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#REDS (Relative Energy Deficiency in Sport): time for a revolution in sports culture and systems to improve athlete health and performance

AckermanKE, etal. Br J Sports Med Month 2020 Vol 0 No 0
#REDS (Relative Energy Deficiency in
Sport): time for a revolution in sports
culture and systems to improve athlete
health andperformance
Kathryn E Ackerman ,1,2 Trent Stellingwerff,3,4 Kirsty J Elliott- Sale,5
Amy Baltzell,6 Mary Cain,7 Kara Goucher,8 Lauren Fleshman,9
Margo L Mountjoy10,11
Changing a sport system requires the
appointment of new leaders or a grass
roots cultural revolution. ‘I got caught in a
system designed by and for men, which
destroys the bodies of young girls,’ said
Mary Cain as she cast light on her toxic
coach/athlete relationship and exposed
unhealthy coaching and nutrition prac-
tices. Her candour has inspired a social
media movement calling for changes to
women’s sport.1 In the following days,
major news publications followed up with
similar reports of athletic women being
body shamed.2–4
It is time for a drastic paradigm change
in women’s sport, coupled with educa-
tion at all levels to improve the long- term
health and athletic achievement of female
athletes. The shift needs to include:
1. Raising awareness of the negative ef-
fects of chronic low energy availability
(LEA) (calorie restriction) so athletes
can make wise choices for their own
long- term health.
2. Updating and developing best- practice
protocols and safe standards for moni-
toring body composition/weight.
3. Eliminating toxic training environ-
ments featuring abusive body shaming.
Overexercising or underfueling, occur-
ring consciously or subconsciously, can
cause Relative Energy Deficiency in Sport
(RED- S). RED- S is the ‘impaired phys-
iological functioning caused by relative
energy deficiency, and includes but is
not limited to impairments of metabolic
rate, menstrual function (for females),
bone health, immunity, protein synthesis
and cardiovascular health.’5 Chronic LEA
(over many weeks to years) leading to
RED- S can limit training adaptation6 and
substantially increase injury risk.5 7 8 It
cripples performance in both female6 and
male athletes.5 It can occur unknowingly
without a diagnosed eating disorder.7
There is good news: there are oppor-
tunities to mitigate the occurrence and
effects of RED- S through system- wide
education including prevention/awareness
interventions and by optimising energy
intake. One of these system opportuni-
ties to address RED- S was spearheaded
in Canadian elite sport when B2ten—a
philanthropic group—sponsored a
3- day meeting of 30 key stakeholders in
November 2019. At the table were inter-
nationally renowned topic experts, Cana-
dian coaches from at- risk sports, and
athlete support staff representing both
sport science and medicine, all of whom
work in Canadian, American or British
sport. This group examined the science,
sport cultures, gaps and opportunities
associated with RED- S. Some of the key
themes developed included:
We need to implement awareness
education adapted to female and male
athletes of all ages and sport levels,
and tailored for support staff, coaches
and parents. Educational initiatives
should underscore the positive aspects
of energy, namely, that food is fuel;
and fuel is needed for performance.
Content should include RED- S signs/
symptoms; positive communication
around menstrual cycles and body
image; appreciation of athletes/
sports at higher risk; and best prac-
tices pertaining to body composi-
tion/weight assessment protocols.
We developed a conceptual frame-
work outlining when, and when not,
to implement these methods (see
figure 1).
Multicentred research is required to
develop and validate a diagnostic tool
for RED- S.
1Divisions of Sports Medicine and Endocrinology,
Boston Children’s Hospital, Boston, Massachusetts, USA
2Neuroendocrine Unit, Massachusetts General Hospital
and Harvard Medical School, Boston, MA, USA
3Canadian Sport Institute, Victoria, British Columbia,
4Department of Exercise Science, Physical & Health
Education, University of Victoria, Victoria, British
Columbia, Canada
5Musculoskeletal Physiology Research Group, Sport
Health and Performance Enhancement Research Centre,
School of Science and Technology, Nottingham Trent
University, Nottingham, UK
6Author, Consultant, Olympian, Past- President of the
Association of Applied Sport Psychology, Boston,
Massachusetts, USA
7Professional Runner, Bronxville, New York, USA
8Professional Runner and Olympian, Athlete Advocate,
Boulder, Colorado, USA
9Professional Runner, Athlete Advocate, Bend, Oregon,
10Department of Family Medicine, McMaster University
Michael G DeGroote School of Medicine, Hamilton,
Ontario, Canada
11IOC Medical Commission Games Group, Lausanne,
Correspondence to Dr Kathryn E Ackerman, Sports
Medicine, Boston Children’s Hospital, Boston, MA
02115, USA; kathryn. ackerman@ childrens. harvard. edu
Figure 1 A conceptual framework on the implementation of body composition assessments (e.g,
height, weight, anthropometrics, skinfolds, etc.) within the context of athlete stage of development
and their nutritional preparation skills. BC, body composition; LTAD, long- term athlete development
model; TBD, to be determined.
on January 10, 2020 at CASEM. Protected by copyright. J Sports Med: first published as 10.1136/bjsports-2019-101926 on 10 January 2020. Downloaded from
2AckermanKE, etal. Br J Sports Med Month 2020 Vol 0 No 0
RED- S- associated diagnostic factors
may include: chronic dietary restric-
tion and/or extreme diets, drive for
thinness, large changes in body weight
or composition in short time periods,
training inconsistencies, prolonged
fatigue, decreased libido, oligo-
amenorrhoea (missing three or more
menstrual cycles in 6 months), two
or more career bone stress injuries
and low bone mineral density for age
(Z- score <-1.0).5
We must ensure athlete access to a
referral network of RED- S and eating
disorder experts, including sport
and exercise medicine physicians,
registered sport dieticians and sport
psychologists, within each country.
The working group also identified
that certain sports have physiological
and energetic requirements that dictate
that certain athlete phenotypes may be
successful. There was much discussion
about methods to safely improve perfor-
mance while ensuring athlete physical and
mental health. Elite athletes may need to
manipulate energy availability for short
periods to change body composition and
improve their power/force profiles for
critical performance windows. On the
other hand, the working group empha-
sised that prolonged LEA impairs health
and performance.
Modeling the work in sport concussion,
we call for national policies requiring sports
to have RED- S prevention, diagnosis and
treatment protocols, targeting athletes,
coaches and the athlete entourage. Media
and sponsors can raise awareness and
support research in the field. Empowering
athletes to identify and protect themselves
from toxic cultures, and to understand the
importance of energy/food as it relates to
RED- S, is paramount.
As signs and symptoms of RED- S are
present in ~2%–60% of female and male
athletes, depending whether athletes are
in endurance, aesthetic, weight categories
and power/sprint sports,5 7 we believe that
a revolution in sport culture and aware-
ness regarding energy availability can
transform the physical and mental health
and performance of athletes globally.
Twitter Kathryn E Ackerman @drkateackerman
Contributors KEA, TS, KJE- S, AB and MLM attended
the B2ten summit and wrote and revised the
manuscript. MC, KG and LF wrote and revised the
manuscript and provided guidance on the athlete’s
Funding The authors have not declared a specific
grant for this research from any funding agency in the
public, commercial or not- for- profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned;
externally peer reviewed.
© Author(s) (or their employer(s)) 2020. No commercial
re- use. See rights and permissions. Published by BMJ.
To cite AckermanKE, StellingwerffT, Elliott-
SaleKJ, etal. Br J Sports Med Epub ahead of print:
[please include Day Month Year]. doi:10.1136/
Accepted 30 December 2019
Br J Sports Med 2020;0:1–2.
Kathryn EAckerman http:// orcid. org/ 0000- 0003- 2626-
1 Cain M. I was the fastest girl in America, until I joined
Nike, 2019. Available: https://www. nytimes. com/ 2019/
11/ 07/ opinion/ nike- running- mary- cain. html
2 Fleshman L. I changed my body for sport. No girl should,
2019. Available: https://www. nytimes. com/ 2019/ 11/ 16/
opinion/ girls- sports. html
3 Futterman M. Another of Alberto Salazar’s Runners
Says He Ridiculed Her Body for Years, 2019. Available:
https://www. nytimes. com/ 2019/ 11/ 14/ sports/ olympics/
alberto- salazar- nike. html
4 Chavez C. Inside the Toxic Culture of the Nike Oregon
Project ’Cult’, 2019. Available: https://www. si. com/
track- and- field/ 2019/ 11/ 13/ mary- cain- nike- oregon-
project- toxic- culture- alberto- salazar- abuse- investigation
5 Mountjoy M, Sundgot- Borgen JK, Burke LM, etal. IOC
consensus statement on relative energy deficiency
in sport (RED- S): 2018 update. Br J Sports Med
6 Vanheest JL, Rodgers CD, Mahoney CE, etal.
Ovarian suppression impairs sport performance in
junior elite female swimmers. Med Sci Sports Exerc
7 Gibbs JC, Williams NI, De Souza MJ. Prevalence of
individual and combined components of the female
athlete triad. Med Sci Sports Exerc 2013;45:985–96.
8 Heikura IA, Uusitalo ALT, Stellingwerff T, etal. Low
energy availability is difficult to assess but outcomes
have large impact on bone injury rates in elite distance
athletes. Int J Sport Nutr Exerc Metab 2018;28:403–11.
on January 10, 2020 at CASEM. Protected by copyright. J Sports Med: first published as 10.1136/bjsports-2019-101926 on 10 January 2020. Downloaded from
... 11,13,19,20 However, some coaches have been identified to prioritise 'high performance' at the cost of long-term health and wellbeing of their athletes. 17,18,21,22 Furthermore, research suggests that while a proportion of coaches collaborate with other health-care practitioners to support athlete health, others fail to appreciate the importance of certain factors (e.g. adequate fuelling for athletes) to mitigate the risks of LEA. ...
... adequate fuelling for athletes) to mitigate the risks of LEA. 7,13,22 Importantly, coaches who employ language and behaviours that overemphasise body composition and/or provide misinformed nutrition advice may predispose athletes to significant harm. 7,8,22,23 Given the potential deleterious implications LEA can have on an athlete's health and performance, 1,8 sporting organisations are starting to acknowledge the importance of providing a nurturing environment to ensure the longterm health of athletes participating in their sport. ...
... 7,13,22 Importantly, coaches who employ language and behaviours that overemphasise body composition and/or provide misinformed nutrition advice may predispose athletes to significant harm. 7,8,22,23 Given the potential deleterious implications LEA can have on an athlete's health and performance, 1,8 sporting organisations are starting to acknowledge the importance of providing a nurturing environment to ensure the longterm health of athletes participating in their sport. 19,24 To assist sporting organisations in achieving these goals, it is important that figures of authority and influence (e.g. ...
Coaches are important figures of influence with potential to create environments that influence athlete health and performance outcomes. Ideally, coaches provide supportive environments that lead to performance optimisation and long-term health. Coaches who employ language and behaviours that overemphasise body composition and/or provide misinformed nutrition advice may predispose athletes to low energy availability (LEA) and the associated health consequences. Having a clear understanding of current knowledge, attitudes and beliefs of coaches with regard to LEA is required to guide future coach education/support initiatives to optimise athlete health and performance. Thus, the aim of this investigation was to systematically review published literature regarding coach knowledge, attitudes/beliefs and behaviours of LEA. Data from 20 eligible studies was extracted into predetermined categories according to coach ‘knowledge‘; ‘attitudes/ beliefs’; and ‘behaviours’ regarding LEA/Relative Energy Deficiency in Sport/Female Athlete Triad and/or eating disorders and/or disordered eating. Any single study could provide outcomes to inform one or multiple of these categories. The majority of results were drawn from studies conducted prior to LEA being defined as a concern for athlete health, which limited our understanding of the contemporary knowledge, attitudes/eliefs and behaviours of coaches on this important issue. That said, indications of gaps in coach knowledge and the employment of inappropriate attitudes/beliefs and behaviours regarding issues associated with LEA were evident. An opportunity exists for key stakeholders to develop comprehensive coach education frameworks, which equip coaches with the adequate capability, opportunity and motivation to support athlete health and avoid the consequences of LEA.
... This involves increasing awareness of REDs through education to all involved in athlete care, such as coaches, trainers, and parents, and having a zero-tolerance policy for toxic training environments or practices that include body shaming, overexercising, and underfuelling. 35 Creating a healthy sport culture may involve coaches focusing on enhancing athletic performance via nondieting strategies such as mental approaches, selecting team captains who have a healthy relationship with food and their body, and deemphasizing talk centered around body weight, food restriction, and/or dieting. 36 Finally, coaches should not be involved in assessing the body composition of athletes, but rather, athletes who express a desire to change body composition should be referred to a sports dietitian who can ensure that safe nutrition changes are made. ...
... Furthermore, from a health perspective, a desire to maintain a low BM or %BF may lead to calorie restriction and a low energy availability, which can impair bone health and result in suboptimal menstrual function (107). This would be indicative of the Female Athlete Triad or Relative Energy Deficit, which has detrimental health implications if not addressed (1). Therefore, caution should be taken when obtaining and translating results from anthropometric assessments. ...
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Beato, M, Datson, N, Anderson, L, Brownlee, T, Coates, A, and Hulton, A. Rationale and practical recommendations for testing protocols in female soccer: A narrative review. J Strength Cond Res XX(X): 000-000, 2023-The aim of this narrative review is to evaluate the presented literature on tests (aerobic, speed, changes of direction [COD], strength, power, jump, and anthropometry) of the varied components of female soccer and to draw attention to the most suitable protocols to allow practitioners to accurately track players' fitness status. The 2 most common field tests used to assess aerobic fitness are the Yo-Yo intermittent test (level 1 and level 2) and the 30-15 intermittent fitness test because of an ability to measure multiple players at once with a soccer-specific intermittent profile. The sprinting performance can be assessed on distances of <30 m; however, longer distances (e.g., 40 m) allow for achieving peak speed (flying sprint test), which can be assessed using global navigation satellite system. Changes-of-direction capacity has been found to be an important component of players testing and training programs, although there is no "gold standard" to assess COD or repeated sprint ability performance in female players. Lower-limb power can be assessed using jump tests that can use force platforms, jump mats, and optoelectronic devices, while maintaining a good reliability. Several in-direct tests are currently available for assessing anthropometry parameters, such as skinfold thickness, hydrodensitometry, and ultrasound. However, dual-energy x-ray absorptiometry is the most valid and reliable method for assessing body composition in team sport athletes, with the addition of bone health that is a key measure in female athletes. In conclusion, the evidence reported in this review will be able to aid practitioners, coaches, and researchers to decide which tests meet the requirements of their environment.
... removing body composition assessments, discouraging supplement use, and promoting eating behaviours and dietary intake that support age-appropriate development) [12], but does not provide an operational approach to manage this outcome. Interestingly, a new conceptual framework layers sport nutrition services onto stages of development and skill level [13], but the scope of focus is limited to the assessment of body composition. The Determinants of Nutrition and Eating (DONE) framework and taxonomy uses tiers, including factors that precede eating, the actions of eating, and the results of eating [2,3], but is not viewed through a sport nutrition lens, nor does it guide servicing decisions. ...
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Appropriate dietary intake can improve athletes’ health and sport performance and is a direct result of eating behaviours. Therefore, assessing and shaping athletes’ eating behaviours and dietary intake is critical to the provision of sport nutrition services. As such, nutrition practitioners must also consider the determinants of eating behaviours. However, dietary intake, eating behaviours, and its determinants are inconsistently defined in the literature, requiring nutrition practitioners to navigate a complicated landscape of concepts and terminology. This is further complicated by limitations in practically measuring and influencing eating behaviours and dietary intake. The proposed Athlete Nutrition Development Approach was developed to aid practitioners in servicing decisions through the athlete development process, through a three-tiered approach to sport nutrition service delivery. Tier 1 addresses the determinants of eating behaviours, Tier 2 directly addresses eating behaviours and dietary intake, and Tier 3 addresses the consequences of dietary intake in relation to health and sport performance. Each tier includes tools for assessment and development.
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Low energy availability (LEA) is a complex health condition that most commonly affects female athletes. Research on LEA is weighted to quantitative approaches, and few studies have employed qualitative methods to understand the development of LEA. Current research fails to understand the complexity of LEA by largely operating within isolated research paradigms. This paper aims to demonstrate the value of integrating a mixed-methods research approach to understand the influence of sporting cultures on the physiological experiences of female athletes with LEA. The mixed-methods approach implemented the use of physiological (quantitative) and socio-psychological (qualitative) data obtained from elite female athletes in three sports: triathlons and running, (n = 11), rugby sevens (n = 9), and track cycling (n = 10). The physiological data consisted of energy availability, haematological analysis, bone health, and body composition. The socio-psychological data consisted of individual semi-structured interviews with topics covering nutrition, body image, the impact of the sporting environment, and experience with LEA. The interview data were thematically analysed. By bringing qualitative and quantitative data together, this paper illustrates the complex relationship between sporting culture and the physiology of LEA. First, endurance athletes categorised as having an LEA showed a positive correlation between the relative energy intake (EI) and serum ferritin, with the interviews revealing a focus on a low body weight and reducing the EI. Second, the interviews with the rugby players showed a strong but hierarchical team culture, with the experienced players monitoring and controlling the EI of novice players. Third, among the cyclists, the EI was reduced in those categorised as having an LEA, with the interviews revealing a coach–athlete power relationship impacting dietary behaviours. To conclude, this paper demonstrates how mixed methods are important for capturing how different sporting cultures impact athletes’ socio-psychological and physiological experiences of LEA.
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Objective To compare multiple body composition analysis methods in athletes with varying states of hydration to the criterion 5-compartment model(5CM) of body composition and assess the relationships of technique-specific estimates of fat and fat-free mass(FM, FFM) to muscle strength. Methods Body composition was assessed in 80(40-female) athletes with a mean age of 21.8±4.2 years. All athletes underwent laboratory-based methods: air-displacement plethysmography(ADP), deuterium-oxide dilution(D 2 O), dual-energy X-ray absorptiometry(DXA), underwater-weighing(UWW), and field-based: 3D-optical(3DO) imaging, and three bioelectrical impedance(BIA) devices(S10/SFB7/SOZO). Participants’ muscular strength was assessed by isokinetic/isometric dynamometry. Accuracy was assessed by Lin’s concordance correlation coefficient(CCC) and precision by root-mean-square coefficient of variation(RMS-CV%). Results Athletes’ hydration status(total body water/FFM) was significantly( p <0.05) outside of the normal range in both males(0.63-0.73%) and females(0.58-0.78%). The most accurate techniques(ADP/DXA) showed moderate-substantial agreement(CCC=0.90-0.95) in FM and FFM, whereas all field assessments had poor agreement(CCC<0.90), except 3DO FFM in females(CCC=0.91). All measures of FFM produced excellent <1.0% precision, whereas FM from ADP, DXA, D 2 O, S10, and UWW had <2.0%. The associations between muscle strength and the various devices’ FFM estimates differed. However, more accurate body composition compared to the criterion produced a better determination of muscle strength by significant quartile p -trends( p< 0.001). The 5CM exhibits the highest determination for all categories of muscle strength which persisted across all hydration measures. Conclusion To optimize accuracy in assessing body composition and muscle strength, researchers and clinicians should prioritize selecting devices based on their accuracy compared to the 5CM. Reliable approaches such as ADP and DXA yield accurate and precise body composition estimates and thereby, better strength assessments, regardless of hydration status. Future athlete studies should investigate the impact of changes in FFM on functional measures compared to the criterion method. Summary Box This study compared various body composition analysis methods in athletes with varying states of hydration to the criterion 5-compartment model(5CM) and assessed their relationship to muscle strength. The results showed that accurate and precise estimates of body composition can be determined in athletes, and a more accurate body composition measurement produced better strength estimates. The best laboratory-based techniques were air displacement plethysmography(ADP) and dual-energy x-ray absorptiometry(DXA), while field assessments had moderate-poor agreement. Prioritize accurate body composition assessment devices compared to the 5CM for better strength estimates in athletes.
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Unlabelled: Young athletes may be at risk for low energy availability (LEA) or dietary habits that are indicative of eating disorders. Thus, the purpose of the current study was to investigate the prevalence of LEA among high school athletes and examine those at risk for eating disorders. A secondary aim was to examine relationships between sport nutrition knowledge, body composition, and LEA. Methods: 94 male (n = 42) and female (n = 52) mean ± SD age: 18.09 ± 2.44 y; height: 172.6 ± 9.8 cm; body mass: 68.7 ± 14.5 kg; BMI: 22.91 ± 3.3 kg·m-2) athletes completed a body composition assessment and electronic versions of the abridged sports nutrition knowledge questionnaire (ASNK-Q), brief eating disorder in athletes questionnaire (BEDA-Q), and the low energy availability for females questionnaire (LEAF-Q; females only). Results: 52.1% of female athletes were classified as being at risk for LEA. Moderate inverse relationships existed for computed LEAF-Q scores and BMI (r = -0.394; p < 0.01). A total of 42.9% of males (n = 18) and 68.6% of females (n = 35) were at risk for eating disorders, with females being at greater risk (p < 0.01). Body fat percentage was a predictor (β = -0.095; p = -0.01) for eating disorder risk status. For every 1 unit increase in body fat percentage, athletes were 0.909 (95% CI: 0.845-0.977) times less likely to be classified as at risk for an eating disorder. Male (46.5 ± 13.9) and female (46.9 ± 11.4) athletes scored poorly on the ASNK-Q, with no differences between sex (p = 0.895). Conclusions: Female athletes were at a greater risk for eating disorders. No relationships existed between sport nutrition knowledge and %BF. Female athletes with a higher %BF had a lower risk for an eating disorder and risk for LEA.
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Female endurance athletes are considered a high-risk group for developing Relative Energy Deficiency in Sport (REDs). Due to the lack of educational and behavioral intervention studies, targeting and evaluating the effects of the practical daily management of REDs, we developed the Food and nUtrition for Endurance athletes—a Learning (FUEL) program, consisting of 16 weekly online lectures and individual athlete-centered nutrition counseling every other week. We recruited female endurance athletes from Norway (n = 60), Sweden (n = 84), Ireland (n = 17), and Germany (n = 47). Fifty athletes with symptoms of REDs and with low risk of eating disorders, with no use of hormonal contraceptives and no chronic diseases, were allocated to either the FUEL intervention (n = 32) (FUEL) or a 16-week control period (n = 18) (CON). All but one completed FUEL, while 15 completed CON. We found strong evidence for improvements in sports nutrition knowledge, assessed via interviews, and moderate to strong evidence in the ratings concerning self-perceived sports nutrition knowledge in FUEL versus CON. Analyses of the seven-day prospective weighed food record and questions related to sports nutrition habits, suggested weak evidence for improvements in FUEL versus CON. The FUEL intervention improved sports nutrition knowledge and suggested weak evidence for improved sports nutrition behavior in female endurance athletes with symptoms of REDs.
While boys and men have historically been underrepresented in eating disorder research, increasing interest and research during the twenty-first century have contributed important knowledge to the field. In this article, we review the epidemiology of eating disorders and muscle dysmorphia (the pathological pursuit of muscularity) in boys and men; specific groups of men at increased risk for eating disorders; sociocultural, psychological, and biological vulnerability factors; and male-specific assessment measures. We also provide an overview of current research on eating disorder and muscle dysmorphia prevention efforts, treatment outcomes, and mortality risk in samples of boys and men. Priorities for future research are including boys and men in epidemiolocal studies to track changes in incidence, identifying (neuro)biological factors contributing to risk, eliminating barriers to treatment access and utilization, and refining male-specific prevention and treatment efforts. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 19 is May 2023. Please see for revised estimates.
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We aimed to (1) report energy availability (EA), metabolic/reproductive function, bone mineral density (BMD) and injury/illness rates in national/world-class female and male distance-athletes; and (2) investigate the robustness of various diagnostic criteria from the Female Athlete Triad (Triad), Low Energy Availability in Females Questionnaire (LEAF-Q) and Relative Energy Deficiency in Sport (RED-S) tools to identify risks associated with low EA. Athletes were distinguished according to benchmarks of reproductive function (amenorrheic [n=13] vs eumenorrheic [n=22]; low [lowest quartile of reference range, n=10] vs normal testosterone [n=14]) and EA calculated from 7-day food and training diaries (< or >30 Sex hormones (p<0.001), triiodothyronine (p<0.05) and BMD (females, p<0.05) were significantly lower in amenorrheic (37%) and low testosterone (40%; 15.1±3.0 nmol/L-1) athletes and bone injuries were ~4.5-fold more prevalent in amenorrheic (ES=0.85; large) and low testosterone (ES=0.52; moderate) groups compared to others. Categorization of females and males using Triad or RED-S tools revealed that higher risk groups had significantly lower T3 (female and male Triad and RED-S:p<0.05) and higher number of all-time fractures (male Triad:p<0.001; male RED-S and female Triad:p<0.01) as well as non-significant but markedly (up to 10-fold) higher number of training days lost to bone injuries during the preceding year. Based on the cross-sectional analysis, current reproductive function (questionnaires/blood hormone concentrations) appears to provide a more objective and accurate marker of optimal energy for health than the more error-prone and time-consuming dietary and training estimation of EA. This study also offers novel findings that athlete health is associated with EA indices.
Competitive female athletes restrict energy intake and increase exercise energy expenditure frequently resulting in ovarian suppression. The purpose of this study was to determine the impact of ovarian suppression and energy deficit on swimming performance (400m swim velocity). Menstrual status was determined by circulating estradiol (E2) and progesterone (P4) in ten junior elite female swimmers (15-17 yrs). The athletes were categorized as cyclic (CYC) or ovarian suppressed (OVS). They were evaluated every two weeks for metabolic hormones, bioenergetic parameters and sport performance over the 12-week season. CYC and OVS athletes were similar (p > 0.05) in age (CYC = 16.2 ± 1.8 yr; OVS = 17 ± 1.7 yr), BMI (CYC = 21 ± 0.4 kg/m; OVS = 25 ± 0.8 kg/m), and gynecological age (CYC = 2.6 ± 1.1 yr; OVS = 2.8 ± 1.5 yr). OVS had suppressed P4 (p < 0.001) and E2 (p = 0.002) across the season. Total triiodothyronine (TT3) and insulin-like growth factor (IGF-1) were lower in OVS (TT3: CYC = 1.6 ± 0.2 nmol/l; OVS = 1.4 ± 0.1 nmol/l p < 0.001; IGF-1: CYC = 243 ± 1 μg/ml; OVS = 214 ± 3 μg/ml p < 0.001) than CYC at Week 12. Energy intake (p < 0.001) and energy availability (p < 0.001) were significantly lower in OVS versus CYC. OVS exhibited a 9.8% decline in [INCREMENT]400m-swim velocity compared to an 8.2% improvement in CYC at Week 12. Ovarian steroids (P4 and E2), metabolic hormones (TT3 and IGF-1) and energy status markers (EA and EI) were highly correlated with sport performance. This study illustrates that when exercise training occurs in the presence of ovarian suppression with evidence for energy conservation (ie. reduced TT3), it is associated with poor sport performance. These data from junior elite female athletes support the need for dietary periodization to help optimize energy intake for appropriate training adaptation and maximal sport performance.
Purpose: The female athlete triad (Triad) is a syndrome linking low energy availability (EA) with or without disordered eating (DE), menstrual disturbances (MD), and low bone mineral density (BMD) in exercising women. The prevalence of Triad conditions (both clinical and subclinical) has not been clearly established.The purpose of this review is to evaluate the studies that determined the prevalence of clinical or subclinical Triad conditions (low EA, DE, MD, and low BMD) in exercising women and in women participating in lean (LS) versus nonlean sports (NLS) using self-report and/or objective measures. Methods: A review of publications using MEDLINE and PubMed was completed. Randomized controlled trials and observational studies that evaluated the prevalence of clinical and subclinical Triad conditions (MD, low BMD, low EA, and DE) in exercising women were included. Results: Sixty-five studies were identified for inclusion in this review (n = 10,498, age = 21.8 ± 3.5 yr, body mass index = 20.8 ± 2.6 kg·m; mean ± SD). A relatively small percentage of athletes (0%-15.9%) exhibited all three Triad conditions (nine studies, n = 991). The prevalence of any two or any one of the Triad conditions in these studies ranged from 2.7% to 27.0% and from 16.0% to 60.0%, respectively. The prevalence of all three Triad conditions in LS athletes versus NLS athletes ranged from 1.5% to 6.7% and from 0% to 2.0%, respectively. LS athletes demonstrated higher prevalence rates of MD and low BMD (3.3% vs 1.0%), MD and DE (6.8%-57.8% vs 5.4%-13.5%), and low BMD and DE (5.6% vs 1.0%) than the NLS athletes. Conclusions: Although the prevalence of individual/combined Triad conditions is concerning, our review demonstrates that additional research on the prevalence of the Triad using objective and/or self-report/field measures is necessary to more accurately describe the extent of the problem.
I was the fastest girl in America, until I joined Nike
  • M Cain
Cain M. I was the fastest girl in America, until I joined Nike, 2019. Available: https://www. nytimes. com/ 2019/ 11/ 07/ opinion/ nike-running-mary-cain. html
I changed my body for sport. No girl should
  • L Fleshman
Fleshman L. I changed my body for sport. No girl should, 2019. Available: https://www. nytimes. com/ 2019/ 11/ 16/ opinion/ girls-sports. html
Another of Alberto Salazar’s Runners Says He Ridiculed Her Body for Years
  • M Futterman
Futterman M. Another of Alberto Salazar's Runners Says He Ridiculed Her Body for Years, 2019. Available: https://www. nytimes. com/ 2019/ 11/ 14/ sports/ olympics/ alberto-salazar-nike. html
Inside the Toxic Culture of the Nike Oregon Project 'Cult
  • C Chavez
Chavez C. Inside the Toxic Culture of the Nike Oregon Project 'Cult', 2019. Available: https://www. si. com/ track-and-field/ 2019/ 11/ 13/ mary-cain-nike-oregonproject-toxic-culture-alberto-salazar-abuse-investigation