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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
... Since 2006, the IOC has released multiple consensus statementssuch as its 2014 consensus statement on RED-S (Mountjoy et al., 2014)-to protect athletes' health and provide guidelines for the IOC and other sports organizations (Weston, 2017). Still, scholars and other athletes have urged sports organizations to take a more proactive role in establishing protocols and eliminating abusive training environments (Ackerman et al., 2020). ...
... For Semenya and Negesa, 'protection' involved adhering to (arbitrary) medical standards to support reductive and biocentric definitions of 'eligibility.' For Cain, despite urging attention to the cultural dimensions that contribute to RED-S (see Ackerman et al., 2020), policy documents remain focused on individual diagnosis and treatment, rather than reimagining toxic sporting cultures. ...
Women's sport remains a contested realm that frequently features standards and regulations premised on women's inferiority and physiological distinctions from men. In response to these purported sex-based differences, a range of protective policies have been implemented to ostensibly ensure women's safety and health, defend “fair competition” in women's sport, and/or prevent the violation of social and medical boundaries that define who is a “woman.” Yet, protective policies encompass a multitude of rationales and strategies, demonstrating the malleability of “protection” in terms of who is protected and why. In this article, I draw from Michel Foucault's theory of “governmentality” to investigate the nuances of protective policies, especially their placed importance on sex differences. To do so, I examine three case studies: World Athletics’ (WA) 2019 female eligibility policy, WA's 2019 transgender eligibility policy, and the International Olympic Committee's (IOC) consensus statement on relative energy deficiency in sport (RED-S). Using document texts and semi-structured interviews with eight scientists involved with developing the case studies, I find that protective policies are developed through messy and often contentious processes that selectively draw from varying knowledges and discourses. This then culminates in contrasting methods of defining, protecting, and governing women athletes and their bodies.
... In addition, the frequency of protein consumption should increase 201,203,204 . By spreading protein intake throughout the day, it is thought that a sufficient pool of protein and amino acids will be available to support protein synthesis 201,203,205,206 . ...
... Guidelines for nutrition and body composition across the stages of athlete development. Adapted from Ackerman (2020)206 . ...
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The Female Athlete Triad (Triad) and the more encompassing Relative Energy Deficiency in Sport (RED-S) are disorders caused by low energy availability (LEA). LEA is a state of insufficient energy intake by an athlete relative to their energy expenditure. Persistent LEA results in the deleterious consequences to health and performance that comprise RED-S. With respect to both the Triad and RED-S, researchers have called for more education of those involved with sport, particularly coaches, to help reduce the incidence of these disorders. Recent studies have shown that as few as 15% of coaches are aware of the Triad, with up to 89% unable to identify even one of its symptoms. RED-S is a more recently established concept such that coach knowledge regarding it has only begun to be assessed, but the results of these initial studies indicate similar trends as for the Triad. In this review, we synthesize research findings from 1986 to 2021 that pertains to LEA and RED-S, which coaches should know so they can better guide their athletes.
... Sustained research on factors associated with LEA is important for practitioners and other health professionals for early detection and aid in the nutrition interventions to prevent potential decrements in health and performance Ackerman et al., 2020). The association between disordered eating behavior and health consequences as a result of LEA in female athletes is well-researched and suggest that particular athletes from weight-sensitive sports, including endurance sports, may be at higher risk (Gibbs et al., 2013). ...
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Relative energy deficiency in sport (RED-S) is a complex syndrome describing health and performance consequences of low energy availability (LEA) and is common among female endurance athletes. Various underlying causes of LEA have been reported, including disordered eating behavior (DE), but studies investigating the association with exercise addiction and food intolerances are lacking. Therefore, the aim of this cross-sectional study was to investigate the association between DE, exercise addiction and food intolerances in athletes at risk of LEA compared to those with low risk. Female endurance athletes, 18-35 years, training ≥5 times/week were recruited in Norway, Sweden, Ireland, and Germany. Participants completed an online-survey comprising the LEA in Females Questionnaire (LEAF-Q), Exercise Addiction Inventory (EAI), Eating Disorder Examination Questionnaire (EDE-Q), and questions regarding food intolerances. Of the 202 participants who met the inclusion criteria and completed the online survey, 65% were at risk of LEA, 23% were at risk of exercise addiction, and 21% had DE. Athletes at risk of LEA had higher EDE-Q and EAI scores compared to athletes with low risk. EAI score remained higher in athletes with risk of LEA after excluding athletes with DE. Athletes at risk of LEA did not report more food intolerances (17 vs. 10%, P = 0.198), but were more frequently reported by athletes with DE (28 vs. 11%, P = 0.004). In conclusion, these athletes had a high risk of LEA, exercise addiction, and DE. Exercise addiction should be considered as an additional risk factor in the prevention, early detection, and targeted treatment of REDS among female endurance athletes.
... This confusion may lead to athletes and coaches alike assuming an athlete is eumenorrheic when HC use may be masking menstrual dysfunction [29]. Given that menstrual dysfunction is an important indicator of Relative Energy Deficiency in Sport (RED-S) [30], and the recent call for positive communication around the menstrual cycle in this context [31,32], increasing awareness of this issue of 'masking' may be important amongst athletes and practitioners. ...
OBJECTIVES The prevalence of hormonal contraceptive (HC) use and the associated symptomology of use or non-use are under-studied in athletic populations, and in particular, in strength and collision sports. This study aimed to investigate the prevalence of hormonal contraceptive use and reported side effects of the menstrual cycle and hormonal contraceptive use in powerlifters and rugby players. METHODS Competitive female powerlifters and rugby players (aged ≥18 y), representing a strength and a collision sport respectively, completed an anonymous online questionnaire for the purpose of assessing self-reported prevalence of HC use, and symptoms of the menstrual cycle and HC use. Athletes were categorized by sport (powerlifters, n=149; rugby players, n=135) in order to conduct a stratified analysis. For open-ended questions, a content analysis was conducted to categorize responses, and frequency analyses were performed. RESULTS Current HC use was reported by 51.1% of athletes, with similar prevalence for the two sports (powerlifting, 48.3% vs. rugby, 54.1%, P=0.34). Side effects of the menstrual cycle were reported in 83.5% of non-HC users, with the most common being unspecified cramping (42.4%), headache/migraine (24.5%), and fatigue (24.5%). Side effects were reported in 40.0% of HC users, with the most common being mood changes (17.9%), stomach pain (8.3%) and headaches/migraines (6.9%). CONCLUSION A large proportion of HC users and non-users in this study experience negative side effects of HC use and the menstrual cycle, respectively. The symptoms experienced by both groups are wide-ranging, with a high degree of variation between individuals. The negative side-effects experienced by HC users and non-users may have an influence on athletic performance, and this requires future investigation.
... When the UWB signal is received by the base station whose coordinate position is known, the real-time position of the label is calculated according to the time information, angle information, or intensity information of the label. There are three main methods for a base station to obtain UWB signals: (1) by using the signal flight time (TOF), the signal arrival time (TOA) sent by the base station receiving the positioning label, and the difference between the arrival time of two base stations receiving the signal (TDOA) to obtain the time information; (2) by using the base station receiving signal arrival strength (RSSI) to obtain the signal strength information [13,14]; and (3) by using the base station receiving signal arrival angle (AOA) to obtain the angle information. Two-dimensional positioning needs at least 2 base stations, and three-dimensional positioning needs at least 3 base stations. ...
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In order to reduce the sports injury caused by high intensity sports classes, it is necessary to monitor the state of the sports load. Therefore, the sport’s load monitoring system based on a threshold classification algorithm is proposed. In this paper, we design the hardware and software structures of the sports load monitoring systems in a physical education class. In this system, the state parameters of the sports load are collected by wireless sensor network nodes, and the feature parameters are fused and clustered by the integrated information fusion method. After that, we establish the movement target image acquisition model, which unifies the ZigBee networking realization to the high intensity sports classroom movement load monitoring. Simulation results show that the designed PE classroom sports load monitoring system based on the threshold classification algorithm has high performance for sports parameter monitoring and can effectively avoid sports injury caused by overload.
... For example, previous findings suggest that careless comments from coaches referencing weight or appearance can precipitate the onset of, or perpetuate, disordered eating or eating disorders in athletes [11]. This evidence, combined with high-profile advocacy from former athletes [12] and a greater appreciation of the longterm health consequences of mismanaging the diet/exercise relationship in adolescent athletes [13], has led to recent calls to fundamentally change how sports manage aspiring athletes [14]. These changes may involve avoiding unwarranted nutrition/food-related discussions, abolishing body composition/weight assessments, raising awareness of the negative effects of chronic low energy availability (LEA), and disrupting toxic training environments featuring abusive body shaming, including the use of training strategies designed to manipulate an athlete's physique independent of performance. ...
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Adolescence (ages 13–18 years) is a period of significant growth and physical development that includes changes in body composition, metabolic and hormonal fluctuations, maturation of organ systems, and establishment of nutrient deposits, which all may affect future health. In terms of nutrition, adolescence is also an important time in establishing an individual’s lifelong relationship with food, which is particularly important in terms of the connection between diet, exercise, and body image. The challenges of time management (e.g., school, training, work and social commitments) and periods of fluctuating emotions are also features of this period. In addition, an adolescent’s peers become increasingly powerful moderators of all behaviours, including eating. Adolescence is also a period of natural experimentation and this can extend to food choice. Adolescent experiences are not the same and individuals vary considerably in their behaviours. To ensure an adolescent athlete fulfils his/her potential, it is important that stakeholders involved in managing youth athletes emphasize eating patterns that align with and support sound physical, physiological and psychosocial development and are consistent with proven principles of sport nutrition.
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Relative Energy Deficiency in sport is experiencing remarkable popularity of late, particularly among female athletes. This condition is underpinned by low energy availability, which is a byproduct of high energy expenditure, inadequate energy intake, or a combination of the two. Several contributing factors exist that may predispose an athlete to low energy availability, and therefore a holistic and comprehensive assessment may be required to identify the root causes. The focus of the current narrative review is to discuss the primary contributing factors as well as known risk factors for low energy availability among female athletes to help practitioners increase awareness on the topic and identify future areas of focus.
Objective No study to date has investigated an intervention program for male athletes that targets eating disorder risk factors. The purpose of this study was to measure the effects of the Male Athlete Body Project (MABP), an adaptation of the Female Athlete Body Project on body dissatisfaction, drive for muscularity, body-ideal internalization, and muscle dysmorphia. Method Participants were 79 male collegiate athletes who were randomized to the MABP (n = 39) or an assessment-only control condition (n = 40). All participants completed psychometrically validated measures at three time points: baseline, post-treatment (3 weeks after baseline for the control condition), and 1-month follow-up. Results Hierarchical Linear Modeling assessed differences between conditions across time. Interaction effects revealed that participation in the MABP improved satisfaction with specific body parts and reduced drive for muscularity and body-ideal internalization at post-treatment compared to a control group. Athletes in the MABP also reported increased body areas satisfaction and reductions in drive for muscularity at 1-month follow-up. Reductions in supplement use were observed at 1-month follow-up only. Discussion This study provides preliminary evidence of the efficacy of the MABP in reducing some eating disorder risk factors up to 1 month after the intervention; follow-up study considerations are discussed. Clinical Trial Registration Number: NCT04077177 Public Significance This study highlights the importance of eating disorder and body image intervention efforts for male athletes. Findings suggest that male college athletes who attended a 3-session group intervention based on a well-established program for college women experienced an increase in satisfaction with specific body areas and a reduction in some eating disorder risk factors (e.g., drive for muscularity, supplement use, and body-ideal internalization) compared to a control group.
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The International Olympic Committee has identified mental health as a priority that significantly affects the physical health and safety of collegiate athletes. Interventions that improve diet quality have been shown to improve mental health in several populations. However, studies are needed to examine this relationship in female collegiate athletes, who have elevated risk of experiencing anxiety and depression symptoms, as well as dietary insufficiencies. In a quantitative, cross-sectional study, female student athletes at a U.S. university completed three mental health questionnaires: Depression Anxiety and Stress Scale (DASS-21), Athlete Psychological Strain Questionnaire (APSQ), and COVID Stress Scales (CSS). Each female athlete also completed a validated, web-based Diet History Questionnaire (DHQ-III) resulting in a Healthy Eating Index (HEI). Seventy-seven participants completed all survey information. HEI scores were consistently higher for athletes with poorer mental health. HEI scores were significantly positively associated with stress (p = 0.015), performance concerns (p = 0.048), CSS components of danger (p = 0.007), contamination (p = 0.006), and traumatic stress (p = 0.003). Although findings support statistically significant associations among dietary quality and mental health indicators, including broad symptom severity or stressors specific to athletics or COVID-19, these associations were in the opposite direction hypothesized. Possible reasons for results and suggestions for future research are discussed.
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Functional hypothalamic amenorrhea (FHA) is a very common condition affecting women of procreative age. There are many reasons for this disorder, including a low availability of energy in the diet, low micro- and macronutrient intake, overly intensive physical activity, disturbed regeneration processes, sleep disorders, stress, and psychological disorders. The main determinant is long-term stress and an inability to handle the effects of that stress. FHA is a very complex disorder and often goes undiagnosed. Moreover, therapeutic interventions do not address all the causes of the disorder, which could have implications for women’s health. As shown by scientific reports, this condition can be reversed by modifying its causes. This review of the literature aims to update the current knowledge of functional hypothalamic amenorrhea and underscores the complexity of the disorder, with particular emphasis on the nutritional aspects and potential interventions for restoring balance.
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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