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Vardardottir B, Gudmundsdottir SL, Tryggvadottir EA, Olafsdottir AS. Patterns of energy availability and carbohydrate intake differentiate between adaptable and problematic low energy availability in female athletes. Front Sports Act Living 2024; 6:1390558. [PMID: 38783864 PMCID: PMC11111999 DOI: 10.3389/fspor.2024.1390558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/17/2024] [Indexed: 05/25/2024] Open
Abstract
Background Problematic low energy availability (EA) is the underlying culprit of relative energy deficiency in sport (REDs), and its consequences have been suggested to be exacerbated when accompanied by low carbohydrate (CHO) intakes. Objectives This study compared dietary intake, nutrition status and occurrence of REDs symptoms in groups of female athletes, displaying different patterns of EA and CHO intake. Methods Female athletes (n = 41, median age 20.4 years) from various sports weighed and recorded their food intake and training for 7 consecutive days via a photo-assisted mobile application. Participants were divided into four groups based on patterns of EA and CHO intakes: sufficient to optimal EA and sufficient to optimal CHO intake (SEA + SCHO), SEA and low CHO intake (SEA + LCHO), low energy availability and SCHO (LEA + SCHO), and LEA and LCHO (LEA + LCHO). SEA patterns were characterised by EA ≥30 and LEA by EA <30 kcal/kg fat free mass, and SCHO patterns characterised by CHO intake ≥3.0 and LCHO <3.0 g/kg body weight for most of the registered days. Body composition was measured with dual energy x-ray absorptiometry, resting metabolic rate with indirect calorimetry and serum blood samples were collected for evaluation of nutrition status. Behavioural risk factors and self-reported symptoms of REDs were assessed with the Low Energy Availability in Females Questionnaire, Eating Disorder Examination Questionnaire Short (EDE-QS), Exercise Addiction Inventory, and Muscle Dysmorphic Disorder Inventory. Results In total, 36.6% were categorised as SEA + SCHO, of which 5/16 were ball sport, 7/10 endurance, 1/7 aesthetic, 2/5 weight-class, and 0/3 weight-class athletes. Of LEA + LCHO athletes (19.5% of all), 50% came from ball sports. Aesthetic and endurance athletes reported the greatest training demands, with weekly training hours higher for aesthetic compared to ball sports (13.1 ± 5.7 vs. 6.7 ± 3.4 h, p = 0.012). Two LEA + LCHO and one SEA + LCHO athlete exceeded the EDE-QS cutoff. LEA + LCHO evaluated their sleep and energy levels as worse, and both LEA groups rated their recovery as worse compared to SEA + SCHO. Conclusion Repeated exposures to LEA and LCHO are associated with a cluster of negative implications in female athletes. In terms of nutrition strategies, sufficient EA and CHO intakes appear to be pivotal in preventing REDs.
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Õnnik L, Mooses M, Suvi S, Haile DW, Ojiambo R, Lane AR, Hackney AC. Influence of energy availability on metabolic hormonal profiles in east African female and male distance runners. J Sports Med Phys Fitness 2024; 64:490-495. [PMID: 38305005 DOI: 10.23736/s0022-4707.23.15253-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
BACKGROUND Energy availability (EA) and relative energy deficiency in sport (RED-S) are understudied in East African endurance athletes, both females (F) and males (M). This study assessed the metabolic hormonal profiles of such athletes relative to their EA status. METHODS Forty athletes (F=16, M=24) had their EA status, training, maximal oxygen uptake, and resting blood samples assessed using standard research practices. Subjects were stratified into two groups, high EA (HiEA) and low EA (LoEA) based on combined median value. RESULTS Cortisol (P=0.034) and insulin (P=0.044) were significantly elevated in the LoEA group, while growth hormone (P=0.045) was significantly suppressed; and, prolactin (P=0.078) trended towards suppression, respectively compared to the HiEA group. All other hormonal comparison were non-significant. CONCLUSIONS Metabolic hormonal profiles of female and male African distance runners are affected by their EA status. Aspects of these alterations agree in part with published findings based upon White populations, although some differences exist and need further investigation.
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Affiliation(s)
| | | | | | | | - Robert Ojiambo
- Moi University, Eldoret, Kenya
- University of Global Health Equity, Butaro, Rwanda
| | - Amy R Lane
- University of North Carolina, Chapel Hill, NC, USA
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Burke LM, Ackerman KE, Heikura IA, Hackney AC, Stellingwerff T. Mapping the complexities of Relative Energy Deficiency in Sport (REDs): development of a physiological model by a subgroup of the International Olympic Committee (IOC) Consensus on REDs. Br J Sports Med 2023; 57:1098-1108. [PMID: 37752007 DOI: 10.1136/bjsports-2023-107335] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2023] [Indexed: 09/28/2023]
Abstract
The 2023 International Olympic Committee (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs) notes that exposure to low energy availability (LEA) exists on a continuum between adaptable and problematic LEA, with a range of potential effects on both health and performance. However, there is variability in the outcomes of LEA exposure between and among individuals as well as the specific manifestations of REDs. We outline a framework for a 'systems biology' examination of the effect of LEA on individual body systems, with the eventual goal of creating an integrated map of body system interactions. We provide a template that systematically identifies characteristics of LEA exposure (eg, magnitude, duration, origin) and a variety of moderating factors (eg, medical history, diet and training characteristics) that could exacerbate or attenuate the type and severity of impairments to health and performance faced by an individual athlete. The REDs Physiological Model may assist the diagnosis of underlying causes of problems associated with LEA, with a personalised and nuanced treatment plan promoting compliance and treatment efficacy. It could also be used in the strategic prevention of REDs by drawing attention to scenarios of LEA in which impairments of health and performance are most likely, based on knowledge of the characteristics of the LEA exposure or moderating factors that may increase the risk of harmful outcomes. We challenge researchers and practitioners to create a unifying and dynamic physiological model for each body system that can be continuously updated and mapped as knowledge is gained.
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Affiliation(s)
- Louise M Burke
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ida A Heikura
- Canadian Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Anthony C Hackney
- Department of Exercise & Sport Science, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Trent Stellingwerff
- Canadian Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
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Monedero J, Duff C, Egan B. Dietary Intakes and the Risk of Low Energy Availability in Male and Female Advanced and Elite Rock Climbers. J Strength Cond Res 2023; 37:e8-e15. [PMID: 35836334 DOI: 10.1519/jsc.0000000000004317] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
ABSTRACT Monedero, J, Duff, C, and Egan, B. Dietary intakes and the risk of low energy availability in male and female advanced and elite rock climbers. J Strength Cond Res 37(3): e8-e15, 2023-There is a culture among rock climbers of striving to maintain low body mass and percentage body fat to enhance performance. Diet practices based on this belief might lead to increased risk of low energy availability (LEA) or eating disorders (EDs). Twenty-five advanced or elite rock climbers (male, n = 14; female, n = 11) had body composition measured, completed 4-day food intake and physical activity diaries while wearing an accelerometer and heart rate monitor, and completed the Eating Attitudes Test (EAT)-26 and the Low Energy Availability in Females Questionnaire (LEAF-Q; n = 11 female subjects only). EAT-26 scores of 3.5 (1.8, 7.0) [median (IQR)] and 9.3 ± 6.4 (mean ± SD ) for male and female subjects, respectively, indicated low risk of ED in this cohort, but 4 female subjects were at high risk of LEA according to LEAF-Q scores. Suboptimal (<45 kcal·kg·FFM -1 ·d -1 ) and LEA (<30 kcal·kg·FFM -1 ·d -1 ) were evident in 88 and 28%, respectively, of climbers. However, only the female climbers had energy intakes (1775 ± 351 kcal·d -1 ) significantly lower than their calculated energy requirements (2056 ± 254 kcal·d -1 ; p = 0.006). In all subjects, carbohydrate intakes were lower (male subjects: 3.8 ± 1.2 g·kg -1 ·d -1 , p = 0.002; female subjects: 3.4 ± 0.7 g·kg -1 ·d -1 , p < 0.001), and fat intakes were higher (male subjects: 1.6 ± 0.5 g·kg -1 ·d -1 , p < 0.001; female subjects: 1.4 ± 0.4 g·kg -1 ·day -1 , p < 0.001) than current sports nutrition recommendations, and inadequate intakes of calcium, magnesium, and vitamin D were observed. Female subjects specifically had lower than recommended intakes of protein and iron. These results show that advanced and elite rock climbers have a high prevalence of LEA and have a risk of having nutritional deficiencies as result of their diet.
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Affiliation(s)
- Javier Monedero
- School of Health and Human Performance, Dublin City University, Dublin, Ireland
- Department of Clinical Sciences and Nutrition, University of Chester, Chester, England; and
| | - Christina Duff
- School of Health and Human Performance, Dublin City University, Dublin, Ireland
| | - Brendan Egan
- School of Health and Human Performance, Dublin City University, Dublin, Ireland
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Tarnowski CA, Wardle SL, O’Leary TJ, Gifford RM, Greeves JP, Wallis GA. Measurement of Energy Intake Using the Principle of Energy Balance Overcomes a Critical Limitation in the Assessment of Energy Availability. SPORTS MEDICINE - OPEN 2023; 9:16. [PMID: 36811697 PMCID: PMC9947205 DOI: 10.1186/s40798-023-00558-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 02/04/2023] [Indexed: 02/24/2023]
Abstract
Prolonged low energy availability, which is the underpinning aetiology of the Relative Energy Deficiency in Sport and the Female and Male Athlete Triad frameworks, can have unfavourable impacts on both health and performance in athletes. Energy availability is calculated as energy intake minus exercise energy expenditure, expressed relative to fat free mass. The current measurement of energy intake is recognized as a major limitation for assessing energy availability due to its reliance on self-report methods, in addition to its short-term nature. This article introduces the application of the energy balance method for the measurement of energy intake, within the context of energy availability. The energy balance method requires quantification of the change in body energy stores over time, with concurrent measurement of total energy expenditure. This provides an objective calculation of energy intake, which can then be used for the assessment of energy availability. This approach, the Energy Availability - Energy Balance (EAEB) method, increases the reliance on objective measurements, provides an indication of energy availability status over longer periods and removes athlete burden to self-report energy intake. Implementation of the EAEB method could be used to objectively identify and detect low energy availability, with implications for the diagnosis and management of Relative Energy Deficiency in Sport and the Female and Male Athlete Triad.
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Affiliation(s)
- Caroline A. Tarnowski
- grid.6572.60000 0004 1936 7486School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - Sophie L. Wardle
- Army Health and Performance Research, Army Headquarters, Andover, UK ,grid.83440.3b0000000121901201Division of Surgery and Interventional Science, Department of Targeted Intervention, University College London, London, UK
| | - Thomas J. O’Leary
- Army Health and Performance Research, Army Headquarters, Andover, UK ,grid.83440.3b0000000121901201Division of Surgery and Interventional Science, Department of Targeted Intervention, University College London, London, UK
| | - Robert M. Gifford
- grid.511172.10000 0004 0613 128XBritish Heart Foundation Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK ,grid.415490.d0000 0001 2177 007XResearch and Clinical Innovation, Royal Centre of Defence Medicine, Birmingham, UK
| | - Julie P. Greeves
- Army Health and Performance Research, Army Headquarters, Andover, UK ,grid.83440.3b0000000121901201Division of Surgery and Interventional Science, Department of Targeted Intervention, University College London, London, UK ,grid.8273.e0000 0001 1092 7967Norwich Medical School, University of East Anglia, Norwich, UK
| | - Gareth A. Wallis
- grid.6572.60000 0004 1936 7486School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, B15 2TT UK
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6
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Lee S, Moto K, Oh T, Taguchi M. Comparison between predicted and measured resting energy expenditures in Korean male collegiate soccer players. J Exerc Nutrition Biochem 2022; 26:25-31. [PMID: 36353827 PMCID: PMC9663256 DOI: 10.20463/pan.2022.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/07/2022] [Indexed: 11/07/2022] Open
Abstract
[Purpose] This study aimed to evaluate the differences between predicted resting energy expenditure (REE), using fat-free mass (FFM)-based prediction equations, and measured REE in Korean male collegiate soccer players. [Methods] Fifteen male collegiate soccer players (18-21 years) participated in this study. The REE measurements were conducted using the Douglas bag method. Body composition was measured by dual-energy X-ray absorptiometry (DXA). The differences between the measured REE and predicted REE, using the five FFM-based REE equations, were analyzed using the t-test, calculation of errors, regression analysis, and the Bland-Altman method. [Results] The Cunningham (1980) and ten Haaf and Weijs (2014) equations showed significantly overestimated REE (1,808 ± 99 kcal/d, p <0.01; 1,838 ± 103 kcal/d, p <0.01; respectively), but the Owen (1988), Taguchi (2011), and Kim (2015) equations’ estimations were not significantly different from the measured REE (1,589 ± 106 kcal/d, 1,640 ± 124 kcal/d, and 1,622 ± 68 kcal/d, respectively). The Taguchi equation gave the best prediction of REE with the lowest constant error (-6 ± 125) and effect size (-0.05), and a non-significant proportional bias (p = 0.95). [Conclusion] The Taguchi equation is recommended for predicting REE in Korean collegiate soccer players. The selection process of a REE-prediction equation must take into consideration the target population’s characteristics. Future studies are recommended to evaluate the validity of the different FFM-based REE-prediction equations in various Korean athletes.
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7
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Gama E, Kasuki L, Paranhos-Neto FP, Madeira M, Mendonça L, Schtscherbyna A, Farias M. Low Energy Availability Interferes With Exercise-Associated Bone Effects in Female Long-Distance Triathletes as Detected by HR-pQCT. J Clin Densitom 2022; 25:160-167. [PMID: 33608221 DOI: 10.1016/j.jocd.2021.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/20/2021] [Accepted: 01/26/2021] [Indexed: 12/27/2022]
Abstract
Female Athlete Triad, initially described as the association of disordered eating, amenorrhea and osteoporosis, was further redefined to focus on low energy availability (EA), which has a central role in development of hypoestrogenism and low bone mineral density (BMD). However, the contribution of each variable, that is, low EA and hypoestrogenism, for bone derangements is still an open question. To evaluate body composition and bone status in long-distance triathletes without hypoestrogenism, as compared to non-athletes, using DXA and HR-pQCT, and the influence of EA. Population comprised 23 triathletes who had completed at least one long-distance race in the previous year, and 17 non-athletic healthy controls. The athletes denied previous oligo-amenorrhea and had spontaneous regular menses or were on hormonal contraceptives. Control patients also had regular menses. Energy deficiency (low EA) was defined as energy intake below the recommended level for athletes, that is, 45 kcal/kg free fat mass/day. Only femoral neck BMD Z-score measured by DXA trended higher in athletes (p = 0.05), whereas high-resolution peripheral quantitative computed tomography detected significantly higher values of entire bone and trabecular bone area, cortical perimeter, trabecular vBMD and trabecular bone volume/tissue volume, and lower trabecular separation and trabecular inhomogeneity in athletes. No difference was found between athletes with spontaneous menses and those on hormone contraceptives in respect to all parameters. The effects of exercise on bone were not so pronounced in athletes with low EA, although they still had better bone parameters than controls. Stress fractures were reported by 4:12 athletes with low EA and by 2:11 athletes with adequate EA. Long-distance female triathletes without hypoestrogenism show higher values of cortical perimeter, bone area, volumetric density and trabecular microstructure, but low EA interferes with exercise-associated bone effects. These innovative findings reinforce the importance of adequate EA in female athletes to guarantee skeletal health.
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Affiliation(s)
- Emf Gama
- Division of Endocrinology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Rio de Janeiro, Brasil.
| | - L Kasuki
- Neuroendocrinology Research Center, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Rio de Janeiro, Brasil
| | - F P Paranhos-Neto
- Division of Endocrinology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Rio de Janeiro, Brasil
| | - M Madeira
- Division of Endocrinology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Rio de Janeiro, Brasil
| | - Lmc Mendonça
- Division of Rheumatology of Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Rio de Janeiro, Brasil
| | - A Schtscherbyna
- Division of Endocrinology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Rio de Janeiro, Brasil
| | - Mlf Farias
- Division of Endocrinology, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Rio de Janeiro, Brasil
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8
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Sterringer T, Larson-Meyer DE. RMR Ratio as a Surrogate Marker for Low Energy Availability. Curr Nutr Rep 2022; 11:263-272. [PMID: 35080753 DOI: 10.1007/s13668-021-00385-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW Low energy availability (EA) poses severe consequences to athlete performance and overall health. Suppressed resting metabolic rate (RMR) has been observed during periods of low EA. Thus, it has been suggested that the ratio of RMR measured via indirect calorimetry to predictive RMR using a standard predictive equation (RMR ratio) may be a useful assessment of EA in athletes. This review evaluated the use of RMR ratio as a surrogate marker for low EA in athletes and compared methodologies for measuring RMR ratio. RECENT FINDINGS Decreased RMR ratio in recent studies often correlates with signs of low EA; however, athletes with less severe cases of energy deficiency may not present with a low RMR ratio. Additionally, the methodology for RMR ratio measurements lacks standardization and varies in recent studies. Use of RMR ratio has promise as a complementary EA measurement when used in combination with other assessment tools.
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Affiliation(s)
- Trisha Sterringer
- Department of Human Nutrition, Foods, and Exercise, Virginia Tech, 295 West Campus Drive, 266 Wallace Hall, Blacksburg, VA, 24061, USA.
| | - D Enette Larson-Meyer
- Department of Human Nutrition, Foods, and Exercise, Virginia Tech, 295 West Campus Drive, 266 Wallace Hall, Blacksburg, VA, 24061, USA
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Duffy D, Yourkavitch J, Bruinvels G, Rinaldi NJ, Wideman L. The development and initial validation of the Health and Reproductive Survey (HeRS). ACTA ACUST UNITED AC 2021; 17:17455065211004814. [PMID: 34348519 PMCID: PMC8358484 DOI: 10.1177/17455065211004814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background: Due to the diversity in profiles associated with the female reproductive cycle and their potential physiological and psychological effects, monitoring the reproductive status of exercising females is important from a practical and research perspective. Moreover, as physical activity can influence menstrual function, the effects of physical activity energy expenditure on reproductive function should also be considered. Aim: The aim of this study was to develop and establish initial face and content validity of the Health and Reproductive Survey (HeRS) for physically active females, which is a retrospective assessment of menstrual function from menarche (first menstruation) to menopause (cessation of menstruation). Methods: Face validity was evaluated qualitatively, and the initial content validity was established through a principal component analysis. The face validity process was completed by 26 females aged 19–67 years and the content validity was established through a survey sent to a convenience sample of 392 females, of which 230 females (57.9% and aged 18–49 years) completed the survey. Results: The revisions made following the face validation improved the understanding, flow, and coherence of the survey. The principal component analysis indicated that, at a minimum, the survey measures these constructs: menstrual cessation and associated moderators, athletic participation and performance levels (as associated with menstruation change and the menstrual cycle), age and menstrual cessation, hormonal contraception (“birth control”), and menarche and associated moderators. Conclusion: The Health and Reproductive Survey (HeRS) is a partially validated tool that can be used by researchers to characterize the menstrual status of physically active females relative to their physical activity status.
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Affiliation(s)
- Donna Duffy
- Center for Women's Health and Wellness, University of North Carolina at Greensboro, Greensboro, NC, USA.,Department of Kinesiology, University of North Carolina at Greensboro, Greensboro, NC, USA
| | - Jennifer Yourkavitch
- Department of Public Health Education, University of North Carolina, at Greensboro, Greensboro, NC, USA
| | - Georgie Bruinvels
- Faculty of Sport, Health and Applied Science, St. Mary's University, Twickenham, UK.,Orreco, Business Innovation Unit, National University of Ireland, Galway, Ireland
| | - Nicola J Rinaldi
- NPNW Consulting, Lexington, MA, USA.,Antica Press LLC, Waltham, MA, USA
| | - Laurie Wideman
- Department of Kinesiology, University of North Carolina at Greensboro, Greensboro, NC, USA
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Gifford RM, O'Leary TJ, Wardle SL, Double RL, Homer NZM, Howie AF, Greeves JP, Anderson RA, Woods DR, Reynolds RM. Reproductive and metabolic adaptation to multistressor training in women. Am J Physiol Endocrinol Metab 2021; 321:E281-E291. [PMID: 34191631 DOI: 10.1152/ajpendo.00019.2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/07/2021] [Indexed: 11/22/2022]
Abstract
Hypothalamic-pituitary-gonadal (HPG) axis suppression in exercising women can be caused by low energy availability (EA), but the impact of a real-world, multistressor training environment on reproductive and metabolic function is unknown. This study aimed to characterize reproductive and metabolic adaptation in women undertaking basic military training. A prospective cohort study in women undertaking 11-month initial military training (n = 47) was carried out. Dynamic low-dose 1-h gonadotrophin-releasing hormone (GnRH) tests were completed after 0 and 7 mo of training. Urine progesterone was sampled weekly throughout. Body composition (dual X-ray absorptiometry), fasting insulin resistance (homeostatic modeling assessment 2, HOMA2), leptin, sex steroids, anti-Müllerian hormone (AMH), and inhibin B were measured after 0, 7, and 11 mo with an additional assessment of body composition at 3 mo. Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) responses were suppressed after 7 mo (both P < 0.001). Among noncontraceptive users (n = 20), 65% had regular (23-35 days) cycles preenrollment, falling to 24% by 7 mo of training. Of women in whom urine progesterone was measured (n = 24), 87% of cycles showed no evidence of ovulation. There was little change in AMH, LH, and estradiol, although inhibin B and FSH increased (P < 0.05). Fat mass fluctuated during training but at month 11 was unchanged from baseline. Fat-free mass did not change. Visceral adiposity, HOMA2, and leptin increased (all P < 0.001). HPG axis suppression with anovulation occurred in response to training without evidence of low EA. Increased insulin resistance may have contributed to the observed pituitary and ovarian dysfunction. Our findings are likely to represent an adaptive response of reproductive function to the multistressor nature of military training.NEW & NOTEWORTHY We characterized reproductive endocrine adaptation to prolonged arduous multistressor training in women. We identified marked suppression of hypothalamic-pituitary-gonadal (HPG) axis function during training but found no evidence of low energy availability despite high energy requirements. Our findings suggest a complex interplay of psychological and environmental stressors with suppression of the HPG axis via activation of the hypothalamic-pituitary adrenal (HPA) axis. The neuroendocrine impact of nonexercise stressors on the HPG axis during arduous training should be considered.
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Affiliation(s)
- Robert M Gifford
- University/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
- Research & Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Thomas J O'Leary
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
| | - Sophie L Wardle
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
| | - Rebecca L Double
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
| | - Natalie Z M Homer
- University/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
- Mass Spectrometry Core, Edinburgh Clinical Research Facility, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - A Forbes Howie
- Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Julie P Greeves
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Richard A Anderson
- Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - David R Woods
- Research & Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, United Kingdom
- Research Institute for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, United Kingdom
- Northumbria and Newcastle NHS Trusts, Wansbeck General and Royal Victoria Infirmary, Newcastle, United Kingdom
| | - Rebecca M Reynolds
- University/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
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11
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Within-Day Energy Balance and Metabolic Suppression in Male Collegiate Soccer Players. Nutrients 2021; 13:nu13082644. [PMID: 34444803 PMCID: PMC8398536 DOI: 10.3390/nu13082644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 11/23/2022] Open
Abstract
Metabolic suppression due to relative energy deficiency can cause various physiological impairments in athletes. The purpose of this study was to evaluate within-day energy balance (WDEB) and the ratio between measured and predicted resting energy expenditure (REEratio) and to investigate the relationships between the markers of metabolic suppression. Ten male collegiate soccer players completed a 7-day food diary, physical activity, and heart rate records during the training and rest days. Energy intake (EI) and energy expenditure (EE) were analyzed to evaluate WDEB components. Body composition was measured using dual-energy X-ray absorptiometry (DXA), and blood sampling was conducted for hormonal analysis. The REE was measured using the Douglas bag method and predicted using the DXA-predicted method to calculate the REEratio. Participants were categorized into the normal (REEratio ≥ 0.94, n = 5) and suppressed (REEratio < 0.94, n = 5) groups. There were no group differences in the components of WDEB, except diet-induced thermogenesis (DIT), but EI was significantly higher in the normal group than in the suppressed group (7-day total: 3660 ± 347 vs. 3024 ± 491 kcal/day, p = 0.046 and rest days: 3772 ± 463 vs. 2796 ± 800 kcal/day, p = 0.046). Analysis of hormonal markers of metabolic suppression only showed a significant positive association between insulin-like growth factor-1 (IGF-1) and REEratio (r = 0.771, p = 0.009). The relationships between metabolic suppression and the markers of energy deficiency were inconclusive. There are possible associations of insufficient EI and IGF-1 levels with metabolic suppression, and further study is required to understand energy deficiency in male soccer players.
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Nattiv A, De Souza MJ, Koltun KJ, Misra M, Kussman A, Williams NI, Barrack MT, Kraus E, Joy E, Fredericson M. The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part 1: Definition and Scientific Basis. Clin J Sport Med 2021; 31:335-348. [PMID: 34091537 DOI: 10.1097/jsm.0000000000000946] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 04/23/2021] [Indexed: 02/02/2023]
Abstract
ABSTRACT The Male Athlete Triad is a syndrome of 3 interrelated conditions most common in adolescent and young adult male endurance and weight-class athletes and includes the clinically relevant outcomes of (1) energy deficiency/low energy availability (EA) with or without disordered eating/eating disorders, (2) functional hypothalamic hypogonadism, and (3) osteoporosis or low bone mineral density with or without bone stress injury (BSI). The causal role of low EA in the modulation of reproductive function and skeletal health in the male athlete reinforces the notion that skeletal health and reproductive outcomes are the primary clinical concerns. At present, the specific intermediate subclinical outcomes are less clearly defined in male athletes than those in female athletes and are represented as subtle alterations in the hypothalamic-pituitary-gonadal axis and increased risk for BSI. The degree of energy deficiency/low EA associated with such alterations remains unclear. However, available data suggest a more severe energy deficiency/low EA state is needed to affect reproductive and skeletal health in the Male Athlete Triad than in the Female Athlete Triad. Additional research is needed to further clarify and quantify this association. The Female and Male Athlete Triad Coalition Consensus Statements include evidence statements developed after a roundtable of experts held in conjunction with the American College of Sports Medicine 64th Annual Meeting in Denver, Colorado, in 2017 and are in 2 parts-Part I: Definition and Scientific Basis and Part 2: The Male Athlete Triad: Diagnosis, Treatment, and Return-to-Play. In this first article, we discuss the scientific evidence to support the Male Athlete Triad model.
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Affiliation(s)
- Aurelia Nattiv
- Division of Sports Medicine and Non-Operative Orthopaedics, Departments of Family Medicine and Orthopaedic Surgery, University of California Los Angeles, Los Angeles, California
| | - Mary Jane De Souza
- Department of Kinesiology, Penn State University, University Park, Pennsylvania
| | - Kristen J Koltun
- Department of Sports Medicine and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Madhusmita Misra
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrea Kussman
- Department of Orthopaedic Surgery, Stanford University, Stanford, California
| | - Nancy I Williams
- Department of Kinesiology, Penn State University, University Park, Pennsylvania
| | - Michelle T Barrack
- Department of Family and Consumer Sciences, California State University, Long Beach, Long Beach, California; and
| | - Emily Kraus
- Department of Orthopaedic Surgery, Stanford University, Stanford, California
| | | | - Michael Fredericson
- Department of Orthopaedic Surgery, Stanford University, Stanford, California
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Commentary in Response to "A Review of Nonpharmacological Strategies in the Treatment of Relative Energy Deficiency in Sport". Int J Sport Nutr Exerc Metab 2021; 31:380-382. [PMID: 34021096 DOI: 10.1123/ijsnem.2021-0084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 03/24/2021] [Indexed: 11/18/2022]
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Areta JL, Taylor HL, Koehler K. Low energy availability: history, definition and evidence of its endocrine, metabolic and physiological effects in prospective studies in females and males. Eur J Appl Physiol 2020; 121:1-21. [PMID: 33095376 PMCID: PMC7815551 DOI: 10.1007/s00421-020-04516-0] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/23/2020] [Indexed: 12/21/2022]
Abstract
Energy availability (EA) is defined as the amount of dietary energy available to sustain physiological function after subtracting the energetic cost of exercise. Insufficient EA due to increased exercise, reduced energy intake, or a combination of both, is a potent disruptor of the endocrine milieu. As such, EA is conceived as a key etiological factor underlying a plethora of physiological dysregulations described in the female athlete triad, its male counterpart and the Relative Energy Deficiency in Sport models. Originally developed upon female-specific physiological responses, this concept has recently been extended to males, where experimental evidence is limited. The majority of data for all these models are from cross-sectional or observational studies where hypothesized chronic low energy availability (LEA) is linked to physiological maladaptation. However, the body of evidence determining causal effects of LEA on endocrine, and physiological function through prospective studies manipulating EA is comparatively small, with interventions typically lasting ≤ 5 days. Extending laboratory-based findings to the field requires recognition of the strengths and limitations of current knowledge. To aid this, this review will: (1) provide a brief historical overview of the origin of the concept in mammalian ecology through its evolution of algebraic calculations used in humans today, (2) Outline key differences from the ‘energy balance’ concept, (3) summarise and critically evaluate the effects of LEA on tissues/systems for which we now have evidence, namely: hormonal milieu, reproductive system endocrinology, bone metabolism and skeletal muscle; and finally (4) provide perspectives and suggestions for research upon identified knowledge gaps.
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Affiliation(s)
- José L Areta
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Tom Reilly Building, Byrom St Campus, Liverpool, L3 3AF, UK.
| | - Harry L Taylor
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Tom Reilly Building, Byrom St Campus, Liverpool, L3 3AF, UK
| | - Karsten Koehler
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
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Wasserfurth P, Palmowski J, Hahn A, Krüger K. Reasons for and Consequences of Low Energy Availability in Female and Male Athletes: Social Environment, Adaptations, and Prevention. SPORTS MEDICINE - OPEN 2020; 6:44. [PMID: 32910256 PMCID: PMC7483688 DOI: 10.1186/s40798-020-00275-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 08/20/2020] [Indexed: 02/07/2023]
Abstract
Low energy availability (LEA) represents a state in which the body does not have enough energy left to support all physiological functions needed to maintain optimal health. When compared to the normal population, athletes are particularly at risk to experience LEA and the reasons for this are manifold. LEA may result from altered dietary behaviours that are caused by body dissatisfaction, the belief that a lower body weight will result in greater performance, or social pressure to look a certain way. Pressure can also be experienced from the coach, teammates, and in this day and age through social media platforms. While LEA has been extensively described in females and female athletes have started fighting against the pressure to be thin using their social media platforms, evidence shows that male athletes are at risk as well. Besides those obvious reasons for LEA, athletes engaging in sports with high energy expenditure (e.g. rowing or cycling) can unintentionally experience LEA; particularly, when the athletes' caloric intake is not matched with exercise intensity. Whether unintentional or not, LEA may have detrimental consequences on health and performance, because both short-term and long-term LEA induces a variety of maladaptations such as endocrine alterations, suppression of the reproductive axis, mental disorders, thyroid suppression, and altered metabolic responses. Therefore, the aim of this review is to increase the understanding of LEA, including the role of an athlete's social environment and the performance effects related to LEA.
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Affiliation(s)
- Paulina Wasserfurth
- Institute of Food Science and Human Nutrition, Leibniz University Hannover, Am Kleinen Felde 30, [PW1] 30167, Hannover, Germany
| | - Jana Palmowski
- Institute of Sports Science, Department of Exercise Physiology and Sports Therapy, Justus-Liebig University Giessen, Kugelberg 62, 35394, Giessen, Germany
| | - Andreas Hahn
- Institute of Food Science and Human Nutrition, Leibniz University Hannover, Am Kleinen Felde 30, [PW1] 30167, Hannover, Germany
| | - Karsten Krüger
- Institute of Sports Science, Department of Exercise Physiology and Sports Therapy, Justus-Liebig University Giessen, Kugelberg 62, 35394, Giessen, Germany.
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Strock NCA, De Souza MJ, Williams NI. Eating behaviours related to psychological stress are associated with functional hypothalamic amenorrhoea in exercising women. J Sports Sci 2020; 38:2396-2406. [PMID: 32619140 DOI: 10.1080/02640414.2020.1786297] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Functional hypothalamic amenorrhoea (FHA) can occur due to the independent or combined effects of psychogenic and energetic stressors. In exercising women, research has primarily focused on energy deficiency as the cause of FHA while psychological stressors have been ignored. To assess both psychological and metabolic factors associated with FHA in exercising women, we performed across-sectional comparison of 61 exercising women (≥2 hours/week, age 18-35 years, BMI 16-25kg/m2), who were eumenorrheic or amenorrhoeic confirmed by daily urine samples assayed for reproductive hormone metabolites. Psychological factors and eating behaviours were assessed by self-report questionnaires. Exercising women with FHA had lower resting metabolic rate (p=0.023), T3 (p<0.001), T4 (p=0.013), leptin (p=0.002), higher peptide YY (p<0.001), greater drive for thinness (p=0.017), greater dietary cognitive restraint (p<0.001), and displayed dysfunctional attitudes, i.e., need for social approval (p=0.047) compared to eumenorrheic women. Amenorrhoeic women displayed asignificant positive correlation between the need for social approval and drive for thinness with indicators of stress, depression, and mood, which was not apparent in eumenorrheic women. In exercising women with FHA, eating behaviours are positively related to indicators of psychological stress and depression.
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Affiliation(s)
- Nicole C A Strock
- 109 Noll Laboratory, Penn State University, University Park , PA.,Women's Health and Exercise Laboratory, Penn State University,University Park , PA
| | - Mary Jane De Souza
- Women's Health and Exercise Laboratory, Penn State University,University Park , PA
| | - Nancy I Williams
- Women's Health and Exercise Laboratory, Penn State University,University Park , PA
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Lizarraga A, Porta M, Ferrer E, Rodas G. Women’s football: towards gaining a deeper understanding. APUNTS SPORTS MEDICINE 2020. [DOI: 10.1016/j.apunsm.2020.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Characterizing the resting metabolic rate ratio in ovulatory exercising women over 12 months. Scand J Med Sci Sports 2020; 30:1337-1347. [DOI: 10.1111/sms.13688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/23/2020] [Accepted: 04/11/2020] [Indexed: 12/20/2022]
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Case Study: Resumption of Eumenorrhea in Parallel With High Training Load After 4 Years of Menstrual Dysfunction: A 5-Year Follow-Up of an Elite Female Cyclist. Int J Sport Nutr Exerc Metab 2020; 30:229–234. [DOI: 10.1123/ijsnem.2019-0284] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/10/2020] [Accepted: 01/10/2020] [Indexed: 11/18/2022]
Abstract
The female athlete triad is a condition where low energy availability is typically observed together with menstrual dysfunction and/or low bone mineral density. How this condition affects maximal work capacity in endurance athletes is not clear, and the recovery time course of menses with increased energy availability with concomitant high training load is unknown. This case study of an amenorrheic elite road cyclist reports resumption of normal menstrual function after weight gain during a 5-year period (2014–2019), while engaged in high training load and competition. The athlete ( 3.54 L/min, 64 ml·min−1·kg−1, aerobic peak power output 300 W, 5.4 W/kg) reported amenorrhea (2013–2015) and oligomenorrhea (2015–2018). Training load increased from 2014 to 2019 (584–818 hr/year and 26,707–41,945 training stress score/year). Regular menses (every 23–35 days) resumed in June 2018, ∼5–6 months after a weight gain episode. During the period of menstrual dysfunction, body mass was 51.3 ± 2.25 kg (mean ± 95% confidence limit) and fat percentage was 19% (dual-energy X-ray absorptiometry, 2016), and after weight gain, body mass was 56.8 ± 2.63 kg and fat percentage was 25% (dual-energy X-ray absorptiometry, 2019). Crank-based power meter data showed absolute mean maximal power (in watts) improvement over the 5 s to 4 hr range through the 2014–2019 period, while relative mean maximal power (in watts per kilogram) likely peaked in the 2015–2016 season for 5 min, 20 min, and 30 min, but remained mostly unchanged across seasons. Results suggest that (a) the best relative power output associated with aerobic capacity (5 min to 1 hr) can be achieved during menstrual dysfunction, (b) high performance achieved despite an increase in body mass, and (c) resumption of menses is achievable while maintaining high training loads when coupled with high energy availability.
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Indices of Resting Metabolic Rate Accurately Reflect Energy Deficiency in Exercising Women. Int J Sport Nutr Exerc Metab 2020; 30:14-24. [DOI: 10.1123/ijsnem.2019-0199] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/24/2019] [Accepted: 10/23/2019] [Indexed: 11/18/2022]
Abstract
Energy deficiency in exercising women can lead to physiological consequences. No gold standard exists to accurately estimate energy deficiency, but measured-to-predicted resting metabolic rate (RMR) ratio has been used to categorize women as energy deficient. The purpose of the study was to (a) evaluate the accuracy of RMR prediction methods, (b) determine the relationships with physiological consequences of energy deficiency, and (c) evaluate ratio thresholds in a cross-sectional comparison of ovulatory, amenorrheic, or subclinical menstrual disturbances in exercising women (n = 217). Dual-energy X-ray absorptiometry (DXA) and indirect calorimetry provided data on anthropometrics and energy expenditure. Harris–Benedict, DXA, and Cunningham (1980 and 1991) equations were used to estimate RMR and RMR ratio. Group differences were assessed (analysis of variance and Kruskal–Wallis tests); logistic regression and Spearman correlations related ratios with consequences of energy deficiency (i.e., low total triiodothyronine; TT3). Sensitivity and specificity calculations evaluated ratio thresholds. Amenorrheic women had lower RMR (p < .05), DXA ratio (p < .01), Cunningham1980 (p < .05) and Cunningham1991 (p < .05) ratio, and TT3 (p < .01) compared with the ovulatory group. Each prediction equation overestimated measured RMR (p < .001), but predicted (p < .001) and positively correlated with TT3 (r = .329–.453). A 0.90 ratio threshold yielded highest sensitivity for Cunningham1980 (0.90) and Harris–Benedict (0.87) methods, but a higher ratio threshold was best for DXA (0.94) and Cunningham1991 (0.92) methods to yield a sensitivity of 0.80. In conclusion, each ratio predicted and correlated with TT3, supporting the use of RMR ratio as an alternative assessment of energetic status in exercising women. However, a 0.90 ratio cutoff is not universal across RMR estimation methods.
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