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Margo Mountjoy

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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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Sherry Robertson, Dan Benardot and Margo Mountjoy

The sport of synchronized swimming is unique, because it combines speed, power, and endurance with precise synchronized movements and high-risk acrobatic maneuvers. Athletes must train and compete while spending a great amount of time underwater, upside down, and without the luxury of easily available oxygen. This review assesses the scientific evidence with respect to the physiological demands, energy expenditure, and body composition in these athletes. The role of appropriate energy requirements and guidelines for carbohydrate, protein, fat, and micronutrients for elite synchronized swimmers are reviewed. Because of the aesthetic nature of the sport, which prioritizes leanness, the risks of energy and macronutrient deficiencies are of significant concern. Relative Energy Deficiency in Sport and disordered eating/eating disorders are also of concern for these female athletes. An approach to the healthy management of body composition in synchronized swimming is outlined. Synchronized swimmers should be encouraged to consume a well-balanced diet with sufficient energy to meet demands and to time the intake of carbohydrate, protein, and fat to optimize performance and body composition. Micronutrients of concern for this female athlete population include iron, calcium, and vitamin D. This article reviews the physiological demands of synchronized swimming and makes nutritional recommendations for recovery, training, and competition to help optimize athletic performance and to reduce risks for weight-related medical issues that are of particular concern for elite synchronized swimmers.

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David B. Pyne, Evert A. Verhagen and Margo Mountjoy

In this review, we outline key principles for prevention of injury and illness in aquatic sports, detail the epidemiology of injury and illness in aquatic athletes at major international competitions and in training, and examine the relevant scientific evidence on nutrients for reducing the risk of illness and injury. Aquatic athletes are encouraged to consume a well-planned diet with sufficient calories, macronutrients (particularly carbohydrate and protein), and micronutrients (particularly iron, zinc, and vitamins A, D, E, B6, and B12) to maintain health and performance. Ingesting carbohydrate via sports drinks, gels, or sports foods during prolonged training sessions is beneficial in maintaining energy availability. Studies of foods or supplements containing plant polyphenols and selected strains of probiotic species are promising, but further research is required. In terms of injury, intake of vitamin D, protein, and total caloric intake, in combination with treatment and resistance training, promotes recovery back to full health and training.

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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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Jennifer Sygo, Alexandra M. Coates, Erik Sesbreno, Margo L. Mountjoy and Jamie F. Burr

Low energy availability (LEA), and subsequent relative energy deficiency in sport, has been observed in endurance, aesthetic, and team sport athletes, with limited data on prevalence in athletes in short-burst activities such as sprinting. We examined prevalence of signs and symptoms of LEA in elite female sprinters at the start of the training season (PRE), and at the end of a 5-month indoor training period (POST). Four of 13 female sprinters (31%) presented at PRE testing with at least one primary (amenorrhea, low bone mineral density, low follicle-stimulating hormone, luteinizing hormone, or estradiol, resting metabolic rate ≤29 kcal/kg fat-free mass, Low Energy Availability in Females Questionnaire score ≥8) and one secondary indicator of LEA (fasting blood glucose <4 mmol/L, free triiodothyronine <3.5 pmol/L, ferritin <25 μg/L, low-density lipoprotein cholesterol >3.0 mmol/L, fasting insulin <20 pmol/L, low insulin-like growth factor-1, systolic blood pressure <90 mmHg, and/or diastolic blood pressure <60 mmHg). At POST, seven out of 13 athletes (54%) presented with at least one primary and one secondary indicator of LEA, three of whom had also presented with indicators of LEA at PRE. Five out of 13 (39%) athletes had previous stress fracture history, though this was not associated with current indicators of LEA (PRE: r = .52, p = .07; POST: r = −.07, p = .82). In conclusion, elite female sprinters may present with signs and symptoms of LEA, even after off-season rest. Medical and coaching staff should be aware of the signs and symptoms of LEA and relative energy deficiency in sport and should include appropriate screening and intervention strategies when working with sprinters.

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

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Margo Mountjoy, Jorunn Sundgot-Borgen, Louise Burke, Kathryn E. Ackerman, Cheri Blauwet, Naama Constantini, Constance Lebrun, Bronwen Lundy, Anna Melin, Nanna Meyer, Roberta Sherman, Adam S. Tenforde, Monica Klungland Torstveit and Richard Budgett

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Ronald J. Maughan, Louise M. Burke, Jiri Dvorak, D. Enette Larson-Meyer, Peter Peeling, Stuart M. Phillips, Eric S. Rawson, Neil P. Walsh, Ina Garthe, Hans Geyer, Romain Meeusen, Luc van Loon, Susan M. Shirreffs, Lawrence L. Spriet, Mark Stuart, Alan Vernec, Kevin Currell, Vidya M. Ali, Richard G.M. Budgett, Arne Ljungqvist, Margo Mountjoy, Yannis Pitsiladis, Torbjørn Soligard, Uğur Erdener and Lars Engebretsen

Nutrition usually makes a small but potentially valuable contribution to successful performance in elite athletes, and dietary supplements can make a minor contribution to this nutrition program. Nonetheless, supplement use is widespread at all levels of sport. Products described as supplements target different issues, including the management of micronutrient deficiencies, supply of convenient forms of energy and macronutrients, and provision of direct benefits to performance or indirect benefits such as supporting intense training regimens. The appropriate use of some supplements can offer benefits to the athlete, but others may be harmful to the athlete’s health, performance, and/or livelihood and reputation if an anti-doping rule violation results. A complete nutritional assessment should be undertaken before decisions regarding supplement use are made. Supplements claiming to directly or indirectly enhance performance are typically the largest group of products marketed to athletes, but only a few (including caffeine, creatine, specific buffering agents and nitrate) have good evidence of benefits. However, responses are affected by the scenario of use and may vary widely between individuals because of factors that include genetics, the microbiome, and habitual diet. Supplements intended to enhance performance should be thoroughly trialed in training or simulated competition before implementation in competition. Inadvertent ingestion of substances prohibited under the anti-doping codes that govern elite sport is a known risk of taking some supplements. Protection of the athlete’s health and awareness of the potential for harm must be paramount, and expert professional opinion and assistance is strongly advised before embarking on supplement use.