctor with expertise in hormones, putting the results in clinical context for the individual. Explaining and advising with practicality and empathy is vital.

This personalised medical approach is crucial when, by definition, subclinical ovulatory disturbances will require guidance on changing behaviours to reverse adaptive hormone changes. When I work with athletes and dancers experiencing hormone disruption due to imbalances in exercise and nutrition, I find it helpful in referring to recovery from a hormone injury as comparable to recovering from a physical injury. Furthermore, there can be a psychological dimension to subclinical ovulatory disturbances. How we interpret external events and think impact our hormones. For example, cognitive dietary restraint (just thinking you should eat less/be thinner) can cause subclinical ovulatory disturbances.

Nurturing Horme

Menstrual cycle hormone choreography is the most intricate and beautiful of all the hormone networks. There is a spectrum of hormone adaptation according to the degree of “stress” put on the system. The visible tip of the iceburg is menstrual disruption such as amenorrhoea and oligomenorrhoea. Less obvious, beneath the surface are subclinical ovulatory disturbances. Subclinical ovulatory disturbances are adaptive hormone responses to unbalanced behaviours and/or interpretation of external events. These subtleties of subclinical ovulatory disturbances can be challenging to identify. However, it is important to do so and provide appropriate medical support to restore these hormones for long term health.

[1] Keay N. Hormones, Health and Human Potential 2022 Sequoia books

[2] Prior J. Adaptive, reversible, hypothalamic reproductive suppression: More than functional hypothalamic amenorrhea Front. Endocrinol 2022 Sec. Reproduction
https://doi.org/10.3389/fendo.2022.893889

Hormone Knowledge is Power

3 December 2022

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

25 November 2022

“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

7 June 2021

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? 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].

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

[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

7 December 2020

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 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….”

27 October 2019

“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].

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)

24 May 2019

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].

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].

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

²Science4Perforamnce, 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?

1 March 2019

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.

LifeSeasonDay To 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

2 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