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

3 Aug, 17 | by BJSM

By Dr Nicky Keay nickykeay

Health is not just the absence of illness, but rather the optimisation of all components of health: physical, mental and social. Exercise has numerous benefits on all these aspects. However, a recent article in the British Medical Journal described how exercise addiction can have detrimental physical, mental and social effects.

Dedication and determination are valuable qualities required to be successful in life, including achieving sporting prowess. Yet, there is a fine line between dedication and addiction.

To improve sports performance, cumulative training load has to be increased in a quantified fashion, to produce an overload and hence the desired physiological and Endocrine adaptive responses. Integrated periodisation of training, recovery and nutrition is required to ensure effective adaptation. Sufficient energy availability and quality of nutrition are essential to support health and desired adaptations. On the graph above the solid blue line represents a situation of energy balance, where the demands of increased training load are matched by a corresponding rise in energy availability. This can be challenging in sports where low body weight confers a performance or aesthetic advantage, where the risk of developing relative energy deficiency in sport (RED-S) has implications for Endocrine dysfunction, impacting all aspects of health and sports performance.

Among those participating in high volumes of exercise, what distinguishes a healthy level of commitment from exercise addiction? Physical factors alone are insufficient: all those engaging in high levels of training can experience overuse injuries and disruption in Endocrine, metabolic and immune systems. Equally, in all these exercising individuals, overtraining can result in underperformance.

Psychological factors are the key distinguishing features between the motivated athlete and the exercise addict. In exercise addiction unhealthy motivators and emotional connection to exercise can be identified as risk factors. In exercise addiction the motivation to exercise is driven by the obsession to comply with an exercise schedule, above all else. This can result in negative effects and conflict in social interactions, as well as negative emotional manifestations, such as anxiety and irritability if unable to exercise, including the perceived necessity to exercise even if fatigued or injured.

Two categories of exercise addiction have been described. Primary exercise addiction is the compulsion to follow an excessive training schedule. Without balancing energy intake, the physical consequence may be a relative energy deficiency, as indicated on the graph by the dashed blue line. In secondary exercise addiction, the situation is compounded by a desire specifically to control body weight. These individuals consciously limit energy intake, almost inevitably developing the full clinical syndrome described in RED-S, dragging them down to the position indicated by the dotted blue line on the chart. These situations of exercise addiction can lead to varying risk categories of RED-S.

As described at the start of this blog, there is a blurred boundary between the dedicated athlete and the exercise addict. In practice there is most likely a cross over. For example, an athlete may start with healthy motivators and positive emotional connection to exercise, which can become a primary addiction to adhere rigidly to a training schedule, rather than putting the emphasis on the outcome of such training. In the case of an athlete where low body weight is an advantage, it is easy to appreciate how this could become a secondary exercise addiction, where the motivation for exercising becomes more driven by the desire to control weight, rather than performance.

In order to support those with exercise addiction, discussion needs to focus on adopting a more flexible approach to exercise, by recognising that exercise addiction has detrimental effects on all aspects of current and long term health. Furthermore, in the case of athletes, a multi-disciplinary approach is desirable to help the individual refocus on the primary objective of training: to improve performance. In all situations, discussion should explore modifications to exercise and nutrition, in order to prevent the negative effects of RED-S on health and performance.

Exercise has numerous health benefits and is usually viewed as positive behaviour. However, the outcome of exercise is related to the amount of training, appropriate nutrition and motivation for exercising.

References

Addiction to Exercise British Medical Journal 2017

Clusters of Athletes

Sport performance and relative energy deficiency in sport British Journal of Sport Medicine 2017

Balance of recovery and adaptation for sports performance British Association of Sport and Exercise Medicine 2017

Optimal Health for all athletes Part 4 Mechanisms of RED-S British Journal of Sport Medicine 2017

Sports Endocrinology – what does it have to do with performance? British Journal of Sport Medicine 2017

Inflammation: Why and How Much? British Association of Sport and Exercise Medicine 2017

Optimising Health, Fitness and Sports Performance for young people

30 Jun, 17 | by BJSM

Part-1 of the blog mini-series on youth

By Dr Nicky Keay

Young 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

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

Health and fitness in young people

 

 

Mechanisms for optimal health…for all athletes!

11 May, 17 | by BJSM

Part-4 of the blog mini-series on RED-S

By Dr Nicky Keay

As described in previous blogs, the female athlete triad (disordered eating, amenorrhoea, low bone mineral density) is part of Relative Energy Deficiency in sports (RED-S). RED-S has multi-system effects and can affect both female and male athletes together with young athletes. The fundamental issue is a mismatch of energy availability and energy expenditure through exercise training. As described in previous blogs this situation leads to a range of adverse effects on both health and sports performance. I have tried to unravel the mechanisms involved. Please note the diagram below is simplified view: I have only included selected major neuroendocrine control systems.

Low energy availability is an example of a metabolic stressor. Other sources of stress in an athlete will be training load and possibly inadequate sleep. These physiological and psychological stressors input into the neuroendocrine system via the hypothalamus. Low plasma glucose concentrations stimulates release of glucagon and suppression of the antagonist hormone insulin from the pancreas. This causes mobilisation of glycogen stores and fat deposits. Feedback of this metabolic situation to the hypothalamus, in the short term is via low blood glucose and insulin levels and in longer term via low levels of leptin from reduced fat reserves.

A critical body weight and threshold body fat percentage was proposed as a requirement for menarche and subsequent regular menstruation by Rose Frisch in 1984. To explain the mechanism behind this observation, a peptide hormone leptin is secreted by adipose tissue which acts on the hypothalamus. Leptin is one of the hormones responsible for enabling the episodic, pulsatile release of gonadotrophin releasing hormone (GnRH) which is key in the onset of puberty, menarche in girls and subsequent menstrual cycles. In my 3 year longitudinal study of 87 pre and post-pubertal girls, those in the Ballet stream had lowest body fat and leptin levels associated with delayed menarche and low bone mineral density (BMD) compared to musical theatre and control girls. Other elements of body composition also play a part as athletes tend to have higher lean mass to fat mass ratio than non-active population and energy intake of 45 KCal/Kg lean mass is thought to be required for regular menstruation.

Suppression of GnRH pulsatility, results in low secretion rates of pituitary trophic factors LH and FSH which are responsible for regulation of sex steroid production by the gonads. In the case of females this manifests as menstrual disruption with associated anovulation resulting in low levels of oestradiol. In males this suppression of the hypothamlamic-pituitary-gonadal axis results in low testosterone production. In males testosterone is aromatised to oestradiol which acts on bone to stimulate bone mineralisation. Low energy availability is an independent factor of impaired bone health due to decreased insulin like growth factor 1 (IGF-1) concentrations. Low body weight was found to be an independent predictor of BMD in my study of 57 retired pre-menopausal professional dancers. Hence low BMD is seen in both male and female athletes with RED-S. Low age matched BMD in athletes is of concern as this increases risk of stress fracture.  In long term suboptimal BMD is irrecoverable even if normal function of hypothamlamic-pituitary-gonadal function is restored, as demonstrated in my study of retired professional dancers. In young athletes RED-S could result in suboptimal peak bone mass (PBM) and associated impaired bone microstructure. Not an ideal situation if RED-S continues into adulthood.

Another consequence of metabolic, physiological and psychological stressor input to the hypothalamus is suppression of the secretion of thyroid hormones, including the tissue conversion of T4 to the more active T3. Athletes may display a variation of “non-thyroidal illness/sick euthyroid” where both TSH and T4 and T3 are in low normal range. Thyroid hormone receptors are expressed in virtually all tissues which explains the extensive effects of suboptimal levels of T4 and T3 in RED-S including on physiology and metabolism.

In contrast, a neuroendocrine control axis that is activated in RED-S is the hypothalamic-pituitary-adrenal axis. In this axis, stressors increase the amplitude of the pulsatile secretion of CRH, which in turn increases the release of ACTH and consequently cortisol secretion from the adrenal cortex. Elevated cortisol suppresses immunity and increases risk of infection. Long term cortisol elevation also impairs the other hormone axes: growth hormone, thyroid and reproductive. In other words the stress response in RED-S amplifies the suppression of key hormones both directly and indirectly via endocrine network interactions.

The original female athlete triad is part of RED-S which can involve male and female athletes of all ages. There are a range of interacting endocrine systems responsible for the multi-system effects seen in RED-S. These effects can impact on current and future health and sports performance.

References

Optimal health: including female athletes! Part 1 Bones British Journal of Sport Medicine

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

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

Keay N, Fogelman I, Blake G. Effects of dance training on development,endocrine status and bone mineral density in young girls. Current Research in Osteoporosis and bone mineral measurement 103, June 1998.

Jenkins P, Taylor L, Keay N. Decreased serum leptin levels in females dancers are affected by menstrual status. Annual Meeting of the Endocrine Society. June 1998.

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

Keay N, Effects of dance training on development, endocrine status and bone mineral density in young girls, Journal of Endocrinology, November 1997, vol 155, OC15.

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.

“Subclinical hypothydroidism in athletes”. Lecture by Dr Kristeien Boelaert at BASEM Spring Conference 2014 on the Fatigued Athlete

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

 

Young athletes’ optimal health: Part 3 Consequences of Relative Energy Deficiency in sports

12 Apr, 17 | by BJSM

Part-3 of the blog mini-series on RED-S

By Dr Nicky Keay

In my previous blogs, I  described the adverse effects of Relative Energy Deficiency in sports (RED-S) in both female and male athletes- 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.

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 .

References

Optimal Health: including female athletes! Part 1 Bones British Journal of Sport Medicine

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

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

4 Apr, 17 | by BJSM

Part-2 of the blog mini-series on RED-S

By Dr Nicky Keay

If you are a male athlete, or work with male athletes, and think that Relative Energy Deficiency in sport (RED-S) is just a problem for females, think again.

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.

References

Optimal health: including female athletes! Part 1 Bones 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 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.

Sport Performance and RED-S, insights from recent Annual Sport and Exercise Medicine and Innovations in Sport and Exercise Nutrition Conferences

17 Mar, 17 | by BJSM

By Dr Nicky Keay

The Holy Grail of any training program is to improve performance and achieve goals.

Periodisation of training is essential in order to maximise beneficial adaptations for improved performance. Physiological adaptations occur after exercise during the rest period, with repeated exercise/rest cycles leading to “super adaptation”. Adaptations occur at the system level, for example cardiovascular system, and at the cellular level in mitochondria. An increase in mitochondria biogenesis in skeletal muscle occurs in response to exercise training, as described by Dr Andrew Philip at a recent conference at the Royal Society of Medicine (RSM). This cellular level adaptation translates to improved performance with a right shift of the lactate tolerance curve.

The degree of this response is probably genetically determined, though further research would be required to establish causal links, bearing in mind the ethical considerations laid out in the recent position statement from the Australian Institute of Sport (AIS) on genetic testing in sport. Dr David Hughes, Chief Medical Officer of the AIS, explored this ethical stance at a fascinating seminar in London. Genetic testing in sport may be a potentially useful tool for supporting athletes, for example to predict risk of tendon injury or response to exercise and therefore guide training. However, genetic testing should not be used to exclude or include athletes in talent programmes. Although there are polymorphisms associated with currently successful endurance and power athletes, these do not have predictive power. There are many other aspects associated with becoming a successful athlete such as psychology. There is no place for gene doping to improve performance as this is both unethical and unsafe.

To facilitate adaptation, exercise should be combined with periodised rest and nutrition appropriate for the type of sport, as described by Dr Kevin Currell at the conference on “Innovations in sport and exercise nutrition”. Marginal gains have a cumulative effect. However, as discussed by Professor Asker Jeukendrup, performance is more than physiology. Any recommendations to improve performance should be given in context of the situation and the individual. In my opinion women are often underrepresented in studies on athletes and therefore further research is needed in order to be in a position to recommend personalised plans that take into account both gender and individual variability. As suggested by Dr Courtney Kipps at the Sport and Exercise Conference (SEM) in London, generic recommendations to amateur athletes, whether male or female, taking in part in marathons could contribute to women being at risk of developing exercise associated hyponatraemia.

For innovation in sport to occur, complex problems approached with an open mind are more likely to facilitate improvement as described by Dr Scott Drawer at the RSM. Nevertheless, there tends to be a diffusion from the innovators and early adapters through to the laggards.

Along the path to attaining the Holy Grail of improved performance there are potential stumbling blocks. For example, overreaching in the short term and overtraining in the longer term can result in underperformance. The underlying issue is a mismatch between periodisation of training and recovery resulting in maladapataion. This situation is magnified in the case of athletes with relative energy deficiency in sport (RED-S). Due to a mismatch of energy intake and expenditure, any attempt at increase in training load will not produce the expected adaptations and improvement in performance. Nutritional supplements will not fix the underlying problem. Nor will treatments for recurrent injuries. As described by Dr Roger Wolman at the London SEM conference, short term bisphosphonante treatment can improve healing in selected athletes with stress fractures or bone marrow lesions.  However if the underlying cause of drop in performance or recurrent injury is RED-S, then tackling the fundamental cause is the only long term solution for both health and sport performance.

Network effects of interactions lead to sport underperformance. Amongst underperforming athletes there will be clusters of athletes displaying certain behaviours and symptoms, which will be discussed in more detail in my next blog. In the case of RED-S as the underlying cause for underperformance, the most effective way to address this multi-system issue is to raise awareness to the potential risk factors in order to support athletes in attaining their full potential.

References

Teaching module RED-S British Association Sport and Exercise Medicine

From population based norms to personalised medicine: Health, Fitness, Sports Performance BJSM 22/2/17

Balance of recovery and adaptation for sports performance 21/1/17 BASEM

Sleep for health and sports performance BJSM 7/7/17

Annual Sport and Exercise Medicine Conference, London 8/3/17

Bisphosphonates in the athlete. Dr Roger Wolman, Consultant in Rheumatology and Sport and Exercise Medicine, Royal National Orthopaedic Hospital

Collapse during endurance training. Dr Courtney Kipps, Consultant in Sport and Exercise Medicine. Consultant to Institute of Sport, medical director of London and Blenheim Triathlons

Innovations in Sport and Exercise Nutrition. Royal Society of Medicine 7/3/17

Identifying the challenges: managing research and innovations programme. Dr Scott Drawer, Head of Performance, Sky Hub

Exercise and nutritional approaches to maximise mitochondrial adaptation to endurance exercise. Dr Andrew Philip, Senior Lecturer, University of Birmingham

Making technical nutrition data consumer friendly. Professor Asker Jeukendrup, Professor of Exercise Metabolism, Loughborough University

Innovation and elite athletes: what’s important to the applied sport nutritionists? Dr Kevin Currell, Director of Science and Technical Development, The English Institute of Sport

Genetic Testing and Research in Sport. Dr David Hughes, Chief Medical Officer Australian Institute of Sport. Seminar 10/3/17

Effects of adaptive responses to heat exposure on exercise performance

Over Training Syndrome, Ian Craig, Webinar Human Kinetics 8/3/17

The Fatigued Athlete BASEM Spring Conference 2014

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.

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Dr Nicky Keay BA, MA (Cantab), MB, BChir, MRCP, Clinical and research experience in Endocrinology applied to Sport and Exercise Medicine.

From population based norms to personalised medicine: Health, Fitness, Sports Performance

22 Feb, 17 | by BJSM

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. – World Health Organisation 1948

By Dr Nicky Keay

There has been criticism of this definition, arguing that the word “complete” has opened the door to today’s more medicalised society. However, this trend coincides with increased volume of “patients” seeking optimal health, together with doctors who have a more extensive repertoire of medical interventions at their disposal. In a time-pressed society there is less opportunity for either patient or doctor to explore longer term adaptive measures and prevention strategies, which facilitate taking responsibility for your health. Fortunately Sport and Exercise Medicine became a recognised medical specialty in the UK in 2006. This encompasses population-based strategies for disease prevention outlined in the global initiative founded in 2007 “Exercise is Medicine“.

What has this got to do with sports performance? There are subgroups within the population, such as athletes already taking plenty of exercise. Elite athletes differ from the general population, due to superior adaptation processes to exercise, probably with a genetic component. So are the same “normal” population-based ranges of quantified medical parameters applicable?

This is precisely the issue that arose when I was on the international medical research team investigating the development of a dope test for growth hormone (GH). Crucially, exercise is one of the major stimuli for growth hormone release from the anterior pituitary. So before we could even start investigating potential downstream markers of exogenous GH abuse, the “normal” range for elite athletes had to be established.

Father and son compete in running race: How will their endocrine markers differ across age and fitness levels?

In a similar way, are the “normal” ranges for other hormones applicable to athletes? In a fascinating lecture delivered by Dr Kristien Boelaert, Consultant Endocrinologist, it was explained that the distribution for thyroid stimulating hormone (TSH) is affected by multiple factors, including illness, age and exercise status. So “normal” for the general population is not necessarily normal for specific subgroups.

The other issue, especially with the Endocrine system is that hormones act on a variety of tissues and so produce a variety of multi-system network effects with interactions and control feedback loops. Therefore symptoms of malfunction/maladaptation and subclinical conditions can be non specific. From a doctor’s perspective this makes Endocrinology fascinating detective work, but challenging when dealing with subgroups in the population who require a more intensive work-up and individualised approach.

The vast majority of research studies involve exclusively male athletes, leaving female athletes under-represented (a recent study on heat adaptation in female athletes being a notable exception). Some areas of research, including my own, have been directed more towards female athletes in the case of female athlete triad, or Relative Energy Deficiency in sports (REDs). REDs is a more appropriate term as it really sums up the important points: male and female can both be affected and therefore should both be studied. There are subgroups within the general population who may not fit the “normal” range: REDs is not necessarily a clinically defined eating disorder from lecture by Professor J. Sundgot-Borgen (IOC working group on female athlete triad and IOC working group on body composition, health and performance).

No medical/physiological/metabolic parameter can be considered in isolation: in the case of REDs, it is not menstrual disturbance and bone health that are affected in isolation. For example, there is currently great debate about whether a low carbohydrate/high fat diet (ketogenic diet) can mobilise fat oxidation and potentially be a training strategy to enhance performance. Needless to say that a recent study contained no female athletes. Given that many female endurance athletes are already lean, potentially driving fat metabolism through diet manipulation may have an impact on Endocrine function, optimal health and hence sport performance. I understand that a forthcoming study will include female athletes.

So a continuum or distinct subgroups in the population? Clearly general medical principles apply to all, with a spectrum from optimal functioning, subclinical conditions through to recognised disease state. We now have evidence of distinct differences between subgroups in the population and even within these subgroups such as male and female athletes. We are moving into a world of personalised medicine, where recommendations for optimal health are tailored for individuals within specific subgroups.

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Dr Nicky Keay BA, MA (Cantab), MB, BChir, MRCP, Clinical and research experience in Endocrinology applied to Sport and Exercise Medicine.

Publications

“Subclinical hypothydroidism in athletes”. Lecture by Dr Kristeien Boelaert at BASEM Spring Conference 2014 on the Fatigued Athlete

Awards

Relative Energy Deficiency in sport (REDs) Lecture by Professor Jorum Sundgot-Borgen, BAEM Spring Conference 2015 on the Female Athlete

Low Carbohydrate, High Fat diet impairs exercise economy and negates the performance benefit from intensified training in elite race walkers

References

How should we define health?

Nobody is average but what to do about it? The challenge of individualized disease prevention based on genomics

Exercise is Medicine

Enhancing Sport Performance: part 1

Effect of adaptive responses to heat exposure on exercise performance

USEMS 2016 National Student Sports Medicine Conference – The Highlights!

6 Dec, 16 | by BJSM

Undergraduate perspective on Sport & Exercise Medicine – a BJSM blog series

By Tej Pandya

conference-day

Manchester SEMSoc Committee – conference organisers.

The 2016 USEMS Student sports medicine conference was held in Manchester on Saturday 12th November. One hundred and fifty keen students attended from all across the UK -representing many different professions. It was fantastic to see such a high level of interest in sports medicine from undergraduates. Below are three of the biggest conference themes,  highlights, & further resources on these key topics – enjoy! ….

Over training syndrome – a condition that we all need to think about

Dr Leon Creaney (@AthleticsDrLeonA) kick started the day with a brilliant talk explaining the concept of over-training in elite athletes. He explained how we can spot over training syndrome (also known as unexplained underperformance syndrome) – having the same training load but recurrent decrease in performance. Causes of this include: rapid increasing in training volume, lack of recovery and training greater than 10% of the day (2.4 hours) in a 24-hour period.1 Careful monitoring is essential to prevent over training. With no specific treatment other than prolonged rest and graduated return to exercise, this can be a frustrating time for both the athlete and the medical team.

Event medical cover is a great way to gain experience in SEM

Dr Clint Gomes (@drclintgomes) fantastically explained what is involved in providing event medical cover at major cycling championship events.2 Getting skilled up- either as a medical student with organisations such as St John Ambulance or as a doctor on courses such as AREA/SCRUMCAPS is key to making yourself flexible. He also gave these tips for success: knowing the sport and type of injuries you may encounter, recognizing and working within the limits of your competence, and not being in “spectator mode” during the event. If working for a smaller club, selecting your own medical kit and asking the club to reimburse your costs will help you to be fully prepared on match days. Finally, after the event, reflect on what went well and what could be better, so that you be even better next time! To hear more about this, listen to the brilliant BJSM podcast by  Prav Mathema.

Motivational interviewing can be useful technique for behavior change 

The brilliant Dr Amal Hassan (@oh_amalhassan) spoke in the afternoon about how we can motivate our patients to be more physically active.  The vicious cycle of: presenting to the doctor, inadequate exercise advice, increasing pain and symptoms leading to the belief that “exercise will make it worse” and then returning to the doctor is a key example of where motivational interviewing can be used to change attitudes. Where possible, using the patients own language, clarifying understanding and asking open questions can help build the collaborative relationship- remember change is not short term!

Be wary of “Female Athlete Triad” in your female athletes

Dr Isobel Heyworth (@IsobelHeyworth) spoke passionately about the importance of recognizing chronically low energy availability, menstrual dysfunction and low bone mineral density in female athletes –  commonly referred to as “The Female Athlete Triad.” 2 Often these symptoms can be difficult to measure in an amateur setting- make sure to ask the difficult questions! Recovery of energy status may well be days or weeks but it can take years to recover bone mineral density so it is important to emphasize this to your patient.

Huge thanks to all organizers, attendees, and presenters!

Thanks to all the fantastic speakers who gave up their time on a Saturday to come to rainy Manchester! Also, thanks to all the sponsors, including our platinum sponsor BASEM, to help keep the costs down and support undergraduate education.

References

  1. Seene T, Kaasik P, Alev K, Pehme A, Riso EM. Composition and turnover of contractile proteins in volume-overtrained skeletal muscle. International journal of sports medicine. 2004 Aug;25(06):438-45.
  2. De Souza MJ, Nattiv A, Joy E, Misra M, Williams NI, Mallinson RJ, Gibbs JC, Olmsted M, Goolsby M, Matheson G, Barrack M. 2014 Female Athlete Triad Coalition Consensus Statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013. British Journal of Sports Medicine. 2014 Feb 1;48(4):289-.

 

Tej Pandya is an intercalating medical student at the University of Manchester and currently President of the Manchester Sports and Exercise Medicine Society (@semsocuk). All enquiries can be directed to semsocuk@gmail.com

Manroy Sahni (@manroysahni) coordinates the BJSM Undergraduate Perspective blog series. He also serves as Education Officer for the Undergraduate Sports and Exercise Medicine Society (USEMS) committee.

Please send your blog feedback and ideas to: manroysahni@gmail.com

 

This week’s answer to MOOC question: Professor Louise Burke on fitness, weight loss and abnormal menstrual periods

5 Mar, 16 | by Karim Khan

LBourne

Each week students in Professor Ian Shrier’s (@McGillU) Massive Open Online Course (MOOC) ask questions. One questions is answered by our world expert panel on the BJSM blog. Here’s this week’s question.

Q: I have been working hard in gym over the last 6 months. I got cool muscles and I look very fit. I also like that instead of losing weight I gained 3 kg extra (muscles). I eat well. But what worries me is the absence of a menstrual period. I wonder if amenorrhea can be caused by just hard training (without weight loss)?

A: Answer by Professor Louise Burke, PhD & Sports Nutritionist. Australia’s multi-Olympic games sports nutritionist, lead Nutritionist at the Australian Institute of Sport and author of the definitive Clinical Sports Nutrition. Member of the IOC Consensus Statement group that described RED-S: the Relative Energy Deficiency Syndrome (read on).

Louise writes…”Being too thin or training too hard were some of the early suspects in our understanding of amenorrhea in athletes. The first version of the Female Athlete Triad syndrome added further confusion with its rigid definition of the co-existence of amenorrhea with eating disorders and osteoporosis. Over the last decade, however, an appreciation of the real dietary problem – low energy availability – has emerged. This new term helps to tie a number of issues and observations together, and provides a new perspective on why amenorrhea occurs, who is at risk, and why you should care. The answer to these questions lies in an understanding of how the body handles energy.

Energy balance just considers the difference between energy intake from food and daily energy expenditure/requirement. When daily energy intake and expenditure is roughly equal, you’re said to be in neutral energy balance (or just “energy balance”).  Energy balance can be changed by changing your intake, changing your expenditure, or changing both. If this change results in an energy intake that is less than expenditure (negative energy balance), there is a general expectation that body energy stores in the form of body fat and muscle are sacrificed to bridge the deficit.

Meanwhile, energy availability focuses on energy requirements, breaking them into two components: energy for exercise and energy for health and maintenance. In an ideal world, where you want to be in top shape and top function, your energy intake would cover both components. However, if we upset this equation by reducing our energy intake, increasing the energy we commit to exercise or a mixture of both, the result is a shortfall in the energy specifically available to support other body functions. Some of these functions are critical for keeping you alive while other functions are “nice to have” but can be turned off or turned down in an emergency.   This situation is termed low energy availability.

Although we’ve said that negative energy balance causes you to break down fat and muscle to contribute these energy stores to the energy deficit and try to address the low energy availability, your body is smart enough to know that this isn’t a good long-term solution. After all, you will eventually disappear if you keep sacrificing your body tissues! Your body’s solution to low energy availability is to turn down or turn off some of the less essential health and maintenance functions to save its energy costs and try to restore energy balance. The good news is that you are now more economical at being you, expending fewer Calories/kilojoules to get through the day. The bad news is that you are no longer maintaining your health and function at its top level. Loss of the menstrual cycle is one of the common casualties of the energy adjustments.

Honing back in on the MOOC question & periods stopping…

This concept raises three important findings of relevance to the current case. First, low energy availability can be associated with negative energy balance and weight loss, but not always. In some situations or some individuals, the body’s priority response to low energy availability is to adjust energy expenditure to restore energy balance at a lower energy intake. Thus, low energy availability can exist without the typical presentation of weight loss or becoming very thin.

The second update is the recognition the energy mismatch that causes low energy availability can occur in a variety of scenarios:

  • Disordered eating and eating disorders
  • Over-enthusiastic and/or misguided weight loss campaigns. Some athletes set unrealistic targets for weight/body fat loss; others have reasonable targets, but try to reach them way too quickly.
  • A high training volume or strenuous competition schedule – particularly when this represents a sudden increase in usual patterns. It can be difficult to get a handle on just how much more energy is needed to support the new exercise program, and your appetite may be blunted by fatigue rather than directing you to eat more
  • An environment in which access to food is difficult and prevents an athlete from finding food at the right time in the right amounts – tight finances, travel, boarding in residences with small windows for meal times, a hectic schedule that means always being on the run.

In other words, different types of factors can be represented in the development of low energy availability ranging from psychological problems to lack of knowledge or simply being in the wrong place at the wrong time in terms of food availability. We need to increase our recognition of the different types of athletes in which low energy availability can occur (including males!) and we need to have different solutions to fit the problem.

The third update on this syndrome belongs in the “why should you care” basket. Although amenorrhea is a common outcome of low energy availability adjustments, it is not universal (think of male athletes or post-menopausal athletes) and may not be recognised or considered problematic by some athletes. However, we now know that many other body systems are impaired by low energy availability, with casualties including poor bones and cardiovascular health, an increased risk of injury and illness, and impaired training adaptations and performance.

There are many incentives to tackle the problems of low energy availability. Indeed, many experts in sports science/medicine have identified the need to re-badge the syndrome so that it casts a wider net on the populations at risk and the problems it causes, as well as focusing attention on the underlying problem. The result is coining of the term “RED-S” (Relative Energy Deficiency in Sport) as a larger umbrella and spotlight on a common problem among athletes. RED-S promotes our new insights and provides a platform for a new approach to recognise, treat and prevent this issue.”

Links:

Listen to Dr Margo Mountjoy, MD, PhD, sports physician & MOOC lecturer – outline Relative Energy Deficiency Syndrome (RED-S) in this BJSM podcast  http://ow.ly/Z5UgW

References

Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A, Ackerman K. The IOC relative energy deficiency in sport clinical assessment tool (RED-S CAT). Br J Sports Med. 2015;49(21):1354.

Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. Authors’ 2015 additions to the IOC consensus statement: Relative Energy Deficiency in Sport(RED-S).

Br J Sports Med. 2015;49(7):417-20.

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 inSport (RED-S). Br J Sports Med. 2014;48(7):491-7

Long

BJSM Virtual Conference – RED-S, FAT and ACL (Enough abbreviations?)

5 Oct, 15 | by BJSM

A monthly round-up of podcasts and articles 

By Steffan Griffin (@lifestylemedic)

Not only does the start of this month bring some fantastic sporting events but also another of our Virtual Conferences. This one is inspired by this fantastic recent podcast with Pippa Bennett, who addresses Relative Energy Deficiency in Sport (RED-S) and anterior cruciate ligament (ACL) injuries– both of which are the focus of this virtual conference.

woma runningRED-S/Female Athlete Triad

If you learn best through listening then your first stop has to be this podcast with Margot Mountjoy, who clarifies the IOC’s consensus statement on this condition, explaining why it is needed, what the controversies are and what clinicians can do in the clinic (amongst other things)  ow.ly/RMYRq

If you are more of a visual learner, then make the most of the IOC consensus statement mentioned in the podcast – full of fantastic graphics and key-points ow.ly/RN0II. Likewise – if you can see yourself using this in practice (although interesting even if not!), here is the link to the RED-S Clinical Assessment Tool (CAT) – also mentioned and explained clearly in the aforementioned podcast ow.ly/RN171

Some of you may be wondering where the historical ‘Female Athlete Triad’ has disappeared to, and in that case you might be pleased/confused/surprised to know that it is still an academic entity. A paper that makes for good reading is one by the #FAT camp (Female Athlete Triad to avoid controversy), which refutes the IOC consensus statement on RED-S http://bit.ly/1jIbnuz

For completion – if you want a good read that provides some deeper insight, then here is the #FAT consensus statement, one of our most popular papers of recent years ow.ly/RN0Ae

ACL Injuries

Moving onto ACLs and a recent paper that has been a huge hit in the football medicine world – using video analysis to determine which on-field football scenarios precede ACL rupture.  You can listen to Markus Walden ow.ly/RMYw5 or again view the recent paper http://ow.ly/QUezQ

Keeping with ACLs – here’s a classic podcast concerning the management and prevention of ACL injuries with Grethe Myklebust – one of the pioneers to investigate the role of exercise for ACL prevention – providing a one-stop shop for all things ACL ow.ly/RMZcX

Any injury prevention programme that can reduce the risk of ACL injury is a golden-ticket to both practitioners and athletes alike. Following the famous Norwegian ACL prevention paper in 2003 – the authors revisit ACL injury incidence in female handball 10 years after the Norwegian ACL prevention study – and demonstrate important clinical as well as research tips to consider for any sports-medicine practitioners ow.ly/RN1jj.

So there we are for another month! If you have any suggestions or would like to see another topic featured then please don’t hesitate to contact us on social media – be it twitter, facebook or Google+.

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