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

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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

Successful Ageing

As I am discovering, ageing is an inevitable process. However what can you do to keep as healthy as possible in order to get the most out of life?

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If you are a Masters athlete, you will know that moving into these age groups means it is advisable to change training emphasis in order to prevent injury and compete successfully. As discussed at the recent conference Royal Society of Medicine on Sports Injuries and Sports Orthopaedics, during the session on “The Ageing Athlete”, older athletes need a longer dynamic warm up with controlled mobilisation and muscle activation, together with strength and conditioning sessions to prevent injury. Moving into next age group every five years gives the opportunity to assess and modify training accordingly.

Childhood development has an impact on long term adult health. Essentially the most rapid changes and potential peaks attained during childhood and adolescence reflect optimal physical and cognitive functioning in later life. The evidence from population cohort studies was presented by Professor Diana Kuh, director of MRC Unit for Lifelong Health and Ageing, at the recent conference at the Royal Society of Medicine. Up to 66% of the decline in functional ability in ageing adults is related to childhood development. In the case of pubertal timing, Professor Kuh described that delay causes 20% reduction of volumetric trabecular bone accrual. In my 3 year longitudinal study of 87 pre and post pubertal girls, high levels of training delayed menarche and blunted attainment of peak bone mass (PBM). Conversely an optimal level of training did not delay menarche and improved bone mineral density compared to age marched sedentary controls. A similar long term effect is seen in older female athletes who have experienced amenorrhoea of more than 6 months duration. Even after retirement and resumption of menses pre-menopause, irreversible loss of bone mineral density (BMD) is seen. Professor Kuh argued for specific and personalised recommendations to individuals to support successful ageing.

From a personalised medical perspective, what about hormonal changes associated with ageing? Although in men testosterone levels decline with age, nevertheless the change is more dramatic in women at menopause where the ovaries stop producing oestrogen and progesterone. This results in increased risk after the menopause of osteoporosis, cardiovascular disease and stroke, together with other vasomotor symptoms and mood changes. With increased life expectancy comes an increasing number of women with menopausal symptoms and health issues which can negatively impact on quality of life. What about hormone replacement therapy (HRT)? HRT improves menopausal symptoms and reduces the risk of post menopausal long term health problems, provided HRT is started within ten years after the menopause. After this window of opportunity replacement oestrogen can actually accelerate cell damage. As with any medical treatment there will be those for whom HRT is contra-indicated. Otherwise the risk:benefit ratio for each individual has to be weighed up so that women can arrive at an informed decision. Regarding the risk of breast cancer, this is increased by 4 cases per 1,000 women aged 50-59 years on combined HRT. This compares to an additional 24 cases in women who have body mass index (BMI)>30 and are not on HRT. This underlines the important of lifestyle which is crucial in all areas of preventative medicine.

What type of HRT has the most favourable risk:benefit ratio? Oral preparations undergo first pass metabolism in the liver, so other routes of delivery such as transdermal may be preferred. There is also an argument that hormones with identical molecular structure are preferable to bio-similar hormones. What functional effect could a slight difference in sex steroid structure have? For example no methyl group and a side chain with hydroxyl group (C-OH) rather than a carbonyl group (C=O)? That is the difference between oestradiol and  testosterone.

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Testosterone
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Oestradiol

In the case of hormones with identical molecular structure to those produced endogenously, there are no potential unwanted side effects or immunogenic issues as the molecule is identical to that produced by the body. Although the oestradiol component in most HRT preparations in the UK has an identical molecular structure to endogenous oestradiol, there is only one licensed micronised progesterone preparation that is has an identical molecular structure. Synthetic, bio-similar progestins have additional glucocorticoid and androgenic effects compared to molecular identical progesterone which exerts a mild anti-mineralocorticoid (diuretic) effect.

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Progesterone
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Norethisterone (synthetic progestin)

With an increasing ageing population and increase in life expectancy, it is important to support successful ageing and quality of life with a personalised and specific approach.

For further discussion on Endocrine and Metabolic aspects of SEM come to the BASEM annual conference 22/3/18: Health, Hormones and Human Performance

References

Conference Royal Society of Medicine 17/1/17 “Sports Injuries and Sports Orthopaedics” Session on “The Ageing Athlete”

Optimal health: especially young athletes! Part 3 Consequences of Relative Energy Deficiency in sports Dr N. Keay, British Association Sport and Exercise Medicine

From population based norms to personalised medicine: Health, Fitness, Sports Performance Dr N. Keay, British Journal of Sport Medicine 22/2/17

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

Bio-identical hormone replacement therapy course. Marion Gluck Training Academy 27/1/17

The British Menopause Society

Royal College of Obstetricians and Gynaecologists 

Optimal health: especially young athletes! Part 3 Consequences of Relative Energy Deficiency in sports

In my previous blogs I have described the adverse effects of Relative Energy Deficiency in sports (RED-S) in both female and male athletes both in terms of current health and sport performance and potential long term health problems. What about young aspiring athletes? There is concern that early sport specialisation, imbalances in training not covering the full range of the components of fitness, together with reduced sleep, all combine to increase injury risk. Young athletes are particularly vulnerable to developing RED-S during a period of growth and development accompanied by a high training load.

Sufficient energy availability and diet quality, including micronutrients, is especially important in young athletes. To investigate further I undertook a three year longitudinal study involving 87 pre- and post-pubertal girls, spread across control pupils at day school together with students in vocational training in both musical theatre and ballet streams. There was a gradation in hours of physical exercise training per week ranging from controls with least, followed by musical theatre, through to ballet stream with the most.

In all girls dietary, training and menstrual history were recorded and collected every six months. At the same visit anthropometric measurements were performed by an experienced Paediatric nurse and bloods were taken for Endocrine markers of bone metabolism and leptin. Annual DEXA scans measured body composition, total body bone mineral density (BMD) and BMD at lumbar spine (including volumetric) and BMD at femoral neck.

The key findings included a correlation between hours of training and the age of menarche and subsequent frequency of periods. In turn, any menstrual dysfunction was associated with low age-matched (Z score) BMD at the lumbar spine. There were significant differences between groups for age-matched (Z score) of BMD at lumbar spine, with musical theatre students having the highest and ballet students the lowest. There were no significant differences in dietary intake between the three groups of students, yet the energy expenditure from training would be very different. In other words, if there is balance between energy availability and energy expenditure from training, resulting in concurrent normal menstrual function, then such a level of exercise has a beneficial effect on BMD accrual in young athletes, as demonstrated in musical theatre students. Conversely if there is a mismatch between energy intake and output due to high training volume, this leads to menstrual dysfunction, which in turn adversely impacts BMD accrual, as shown in the ballet students.

I was fortunate to have two sets of identical twins in my study. One girl in each twin pair in the ballet stream at vocational school had a twin at a non-dance school. So in each twin set, there would be identical genetic programming for age of menarche and accumulation of peak bone mass (PBM). However the environmental influence of training had the dominant effect, as shown by a much later age of menarche and decreased final BMD at the lumbar spine in the ballet dancing girl in each identical twin pair.

After stratification for months either side of menarche, the peak rate of change for BMD at the lumbar spine was found to be just before menarche, declining rapidly to no change by 60 months post menarche. These findings suggest that optimal PBM and hence optimal adult BMD would not be attained if menarche is delayed due to environmental factors such as low energy density diet. If young athletes such as these go on to enter professional companies, or become professional athletes then optimal, age-matched BMD may never be attained as continued low energy density diet and menstrual dysfunction associated with RED-S may persist. Associated low levels of vital hormones such as insulin like growth factor 1 (IGF-1) and sex steroids impair bone microarchitecture and mineralisation. Thus increasing risk of injury such as stress fracture and other long term health problems. The crucial importance of attaining peak potential during childhood and puberty was described at a recent conference at the Royal Society of Medicine based on life course studies. For example, delay in puberty results in 20% reduction of bone mass.

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It is concerning that RED-S continues to occur in young athletes, with potential current and long term adverse consequences for health. Young people should certainly be encouraged to exercise but with guidance to avoid any potential pitfalls where at all possible. In my next blog I will delve into the Endocrine mechanisms involved in RED-S: the aetiology and the outcomes.

For further discussion on Endocrine and Metabolic aspects of SEM come to the BASEM annual conference 22/3/18: Health, Hormones and Human Performance

References

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

Optimal health: including male athletes! Part 2 Relative Energy Deficiency in sports Dr N. Keay, British Journal of Sport Medicine 4/4/17

Keay N. The modifiable factors affecting bone mineral accumulation in girls: the paradoxical effect of exercise on bone. Nutrition Bulletin 2000, vol 25, no 3. 219-222.

Keay N The effects of exercise training on bone mineral accumulation in adolescent girls. Journal of Bone and Mineral Research. Vol 15, suppl 1 2000.

Keay N, Frost M, Blake G, Patel R, Fogelman I. Study of the factors influencing the accumulation of bone mineral density in girls. Osteoporosis International. 2000 vol 11, suppl 1. S31.

New S, Samuel A, Lowe S, Keay N. Nutrient intake and bone health in ballet dancers and healthy age matched controls: preliminary findings from a longitudinal study on peak bone mass development in adolescent females, Proceedings of the Nutrition Society, 1998

Keay N, Dancing through adolescence. Editorial, British Journal of Sports Medicine, vol 32 no 3 196-7, September 1998.

Bone health and fractures in children. National Osteoporosis Society

Lifetime influences on musculoskeletal ageing and body composition. Lecture by Professor Diana Kuh, Director of MRC Unit for Lifelong Healthy Ageing, at Royal Society of Medicine, conference on Sports Injuries and sports orthopaedics. 17/1/17

Relative Energy Deficiency in sport (REDs) Lecture by Professor Jorum Sundgot-Borgen, IOC working group on female athlete triad and IOC working group on body composition, health and performance. BAEM Spring Conference 2015.

Health and fitness in young people

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

skijump

As discussed in my previous blog Optimal health: including female athletes! Part 1 Bones, the female athlete triad is well described since 1984. The triad comprises disordered eating, amenorrhoea and reduced bone mineral density (BMD). What was uncertain was whether this was a reversible training effect. My study of professional retired pre-menopausal female dancers demonstrated that such bone loss is irreversible, despite resumption of menses. Furthermore, low body weight, independent of amenorrhoea, causes BMD loss. A few female athletes in my subsequent longitudinal study of professional dancers in the English National Ballet company were “robust” and continued to menstruate, in spite of low body weight. However this could have involved anovulatory cycles and therefore low oestrogen. One parameter cannot be considered in isolation.

Furthermore, it has become apparent that the female athlete triad is just part of a much larger picture, known as Relative Energy Deficiency in sport (RED-S). The fundamental issue is that of energy deficiency caused by a mismatch of energy intake and energy expenditure from exercise training. Quality of diet, including micronutrients is also important.

If you are a male athlete, you may be thinking that this is all just a problem for female counterparts? No. Male athletes can also develop RED-S, especially in sports where low body weight confers a sport performance advantage, for example long-distance runners and road cyclists (especially climbers). In a fascinating lecture, Professor Jorum Sundgot-Borgen from the Department of Sport Medicine, at the Norwegian School of Sport and Exercise Science, described the occurrence in male ski jumpers.

This energy deficient state in RED-S in both female and male athletes produces a cascade, network effect on multiple systems: immune, cardiovascular, endocrine, metabolic and haematological effects. Clearly suboptimal functioning in these key areas has implications for current physical and psychological health of athletes and therefore their sport performance. The psychological element is of note as this may be both cause and effect of RED-S. After all in order to be a successful, especially in sport, a high level of motivation, bordering on obsession, is required. Although athletes with RED-S may not fall into a defined clinical disease state, they demonstrate a subclinical condition that impacts health. Performance implications include decreased training response with reduced endurance, muscle strength and glycogen storage, alongside an increased risk of injury, probably due to impaired adaptive response to training and a decrease in co-ordination and concentration. Psychological sequelae include depression and irritability.

Some features of RED-S may be lead to irreversible health issues in the future, as seen in the case of athletic hypothalamic amenorrhoea in female athletes with permanent loss of BMD. In both male and female athletes low energy density diet relative to energy expenditure with training results in low levels of insulin like growth factor 1 (IGF-1) and sex steroid hormones which impair not only sport performance but bone microarchitecture and mineralisation. Although hypothalamic suppression in females is manifest by lack of menstruation, there is no such obvious clinical sign in males, who may nevertheless also be experiencing suppression of the hypothalamic-pituitary-gonadal axis. It has been shown that oestradiol is the key sex steroid hormone in promoting bone mineralisation: for both male and female. In males testosterone is aromatised to oestradiol which in turn acts on bone. As the same mechanisms are involved in the aetiology and effects of RED-S, then the long term consequences will most likely be the same for both female and male athletes.

In my next blog I will explore the consequences of RED-S in young athletes and delve into the Endocrine mechanisms involved in the aetiology and multi-system outcomes for male and female athletes of all ages.

For further discussion on Endocrine and Metabolic aspects of SEM come to the BASEM annual conference 22/3/18: Health, Hormones and Human Performance

References

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

Keay N, Fogelman I, Blake G. Bone mineral density in professional female dancers. British Journal of Sports Medicine, vol 31 no2, 143-7, June 1997.

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

Relative Energy Deficiency in sport (REDs) Lecture by Professor Jorum Sundgot-Borgen, IOC working group on female athlete triad and IOC working group on body composition, health and performance. BAEM Spring Conference 2015.

Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. The IOC consensus statement: beyond the Female Athlete Triad-Relative Energy Deficiency in Sport (RED-S).Br J Sports Med. 2014 Apr;48(7):491-7.

Margo Mountjoy, IOC Medical Commission Games Group. Relative Energy Deficiency in Sport. Aspetar Sports Medicine Journal.

Sleep for Health and Sports Performance

“Sleep.. chief nourisher in life’s feast,” Macbeth.

In my blog for British Association of Sport and Exercise Medicine, I described improving sport performance by balancing the adaptive changes induced by training together with the recovery strategies to facilitate this, both in the short and long term.  alec0120-12x17

A recovery strategy which is vital in supporting both health and sport performance, during all stages of the training cycle is sleep.

Sufficient sleep is especially important in young athletes for growth and development and in order to support adaptive changes stimulated by training and to prevent injury. Amongst teenage athletes, studies have shown that a lack of sleep is associated with higher incidence of injury. This may be partly due to impaired proprioception associated with reduced sleep. Sleep is vital for consolidating neurological function and protein synthesis, for example in skeletal muscle. Sleep and exercise are both stimuli for growth hormone release from the anterior pituitary, which mediates some of these adaptive effects.

Lack of sleep can also interfere with functioning of the immune system due to disruption of the circadian rhythm of secretion in key areas of the Endocrine system. Athletes in heavy training, with high “stress” loads and associated elevated cortisol can also experience functional immunosuppression. So a combination of high training load and insufficient sleep can compound to disrupt efficient functioning of the immune system and render athletes more susceptible to illness and so inability to train, adapt and recover effectively.  Lack of sleep disrupts carbohydrate metabolism and recently found to suppress expression of genes regulating cholesterol transport. In overreaching training, lack of sleep could be either a cause or a symptom of insufficient recovery. Certainly sleep deprivation impairs exercise performance capacity (especially aerobic exercise) although whether this is due to a psychological, physical or combination effect is not certain.

Sufficient sleep quality and quantity is required for cognitive function, motor learning, and memory consolidation. All skills that are important for sports performance, especially in young people where there is greater degree of neuroplasticity with potential to develop neuromuscular skills. In a fascinating recorded lecture delivered by Professor Jim Horne at the Royal Society of Medicine, the effects of prolonged wakefulness were described. Apart from slowing reaction time, the executive function of the prefrontal cortex involved in critical decision making is impaired. Important consequences not only for athletes, but for doctors, especially for those of us familiar with the on call system in hospitals back in the bad old days. Sleep pattern pre and post concussive events in teenage athletes is found to be related to degree and duration of concussive symptoms post injury. The explanation of how sleep deprivation can cause these functional effects on the brain has been suggested in a study where subtle changes in cerebral neuronal structural properties were recorded. It is not known whether these changes have long term effects.

So given that sleep is essential not only for health and fitness, but to support sports performance, what strategies to maximise this vital recovery process? Use of electronic devices shortly before bedtime suppresses secretion of melatonin (neurotransmitter and hormone), which is a situation not conducive for sleep. Tryptophan is an amino acid precursor in the synthesis of melatonin and serotonin (neurotransmitter) both of which promote sleep. Recent research demonstrates that protein intake before bed can support skeletal and muscle adaptation from exercise and also recovery from tendon injury. Conversely there is recent report that low levels of serotonin synthesis may contribute to the pathogenesis of autoimmune inflammatory disease such as rheumatoid arthritis. This highlights the subtle balance between degree of change required for positive adaptation and a negative over-response, as in inflammatory conditions. This balance is different for each individual, depending on the clinical setting. So maybe time to revisit the warm milky drink before bed? Like any recovery strategy, sleep can also be periodised to support exercise training, with well structured napping during the day as described by Dr Hannah Macleod, member of gold winning Olympic Hockey team.

In conclusion, when you are planning your training cycle, don’t forget that periodised recovery to compliment your schedule should be factored in, with sleep a priority recovery and adaptation strategy.

For further discussion on Endocrine and Metabolic aspects of SEM come to the BASEM annual conference 22/3/18: Health, Hormones and Human Performance

References

Balance of recovery and adaptation for sports performance Dr N. Keay, British Association of Sport and Exercise Medicine

Sleep, Injury and Performance

Keay N. The effects of growth hormone misuse/abuse. Use and abuse of hormonal agents: Sport 1999. Vol 7, no 3, 11-12.

Wallace J, Cuneo R, Keay N, Sonksen P. Responses of markers of bone and collagen turover to exercise, growth hormone (GH) administration and GH withdrawal in trained adult males. Journal of Endocrinology and Metabolism 2000. 85 (1): 124-33.

Sleep and sporting performance

Young people: neuromuscular skills for sports performance

Prolonged sleep restriction induces changes in pathways involved in cholesterol metabolism and inflammatory responses

“Sleepiness and critical decision making”. Recorded lecture Professor Jim Horne, Royal Society of Medicine 16/11/16

What Does Sleep Deprivation Actually Do To The Brain?

Pre-Sleep Protein Ingestion to Improve the Skeletal Muscle Adaptive Response to Exercise Training

Exercise and fitness in young people – what factors contribute to long term health? Dr N. Keay, British Journal of Sports Medicine

Serotonin Synthesis Enzyme Lack Linked With Rheumatoid Arthritis

“Science in Elite Sport” Dr Hannah Macleod, University of Roehampton, 6/12/16

Optimising Health, Fitness and Sports Performance for young people

Version 2Young people need information in order to make life decisions on their health, fitness and sport training with the support of their families, teachers and coaches.

As discussed in my previous blog anima sana in corpore sano, exercise has a positive effect on all aspects of health: physical, mental and social. The beneficial impact of exercise is particularly important during adolescence where bodies and minds are changing. This time period presents a window of opportunity for young people to optimise health and fitness, both in the short term and long term.

The physical benefits of exercise for young people include development of peak bone mass, body composition and enhanced cardio-metabolic health. Exercise in young people has also been shown to support cognitive ability and psychological wellbeing.

Optimising health and all aspects of fitness in young athletes is especially important in order to train and compete successfully. During this phase of growth and development, any imbalances in training, combined with changes in proportions and unfused growth plates can render young athletes more susceptible to overuse injuries. A training strategy for injury prevention in this age group includes development of neuromuscular skills when neuroplasticity is available. Pilates is an excellent form of exercise to support sport performance.

In athletes where low body weight is an advantage for aesthetic reasons or where this confers a competitive advantage, this can lead to relative energy deficiency in sport (RED-S). Previously known as the female athlete triad, this was renamed as male athletes can also be effected. The consequences of this relative energy deficiency state are negative effects on metabolic rate, menstrual function, bone health, protein synthesis and immunity. If this situation arises in young athletes, then this is of concern for current health and may have consequences for health moving into adulthood.

A well informed young person can make decisions to optimise health, fitness and sports performance.

Link to Workshops

For further discussion on Endocrine and Metabolic aspects of SEM come to the BASEM annual conference 22/3/18: Health, Hormones and Human Performance

References

Optimal Health: Especially Young Athletes! Part 3 – Consequences of Relative Energy Deficiency in Sports Dr N. Keay, British Association Sport and Exercise Medicine 13/4/17

Report from Chief Medical Officer

Cognitive benefits of exercise

Injuries in young athletes

Young people: neuromuscular skills for sports performance

IOC consensus statement\

Exercise and fitness in young people – what factors contribute to long term health? Dr N. Keay, British Journal of Sports Medicine

 

Amina Sana in Corpore Sano

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Barnes Studio

Why not give both your body and brain a workout simultaneously? Recall sequences of steps and translate into movement with musicality and expression. Challenge mind and body by taking a Ballet class. Develop and maintain a healthy mind in a healthy body.

A healthy mind in a healthy body: the WHO (World Health Organisation) defines health as a positive state, incorporating the elements of physical, mental and social health, not simply the absence of disease.

Medical evidence demonstrates that exercise is beneficial for the cardio vascular, respiratory, metabolic, endocrine and musculoskeletal systems. It also enhances wellbeing, through the release of endorphins.

Longer term interaction of physical and mental health is now being reported more in scientific journals and the press. Exercise has a long term positive effect on mental health. Exercise is a modifiable lifestyle factor that can decrease the risk of cognitive decline by 18-30%. The mechanism is thought to be related to blood flow to areas of the brain associated with memory.

Ballet is recommended by American Academy of Orthopaedic Surgeons as an injury prevention strategy for athletes as improves neuromuscular skills, proprioception, muscle tone and muscle dynamics.

Ballet

For further discussion on Endocrine and Metabolic aspects of SEM come to the BASEM annual conference 22/3/18: Health, Hormones and Human Performance

References

http://gpcpd.walesdeanery.org/index.php/welcome-to-motivate-2-move

http://www.businessinsider.com/master-athletes-stopped-exer…

Ballet for Injury Prevention