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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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Rebekah D. Alcock, Gregory C. Shaw, Nicolin Tee, Marijke Welvaert, and Louise M. Burke

The urinary excretion of hydroxyproline (Hyp), abundant in collagen protein, may serve as a biomarker of habitual collagen intake, assisting with investigations of current interest in the role of dietary collagen intake in supporting the synthesis of collagenous body tissues. This study investigated the time course of urinary Hyp excretion in “free-living,” healthy, active males following the ingestion of a standardized bolus (20 g) of collagenous (gelatin and a hydrolyzed collagen powder) and dairy (calcium caseinate and hydrolyzed casein) proteins. The excretion of Hyp was assessed over a 24-hr period, separated into three collection periods: 0–6, 6–12, and 12–24 hr. Hyp was elevated for 0–6 hr after the consumption of collagen-containing supplements (gelatin 31.3 ± 8.8 mmol/mol and hydrolyzed collagen 33.7 ± 22.0 mmol/mol vs. baseline: gelatin 2.4 ± 1.7 mmol/mol and hydrolyzed collagen 2.8 ± 1.5 mmol/mol; p < .05), but not for the dairy protein supplements (calcium caseinate 3.4 ± 1.7 mmol/mol and hydrolyzed casein 4.0 ± 3.7 mmol/mol; p > .05). Therefore, urinary Hyp reflects an acute intake of collagenous protein, but is not suitable as a biomarker for quantifying habitual collagen intake, provided through regular dietary practices in “free-living,” healthy, active males.

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Naroa Etxebarria, Brad Clark, Megan L. Ross, Timothy Hui, Roland Goecke, Ben Rattray, and Louise M. Burke

The ingestion of quinine, a bitter tastant, improves short-term (30 s) cycling performance, but it is unclear whether this effect can be integrated into the last effort of a longer race. The purpose of this study was to determine whether midtrial quinine ingestion improves 3,000-m cycling time-trial (TT) performance. Following three familiarization TTs, 12 well-trained male cyclists (mean ± SD: mass = 76.6 ± 9.2 kg, maximal aerobic power = 390 ± 50 W, maximal oxygen uptake = 4.7 ± 0.6 L/min) performed four experimental 3,000-m TTs on consecutive days. This double-blind, crossover design study had four randomized and counterbalanced conditions: (a) Quinine 1 (25-ml solution, 2 mM of quinine); (b) Quinine 2, replicate of Quinine 1; (c) a 25-ml sweet-tasting no-carbohydrate solution (Placebo); and (d) 25 ml of water (Control) consumed at the 1,850-m point of the TT. The participants completed a series of perceptual scales at the start and completion of all TTs, and the power output was monitored continuously throughout all trials. The power output for the last 1,000 m for all four conditions was similar: mean ± SD: Quinine 1 = 360 ± 63 W, Quinine 2 = 367 ± 63 W, Placebo = 364 ± 64 W, and Control = 367 ± 58 W. There were also no differences in the 3,000-m TT power output between conditions. The small perceptual differences between trials at specific 150-m splits were not explained by quinine intake. Ingesting 2 mM of quinine during the last stage of a 3,000-m TT did not improve cycling performance.

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Ida A. Heikura, Marc Quod, Nicki Strobel, Roger Palfreeman, Rita Civil, and Louise M. Burke

Purpose: To assess energy and carbohydrate (CHO) availability and changes in blood hormones in 6 professional male cyclists over multiple single-day races. Methods: The authors collected weighed-food records, power-meter data, and morning body mass measurements across 8 d. CHO intakes were compared with contemporary guidelines. Energy availability (EA) was calculated as energy intake minus exercise energy expenditure, relative to fat-free mass (FFM). Skinfold thickness and blood metabolic and reproductive hormones were measured prestudy and poststudy. Statistical significance was defined as P ≤ .05. Results: Body mass (P = .11) or skinfold thickness (P = .75) did not change across time, despite alternate-day low EA (14 [9] vs 57 [10] kcal·kg−1 FFM·d−1, race vs rest days, respectively; P < .001). Cyclists with extremely low EA on race days (<10 kcal·kg−1 FFM·d−1; n = 2) experienced a trend toward decreased testosterone (−14%) and insulin-like growth factor 1 (−25%), despite being high EA (>46 kcal·kg−1 FFM·d−1) on days between. CHO intakes were significantly higher on race versus rest days (10.7 [1.3] vs 6.4 [0.8] g·kg−1·d−1, respectively; P < .001). The cyclists reached contemporary prerace fueling targets (3.4 [0.7] g·kg−1·3 h−1 CHO; P = .24), while the execution of CHO guidelines during race (51 [9] g·h−1; P = .048) and within acute (1.6 [0.5] g·kg−1·3 h−1; P = .002) and prolonged (7.4 [1.0] g·kg−1·24 h−1; P = .002) postrace recovery was poor. Conclusions: The authors are the first to report the day-by-day periodization of energy and CHO in a small sample of professional cyclists. They also examined the logistics of conducting a field study under stressful conditions in which major cooperation from the subjects and team management is needed. Their commentary around these challenges and possible solutions is a major novelty of the article.

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Alisa Nana, Gary J. Slater, Arthur D. Stewart, and Louise M. Burke

Dual energy X-ray absorptiometry (DXA) is rapidly becoming more accessible and popular as a technique to monitor body composition, especially in athletic populations. Although studies in sedentary populations have investigated the validity of DXA assessment of body composition, few studies have examined the issues of reliability in athletic populations and most studies which involve DXA measurements of body composition provide little information on their scanning protocols. This review presents a summary of the sources of error and variability in the measurement of body composition by DXA, and develops a theoretical model of best practice to standardize the conduct and analysis of a DXA scan. Components of this protocol include standardization of subject presentation (subjects rested, overnight-fasted and in minimal clothing) and positioning on the scanning bed (centrally aligned in a standard position using custom-made positioning aids) as well as manipulation of the automatic segmentation of regional areas of the scan results. Body composition assessment implemented with such protocol ensures a high level of precision, while still being practical in an athletic setting. This ensures that any small changes in body composition are confidently detected and correctly interpreted. The reporting requirements for studies involving DXA scans of body composition include details of the DXA machine and software, subject presentation and positioning protocols, and analysis protocols.

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Eric C. Haakonssen, David T. Martin, David G. Jenkins, and Louise M. Burke

Purpose:

This study investigated the satisfaction of elite female cyclists with their body weight (BW) in the context of race performance, the magnitude of BW manipulation, and the association of these variables with menstrual function.

Methods:

Female competitors in the Australian National Road Cycling Championships (n = 32) and the Oceania Championships (n = 5) completed a questionnaire to identify current BW, BW fluctuations, perceived ideal BW for performance, frequency of weight consciousness, weight-loss techniques used, and menstrual regularity.

Results:

All but 1 cyclist reported that female cyclists are “a weight-conscious population,” and 54% reported having a desire to change BW at least once weekly; 62% reported that their current BW was not ideal for performance. Their perceived ideal BW was (mean ± SD) 1.6 ± 1.6 kg (2.5% ± 2.5%) less than their current weight (P < .01), and 73% reported that their career-lowest BW was either “beneficial” or “extremely beneficial” for performance. 65% reported successfully reducing BW in the previous 12 months with a mean loss of 2.4 ± 1.0 kg (4.1% ± 1.9%). The most common weight-loss technique was reduced energy intake (76%). Five cyclists (14%) had been previously diagnosed as having an eating disorder by a physician. Of the 18 athletes not using a hormonal contraceptive, 11 reported menstrual dysfunction (oligomenorrhea or amenorrhea).

Conclusion:

Elite Australian female cyclists are a weight-conscious population who may not be satisfied with their BW leading into a major competition and in some cases are frequently weight conscious.

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Matthew W. Hoon, Nathan A. Johnson, Phillip G. Chapman, and Louise M. Burke

The purpose of this review was to examine the effect of nitrate supplementation on exercise performance by systematic review and meta-analysis of controlled human studies. A search of four electronic databases and cross-referencing found 17 studies investigating the effect of inorganic nitrate supplementation on exercise performance that met the inclusion criteria. Beetroot juice and sodium nitrate were the most common supplements, with doses ranging from 300 to 600 mg nitrate and prescribed in a manner ranging from a single bolus to 15 days of regular ingestion. Pooled analysis showed a significant moderate benefit (ES = 0.79, 95% CI: 0.23–1.35) of nitrate supplementation on performance for time to exhaustion tests (p = .006). There was a small but insignificant beneficial effect on performance for time trials (ES = 0.11, 95% CI: –0.16–0.37) and graded exercise tests (ES = 0.26, 95% CI: –0.10–0.62). Qualitative analysis suggested that performance benefits are more often observed in inactive to recreationally active individuals and when a chronic loading of nitrate over several days is undertaken. Overall, these results suggest that nitrate supplementation is associated with a moderate improvement in constant load time to exhaustion tasks. Despite not reaching statistical significance, the small positive effect on time trial or graded exercise performance may be meaningful in an elite sport context. More data are required to clarify the effect of nitrate supplementation on exercise performance and to elucidate the optimal way to implement supplementation.

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Amelia J. Carr, Gary J. Slater, Christopher J. Gore, Brian Dawson, and Louise M. Burke

Purpose:

The aim of this study was to determine the effect and reliability of acute and chronic sodium bicarbonate ingestion for 2000-m rowing ergometer performance (watts) and blood bicarbonate concentration [HCO3 ].

Methods:

In a crossover study, 7 well-trained rowers performed paired 2000-m rowing ergometer trials under 3 double-blinded conditions: (1) 0.3 grams per kilogram of body mass (g/kg BM) acute bicarbonate; (2) 0.5 g/kg BM daily chronic bicarbonate for 3 d; and (3) calcium carbonate placebo, in semi-counterbalanced order. For 2000-m performance and [HCO3 ], we examined differences in effects between conditions via pairwise comparisons, with differences interpreted in relation to the likelihood of exceeding smallest worthwhile change thresholds for each variable. We also calculated the within-subject variation (percent typical error).

Results:

There were only trivial differences in 2000-m performance between placebo (277 ± 60 W), acute bicarbonate (280 ± 65 W) and chronic bicarbonate (282 ± 65 W); however, [HCO3 ] was substantially greater after acute bicarbonate, than with chronic loading and placebo. Typical error for 2000-m mean power was 2.1% (90% confidence interval 1.4 to 4.0%) for acute bicarbonate, 3.6% (2.5 to 7.0%) for chronic bicarbonate, and 1.6% (1.1 to 3.0%) for placebo. Postsupplementation [HCO3 ] typical error was 7.3% (5.0 to 14.5%) for acute bicarbonate, 2.9% (2.0 to 5.7%) for chronic bicarbonate and 6.0% (1.4 to 11.9%) for placebo.

Conclusion:

Performance in 2000-m rowing ergometer trials may not substantially improve after acute or chronic bicarbonate loading. However, performances will be reliable with both acute and chronic bicarbonate loading protocols.

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Louise M. Burke, Bronwen Lundy, Ida L. Fahrenholtz, and Anna K. Melin

The human body requires energy for numerous functions including, growth, thermogenesis, reproduction, cellular maintenance, and movement. In sports nutrition, energy availability (EA) is defined as the energy available to support these basic physiological functions and good health once the energy cost of exercise is deducted from energy intake (EI), relative to an athlete’s fat-free mass (FFM). Low EA provides a unifying theory to link numerous disorders seen in both female and male athletes, described by the syndrome Relative Energy Deficiency in Sport, and related to restricted energy intake, excessive exercise or a combination of both. These outcomes are incurred in different dose–response patterns relative to the reduction in EA below a “healthy” level of ∼45 kcal·kg FFM−1·day−1. Although EA estimates are being used to guide and monitor athletic practices, as well as support a diagnosis of Relative Energy Deficiency in Sport, problems associated with the measurement and interpretation of EA in the field should be explored. These include the lack of a universal protocol for the calculation of EA, the resources needed to achieve estimates of each of the components of the equation, and the residual errors in these estimates. The lack of a clear definition of the value for EA that is considered “low” reflects problems around its measurement, as well as differences between individuals and individual components of “normal”/“healthy” function. Finally, further investigation of nutrition and exercise behavior including within- and between-day energy spread and dietary characteristics is warranted since it may directly contribute to low EA or its secondary problems.