recovery – Dr Nicky Keay

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

What is Dance Medicine?

22 July 2018

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

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

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

BalletDials — Integrated periodisation of training, nutrition and recovery support perforamnce

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

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

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

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

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

References

Presentations

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

Fit to Dance 2 Dance UK

One Dance

Your body your risk. Dance UK

Fit but fragile. National Osteoporosis Society

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

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

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

Dancing through Adolescence Dr N Keay BJSM

Healthy Hormones Dr N Keay BASEM 2018

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

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

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

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

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

24 May 2018

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.

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 2

8 April 2018

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 the recent BASEM spring conference set out to demonstrate. The previous blog described functional disruption of Endocrine networks caused by non-integrated periodisation of the three key lifestyle factors of exercise/training, nutrition and recovery/sleep, can lead to adverse effects on health and athletic performance.

Integrated periodisation of exercise, nutrition, recovery for optimisation of health and performance (Keay BJSM 2017)

Grace, aesthetic line and ethereal quality belie the athletic prowess required in ballet. What are the Endocrine, metabolic and bone health consequences for this unique group of athletes? Dr Roger Wolman (Medical Advisor to National Institute for Dance Medicine and Science) returned to the important topic of insufficient energy availability in sport/dance where being lightweight confers a performance advantage, resulting in dysfunction in multiple endocrine axes. Dr Wolman discussed his recent research studies in dancers revealing an intriguing synergistic action between oestrogen and vitamin D, which is itself a steroid hormone. Evidence was presented to demonstrate how being replete in vitamin D has beneficial effects on bone, immunity and muscle function. Thus it is key in preventing injury and supporting health in athletes, with particular relevance in premenarchal and postmenopausal women, who are in relative oestrogen deficient states. This presentation will certainly change my clinical practice and, I am sure, that of many in the audience, in ensuring that athletes/patients are vitamin D replete. This may have to be achieved in the form of strategic use of sports informed vitamin D supplementation, given that even walking naked for 5 hours a day outside during UK winter, would not stimulate enough vitamin D production. Therefore, to the relief of many in the audience, Dr Wolman did not recommend this strategy.

Dr Kate Ackerman (member of RED-S IOC working group) explained why we should all tap into our inner endocrinologist. Sport and Exercise Medicine (SEM) goes far beyond diagnosing and treating injury. Is there any underlying endocrine cause for suboptimal health, performance or injury? Be this an endocrine diagnosis that should not be missed, or a functional endocrine dysfunction due to relative energy deficiency in sports (RED-S). Dr Ackerman explained the importance of the multidisciplinary team in both identifying and supporting an athlete experiencing the consequences of RED-S. New research from Dr Ackerman’s group was presented indicating the effects of RED-S on both health and athletic performance.

Females now have combative roles alongside their male counterparts. What are the implications of this type of intensive exercise training? Dr Julie Greaves (Research Director of the ministerial women in ground close combat research programme) presented insightful research revealing that differences in the geometry of bone in men and women can predispose towards bone stress injury and account for increased incidence in this type of injury in female recruits.

Lunchtime discussion and debate was focused on the determinants of athletic gender, lead by Dr Joanna Harper and Professor Yannis Pitsiladis (International Federation of Sports Medicine). Rather than relying on genetic sex, testosterone concentration was proposed as the criteria for determining whether an athlete competes in male or female events. That testosterone concentration is linked to performance was demonstrated in a study published last year in the BMJ where female athletes in the upper tertile of testosterone were shown to have a performance advantage in certain strength based track and field disciplines. This could potentially be an objective, functional metric used to determine sporting categories for transgender and intersex athletes. The only current uncertainty is how previously high levels of testosterone seen in male, or intersex athletes would have already had an impact on physiology, if this athlete then wished to compete as female and therefore lower testosterone levels with medication.

Nutrition is a key component in optimising health and performance through the Endocrine system. Dr Sophie Killer (English Institute of Sport) explained practical implications for athletes. In a study stimulating a training camp, there were distinct differences between athletes on different regimes of carbohydrate intake in terms of endocrine markers and psychological effects. Those athletes on restricted carbohydrate intake fared worse.

Insulin insensitivity is the underlying pathological process in developing type 2 diabetes mellitus (T2DM) and metabolic syndrome. What is the crucial lifestyle intervention to combat this? Dr Richard Bracken (Swansea University) presented the science behind why and how exercise improves blood glucose control and therefore ultimately risk of developing the macro and microvascular complications of diabetes. T2DM is an increasing health issue in the population, which has to be addressed beyond reaching for the prescription pad for medication. Dr Bracken outlined some effective strategies to encourage the reluctant exerciser to become more active. Having worked myself in NHS diabetic clinics over many years, this was a key presentation at the conference to demonstrate that SEM goes far beyond a relatively small group of elite athletes. Highlighting the crucial role of physical activity in supporting health and performance through optimisation of endocrine networks: uniting the elite athlete and the reluctant exerciser.

One road to Rome — One Road to Rome (BJSM Keay 2017)

Motivate2Move initiative aims to shift the emphasis from treating disease, to preventing disease. Dr Brian Johnson presented the excellent resource for healthcare professionals to encourage, motivate and educate patients in order to consider exercise as an effective and enjoyable way to improve health.

Hormones play a key role in health and human performance, applicable to all levels of exerciser from reluctant exerciser to elite athlete.

FactorsWordCloud4

References

Health, Hormones and Human Performance BASEM Spring Conference

Video of presentation on Endocrine and Metabolic aspects of Sport and Exercise Medicine from BASEM Spring Conference

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

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

One road to Rome: Exercise Keay, BJSM 2017

Healthy Hormones

8 April 2018

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

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

webmd_rm_photo_of_porous_bones — Bone health can be at risk if hormone status not optimal

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

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

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

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

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

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

Screen Shot 2017-05-20 at 19.16.28 — Potential Performance effects of RED-S (IOC statement BJSM 2014)

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

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

Key Points

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

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

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

Check points

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

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

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

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

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

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

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

References

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

Optimal health: including female athletes! Part 1 BJSM 2017

Optimal health: including male athletes! Part 2 BJSM 2017

Optimal Health: Especially Young Athletes! Part 3 BASEM 2017

Optimal Health: For All Athletes! Part 4 BASEM 2017

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

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

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

Health, Hormones and Human Performance Part 1

2 April 2018

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.

Triumvirate of external factors impacting Endocrine system and hence performance

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

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

References

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

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

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

Cyclists: Make No Bones About It

20 February 2018

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

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

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

fullsizeoutput_2b8 — Site Specific Effects on Bone Mineral Density

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

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

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

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

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

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

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

References

Male Cyclists: bones, body composition, nutrition, performance

Cycling and bone health: a systematic review BMC Medicine 2012

Male Athletes: the Bare Bones of Cyclists

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

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

Kings and Queens of the Mountains Science4Perforamnce

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

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

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

Male Athletes: the Bare Bones of Cyclists

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

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

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

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

Male Athletes: the Bare Bones of Cyclists

16 February 2018

Chris Boardman is an Olympic gold medal winner and world record breaking cyclist. However, he explains in his biography that he retired in his early thirties with weak bones and low testosterone. At the time he was treated with medication aimed at improving his bone strength, but this severely impacted his performance on the bike.

What was the cause of this superlative male athlete’s unhealthy condition that ultimately lead to his retirement? Is this still an issue for male cyclists today? Is it limited to elite professional riders?

Periodisation of key training factors support the Endocrine system to optimise performance

In 2014 the IOC published a description of relative energy deficiency in sports (RED-S), where nutrition intake is insufficient to cover training demands and the basic “housekeeping” activities of the body. This induces an energy-saving mode that impacts health and therefore athletic performance. The female athlete triad had been previously described as the combination of disordered eating, menstrual disruption and impaired bone health. RED-S goes beyond the female athlete triad to include a broader range of impacts on systems other than just the bones and female hormone production. Significantly RED-S includes male athletes. Today, Chris Boardman would be diagnosed with RED-S.

Has this new information improved the identification and support of male athletes at risk of RED-S? In a recent pilot study, 5 out of 10 competitive amateur riders (Category 2 and above) were in the lowest age-matched percentile of body fat and 9 out 10 where in the lowest 6% relative to the population of similar age. Significantly, 7 out of 10 riders had below-average for age bone mineral density (BMD) in the lumbar spine, with two males having bone densities that would be low for an 85 year old.

Why is poor bone health a particular risk for competitive male cyclists? Depending on the type of exercise, beneficial adaptations include mechanical strengthening of specific parts of the skeletal system. For example, assuming good nutrition, runners tend to have strong hips, whereas rowers have more robust spines in terms of BMD and bone microarchitecture. Conversely the non-weight-bearing nature of cycling and the generally lower level of upper-body musculature reduce the mechanical loading forces though the spine: low osteogenic (bone building) stimuli. Although similar to swimming, in the sense that body weight is supported in the water, the major difference between these two forms of exercise is that in cycling, particularly for climbing, low body mass confers a performance advantage. This brings in the additional factor for bone health of potential inadequacies in nutrition and therefore consequences on hormone production.

An optimal balance of training, nutrition and recovery drives beneficial adaptations to exercise throughout the body. The body’s Endocrine system releases hormones that stimulate positive changes, such as the process of improving the efficiency of delivering and utilising oxygen and nutrients to exercising tissues, including the skeletal system. Any imbalances in periodisation between the three inputs of training, nutrition and recovery will compromise health and athletic performance.

Cyclists are at particular risk of insufficient fuelling. This may be an intentional attempt to maintain low body weight, which can lead to healthy eating becoming an unhealthy orthorexic pattern, where vital food groups for endurance sport, such as carbohydrates are excluded. There is also a practical element to fuelling adequately during long rides and refuelling afterwards. Consistency of nutrition throughout the day has been highlighted in a recent study of male endurance athletes where although an average 24 hour intake may be sufficient, if there are any significant deficits during this time, then this is reflected in increased adverse impact on catabolic Endocrine makers. In another study of male athletes if refuelling with carbohydrate and protein after training did not occur promptly, this lead to an increase in bone resorption over formation markers.

Recovery is an essential part of a training schedule, because the adaptations to exercise occur during rest. Sleep, in particular, is a major stimulus for growth hormone release, which drives positive adaptive changes in terms of body composition and bone turnover. Conversely, insufficient recovery time due to a packed schedule of training and work, places extra stresses on the Endocrine system. Getting to bed half an hour earlier than usual every day quickly adds up to an extra night’s sleep.

Does it matter if some areas of the skeleton are weaker than others? Yes, because this increases your risk of fracture, not just if you come off your bike, but also with relatively low force impacts. In the case of runners and triathletes, bone stress injuries are more likely to occur as an early warning sign of impaired bone health due to RED-S. Since low impact forces are absent in cycling, it may take a crash to reveal the strength of a rider’s bones. Studying the list of injuries in elite cyclists there are many fractures, with longer recovery time for vertebral fractures. So potentially cyclists can develop more severe bone health issues than other athletes, before becoming aware of the situation.

If you are a male cyclist, what can you do to prevent issues of bone health and risk of developing RED-S and suboptimal performance on the bike? Watch this space! A study is planned to investigate practical and effective strategies to optimise health and performance on the bike. In meantime there will be more discussion on “Health, Hormones and Human Performance” at the BASEM conference 22 March. All welcome, including athletes and coaches, alongside healthcare professional working with athletes.

References

Mechanisms for optimal health…for all athletes! BJSM 2017

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

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

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

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

Within-day Energy Deficiency and Metabolic Perturbation in Male Endurance Athletes International Journal of Sport Nutrition and Exercise Metabolism 2018

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

Sleep for health and sports performance BJSM 2017

Conferences in Sport/Dance, Exercise Science and Medicine 2018

12 December 2017

Conferences for the New Year:

BAsem2018_SpringConf_BJSM

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

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

CPD points awarded from Faculty of Sports and Exercise Medicine FSEM

BASES British Association of Sport and Exercise Sciences CPD awarded

British Journal of Sports Medicine Quality International Education Approved

CPD points from Royal College of Physicians

CPD from REP-S

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

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

· Key role of Sports Endocrinology in health and performance

· Effects of exercise modalities on body composition and bone health

· Machine learning in interpreting biochemical & metabolomic patterns

· Endocrine & metabolic markers in assessing health & training status

· Gut metabolism in supporting health and performance

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

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

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

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

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

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

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Health and Performance during Lifespan: latest research

16 November 2017

LifeSeasonDay

Your lifespan depends on genetic and key lifestyle choices

Lifespan is dependent on a range of genetic factors combined with lifestyle choices. For example a recent study reported that an increase in one body mass index unit reduced lifespan by 7 months, whilst 1 year of education increased lifespan by 11 months. Physical activity was shown to be a particularly important lifestyle factor through its action on preventing age-related telomere shortening and thus reducing of cellular ageing by 9 years. Nevertheless, even though males and females have essentially identical genomes, genetic expression differs. This results in different disease susceptibilities and evolutionary selection pressures. More studies involving female participants are required!

Circadian clock

Much evidence is emerging about the importance of paying respect to our internal biological clocks when considering the timing of lifestyle factors such as eating, activity and sleep. For example intermittent fasting, especially during the night, and time restricted eating during the day enables metabolic flexibility. In other words, eating within a daylight time window will support favourable metabolism and body composition. No midnight snacks!

For athletes, even more care needs be given to timing of nutrition to support athletic performance. In the short term there is evidence that rapid refuelling after training with a combination of carbohydrate and protein favours a positive balance of bone turnover that supports bone health and prevents injury in the longer term. Periodised nutrition over a training season, integrated with exercise and recovery, is important in order to benefit from training adaptations and optimise athletic performance.

Protein intake in athletes and non athletes

Recovering from injury can be a frustrating time and some athletes may be tempted to reduce food intake to compensate for reduced training. However, recommendations are to maintain and even increase protein consumption to prevent a loss of lean mass and disruption of metabolic signalling. In the case of combined lifestyle interventions, such as nutrition and exercise aimed at reducing body weight, these should be directed at improving body composition. Adequate protein intake alongside exercise will maintain lean mass in order to minimise the risk of sarcopenia and associated bone loss which can occur during hypocaloric regimes. Good protein intake is important for bone health to support bone mineral density and reduce the risk of osteoporosis and fracture.

Adolescent Athlete

In the young athlete, integrated periodisation of training, nutrition and recovery is of particular importance, not only to support health and performance, but as an injury prevention strategy. Sufficient sleep and nutrition to match training demands are key.

Differences between circadian phenotype and performance in athletes

For everyone, whether athlete or reluctant exerciser, balancing and timing key lifestyle choices of exercise, nutrition and sleep are key for optimising health and performance. However there are individual differences when it comes to the best time for athletes to perform, according to circadian phenotype/chronotype. In other words personal biological clocks which run on biological time. An individual’s performance can vary by as much as 26% depending on the time of day relative to one’s entrained waking time.

Later in Life

Ageing can be can be confused with loss of fitness and ability to perform activities of daily living. Although a degree of loss of fitness does occur with increasing age, this can be prevented to a certain degree and certainly delayed with physical activity. Exercise attenuates sarcopenia, which supports bone mineral density with the added benefit of improved proprioception, helping to reduce risk of falls and potential fracture; not to mention the psychological benefits of exercise.

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

BAsem2018_SpringConf_BJSM