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

Health4Performance is a recently developed BASEM open access educational resource

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

What?

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

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

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

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

EnergyBalance

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

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Why?

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

How?

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

References

Heath4Performance BASEM Educational Resource

Video introduction to Health4Performance website

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

What is Dance Medicine? BJSM 2018

Identification and management of RED-S Podcast 2018

Low energy availability assessed by a sport-specific questionnaire and clinical interview indicative of bone health, endocrine profile and cycling performance in competitive male cyclists Keay, Francis, Hind. BJM Open Sport and Exercise Medicine 2018

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

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

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

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

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

 

Relative Energy Deficiency in Sport (RED-S) 2018 update

What updates are presented in the IOC consensus statement on RED-S 2018?

Prevention

Awareness is the key to prevention. Yet RED-S continues to go unrecognised. Less than 50% of clinicians, physiotherapists and coaches are reported as able to identify the components of the female athlete triad. In a survey of female exercisers in Australia, half were unaware that menstrual dysfunction impacts bone health. Note that these concerning statistics relate to the female athlete triad. Lack of awareness of RED-S in male athletes is even more marked. RED-S as a condition impacting males, as well as females, was described in the initial IOC consensus statement published in 2014. However there is evidence of the occurrence of RED-S in male athletes pre-dating this.

Identification

Identifying an athlete/dancer with RED-S is not always straight forward. In dance or sports where being light weight confers a performance or aesthetic advantage, how can a coach/teacher distinguish between athletes who have this type of physique “naturally” and those who have disordered eating and are at risk of RED-S?  Equally, low energy availability could be a result either of intentional nutrition restriction to control body weight and composition, or an unintentional consequence of not matching an increase in energy expenditure (due to increased training load), with a corresponding increase in energy intake.

Performance effects

Performance is paramount to any athlete or dancer. Apart from physical ability, being driven and determined are important characteristics to achieve success. If weight loss is perceived as achieving a performance advantage, then this can become a competitive goal in its own right: in terms of the individual and amongst teammates. This underlies the interactive effect of psychological factors in the development and progression in the severity of RED-S.

There is both theoretical and practical evidence that short term low energy availability impairs athletic performance as the body is less able to undertake high quality sessions and benefit from the physiological adaptations to exercise. Within day energy deficits have been shown to have adverse effects in both male and female athletes in terms of impact on oestradiol/testosterone and cortisol concentrations. Failure to refuel with carbohydrate and protein promptly after a training session in male runners has been shown to have an adverse effect on bone turnover markers.

To underline the adverse performance effect of low energy availability, a recent study demonstrated that in female athletes, those with functional hypothalamic amenorrhea displayed decreased neuromuscular performance compared to their eumenorrhoeic counterparts. This adverse effect on performance is of particular concern where such skills are crucial in precisely those sports/dance where RED-S is most prevalent. Clearly this situation puts such athletes at increased injury risk, especially if associated with adverse bone mineral density (BMD) due to low energy availability.

Ironically the long term consequences of low energy availability produce adverse effects on body composition: increased fat/lean and reduction in BMD. In other words, the precise opposite effects of what an energy restricted athlete is trying to achieve. In terms of bone health, the lumbar spine is most sensitive to nutrition/endocrine factors (apart from rowers where mechanical loading can attenuate BMD loss at this site in RED-S). Suboptimal BMD is associated with an increased risk of bone injury and therefore impaired performance.

REDs
Keay BJSM 2017

Medical Assessment

Low energy availability is the fundamental issue driving the multi-system dysfunction in the endocrine, metabolic, haematological, cardiovascular, gastrointestinal, immunological and psychological systems in RED-S. However, there are practical issues with directly quantifying energy availability as this is subject to the inaccuracies of reliably measuring energy intake and output. Endocrine and metabolic markers have been shown to more objective indicators of low energy availability, which in turn are correlated to performance outcomes such as bone stress injury in male and female athletes. In the case of female athletes there is an obvious clinical indicator of sufficient energy availability: menstrual cycles. As there is no such obvious clinical sign in male athletes is this why RED-S is less frequently recognised? In both female and male athletes there is some degree of clinical variation: there is no absolute threshold cut off with a set temporal component of low energy availability resulting in amenorrhoea or low testosterone in males. Therefore the IOC recommends that individual clinical evaluation include discussion of nutrition attitudes and practices, combined with menstrual history for females and endocrine markers for male and female athletes will give a very clear indication if an athlete is at risk of/has RED-S.

 

Management

RED-S is a diagnosis of exclusion. Once medical conditions per se have been excluded, RED-S presents a multi-system dysfunction caused by a disrupted periodisation of nutrition/training/recovery. For an athlete the motivation to address these imbalances is to be in a position reach their full athletic potential. This attainment is compromised in RED-S.

Pharmacological interventions are not recommended as first line management in amenorrhoeic athletes. Oral contraception (OCP) masks amenorrhoea with withdrawal bleeds. OCP does not support bone health and indeed may exacerbate bone loss by suppressing further IGF-1. Although transdermal oestrogen, combined with cyclic progesterone does not down regulate IGF-1, nevertheless any hormonal intervention cannot be a long term solution, as bone loss will continue if energy availability is not addressed as a priority.

What next?

The IOC statement suggests further research should include studies with allocation of athletes to intervention groups, with assessment of effects over a substantial time period. Currently a study of competitive male road cyclists over a training/competition season is being undertaken to evaluate the effects of nutrition advice and off bike skeletal loading exercise. Crucially outcome measures will not only be based on bone health and endocrine markers, but measures of performance in terms of power production and race results.

To raise awareness and build support pathways as recommended in the IOC statement,  this is an on going process which requires communication between athlete/dancers, coaches/teachers, parents and healthcare professionals both medical and non medical working with male and female athletes.

References

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

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

Male Athletes: the Bare Bones of Cyclists

Addiction to Exercise – what distinguishes a healthy level of commitment from exercise addiction? BJSM 2017

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

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

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

Reduced Neuromuscular Performance in Amenorrheic Elite Endurance Athletes Medicine & Science in Sports & Exercise. 49(12):2478–2485, DEC 2017

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

Cyclists: Make No Bones About It BJSM 2018

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

Part 2: Health, Hormones and Human Performance take centre stage BJSM 2018

Cyclists: How to Support Bone Health?

Healthy Hormones BASEM 2018

 

 

 

Health, Hormones and Human Performance Part 1

How hormones determine health and athletic performance

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

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

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

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

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

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Triumvirate of external factors impacting Endocrine system and hence performance

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

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

References

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

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

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

 

 

 

Male Cyclists: Bones, Body composition, Nutrition, Performance

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There has been much recent coverage regarding female runners suffering with health and performance issues due to relative energy deficiency in sports (RED-S). What about male athletes? A recent article about male cyclists who explained how they developed RED-S, did not receive as sympathetic a response as articles concerning female athletes. Yet multiple Endocrine network disruption in RED-S, associated with suboptimal health and performance, is equally applicable to male and female athletes.

Although competitive road cycling is excellent for cardiovascular (CV) fitness, why are male cyclists at particular risk of impaired bone health and RED-S? Cycling is a non-weight bearing type of exercise, as is swimming, so does not provide much osteogenic (bone building) stimulus. The additional element in road cycling is that, in the short term, low body weight, with associated low body fat, confers a performance advantage. However this can lead to restrictive nutrition and RED-S, that have adverse effects on health and performance, over the longer term.

A recent study looking at bone acquisition in adolescent males found that bone mass, microarchitecture and makers of bone formation were more favourable in footballers compared with cyclists and swimmers. Swimmers had the lowest Vitamin D, presumably as this is generally an indoor sport (unless you live in Australia where outdoor 50m pools abound). Another study found reduction in femoral neck bone mineral accumulation in adolescent male cyclists compared against increases over the same time frame seen in controls.

What about adult male road cyclists? When runners and cyclists were matched for age and body weight, there were no significant differences in hormone or nutrition status, yet cyclists were 7 times more likely to have osteopenia of the lumbar spine than runners. Similar results were found in another study where competitive male road cyclists were found to have reduced lumbar spine bone mineral density (BMD) for age, despite normal levels of testosterone and insulin-like growth factor 1 (IGF1), although intriguingly an inverse correlation with lumbar spine BMD and IGF1 was found. It appears that the biomechanical stress patterns on the spine in cycling are not oesteogenic in nature, which contrasts with rowing where, although also seated, the biomechanical load exerted through the spine does provide an osteogenic effect.

In addition to the non-load bearing nature of cycling on the skeleton, restrictive nutrition can contribute to suboptimal bone health. Reducing energy availability by restricting energy intake whilst increasing training load can be a strategy, especially during pre-season training to reduce body weight and body fat. Essentially, cycling up a steep incline demands less power through the pedals if your body weight is low. Nevertheless, reducing energy availability runs the risk of developing RED-S, associated Endocrine dysfunction and suboptimal bone health, on top of the non-beneficial mechanical osteogenic effect of cycling. On a practical note, with long training rides in the saddle it can be physically and practically difficult to fuel optimally. Recent research in female athletes shows that within day energy deficits magnify hormonal disruption. Could this be a factor in male cyclists where consistent fuelling is either actively avoided and/or practically difficult?

The psychological element of disordered eating has been described amongst elite male cyclists. Male cyclists, in particular, collect many metrics associated with training and racing which could be a manifestation of a drive to perfectionism. Determination and attention to detail are laudable qualities for athletes, but there is a fine line when the balance swings to behaviours and attitudes that can be detrimental to health and performance. Even starting off with good intentions can lead to problems as seen with the growing emergence of orthorexia: “clean eating”, which, ironically, becomes detrimental to health and performance with exclusion of food groups such as carbohydrates.

Exclusively practising a non weight bearing sport such as cycling although great for CV fitness, is not so good for bone health. Does this matter? Potentially injury is more likely in bike spills, which occur both in training and competition even for the most experienced bike handler. Combined with the drive for low body weight in competitive road cycling, health and performance issues can be compounded with RED-S. What are the solutions for the cyclist to support favourable body composition and bone health, which ultimately also optimises performance? A further planned study, following a current pilot study of competitive road cyclists, aims to investigate the potential beneficial effects of strength and conditioning to load the skeleton combined with a review of nutrition. See details of next study to see if you wish to participate.

For more discussion on the Endocrine aspects of Sports and Exercise Science and Medicine, BASEM Spring conference 22 March 

References

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

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

Too healthy to ride? How clean living could slow you down Cycling Weekly 2017

Body Composition for Health and Sports Performance

Longitudinal Adaptations of Bone Mass, Geometry, and Metabolism in Adolescent Male Athletes: The PRO-BONE Study JBMR 2017

Bone Related Health Status in Adolescent Cyclists Plos 2011

Participation in road cycling vs running is associated with lower bone mineral density in men Metabolism 2008

Evaluation of the Bone Status in High-Level Cyclists Journal of Clinical Densitometry 2012

Effect of exercise training programme on bone mineral density in novice college rowers BJSM 1995

Energy Intake and Energy Expenditure of Elite Cyclists During Preseason Training Int J Sports Med 2005
Kings and Queens of the Mountains Science4Performance 2017

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

Perfectionism and Risk for Disordered Eating among Young French Male Cyclists of High Performance Perceptual and Motor Skills 2004

Kings and Queens of the Mountains Science4Performance 2017

Addiction to Exercise – what distinguishes a healthy level of commitment from exercise addiction? BJSM 2017

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

 

 

 

 

 

Conferences in Sport/Dance, Exercise Science and Medicine 2018

Conferences for the New Year:

BAsem2018_SpringConf_BJSM

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

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

CPD points awarded from Faculty of Sports and Exercise Medicine FSEM

BASES British Association of Sport and Exercise Sciences CPD awarded

British Journal of Sports Medicine Quality International Education Approved

CPD points from Royal College of Physicians

CPD from REP-S

 

FSEM_CPD_AwardScreen Shot 2017-12-12 at 14.47.15fullsizeoutput_2b2fullsizeoutput_2b6

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

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

· Key role of Sports Endocrinology in health and performance

· Effects of exercise modalities on body composition and bone health

· Machine learning in interpreting biochemical & metabolomic patterns

· Endocrine & metabolic markers in assessing health & training status

· Gut metabolism in supporting health and performance

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

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

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

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

 

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

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

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Body Composition for Health and Sports Performance

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Body Composition from DEXA scan

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

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

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

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

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

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

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

BAsem2018_SpringConf_BJSMFSEM_CPD_AwardScreen Shot 2017-12-12 at 14.47.15

References

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

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

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

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

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

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

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

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

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

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

Kings and Queens of the Mountains Science4Performance

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

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

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

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

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

 

 

 

Lifestyle Choices

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Lifestyle Choices: Exercise, Nutrition, Sleep

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

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

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

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

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

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

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

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

 

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

BAsem2018_SpringConf_BJSM

References

Presentations

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

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

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

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

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

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

BASEM/FSEM Annual Conference 2017, Assembly Rooms, Bath

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

The Effect of Postexercise Carbohydrate and Protein Ingestion on Bone Metabolism Translational Journal of the American College of Sports Medicine October 2107

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

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

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

Optimising Health and Athletic Performance

FactorsWordCloud4

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

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

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

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

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

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

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

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

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

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

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

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

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

Presentations

References

Athletic Fatigue: Part 2 Dr N. Keay

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

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

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

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

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

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

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

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

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

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

Metabolic and Endocrine System Networks Dr N. Keay

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

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

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

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

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

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

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

Sleep Duration and Risk of Type 2 Diabetes Paediatrics 2017

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

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

Immunity around the clock Science

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

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

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

 

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

EnergyBalance

Introduction Relative Energy Deficiency in Sport (RED-S) has evolved from the previously described Female Athlete Triad (menstrual dysfunction, disordered eating and decreased bone mineral density). The reason for the development of this clinical model of RED-S is that it has become apparent that low energy availability, ie not eating enough calories to support the combined energy demands of health and training, has more widespread adverse impacts on health and consequently performance in athletes and dancers than previously recognised. Furthermore, the RED-S model includes both male and female athletes– so if you are a male athlete, please do not stop reading! Low energy availability can impact male and female exercises of all levels and of all ages. Young developing athletes can be at particular risk of RED-S as this represents a time of growth and development, which entails many nutritional demands, in addition to those to support training. This represents a time to set up the template for health into adulthood.

Why does RED-S occur? RED-S is particularly prevalent in sports where low body weight confers a performance advantage or for aesthetic reasons. For example: long distance running, triathlon, gymnastics, dance and cycle road racing. However, RED-S could also occur not as an intentional strategy to control body weight, but rather during cycles of increased training load where periodised nutrition has not been synchronised with the increased demand on the body.

What is RED-S? Fundamentally there is a mismatch between food intake (in terms of energy and micronutrients) and the demand for nutrition required to cover expenditure, both of exercise training and for basic “housekeeping” tasks in the body to maintain health. If there is insufficient energy availability, then the body switches into an energy saving mode. This “go slow” mode has implications for hormone production and metabolic processes, which impacts all systems throughout the body. The reason why RED-S was originally described as the Female Athlete Triad is that in women the “energy saving mode” involves menstrual periods being switched off: a pretty obvious external sign as all women of child bearing age should have periods (apart from when pregnant). Low oestrogen levels have an adverse effect on bone health, resulting in decrease in bone mineral density. This effectively renders young women at increased risk of both soft tissue and bone injury, as seen in post-menopausal women. As described in the IOC statement published 2014 and updated 2018 in British Journal of Sports Medicine , the Female Athlete Triad is now recognised as just the tip of the iceberg. Disruption of hormone levels does not only adversely impact menstrual periods and bone health. There are knock on effects impacting the immune system, cardiovascular system, muscles, nervous system, gut health and the list goes on. Importantly, it is recognised that this situation is also seen in male athletes: low energy availability resulting in adverse health and performance consequences. Although exercise/dance is known to have many beneficial effects on health, all these beneficial effects are negated by low energy availability. For example, whether or not a sport is weight bearing, which traditionally improves bone health, in RED-S the predominant effect of disrupted hormones is to decrease bone density, leading to increased fracture risk.

Male cyclists Road cyclists are doubly at risk of the detrimental effects of RED-S on bone health. Performing a non-weight bearing form of exercise deprives the skeleton of the positive effect of mechanical skeletal loading on bone health. Furthermore being low body weight is a performance advantage for road cyclists when it comes to riding up hills/mountains in order to produce higher Watts/Kg over 60 minutes (60 minute functional threshold power FTP). This puts cyclists at risk of developing low energy availability, endocrine dysfunction and consequent impairment of bone health. In weight bearing sport the warning sign of suboptimal bone health if often stress fracture. This will be absent in cyclists. Hence low energy availability may go unrecognised until a bike fall results in serious fracture and indeed fractures appears as the most common type of injury amongst cyclists. Furthermore, the lumbar spine is recognised as the site most susceptible to endocrine dysfunction in RED-S. Vertebral fracture is recorded as the type of fracture in cyclists requiring the longest time off the bike. In a recent study, it was found that the factor most indicative of 60 minute FTP, was training load and NOT low body fat. Furthermore, training in low energy availability state will not result in the expected 60 minute FTP performance. So far more effective to train with sufficient nutrition on board, rather than restricting intake which will render training less effective.

What is the significance of RED-S? Do these effects of RED-S matter? Yes: there is a detrimental effect on not only health, but on all elements of sports performance. These include an inability to improve as expected in response to training and increased risk of injury. In the long-term there are potential implications for health with inability to reach peak bone mass for young athletes and at the other end of the scale, irreversible bone loss being seen in retired athletes.

Here is a summary of the potential impact of RED-S:

• Endocrine dysfunction: decreased training response

• Metabolic disruption: decreased endurance performance

• Bone health: increased risk bone stress injuries

• Decreased functional immunity: prone to infection

• Gut malfunction: impaired absorption of nutrients

• Decreased neuromuscular co-ordination: injury risk

• Psychological impact: inability to recognise risk developing RED-S

As you can see, these adverse effects are all relevant to performance in endurance sport.

What to do if you are concerned you may have RED-S?

Health Considerations:

• Women: even if your adult weight is steady, if you are a female athlete of reproductive age whose periods have stopped, then do not ignore this! In the first instance, you need to exclude any other causes (for example polycystic ovary syndrome and other hormone issues) in conjunction with your doctor. Then take a look at how you are eating in line with your training load – see the nutritional considerations section below.

• Men: if you are a male athlete struggling to improve sport performance, then review both your training load and your periodised nutrition and recovery. If the cause is RED-S then do not wait until your sport performance drops or you get injured before taking action. You may also want to consider having your testosterone levels measured to check that these are in the normal range.

Nutritional Considerations: From colleague Jo Scott-Dalgleish BSc (Hons), mBANT, CNHC

It is important to consider whether the energy deficiency that you are experiencing is intentional or unintentional.

Intentional: you may be deliberately restricting your calorie intake to lose weight and body fat, although you are already a healthy weight, as you believe this will improve your power-to-weight ratio or run speed.

  • If you are trying to lose weight – or anxious about gaining weight – and experiencing issues with hormones (such as missing your periods or not experiencing morning erections) or bone health (such as getting a stress fracture) or finding that your performance is declining rather than improving, it may be time to seek support.
  • This is particularly important if your eating patterns have become disordered, eg exclusion of multiple food groups, binge eating and/or purging, or deliberately avoiding social situations around food.
  • Please visit the resources section of an excellent campaign website that has been put together to help athletes talk more openly about their experiences with food, disordered eating and RED-S and find help: https://trainbrave.org/resources/.
  • Another great resource to learn more about RED-S and how it can adversely affect your health is http://health4performance.co.uk/athlete-dancer/

Unintentional: eating fewer calories than your body needs when you are training hard is common in endurance athletes and often not deliberate.

  • You may not yet be experiencing the symptoms of RED-S outlined as above, but you are greatly at risk of doing so if you continue to under-eat relative to your training over a period of months or years.
  • You do not need to be losing weight to be energy deficient, as your body’s metabolism adjusts to a lower intake but compromises on other functions while your weight stays the same. For example, you may experience constipation or bloating due to slowed digestive function. Here are some tips to help you meet your energy needs.

Here are some tips to help you to better manage your energy intake if you are at unintentional risk of RED-S.

  • Track your food intake vs energy expenditure for a short period. Use My Fitness Pal or a similar app to track these daily over the course of week. On any day when you train, if you are consuming fewer than 2500 calories as a male endurance athlete and 2000 calories as a female endurance athlete after taking your energy expenditure through training into account, your intake is likely to be inadequate as these are the guidelines for the general population. Use this data to learn more about appropriate food choices and serving sizes and introduce some changes to increase your intake in line with your training load. But I do not suggest using apps like these on a long-term basis as they may encourage an unhealthy obsession with your food intake.
    • Periodise your carbohydrate intake in line with your training. Increase your intake of starches and sugars (including vegetables and fruit) on your heavier training days. A low daily carbohydrate intake might be in the range of 2-4 g/kg of body weight. This is OK for lower volume training days but should be increased to 5-8 g/kg when training for 2-3 hours or more in a single day. This would include use of sports nutrition products like bars, gels and sports drinks during training. Again, use an app like My Fitness Pal for a week to help you assess your carbohydrate intake.
  • Pay attention to your recovery nutrition. Consuming 15-25g of protein and 45-75g of carbohydrate in the hour after exercise, whether as a snack or as part of a meal will help you to each your energy intake goals, restock your glycogen stores for your next training session and protect lean muscle mass.
  • Avoid excluding foods, whole food groups or following ‘fad diets’. Unless you have a genuine allergy or a diagnosed medical condition such as coeliac disease or lactose intolerance. Or you have been advised to avoid certain foods by a dietician or other well-qualified nutrition practitioner to help manage a health condition such as Irritable Bowel Syndrome. If you are vegetarian or vegan, see my blog here [link to https://www.endurancesportsnutritionist.co.uk/blog/vegan-diets-guide-endurance-athlete/] for tips on ensuring a well-balanced approach.
  • Focus on nutrient density. Make good quality food choices to help you get enough vitamins and minerals as well as carbohydrates, protein, fat and fibre. Try to eat fresh, minimally processed foods rather than too much packaged food, including 3-5 servings of vegetables and 2-3 pieces of fresh fruit each day.

If you are experiencing relative energy deficiency, avoid following approaches like fasted training, where the training benefits are likely to be outweighed by the pitfalls of inadequate calorie intake. I also suggest avoiding low carb-high fat diets (LCHF) due to potential adverse effects on thyroid hormones, particularly T3, which may slow down metabolism and impact on performance. It can also be difficult to obtain adequate calories from these types of diets due to the near exclusion of a whole food group – which is why they may be very effective for weight loss in people who are overweight – and the lack of carbohydrate may harm performance through a loss of metabolic flexibility, ie ability to utilise carbohydrate as fuel when required for high intensity efforts.

Conferences in Sport/Dance, Exercise Science and Medicine 2018

References

Raising Awareness of RED-S in Male and Female Athletes and Dancers Dr N. Keay, British Journal of Sport Medicine 2018

2018 UPDATE: Relative Energy Deficiency in Sport (RED-S) Dr N. Keay, British Journal of Sport Medicine 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 N, Francis G, Hind K. BMJ Open Sport & Exercise Medicine 2018

Optimal health: including female athletes! Part 1 Bones Dr N. Keay, British Journal of Sport Medicine 2017

Optimal health: including male athletes! Part 2 Relative Energy Deficiency in sports Dr N. Keay, British Journal of Sport Medicine 2017

Optimal Health: Especially Young Athletes! Part 3 – Consequences of Relative Energy Deficiency in Sports Dr N. Keay, British Association of Sport and Exercise Medicine 2017

Mechanisms for optimal health…for all athletes! Dr N. Keay, British Journal of Sport Medicine 2017

The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S) British Journal of Sports Medicine 2014

Nutritional considerations for vegetarian endurance athletes Jo Scott-Dalgleish, Endurance Sports Nutrition 2017

 

Athletic Fatigue: Part 2

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

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

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

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

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

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

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

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

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

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

Presentations

References

Athletic Fatigue: Part 1

Endocrine system: balance and interplay in response to exercise training

Temporal considerations in Endocrine/Metabolic interactions Part 1

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

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

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

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

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

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

Strava Fitness and Freshness Science4Performance 2017

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

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