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Anna K. Melin, Ida A. Heikura, Adam Tenforde and Margo Mountjoy

The reported prevalence of low energy availability (LEA) in female and male track and field athletes is between 18% and 58% with the highest prevalence among athletes in endurance and jump events. In male athletes, LEA may result in reduced testosterone levels and libido along with impaired training capacity. In female track and field athletes, functional hypothalamic amenorrhea as consequence of LEA has been reported among 60% of elite middle- and long-distance athletes and 23% among elite sprinters. Health concerns with functional hypothalamic amenorrhea include impaired bone health, elevated risk for bone stress injury, and cardiovascular disease. Furthermore, LEA negatively affects recovery, muscle mass, neuromuscular function, and increases the risk of injuries and illness that may affect performance negatively. LEA in track and field athletes may occur due to intentional alterations in body mass or body composition, appetite changes, time constraints, or disordered eating behavior. Long-term LEA causes metabolic and physiological adaptations to prevent further weight loss, and athletes may therefore be weight stable yet have impaired physiological function secondary to LEA. Achieving or maintaining a lower body mass or fat levels through long-term LEA may therefore result in impaired health and performance as proposed in the Relative Energy Deficiency in Sport model. Preventive educational programs and screening to identify athletes with LEA are important for early intervention to prevent long-term secondary health consequences. Treatment for athletes is primarily to increase energy availability and often requires a team approach including a sport physician, sports dietitian, physiologist, and psychologist.

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Ida A. Heikura, Louise M. Burke, Antti A. Mero, Arja Leena Tuulia Uusitalo and Trent Stellingwerff

We investigated one week of dietary microperiodization in elite female (n = 23) and male (n = 15) runners and race-walkers by examining the frequency of training sessions and recovery periods conducted with recommended carbohydrate (CHO) and protein availability. Food and training diaries were recorded in relation to HARD (intense or >90min sessions; KEY) versus RECOVERY days (other-than KEY sessions; EASY). The targets for amount and timing of CHO and protein around KEY sessions were based on current nutrition recommendations. Relative daily energy and CHO intake was significantly (p < .05) higher in males (224 ± 26 kJ/kg/d, 7.3 ± 1.4 g/kg/d CHO) than females (204 ± 29 kJ/kg/d, 6.2 ± 1.1 g/kg/d CHO) on HARD days. However, when adjusted for training volume (km), there was no sex-based difference in CHO intake daily (HARD: 0.42 ± 0.14 vs 0.39 ± 0.15 g/kg/km). Females appeared to periodize energy and protein intake with greater intakes on HARD training days (204 ± 29 vs 187 ± 35 kJ/kg/d, p = .004; 2.0 ± 0.3 vs 1.9 ± 0.3 g/kg/d protein, p = .013), while males did not periodize intakes. Females showed a pattern of periodization of postexercise CHO for KEY vs EASY (0.9 ± 0.4 vs 0.5 ± 0.3 g/kg; p < .05) while males had higher intakes but only modest periodization (1.3 ± 0.9 vs 1.0 ± 0.4; p = .32). There was only modest evidence from female athletes of systematic microperiodization of eating patterns to meet contemporary sports nutrition guidelines. While this pattern of periodization was absent in males, in general they consumed more energy and CHO daily and around training sessions compared with females. Elite endurance athletes do not seem to systematically follow the most recent sports nutrition guidelines of periodized nutrition.

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Ida A. Heikura, Trent Stellingwerff, Antti A. Mero, Arja Leena Tuulia Uusitalo and Louise M. Burke

Contemporary nutrition guidelines promote a variety of periodized and time-sensitive recommendations, but current information regarding the knowledge and practice of these strategies among world-class athletes is limited. The aim of this study was to investigate this theme by implementing a questionnaire on dietary periodization practices in national/international level female (n = 27) and male (n = 21) middle- and long-distance runners/race-walkers. The questionnaire aimed to gain information on between and within-day dietary choices, as well as timing of pre- and posttraining meals and practices of training with low or high carbohydrate (CHO) availability. Data are shown as percentage (%) of all athletes, with differences in responses between subgroups (sex or event) shown as Chi-square x2 when p < .05. Nearly two-thirds of all athletes reported that they aim to eat more food on, or after, hard training days. Most athletes said they focus on adequate fueling (96%) and adequate CHO and protein (PRO) recovery (87%) around key sessions. Twenty-six percent of athletes (11% of middle vs 42% of long-distance athletes [x 2 (1, n = 46) = 4.308, p = .038, phi = 0.3])) reported to undertake training in the fasted state, while 11% said they periodically restrict CHO intake, with 30% ingesting CHO during training sessions. Our findings show that elite endurance athletes appear to execute pre- and post-key session nutrition recovery recommendations. However, very few athletes deliberately undertake some contemporary dietary periodization approaches, such as training in the fasted state or periodically restricting CHO intake. This study suggests mismatches between athlete practice and current and developing sports nutrition guidelines.

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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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Ida A. Heikura, Louise M. Burke, Dan Bergland, Arja L.T. Uusitalo, Antti A. Mero and Trent Stellingwerff

Purpose: The authors investigated the effects of sex, energy availability (EA), and health status on the change in hemoglobin mass (ΔHbmass) in elite endurance athletes over ∼3–4 wk of live-high–train-high altitude training in Flagstaff, AZ (2135 m; n = 27 women; n = 21 men; 27% 2016 Olympians). Methods: Precamp and postcamp Hbmass (optimized carbon monoxide rebreathing method) and iron status were measured, EA was estimated via food and training logs, and a Low Energy Availability in Females Questionnaire (LEAFQ) and a general injury/illness questionnaire were completed. Hypoxic exposure (h) was calculated with low (<500 h), moderate (500–600 h), and high (>600 h) groupings. Results: Absolute and relative percentage ΔHbmass was significantly greater in women (6.2% [4.0%], P < .001) than men (3.2% [3.3%], P = .008). %ΔHbmass showed a dose–response with hypoxic exposure (3.1% [3.8%] vs 4.9% [3.8%] vs 6.8% [3.7%], P = .013). Hbmasspre was significantly higher in eumenorrheic vs amenorrheic women (12.2 [1.0] vs 11.3 [0.5] g/kg, P = .004). Although statistically underpowered, %ΔHbmass was significantly less in sick (n = 4, −0.5% [0.4%]) vs healthy (n = 44, 5.4% [3.8%], P < .001) athletes. There were no significant correlations between self-reported iron intake, sex hormones, or EA on Hbmass outcomes. However, there was a trend for a negative correlation between LEAFQ score and %ΔHbmass (r = −.353, P = .07). Conclusions: The findings confirm the importance of baseline Hbmass and exposure to hypoxia on increases in Hbmass during altitude training, while emphasizing the importance of athlete health and indices of EA on an optimal baseline Hbmass and hematological response to hypoxia.

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Ida A. Heikura, Arja L.T. Uusitalo, Trent Stellingwerff, Dan Bergland, Antti A. Mero and Louise M. Burke

We aimed to (a) report energy availability (EA), metabolic/reproductive function, bone mineral density, and injury/illness rates in national/world-class female and male distance athletes and (b) investigate the robustness of various diagnostic criteria from the Female Athlete Triad (Triad), Low Energy Availability in Females Questionnaire, 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] versus normal testosterone [n = 14]), and EA calculated from 7-day food and training diaries (< or >30 kcal·kg−1 fat-free mass·day−1). Sex hormones (p < .001), triiodothyronine (p < .05), and bone mineral density (females, p < .05) were significantly lower in amenorrheic (37%) and low testosterone (40%; 15.1 ± 3.0 nmol/L) athletes, and bone injuries were ∼4.5-fold more prevalent in amenorrheic (effect size = 0.85, large) and low testosterone (effect size = 0.52, moderate) groups compared with others. Categorization of females and males using Triad or RED-S tools revealed that higher risk groups had significantly lower triiodothyronine (female and male Triad and RED-S: p < .05) and higher number of all-time fractures (male Triad: p < .001; male RED-S and female Triad: p < .01) as well as nonsignificant 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.

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Joanne G. Mirtschin, Sara F. Forbes, Louise E. Cato, Ida A. Heikura, Nicki Strobel, Rebecca Hall and Louise M. Burke

The authors describe the implementation of a 3-week dietary intervention in elite race walkers at the Australian Institute of Sport, with a focus on the resources and strategies needed to accomplish a complex study of this scale. Interventions involved: traditional guidelines of high carbohydrate (CHO) availability for all training sessions; a periodized CHO diet which integrated sessions with low and high CHO availability within the same total CHO intake; and a ketogenic low-CHO high-fat diet. Seven-day menus and recipes were constructed for a communal eating setting to meet nutritional goals as well as individualized food preferences and special needs. Menus also included nutrition support before, during, and after exercise. Daily monitoring, via observation and food checklists, showed that energy and macronutrient targets were achieved. Diets were matched for energy (∼14.8 MJ/d) and protein (∼2.1 g·kg−1·day−1) and achieved desired differences for fat and CHO, with high CHO availability and periodized CHO availability: CHO = 8.5 g·kg−1·day−1, 60% energy, fat = 20% of energy and low-CHO high-fat diet: 0.5 g·kg−1·day−1 CHO, fat = 78% energy.  There were no differences in micronutrient intake or density between the high CHO availability and periodized CHO availability diets; however, the micronutrient density of the low-CHO high-fat diet was significantly lower. Daily food costs per athlete were similar for each diet (∼AU$ 27 ± 10). Successful implementation and monitoring of dietary interventions in sports nutrition research of the scale of the present study require meticulous planning and the expertise of chefs and sports dietitians. Different approaches to sports nutrition support raise practical challenges around cost, micronutrient density, accommodation of special needs, and sustainability.

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Alannah K. A. McKay, Ida A. Heikura, Louise M. Burke, Peter Peeling, David B. Pyne, Rachel P.L. van Swelm, Coby M. Laarakkers and Gregory R. Cox

Sleeping with low carbohydrate (CHO) availability is a dietary strategy that may enhance training adaptation. However, the impact on an athlete’s health is unclear. This study quantified the effect of a short-term “sleep-low” dietary intervention on markers of iron regulation and immune function in athletes. In a randomized, repeated-measures design, 11 elite triathletes completed two 4-day mixed cycle run training blocks. Key training sessions were structured such that a high-intensity training session was performed in the field on the afternoon of Days 1 and 3, and a low-intensity training (LIT) session was performed on the following morning in the laboratory (Days 2 and 4). The ingestion of CHO was either divided evenly across the day (HIGH) or restricted between the high-intensity training and LIT sessions, so that the LIT session was performed with low CHO availability (LOW). Venous blood and saliva samples were collected prior to and following each LIT session and analyzed for interleukin-6, hepcidin 25, and salivary immunoglobulin-A. Concentrations of interleukin-6 increased acutely after exercise (p < .001), but did not differ between dietary conditions or days. Hepcidin 25 increased 3-hr postexercise (p < .001), with the greatest increase evident after the LOW trial on Day 2 (2.5 ± 0.9 fold increase ±90% confidence limit). The salivary immunoglobulin-A secretion rate did not change in response to exercise; however, it was highest during the LOW condition on Day 4 (p = .046). There appears to be minimal impact to markers of immune function and iron regulation when acute exposure to low CHO availability is undertaken with expert nutrition and coaching input.