Kinesiology 454: Exam 2

energy intake - exercise energy expenditure = energy availability

energy availability is the amount of energy remaining for other physiological functions after accounting for the energetic cost of exercise training

energy and estrogen deficiency on bone quality

energy deficient women exhibited: -lower total and trabecular BMD -lower cortical area and thickness estrogen deficient women exhibited: -lower total and cortical BMD -larger trabecular area interaction between the two for total trabecular area. a combination of estrogen and energy deficiency is more detrimental to bone than either deficiency alone

refuel: resumption of menses associated with inc energy intake

gained weight at all months! increase! month 3: 1.0 kg inc month 6: 1.5 kg inc month 9: 1.5 kg inc month 12: 3.0 kg inc

pathological weight control behavior

history of self-induced vomiting, use of laxatives, diuretics and/or diet pills

overall men tend to have higher BMI but lower % body fat compared to women participating in the same sport and at a similar competition level.

however there are few differences observed in BMI or % body fat between lean sport types in women and men

energy availability units

kcal/kg FFM/day

female athlete triad in 2007

level A: -Severe undernutrition impairs reproductive and skeletal health. -Menstrual irregularities and low BMD increase stress fracture risk. -Disordered eating, eating disorders and amenorrhea occur more frequently in sports that emphasize leanness. -Refeeding a modest volume of extra calories restores menses. level B: -To diagnose functional hypothalamic amenorrhea, other causes must be excluded. -Treatment for disordered eating and eating disorders includes nutritional counseling and individual psychotherapy. Cognitive behavioral, group therapy, and/or family therapy may also be used.

where did the EA threshold come from?

look at ss -each person went through an energy deplete condition (left): most severe -over the course of 24 hours the pulse frequency decreases and the pulse hight increases, getting less severe as you increase energy intake -under an EA of 30, this is when we start to see a dec in pulse frequency (# pulses of LH) and an increase in pulse height -she had indivuals eat at different EAs and then tested their LH surges. she said that if the EA is less than 30 then there are issues with the pulses in LH. She proposed that EA lower than 30 will give rise to menstrual abnormalities

amenorrheic athletes have a ______ than regularly menstrating eumenorrheic athletes

lower bone density

RMR =

mRMR/pRMR anything less than 0.90 is energy deficient associated with: •high drive for thinness •menstrual disturbances •high cognitive restraint •low total triiodothyronine (TT3) •high peptide YY •measured low EA

REFUEL: Resumption of Menses associated with increased TT3

tt3 levels did not change until month 12!!! month 3, 6 and 9 are constant month 12: 15% inc!!

eating disorders

up to 48% among athletes compared to 5-9% in the general population and 28% in lean-build athletes

disordered eating

up to 89% prevalence of dietary restriction, binge eating and purging behaviors among lean-build athletes

intentional weight loss without disordered eating

want to lose weight for health reasons but does so in an unhealthy way because they do not know what they are doing -requires referral to sport dietitian or nutritional educator

potential RX targets for bone recovery

we must start at chronic energy deficiency/low EA!!! we must start by targeting the chronic energy deficiency first!!! before targeting low hormone levels, bone resorption or anything

RMR

when at rest, minimum amount of energy needed to support the process: reproduction, thermoregulation, cellular maintenance, locomotion, growth

inadvertent under-eating

which presumably occurs when caloric intake does not meet energy expenditure needs in the absence of conscious restriction of food intake accidentally under-eating -requires referral to sport dietitian or nutritional educator

summary

•Bone density is typically low in women with HA secondary to an energy deficiency. •The positive effects of exercise are "undone" in the face of energy and estrogen deficiency •Both energy and estrogen deficiency act to induce bone loss •If left untreated, BMD may decrease 2- 3% per year. •Corresponding decrements occur in bone microarchitecture and estimates of bone strength •Non-pharmacological therapy with goal of weight restoration and resumption of menses, i.e. nutritional recovery, is the first line of a treatment plan. Both factors are associated with increased BMD of 2-3%/yr (in AN). •Practical recommendations are available in Triad Consensus Statement •Non-oral estrogens recommended after failed non-pharmacological nutritional therapy •Whether complete reversal of bone loss is possible is unknown

risk factors for low energy availability

•High drive for thinness •High body dissatisfaction •High dietary restraint •Eating in secret; avoiding certain foods; limiting oneself to very few food choices •Excessive exercise as a means for weight control

thoughts to consider

•Which relationships outlined in the model are truly causal? •Do varying levels of RED-S impact outcomes? •Should all outcomes carry the same weight (i.e. should GI be depicted to be equally important to bone) •Is RED-S reversible? •What are the quantifiable and reproducible measures of cardiovascular, gastrointestinal, immunological, hematological systems?

4 pathways to low energy availability/energy deficiency

1. inadvertent undereating 2. disordered eating 3. intentional weight loss without disordered eating 4. clinical eating disorder

as your menstrual cycles per year decrease, you start to have a greater risk for stress fracture

-10-13 periods per year: 20% fracture risk -6-9 periods: 40% -0-5 periods: 50%

absence of mechanical loading adaptive effects on lower extremety bone may account for inc stress fractures in OA athltes

-12 mo longitudinal study -14-25 year old oligo-amenorrheic and eumenorrheic athletes (EA) and non-athletes -OA athletes maintain lower BMD than EA across 12 mo -at 12 mo follow up, radial failure load was lower in OA vs NA and tibial failure load lower in OA and NA vs EA -hypoestrogenism may negate the effect of weight bearing activity on bone -estrogen is permissive for the activation of the mechanostat with bone loading -hypoestrogenism (low estrogen) may negate the effect of weight beaating acivity on bone -estrogen is permissive for the activation of bond loading (mechanostat)

energetic lessons from refuel

-68% of all REFUEL Oligo/Amen+CAL participants had menses within 3 months. -Onset of menses was associated with significant increases in body weight and body fat. -Calories were increased slowly- menses initiated with as little as 200- 400 kcal/day- 20% above EEE (average 352/day) -Resumption is more than simple resumption of menses and requires more sophisticated hormonal recovery. -The goal for menstrual recovery should be 3 menses in a row of 26-34 days. -Recovery of adequate estrogen exposure likely required more time.

rethinking our understanding of EA and the female triad as of 2019

-A single absolute EA threshold below 30 kcal/kg/LBM/d is NOT associated with menstrual disorders in long-term RCT studies of menstrual function -Based on our results, we propose that a dose response continuum exists between EA/energy deficiency and menstrual abnormalities such that when EA/energy deficiency decreases, the likelihood of a menstrual abnormality increases. -Measurements that can be serially monitored such as body weight and composition, resting metabolic rate, may be more informative than an absolute value of EA. -A sliding scale of EA around 45 kcal/kg/LBM/d likely appropriate to represent a healthy energetic goal. as someone moves into the ED range there is a greater likely hood they will have a menstrual disturbance -she never measured menstrual function and LH pulsatile is not measuring the cycle and periods

higher incidence of stress fractures in oligoamen athletes vs anorexic and control

-AN and OA athletes have more overall fractures than controls -OA athletes have more stress fractures than AN and controls -OA athletes: --2-4x greater risk of SFx -inc risk of having multiple stress fractures!! (especially in metatarsals)

how is BMD measured using T and Z scores?

-DXA provides measurement of one mineral mass per area -in order to compare BMD relative to others T and Z scores are used -comparisons depending on age

how to we measure BMD?

-DXA scan (dual energy x-ray absorptiometry) -we can do a scan of the entire body without tons of radiation exposure -scans total body, total hip, lumbar spine

low energy availability threshold

-EA>45 kcal/kg FFm/day = meets energy needs in women, no menstrual disturbances -EA <30 kcals/kg FFM/day = fails to meet energy needs, associated with menstrual disorders

cumulative risk factors

-disordered eating -menstrual dysfunction -leanness sport/activity -late age of menarche (late period) -low BMI or body weight -genetics -bone geometry abnormalities -nutritional inadequacies

treatment: oral contraceptives not effective

-First pass effects" of oral estrogen suppresses hepatic IGF-1, which in turn likely impacts the therapeutic benefit -IGF-1 is anabolic to bone and ↑ bone formation -when we take oral contraceptives, the body needs to process the pill in the liver and when we do so, there is a suppression of igf-1 since it is synthesized and produced in the liver

treatment: oral contraceptive therapy in oligo/AA runners

-In long-distance runners with OA, a decrease in BMD of 2.1% at the lumbar spine (shown) and 1.4% at the femoral neck (not shown) during a 1-yr follow- up of no treatment. -No effect of oral contraceptives was observed after 12 months. -Effects of OC's to improve BMD in AA has been largely ineffective.

summary of Lutenizing Hormone issues

-LH pulsatility decreased -inc LH pulse amplitude -decreased LH pulse frequency -origin site = hypothalamus

subclinical menstrual disorders

-LPD: up to 43% athletes -anovulation: up to 30% in athletes

what do we know about replacing estrogen orally

-Many athletes and AN prescribed OC's to "regulate" irregular cycles or for amenorrhea, or for bone health -May provide a false sense of security and discourage weight restoration -AN: Not effective -Athletes: Mixed outcomes for bone density and stress fractures (may preserve bone density in those with very low bone density).

summary of RMR ratio

-Objective measure of energetic status --Remember EA is based on self-report (subjective) -RMR ratio threshold (0.90) is related to other risk factors and markers of energy deficiency -Can be used to accurately characterize exercising women, based on TT3 values

what is the best strategy for treatment: summary to date of pharmacological options

-Oral estrogen not effective, suppresses IGF-1 -Transdermal estrogen is more effective than oral estrogen -Oral estrogen with IGF-1 ↑ BMD in AN has minimal effects -Leptin increases BMD, but causes weight loss, fat loss and suppresses appetite in FHA -Bisphosphonates ↑ BMD in adult AN (can mess up childbirth) -Teraparatide increases BMD

Thoughts to consider

-RED-S authors use the term "relative energy deficiency" is used interchangeably with "low energy availability" -these are not one in the same -how can relative energy deficiency actually be measured -what are the units of measure?

RMR is suppressed in energy deficit states

-RMR: ratio of measured RMR/predicted RMR -lab defintion: <0.90 = energy deficient -influenced by research in anorexia nervosa patients --typically between 49-91% of harris Benedict predicted values

amenorrhea

-absence of menstruation -no LH because there is no estrogen to produce a priming peak -no period and so there is no follicle growing to produce any of the hormones -no progesterone -changes in length of cycle -severe ovarian suppression of proges and E2 -no phasic elevations of ovarian steroids -no follicular or luteal development -over 90 days no period -ss

anovulation

-absence of ovulation -no change in cycle length -decreases in most hormones: E2, LH and proges. -NO progesterone produced because the LH surge is unsuccessful and cannot produce the CL which produces the progesterone -no evidence of ovulation -cycle length is unchanged so athlete does not notice -ss

clinical eating disorder

-anorexia nervosa -eating disorders not otherwise specified -bulimia nervosa -requires referral: to physician, mental health practitioner and sport dietitian and nutrition educator

dose-dependent response of energy + estrogen deficiency on spine BMD

-anorexia not only a severe energy deficiency but also has ammenorhea sometimes which is stemming from the Energy D -spine BMD of an anorexic individual is about 35% less thana. normal menstrating woman

the female and male athlete traid

-each of the 3 health problems may present alone or in combo -athletes need not to be elite or competitive to experience it -can occur in recreationally active women and men -most serious clinical sequelae are to bone in both sexes -most commonly observed in female and male athletes involved in sports where leanness or aesthetics is the emphasis

who is at risk for the FAT

-athletes partiipating in aesthetic and lean build sports like competitive dance, diving, figure skating -those who believe or are told their performance will improve if they lose weight, even when they are at a healthy weight -suddenly inc training volume -inadvertently consume fewer calories than needed to support the active lifestyle -athletes who begin training or dieting for a specific sport at the young age

what is a bone stress injury

-bone stress injuries represent a spectrum of injuries ranging from inflammation of the periosteum to a complete stress fracture that includes a full cortical break -a tiny crack in a bone caused by repetitive stress or force, often from overuse -forces that can cause a stress fracture could include repeatedly jumping up and down or running long distances -swelling and pain that worsen over time are symptoms -overall more women than men experience this

how is bone turnover/remodeling measured

-bone turnover markers reflect products released during the formation/resorption process -formation: osteocalcin and P1NP -resorption: NTx, CTx -pros: •Measured in blood or urine •Can reflect short-term changes in bone metabolism that you might not be able to cover in a DEXA -cons: •Wide variability •Lack of reference data •Often measured in isolation

similarities between the models

-both highlight that inadequate energy intake leads to health consequences --overall theme -> concern for wellbeing of athletes -introduce risk assessment algorithms to quantify risk and help with clearance/return to play decisions -both models include impacts known in girl/women related to disordered eating, menstrual function and bone health

using indirect calorimetry

-bringing someone into the lab, fasted, rested, lay down for 30 mins -measuring the amount of co2 and o2 -use the ratio of measured to predicted RMR -measurement: pics on right -predicted: some cannot use the tool on the right so there is a calculation they can do to predict the RMR based on certain measurements

treatment of female athlete triad

-cause of the triad: energy deficiency -treatment of the components of the FAT process beginning with recovering energy status -recovery of each component occurs at different rates -energy availability may change on a daily or weekly basis -recovery of menses may take several months (2-6 mo) -recovery of BMD is a slow process and may take YEARS

EA threshold related to Low TT3

-closely related to RMR -proposed that EA <30 was associated with suppression of total TT3 -other hormones were also suppressed below an EA of 30

female athlete triad in 2014

-comprehensive recommendations based on detailed and careful review of the science available to date -include detailed info on diagnosis, to include easy to use algorithms -detailed recommendations for treatment of each component of the triad with step by step methods to follow -clearance and return to play is addressed and contracts provided

researchers of the triad (6)

-de souza -williams -loucks -misra -joy -nattiv

in female athletes decreased bone strength increases fracture risk by:

-decreasesing the areal BMD in the lumbar spine, hip and total body -decreasing the trabecular density -decreaseing the trabecular number -increasing the trabecular spacing -increasing cortical thinnning

low energy can impact bone both directly and indirectly

-directly: through metabolic hormones like IGF-1 -indirectly: by effecting menstrual dysfunction which will in turn effect bone health

time course of recovery in energy, menstrual and bone factors

-energy (fast) - changes in RMR and metabolic hormones (days) --can be a fast recovery, you are able to compensate for calories but changes to RMR and metabolic hormones take a long time to replete -menstral cycles (moderate) - monthly recovery. if we start eating more calories within a few months we can get a period to show up again but ovulation may take a long time (just having periods again doesn't mean you are ovulating) -bone (slow change) --refeeding may not be enough to show changes in bone mass

chronic description

-energy stores: BMI, body weight, body fat -metabolic adaptions to low EA --dec RMR, ratio of mRMR/pRMR --dec metabolic hormones: t3, igf-1, leptin, insulin -measures listed are helpful to assess repeatedly over time to track individuals

energy and estrogen status impacts on bone (studied in lab)

-exercising women (109) operationally defined as: --energy-deficient or replete based on total t3 concentration --estrogen-deficient or replete based on menstrual cycle history and reproductive hormone metabolites -when estrogen deficiency is present in concert with energy efficiency there is evidence of inc bone resorption and dec bone formation highlighting the importance of avoiding energy deficiency

2014

-female athlete triad consensus statement -IOC consensus statement! about RED-S

osteoporosis: effects on the female

-female athletes with an energy deficiency are at high risk for bone loss -in those athletes with an estrogen deficiency + energy deficiency = risk of bone loss is even higher -energy and estrogen deficiency act independently and in combination to impair bone health

women with amenorrhea usually have a lower BMD at which two locations?

-femoral neck (hip) -lumbar spine you are not creating estrogen because of the lack of a period and so the bones are not being protected and the bone is resorbed at a greater rate

recovery of poor bone health

-first step --must be to correct the chronic energy deficiency and low energy availability in order to correct menstrual cycles and bones --duration (min 1 year) -we start at 350 cal for one year bc it is an attainable number and will be easy for those who have rigid eating behaviors

refuel: resumption of menses associated with inc energy intake

-gained fat mass starting at week three and continued through the 12 mo time period month three: 0.75 kg inc in fat mass month 6: 1.25 kg inc month 9: 1.5 kg month 12: 2.25 kg inc

food goes in the body

-gets transferred to the liver, adipose tissue and to serve metabolic functions such as: -reproduction -thermoregulation -cellular maintenance -locomotion -growth

measuring RMR

-gold standard through indirect calorimetry -controlled lab measure (objective) -SUPERIOR to subjective

RED-S Model highlights

-highlights that research is necessary in male athletes, racial minorities, athletes with disabilities -assumes that this work can be used upon all races, genders and disabilities -this is not how research works as they came up with this idea that energy impacts all of these outcomes and that it can be applied to the entire population

energy and estrogen deficiency on bone turnover

-in estrogen deficiency women, those who were also energy deficient had lower bone formation than those who were energy replete -bone formation associated with energetic variables including: --BMI, weight, body far, fat mass, tt3

combination of two: low estrogen and low energy

-not only do we have the increase in resorption but we also have a decrease in bone building activity because the energy status is compromising the bone building activity (most common in triad)

oligomenorrhea

-irregular menstrual cycles -inconsistent cycle lengths (36-90 days) -unpredictable. fluctuating hormones -LH surge is unsuccessful so no CL is produced = no proges. -can be anovulatory -ss

endurance and leanness sports; prominent menstrual dysfunction and low BMD

-large prevelence of runners who have a z score of -1 and so 40% of them have bonemineral density that is low -12-13% of the adolescents ahve a really low BMD at lower than -2 -look at ss to see the distribution

estrogen dependent risk factors

-late onset of menarche -menstrual irregularity

risk factors for menstrual dysfunction

-late onset of period >15 -intense training before puberty -psychological stress: increases susceptibility to the disturbances -gynecological age: fewer years of this increases risk (years since your 1st period) -all increase liklihood to have dysfunction especially with low EA

poor energy bone

-limits the osteoblast ability to build bone. Osteoclast activity is still on high while the decrease of igf1 (because there is not a lot of it, the osteoblasts are not as active and so we are not getting enough bone build up)

energy dependent risk factors

-low body weight -inadequate calcium/vitamin D intake -elevated scores on disordered eating questionnaires -insufficient energy intake

risk factors of low bone mineral density in exercising women

-low body weight (having 85%) and a low bmi (lower than 18.5) -late onset of menarche (older than 15) -menstrual irregularity -lean sport participation -history of bone stress injuries (the most of these you have the greater risk)!

the female athlete triad: middle

-low bone mass -menstrual disturbances -reduced energy availability

the female athlete triad: unhealthy

-low energy availability with or without disordered eating -osteoporosis -amenorrhea

in the process work

-male athlete triad consensus statement -female athlete triad consensus statement update

refuel: reproductive outcome measures

-menstrual recovery extends well beyond simply recovery of menses -hormonal dynamics are important and likely impact clinical outcomes -menstrual recovery: resumption of menses or should we be concerned with the hormonal dynamics too? -reproductive status is based on estrogen, progesterone, LH

researchers of the RED-S (5)

-mountjoy -sundgot-borgen -burke -ackerman -melin

luteal phase defect

-no change in cycle length but changes in hormones -progesterone is decreased because the corpus luteum is not properly functioning -short luteal phase: should be 14 days but if it is less than 10 days it is considered defective and now you have a decrease in progesterone -there is either a short luteal phase, low progesterone levels or both! -ovulation still occurs and the cycle length unchanged -short Luteal phase means longer Follicular phase (cycle length same so the athlete does not notice) -ss

secondary amenorrhea

-no menses for 3 months or over 90 days in a woman who had previously menstruated -up to 60% exercising women compared to 2-5% in general population -70% high school athletes

Primary amenorrhea

-no menses in a 15 year old -delayed menarche/menses means no menses in 14 year old -not getting your first period at the normal age of 12.1

Eumenorrhea

-normal menstruation -normal estrogen, LH and progesterone -26-35 days -ss -normal cycle length

casual relationships remain to be documented for the majority of REDS physiological outcomes

-only one two-way arrow -many arrows are not proven! -it is not proven that RED S causes gastrointestinal, immune system, hematological or heart problems !

the female athlete triad: healthy

-optimal energy availability -optimal bone health -optimal menstrual health

Total Daily Energy Expenditure (TDEE)

-physical activity (25-35%) --purposeful: runs, walks, exercise --non purposeful: chores around the home -thermic effect of a meal (10%) --when we eat we produce heat through digestion -RMR (60-70%) --big component of energy expenditure and is a big component of what is going on in the body

Hypogonadotropic hypogonadism

-prepubetal: LH surges not very active but are consistent -early puberty: pulses at night not many during the day. high amplitude -late puberty: pulses frequent and similar amplitude -the site of the problem is at the hypothalamus!!!!!!

can bone health be restored

-recovery of bone is strongly related to resumption of menstrual function and inc body weight -energy metabolic recovery + menstrual estrogen recovery = bone restoration (hopefully)

when we are not eating enough, which metabolic functions get suppressed?

-reproduction and growth since they aren't deemed necessary and the energy is then used for the three others. -T3 starts to go down without sufficient calories and so since it regulates RMR, RMR decreases -we start to see a decrease in both estrogen and progesterone (ammen)

LH pulsatility in amenorrheic vs menstruating athletes

-sedentary LH pulses were frequent and during the day -amm: very few pulses with only some being at night -pulses indicated by an asterisk -ss of the study done

calculation of EA

-self report -based on energy expenditure and intake (subjective) -not as preferred

bone stress injury (ss)

-starts with shin splits: first indication that something it wrong -then moves to stress reaction if not taken care of -then moves to stress fracture (inc in sacral stress fractures in runners) -then to a full fracture!

characteristics of the HPO axis in energy deficiency associated hypothalamic amenorrhea

-suppression of the GnRH pulse generator -reduced LH pulse frequency and inc in LH amplitude -pulsatility pattern resorts to prepubertal -ovaries production of estrogen and progesterone are suppressed -issue is with the hypothalamus bc if we give gnrh then we start to see regular LH surges

De Souza lab results

-took 35 sedentary women, trained them and then reduced their EA levels (all at different EA levels) -if the number was 1, they had menstrual disturbances -if the number was 0, they did not have disturbances -the study told us that women are having menstrual disturbances even at an EA of 30 -When EA dropped below 30, the probability that a participant would experience a menstrual disturbance exceeded 50% -so her study disproved the threshold

we start by improving energy status

-we increase energy intake, dec expenditure or both -we inc body weight and fat -we recover menstrual function -ultimately to improve bone health

menstrual disturbances: low energy availability: suppression of the hypothalamus

-when energy intake <<<energy expenditure there is low energy availability which leads to -a decrease in leptin, a decrease in insulin, a decrease in IGF1, TT3 and glucose -an INCREASE in ghrelin, pYY, cortisol and GH -ghrelin tells us to eat but pyy signals satiety and says we are full -so you are not only restricting calories intuitively but now because of the Pyy. there is resistance at the cellular level to ghrelin and GH and so there is a decrease in appetite -we do not know which one is the main factor on the GnRH and then on FSH and LH to in turn mess up menstrual function but we know that it could be one or many hormones at once

energy availability hypothesis

-when we are not eating enough food to account for our energy expenditure the limited food we do have is used to drive processes for survival like: thermoregulation, locomotion, and cellular maintenance -Less critical physiological functions, such as growth and reproduction, are suppressed

BMD reporting in women prior to menopause and in males younger than 50

-z scores, not t scores are preferred, especially in children -a z score of -2.0 or lower is defined as below the expected range for age (bad) -a z score above -2.0 is within the expected range for age -a z score of greater than -1.0 is used as a definition of low BMD because of the expected beneftis of weight-beating activity on bone health

the big questions

1. does one model replace the other 2. can both exist

energy deficiency + estrogen deficiency = low bone mass

1. energy status directly alters bone formation. energy deficiency downregulates bone formation via suppressed IGF1 and leptin 2. estrogen status directly alters bone resorption. low estrogen upregulates bone resorption

triad model demonstrated casual relationships

1. low EA and menstrual function 2. low EA and bone health 3. menstrual function and bone health (directionality and reversibility carefully described)

what sports potentially have the highest risk for the triad

1.technical/gravitational sports (high body weight restricts performance: skiing, high jump, long jump) 2. endurance sports (a high body weight restricts performance: cycling, running, rowing, swimming) 3. weight class sports: weight requirements must be met prior to competition (judo, wrestling, karate, rowing) 4. aesthetic sports (subjective judging on presentation: diving, figure skating, gymnastics, dance)

severe energy deficiency

10 cal/kg FFM/day (~1,100 kcal/day)

back in the day, what did we know

1950-60: several papers were published on menstrual disorders noted in female athletes particularly olympians 1970s: increasing focus on menstrual disturbances in athletes, particularly cross country runners 1979: classic shangold marathon training paper --the luteal phase was shorter and progesterone decreased as training mileage increased

moderate energy deficiency

20 kcal/ kg FFM/day (~1,540 kcal/day)

timeline of triad and introduction of RED-S

2014: both consensus statements 2014 later: large group issued a rebuttle against the IOC statement, addressing all of the issues, irregulatiries and mistakes int he RED-S model. the IOC watered down decades of research 2015: IOC came back and said they are not doing anything about RED-S complaints 2018: IOC restates what they said in 2014 2019: Triad researchers issued a comparison of the scientific rigor that the triad is supported by and explained that the RED-S wants to fragment the field while the triad is saying that they are diluting all previous work

mild energy deficiency

30 kcal/kg FFM/day (~1,980 kcal/day)

if your gynecological age is less than ___ years you are at high risk for menstrual disturbances

5 or lower

cross sectional study from the lab

91 exercising women with varying types of menstural disturbances to compare dependent variables -independent variables; compare eumenorrheic to amenorrheic exercising women -dependent: EA, TT3, body weight, fat -found that the avg ammenorrehic EA values were above the threshold of 30, goes against the previous study

energy replete

>40-45 kcal/kg FFM/day (>2,640 kcal/day)

1997, 2005, 2007

ACSM released a position stance on the female athlete triad

triiodothyronine (thyroid hormone)

Abbreviation: T3 Source: thyroid gland Target: all actively metabolic tissues

non-oral estrogen is more effective

Transdermal and Vaginal Estrogen Non-oral routes, such as transdermal and vaginal estrogen may not suppress IGF-1 and markers of bone turnover as does oral administration -the patch improves spine, femoral neck and total hip BMD -estrogen inc in path -igf-1 and P1NP dec in pill

pharmacological recommendations

If estrogen administration is considered (if growth complete) -Consider non-oral options such as transdermal and vaginal estrogen since they do not suppress IGF-1 and markers of bone turnover as does oral administration -Unproven contraceptive efficacy, so additional contraception necessary (patch is not efficient as a means of contraceptives!) -bottom line is to use something with estrogen in it

refuel: resumption of menses associated with inc energy intake

OA groups: month 3, 6, 9, 13: sustained energy intake

RED-S model

The syndrome of RED-S refers to impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health directly caused by relative energy deficiency

difference between the models: focus

Triad: more specified to focus mainly on energy, reproduction, bone --however: psychological, endocrine, and metabolic systems are tightly intertwined in these outcomes RED-S: expands to more physiological systems

difference between the models: supporting evidence

Triad: over 3 decades of rigorous and controlled scientific experimentation, including gold standard RCTS to demonstrate casual relationships RED-S: to date, only triad related conditions are backed by high quality evidence, other evidence is mainly survey-based self report data

tension between nutrition and training goals

athletes straddle a line between nutrition goals for a specific training session or phase of the nutrition plan and between maximizing the overall training plan and adaptations to the training plan

how is bone quality measured

bone density is measured through the DXA but bone quality is measured using a PQct which is another form of an x ray that measures and provides information about bone quality as in the previous slide

bone strength refers to the ability of the bone to withstand a fracture and is catagorized by:

bone quality and bone density

high dietary cognitive restraint

conscious restriction of energy intake in order to achieve or maintain a desired body weight

RCT shows EA threshold of 30 does not apply

control group: black line -maintained diet/exercise red line (10% ED) -maintained deficit over the 3 menstrual cycles blue line -linear dec in ED green line -very energy deficient for the duration of the study -We see that there are plenty of menstrual disturbances above the threshold of 30 and there are many absences of disturbances below 30 and so the threshold does not apply

take home message of RED-S

controlled, scientifically rigorous experiments are essential to define and develop the RED-S model we must follow the data and use an evidence based approach!!

disordered eating

mild, moderate, or severe disturbance in eating habits and attitudes. high drive for thinness and high cognitive restraint of food -requires referral to sport dietitian or nutritional educator -for men: high drive for muscularity and thinnness

RED-S and gastrointestinal

no casual relationship of RED-S and Gastrointestinal symptoms has been demonstrated to date

RED-S and CVD

no casual relationship of RED-S on CVD function has been demonstrated to date

RED-S and Immune System!

no casual relationship of RED-S on immune function has been demonstrated to date

Z scores allow for comparison to an age-matched group

post menopausal women using the z score which takes the dexa measurement minus the mean BMD of the group of similarly aged women and then divided by the SD of the BMD of the older age people

high thrive for thinness

preoccupation with body weight, body shape, fear of gaining weight, restrictive eating patterns

key concept

primary objective of treatment for any component of the FAT is to inc energy availability and reverse any apparent energy deficiency by inc energy intake, preferably and/or reducing exercise energy expenditure

metabolism

process of converting the food we eat into energy -carbs -protein -fat food for physiological processes

A 19 year old goes to the Dr. to ask for help with her amenorrhea of 14 months since joining the cross country team at PSU. What is the most common strategy a lot of physicians might utilize who are not Triad experts to treat this athlete??

putting her on the pill! but the ovaries are suppressing the reproductive hormones even more

low energy availability leads to

shunting energy away from reproduction: suppressed estrogen and progesterone and decreased LH pulse frequency shunting away from growth: suppressed bone formation, suppressed t3

how would RED-S look if they correctly demonstrated casual relationships?

ss

oligo/amen+cal group who inc energy intake by a moderate amount were 2x as likely to experience menses during the intervention compared to the oligo/amencontrol group

ss

T scores allow for comparison to a normal, young population

take the persons BMD measured through DEXA then subtract the mean BMD from a young normal population and then divide that by the SD of the bone mineral density of the young normal population (how good/fair your BMD is against the normal pop)

1993

the first paper was written on the female athlete triad

treatment: resumption of menses and weight change

the overall results of the study was that -estrogen is heavily impactful in the spine BMD -body weight is heavily impactful in the hip BMD!

when there is an energy deficiency

there are physiological adaptations to conserve full which lead to metabolic and reproductive suppression which both lead to skeletal health problems

difference between the models: scope

triad: female athletes and recreational exercisers. acknowledge that triad syndrome happens in men RED-S: calls to expand research to include men, racial minorities and athletes with disabilities