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

 

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

 

 

 

Conferences in Sport/Dance, Exercise Science and Medicine 2018

Conferences for the New Year:

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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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