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Louise M. Burke, Graeme L. Close, Bronwen Lundy, Martin Mooses, James P. Morton, and Adam S. Tenforde

Low energy availability (LEA) is a key element of the Female Athlete Triad. Causes of LEA include failure to match high exercise energy expenditure (unintentional) or pathological behaviors of disordered eating (compulsive) and overzealous weight control programs (misguided but intentional). Recognition of such scenarios in male athletes contributed to the pronouncement of the more inclusive Relative Energy Deficiency in Sport (RED-S) syndrome. This commentary describes the insights and experience of the current group of authors around the apparently heightened risk of LEA in some populations of male athletes: road cyclists, rowers (lightweight and open weight), athletes in combat sports, distance runners, and jockeys. The frequency, duration, and magnitude of the LEA state appear to vary between populations. Common risk factors include cyclical management of challenging body mass and composition targets (including “making weight”) and the high energy cost of some training programs or events that is not easily matched by energy intake. However, additional factors such as food insecurity and lack of finances may also contribute to impaired nutrition in some populations. Collectively, these insights substantiate the concept of RED-S in male athletes and suggest that a specific understanding of a sport, subpopulation, or culture may identify a complex series of factors that can contribute to LEA and the type and severity of its outcomes. This commentary provides a perspective on the range of risk factors that should be addressed in future surveys of RED-S in athletic populations and targeted for specific investigation and modification.

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Margo L. Mountjoy, Louise M. Burke, Trent Stellingwerff, and Jorunn Sundgot-Borgen

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Sherry Robertson and Margo Mountjoy

The syndrome of relative energy deficiency in sport (RED-S) is a clinical entity characterized by low energy availability, which can negatively affect the health and performance of both male and female athletes. The underlying mechanism of RED-S is an inadequacy of dietary energy to support optimal health and performance. This syndrome refers to impaired physiological function, including metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health, with psychological consequences that can either precede (through restrictive dietary habits) or result from RED-S. The term RED-S extends beyond the condition termed the “Female Athlete Triad.” Formerly known as synchronized swimming, artistic swimming is an Olympic sport requiring a high level of fitness as well as technical skill and artistry. The risk of RED-S is high in artistic swimming as it is an aesthetic, judged sport with an emphasis on a lean physique. RED-S is of significant concern in the sport of artistic swimming because of the potential negative effects on physical and mental health as well as consequences on athletic performance. This paper reviews health and performance consequences associated with low energy availability resulting in RED-S in artistic swimming. Medical and nutritional considerations specific to artistic swimming are reviewed, and methods to help detect and manage RED-S are discussed. Prevention and management of RED-S in this athlete population should be a priority for coaches, and the sport medicine professionals working with artistic swimming athletes should utilize the RED-S CAT, a Clinical Assessment Tool for screening and managing RED-S.

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Monica Klungland Torstveit, Ida Fahrenholtz, Thomas B. Stenqvist, Øystein Sylta, and Anna Melin

Endurance athletes are at increased risk of relative energy deficiency associated with metabolic perturbation and impaired health. We aimed to estimate and compare within-day energy balance in male athletes with suppressed and normal resting metabolic rate (RMR) and explore whether within-day energy deficiency is associated with endocrine markers of energy deficiency. A total of 31 male cyclists, triathletes, and long-distance runners recruited from regional competitive sports clubs were included. The protocol comprised measurements of RMR by ventilated hood and energy intake and energy expenditure to predict RMRratio (measured RMR/predicted RMR), energy availability, 24-hr energy balance and within-day energy balance in 1-hr intervals, assessment of body composition by dual-energy X-ray absorptiometry, and blood plasma analysis. Subjects were categorized as having suppressed (RMRratio < 0.90, n = 20) or normal (RMRratio > 0.90, n = 11) RMR. Despite there being no observed differences in 24-hr energy balance or energy availability between the groups, subjects with suppressed RMR spent more time in an energy deficit exceeding 400 kcal (20.9 [18.8–21.8] hr vs. 10.8 [2.5–16.4], p = .023) and had larger single-hour energy deficits compared with subjects with normal RMR (3,265 ± 1,963 kcal vs. −1,340 ± 2,439, p = .023). Larger single-hour energy deficits were associated with higher cortisol levels (r = −.499, p = .004) and a lower testosterone:cortisol ratio (r = .431, p = .015), but no associations with triiodothyronine or fasting blood glucose were observed. In conclusion, within-day energy deficiency was associated with suppressed RMR and catabolic markers in male endurance athletes.

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Ken Pitetti, Ruth Ann Miller, and E. Michael Loovis

Male youth (8–18 years) with intellectual disability (ID) demonstrate motor proficiency below age-related competence capacities for typically developing youth. Whether below-criteria motor proficiency also exists for females with ID is not known. The purpose of this study was to determine if sex-specific differences exist in motor proficiency for youth with ID. The Bruininks-Oseretsky Test of Motor Proficiency was used to measure motor proficiency: six items for upper limb coordination, seven items for balance, and six items for bilateral coordination. One hundred and seventy-two (172) males and 85 females with ID but without Down syndrome were divided into five age groups for comparative purposes: 8–10, 11–12, 13–14, 15–16, and 17–21 years. Males scored sufficiently higher than females to suggest that sex data should not be combined to established Bruininks-Oseretsky Test of Motor Proficiency standards for upper limb coordination, balance, and bilateral coordination subtests.

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D. Enette Larson-Meyer, Kathleen Woolf, and Louise Burke

Nutrition assessment is a necessary first step in advising athletes on dietary strategies that include dietary supplementation, and in evaluating the effectiveness of supplementation regimens. Although dietary assessment is the cornerstone component of the nutrition assessment process, it should be performed within the context of a complete assessment that includes collection/evaluation of anthropometric, biochemical, clinical, and environmental data. Collection of dietary intake data can be challenging, with the potential for significant error of validity and reliability, which include inherent errors of the collection methodology, coding of data by dietitians, estimation of nutrient composition using nutrient food tables and/or dietary software programs, and expression of data relative to reference standards including eating guidance systems, macronutrient guidelines for athletes, and recommended dietary allowances. Limitations in methodologies used to complete anthropometric assessment and biochemical analysis also exist, as reference norms for the athlete are not well established and practical and reliable biomarkers are not available for all nutrients. A clinical assessment collected from history information and the nutrition-focused physical exam may help identify overt nutrient deficiencies but may be unremarkable in the well-trained athlete. Assessment of potential food-drug interactions and environmental components further helps make appropriate dietary and supplement recommendations. Overall, the assessment process can help the athlete understand that supplement intake cannot make up for poor food choices and an inadequate diet, while a healthy diet helps ensure maximal benefit from supplementation. Establishment of reference norms specifically for well-trained athletes for the nutrition assessment process is a future research priority.

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Ina Garthe and Ronald J. Maughan

In elite sport, where opponents are evenly matched, small factors can determine the outcome of sporting contests. Not all athletes know the value of making wise nutrition choices, but anything that might give a competitive edge, including dietary supplements, can seem attractive. Between 40% and 100% of athletes typically use supplements, depending on the type of sport, level of competition, and the definition of supplements. However, unless the athlete has a nutrient deficiency, supplementation may not improve performance and may have a detrimental effect on both performance and health. Dietary supplements are classified as a subcategory of food, so manufacturers are not required to provide evidence of product safety and efficacy, nor obtain approval from regulatory bodies before marketing supplements. This creates the potential for health risks, and serious adverse effects have been reported from the use of some dietary supplements. Athletes who compete in sports under an anti-doping code must also realize that supplement use exposes them to a risk of ingesting banned substances or precursors of prohibited substances. Government systems of regulations do not include specific laboratory testing for banned substances according to the WADA list, so a separate regulatory framework to evaluate supplements for their risk of provoking a failed doping test is needed. In the high-performance culture typical of elite sport, athletes may use supplements regardless of possible risks. A discussion around medical, physiological, cultural, and ethical questions may be warranted to ensure that the athlete has the information needed to make an informed choice.

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Eric S. Rawson, Mary P. Miles, and D. Enette Larson-Meyer

Some dietary supplements are recommended to athletes based on data that supports improved exercise performance. Other dietary supplements are not ergogenic per se, but may improve health, adaptation to exercise, or recovery from injury, and so could help athletes to train and/or compete more effectively. In this review, we describe several dietary supplements that may improve health, exercise adaptation, or recovery. Creatine monohydrate may improve recovery from and adaptation to intense training, recovery from periods of injury with extreme inactivity, cognitive processing, and reduce severity of or enhance recovery from mild traumatic brain injury (mTBI). Omega 3-fatty acid supplementation may also reduce severity of or enhance recovery from mTBI. Replenishment of vitamin D insufficiency or deficiency will likely improve some aspects of immune, bone, and muscle health. Probiotic supplementation can reduce the incidence, duration, and severity of upper respiratory tract infection, which may indirectly improve training or competitive performance. Preliminary data show that gelatin and/or collagen may improve connective tissue health. Some anti-inflammatory supplements, such as curcumin or tart cherry juice, may reduce inflammation and possibly delayed onset muscle soreness (DOMS). Beta-hydroxy beta-methylbutyrate (HMB) does not consistently increase strength and/or lean mass or reduce markers of muscle damage, but more research on recovery from injury that includes periods of extreme inactivity is needed. Several dietary supplements, including creatine monohydrate, omega 3-fatty acids, vitamin D, probiotics, gelatin, and curcumin/tart cherry juice could help athletes train and/or compete more effectively.

Open access

In the article by Gough, L.A., Rimmer, S., Osler, C.J., & Higgins, M.F. (2017). Ingestion of sodium bicarbonate (NaHCO3) following a fatiguing bout of exercise accelerates postexercise acid-base balance recovery and improves subsequent high-intensity cycling time to exhaustion, International Journal of Sport Nutrition and Exercise Metabolism, 27(5), 429–438, doi:10.1123/ijsnem.2017-0065, we did not accurately reflect several content and layout corrections which were needed.

These include:

  1. (a)The key for Figure 1 was erroneously included for Figure 3 (and not for Figure 1).
  2. (b)The abbreviation for PRE was missing from the Figure 1 key.
  3. (c)Figure 3 contained two indicators (+) which were not necessary.

The online version of this article has been corrected. We sincerely apologize for these errors.