What is the evidence for a Triad-like syndrome in exercising men?

Male Endurance Athletes: Examination of Energy and Carbohydrate Availability and Hormone Responses

BACKGROUND

This study investigated the effects of decreased energy availability (EA) and carbohydrate availability (CA) on reproductive and metabolic hormones in male endurance-trained athletes.

METHODS

Thirteen athletes (age: 26.08 ± 4.3 years; weight: 70.9 ± 6.5 kg; height: 179.9 ± 4.2 cm) participated in two training weeks with varying training volumes (low [LV] and high [HV]). The participants logged their diet and exercise for seven days and provided blood samples to measure hormone levels (Testosterone [T], insulin, leptin, cortisol, and interleukin-6 [IL-6]).

RESULTS

Results showed that 46.2% (HV) and 38.5% (LV) of participants were at risk for low EA (≤25 kcal/kg FFM·d-1), while 53.8% (HV) and 69.2% (LV) had low CA (<6 g/kg). Strong positive correlations were found between leptin and body fat percentage (DXABFP) in both weeks (HV: r(11) = 0.88, p < 0.001; LV: r(11) = 0.93, p < 0.001). Moderate correlations were observed between T and DXABFP (r(11) = 0.56, p = 0.05) and negative correlations between leptin and fat intake (r(11) = -0.60, p = 0.03). Regression analyses indicated significant relationships between DXABFP and T (F(1,11) = 4.91, p = 0.049), leptin (HV: F(1,11) = 40.56, p < 0.001; LV: F(1,11) = 74.67, p < 0.001), and cortisol (F(1,11) = 6.69, p = 0.025).

CONCLUSIONS

These findings suggest that monitoring body composition and macronutrients can be clinically useful for male athletes, especially those without access to blood testing. Ultimately, a greater understanding of health and performance outcomes for male athletes is needed.

Hierarchies in the energy budget: Thyroid hormones and the evolution of human life history patterns

The evolution of human life history characteristics required dramatic shifts in energy allocation mechanisms compared with our primate ancestors. Thyroid hormones, such as thyroxine (T4) and triiodothyronine (T3), are sensitive to energy balance, and are significant determinants for both tissue-specific and whole-body metabolic rate. Thus, thyroid hormones are in part responsible for setting the body's overall energy budget and likely played an important role in the evolution of human life history patterns. We propose that the dynamics of mammalian T3 production, uptake, and action have evolved so that energy allocation prioritizes the high demands of brain development and functioning, often at the expense of growth and reproduction. This paper explores the role of thyroid hormone dynamics in the evolution of human encephalization, prolonged childhood and adolescence, long lifespans, reproduction, and human aging.

Hungry runners - low energy availability in male endurance athletes and its impact on performance and testosterone: mini-review

Low Energy Availability (LEA) arises from the inability to cover energy needs and requirements of training or normal physiological functions. This value differs from the energy balance, which takes into account the total daily energy intake compared to all the energy expended, regardless of the amount of fat-free mass. Insufficient energy consumption affects recovery, adaptation processes, increases the risk of injury or illness, so all of this can negatively affect performance. This mini-review is written on research articles in Pubmed database related to LEA in endurance-trained men and its impact on performance and testosterone. This article also clarifies the prevalence of LEA in male endurance athletes and its correlation to Relative Energy Deficiency in Sports (RED-S). LEA occurs in male endurance athletes and correlates with decreased testosterone levels, decreased bone density and also Resting Metabolic Rate. In endurance-trained men, there is great potential for the negative consequences of low energy availability. It can also be said that there are possibilities for primary screening, so we recommend regular check-ups of blood markers, body structure and keeping not only training but also dietary records, which can increase awareness of an adequate energy balance.

Study the Effect of Relative Energy Deficiency on Physiological and Physical Variables in Professional Women Athletes: A Randomized Controlled Trial

Energy deficits are often observed in athletes, especially in female athletes, due to the high expenditure of sport and strict diets. Low energy availability can cause serious health problems and affect sport performance. The aim of this study was to evaluate the effects of different personalized dietary plans on physiological and physical factors related to energy deficit syndrome in female professional handball players. Twenty-one professional female handball players, aged 22 ± 4 years, 172.0 ± 5.4 cm and 68.4 ± 6.7 kg, divided into three groups (FD: free diet; MD: Mediterranean diet; and AD: high antioxidant diet), participated in this 12-week randomized controlled trial. Energy expenditure through indirect calorimetry, energy availability, 7 day dietary intake analysis, blood pressure, cholesterol, menstrual function, body composition by both anthropometry and bioelectrical impedance, and strength performance were assessed. All participants showed low energy availability (<30 kcal/lean mass per day); despite this, all had eumenorrhea. Significant improvements were found after the intervention in all components of body composition (p < 0.05). In the remaining variables, despite slight improvements, none were significant neither over time nor between the different groups. Low energy availability has been observed in all professional female handball players, which may lead to serious consequences. A longer period of intervention is required to assess the differences between diets and improvements in other parameters.

Energy availability and RED-S risk assessment among Kho-Kho players in India

Purpose

Energy availability (EA) is considered an important measure for athletes, particularly due to the possible health and performance outcomes defined under the RED-S. Low EA is reported to have far-reaching health consequences among female athletes, especially in weight-sensitive sport. However, it is less explored among male athletes, particularly in the traditional Indian tag sport called Kho-Kho. This cross-sectional observational study aimed to determine the prevalence of LEA and associated RED-S health and performance outcomes among Kho-Kho players.

Methods

Fifty-two male national-level Kho-Kho players aged 16-31 years were assessed for energy availability, bone mineral density (BMD), sleep quality, disordered eating, selected metabolic (hemoglobin, blood glucose, etc.) and performance outcomes (agility, speed, and power) as per RED-S risk assessment tool. Differences across the low EA (≤ 25 kcal/ kg fat-free mass) and Optimal EA (> 25 kcal/ kg fat-free mass) groups were evaluated using the Independent Samples t test and the chi-square test.

Results

Low EA among athletes was associated with lower z-scores for BMD, sleep quality and agility, compared to athletes with optimal EA. At least one moderate-to-high RED-S risk outcome was prevalent among 98% of the Kho-Kho players, irrespective of EA. Most athletes exhibited a lower EAT score and disordered eating outcomes, with no significant differences across groups.

Conclusion

The male Kho-Kho players showed a prevalence of low EA that can be due to higher training loads and unintentional under-eating, not related to an eating disorder. The players also exhibited higher RED-S risk outcomes; however, it was irrespective of low EA.

High Energetic Demand of Elite Rowing - Implications for Training and Nutrition

Purpose: Elite rowers have large body dimensions, a high metabolic capacity, and they realize high training loads. These factors suggest a high total energy requirement (TER), due to high exercise energy expenditure (EEE) and additional energetic needs. We aimed to study EEE and intensity related substrate utilization (SU) of elite rowers during rowing (EEE_ROW) and other (EEE_NON-ROW) training.

Methods: We obtained indirect calorimetry data during incremental (N = 174) and ramp test (N = 42) ergometer rowing in 14 elite open-class male rowers (body mass 91.8 kg, 95% CI [87.7, 95.9]). Then we calculated EEE_ROW and SU within a three-intensity-zone model. To estimate EEE_NON-ROW, appropriate estimates of metabolic equivalents of task were applied. Based on these data, EEE, SU, and TER were approximated for prototypical high-volume, high-intensity, and tapering training weeks. Data are arithmetic mean and 95% confidence interval (95% CI).

Results: EEE_ROW for zone 1 to 3 ranged from 15.6 kcal·min⁻¹, 95% CI [14.8, 16.3] to 49.8 kcal·min⁻¹, 95% CI [48.1, 51.6], with carbohydrate utilization contributing from 46.4%, 95% CI [42.0, 50.8] to 100.0%, 95% CI [100.0, 100.0]. During a high-volume, a high-intensity, or a taper week, TER was estimated to 6,775 kcal·day⁻¹, 95% CI [6,651, 6,898], 5,772 kcal·day⁻¹, 95% CI [5,644, 5,900], or 4,626 kcal∙day⁻¹, 95% CI [4,481, 4,771], respectively.

Conclusion: EEE in elite open-class male rowers is remarkably high already during zone 1 training and carbohydrates are dominantly utilized, indicating relatively high metabolic stress even during low intensity rowing training. In high-volume training weeks, TER is presumably at the upper end of the sustainable total energy expenditure. Periodized nutrition seems warranted for rowers to avoid low energy availability, which might negatively impact performance, training, and health.

Examination of Athlete Triad Symptoms Among Endurance-Trained Male Athletes: A Field Study

Background: Studies examining the physiological consequences associated with deficits in energy availability (EA) for male athletes are sparse. Purpose: To examine male athlete triad components; low energy availability (LEA) with or without an eating disorder risk (ED), reproductive hormone [testosterone (T)], and bone mineral density (BMD) in endurance-trained male athletes during different training periods. Methods: A cross-sectional design with 14 participants (age: 26.4 ± 4.2 years; weight: 70.6 ± 6.4 kg; height: 179.5 ± 4.3 cm; BMI: 21.9 ± 1.8 kg/m2) were recruited from the local community. Two separate training weeks [low (LV) and high (HV) training volumes] were used to collect the following: 7-day dietary and exercise logs, and blood concentration of T. Anthropometric measurements was taken prior to data collection. A one-time BMD measure (after the training weeks) and VO2max-HR regressions were utilized to calculate EEE. Results: Overall, EA presented as 27.6 ± 10.7 kcal/kgFFM·d-1 with 35% (n = 5) of participants demonstrating increased risk for ED. Examining male triad components, 64.3% presented with LEA (≤ 30 kcal/kgFFM·d-1) while participants presented with T (1780.6 ± 1672.6 ng/dl) and BMD (1.31 ±.09 g/cm2) within normal reference ranges. No differences were found across the 2 training weeks for EI, with slight differences for EA and EEE. Twenty-five participants (89.3%) under-ingested CHO across both weeks, with no differences between weeks. Conclusion: Majority of endurance-trained male athletes presented with one compromised component of the triad (LEA with or without ED risk); however, long-term negative effects on T and BMD were not demonstrated. Over 60% of the participants presented with an EA ≤ 30 kcal/kgFFM·d-1, along with almost 90% not meeting CHO needs. These results suggest male endurance-trained athletes may be at risk to negative health outcomes similar to mechanistic behaviors related to EA with or without ED in female athletes.

Collegiate Male Athletes Exhibit Conditions of the Male Athlete Triad

The primary purpose of this study was to determine prevalence of the Male Athlete Triad (MAT) conditions: low energy availability (EA), low bone mineral density (BMD), and low testosterone in male collegiate athletes from different sports. Participants included 44 collegiate male athletes (age, 20.4 ± 0.2 yr; BMI, 25.3 ± 1.3 kg/m2) from seven sports (cross country, soccer, basketball, wrestling, track, golf, and baseball). Resting metabolic rate, three-day food intake, seven-day exercise energy expenditure, body composition, and reproductive and metabolic hormones were assessed. Of the total participants, 15% had low EA, 0% had low BMD, 28% had low total testosterone (TT), and 80% had low calculated free testosterone (cFT). There were no significant correlations between EA, BMD, TT, and cFT. Insulin and sex hormone binding globulin (SHBG) were below and on the upper end of the reference range for healthy male adults, respectively. Insulin was negatively correlated with total (r = -0.330, p = 0.043) and lumbar spine BMD z-scores (r = -0.413, p = 0.010). Low TT and low cFT were the most prevalent MAT conditions among all athletes. Further research should investigate the relationship between insulin and SHBG and the role of these hormones in the MAT. Novelty Bullets • Assessment of energy availability alone is not sufficient to identify physiological disturbances in collegiate male athletes. • Low total and/or free testosterone may be present in some collegiate male athletes, regardless of BMD status. • Low insulin and high SHBG concentration may portray the presence of conditions of the MAT in male collegiate athletes.

The Psychological and Physiological Consequences of Low Energy Availability in a Male Combat Sport Athlete

PURPOSE

This study aimed to evaluate the effects of low energy availability (EA) on health and performance indices associated with the Male Athlete Triad and Relative Energy Deficiency in Sport (RED-S) models.

METHODS

Over an 8-wk period, a male combat sport athlete adhered to a phased body mass (BM) loss plan consisting of 7-wk energy intake (EI) equating to resting metabolic rate (RMR) (1700 kcal·d-1) (phase 1), 5 d of reduced EI (1200-300 kcal·d-1) before weigh-in (phase 2), and 1 wk of ad libitum EI postcompetition (phase 3). EA fluctuated day by day because of variations in exercise energy expenditure. Regular assessments of body composition, RMR, cardiac function, cardiorespiratory capacity, strength and power, psychological state and blood clinical chemistry for endocrine, bone turnover, hydration, electrolyte, renal, liver, and lipid profiles were performed.

RESULTS

BM was reduced over the 8-wk period by 13.5% (72.5 to 62.7 kg). No consequences of Male Athlete Triad or RED-S were evident during phase 1, where mean daily EA equated to 20 kcal·kg·fat free mass (FFM)-1·d-1 (range, 7 to 31 kcal·kg FFM-1·d-1) and BM and fat mass (FM) losses were 6.5 and 4.4 kg, respectively. However, consequences did present in phase 2 when mean daily EA was consistently <10 kcal·kg FFM-1·d-1, as evidenced by alterations to endocrine hormones (e.g., testosterone <5 nmol.L-1) and reduced RMR (-257 kcal·d-1).

CONCLUSION

Data demonstrate that 7 wk of daily fluctuations in EA equating to a mean value of 20 kcal·kg FFM-1·d-1 permits reductions of BM and FM without perturbations to physiological systems associated with the Male Athlete Triad and RED-S. By contrast, a subsequent period of five consecutive days of EA <10 kcal·kg FFM-1·d-1 induced consequences of Male Athlete Triad and RED-S.

Association of Low Energy Availability and Suppressed Metabolic Status in Korean Male Collegiate Soccer Players: A Pilot Study

Low energy availability (EA) can impair physiological function in athletes. The purpose of this study was to investigate EA status, metabolic status, and bone metabolism with biochemical analysis in Korean male soccer players. Twelve male athletes (18–20 years) completed the study. Body composition and bone mineral density were measured using dual energy X-ray absorptiometry (DXA), while VO₂ max was determined by an incremental exercise test. Blood samples were taken for bone marker and hormone analyses. Resting energy expenditure (REE) was measured using the Douglas bag method and predicted using the DXA method. Food diaries and heart rates (HR) during training were recorded, and the Profile of Mood States 2 and Eating Attitude Test 26 were completed. Group differences between low EA (LEA <30 kcal/kg FFM/d, n = 5) and high EA (HEA ≥30 kcal/kg FFM/d, n = 7) were evaluated. The mean EA of the all participants was 31.9 ± 9.8 kcal/kg FFM/d with only two participants having an EA above 45 kcal/kg FFM/d. LEA showed suppressed REE (LEA: 26.0 ± 1.7 kcal/kg/d, HEA: 28.8 ± 1.4 kcal/kg/d, p = .011) with a lower REE_ratio (LEA: 0.91 ± 0.06, HEA: 1.01 ± 0.05, p = .008) as well as a lower insulin-like growth factor 1 (IGF-1) level (LEA: 248.6 ± 51.2 ng/mL, HEA: 318.9 ± 43.4 ng/mL, p = .028) compared to HEA. There were no group differences in bone markers or other hormone levels. Korean male athletes exhibited low EA status with suppressed metabolism, but there was limited evidence on the effect of EA on bone metabolism, endocrine system, and psychological parameters.

Where are all the men? Low energy availability in male cyclists: A review

Most of the low energy availability (LEA) research has been conducted in female populations. The occurrence of LEA in male athletes is not well known, even with an understanding of the components involved in and contributing to LEA. Cycling is a major risk factor for LEA due to inherent sports characteristics: low impact, high energy demands, and a common perception that leanness is a performance advantage. The purpose of this review is to discuss the cycling-specific studies that have documented components of RED-S. The review demonstrates male cyclists (1) experience energy deficits daily, weekly and throughout a season; (2) exhibit lower bone mineral density at the spine compared to the hip, and low bone mineral density correlating with LEA and; (3) demonstrate downregulation of the endocrine system with elevated cortisol, reduced testosterone and insulin-like growth factor 1. The complexity of LEA is further explored by the socio-psychological contribution that may impact eating behaviours, and therefore increase the risk of developing LEA. Future research directions include applying multifaceted research methods to gain a greater understanding of this syndrome and the effect of LEA on male cyclists.Highlights Competitive male cyclists tend to train and compete in low energy availability states, increasing the risk of developing low bone mineral density.The metabolic and hormonal changes in competitive male cyclists demonstrate a multifaceted downregulation of the endocrine system.The socio-psychological contributions may impact eating behaviours, therefore increase the risk of developing low energy availability in competitive male cyclists.Future research using mixed-method approaches will contribute to more multidimensional understandings of the risks and effects of LEA on male cyclists.

Low energy availability: history, definition and evidence of its endocrine, metabolic and physiological effects in prospective studies in females and males

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.

Difficulties in Emotion Regulation, Alexithymia, and Social Phobia Are Associated With Disordered Eating in Male and Female Undergraduate Athletes

Investigations of disordered eating in the athlete population tend to focus on females and the influence of sport level. This leaves unanswered whether, and how, team interdependence (i.e., whether the competition is engaged with one person or as a team) may differentially impact male athletes. In the present study, we recruited a sample of non-athletes, individual athletes, and team athletes and examined the interaction of gender and teammate interdependence on established psychosocial risk factors for disordered eating, including social phobia, alexithymia, and emotion regulation. Although we identified a significant main effect of gender, there was no main effect of team type, nor was there a significant interaction of gender and team type. Using descriptive discriminant analysis, these variables significantly discriminated between genders. Women were defined by higher scores than men on drive for thinness, body dissatisfaction, and emotion recognition and men were defined by relatively higher scores on emotion dysregulation and binge eating. When we combined all athletes and compared them with non-athletes, a significant interaction of gender and athlete status emerged such that female athletes, compared to male athletes and women non-athletes, were defined by higher scores on drive for thinness, emotion dysregulation, and binge eating. Conversely, male athletes, compared to female athletes, were defined by greater difficulty identifying feelings and body dissatisfaction. Non-athletes were not well defined by the discriminant function. These results highlight that emotional processes convey risk of eating disorders in men and women, particularly in athletes, and these risk factors are not uniform.

Female Athlete Triad Coalition cumulative risk assessment tool: proposed alternative scoring strategies

We (i) identified alternative scoring strategies for the Female Athlete Triad Coalition cumulative risk assessment (CRA) tool to be utilized when particular risk factors (bone mineral density (BMD), oligomenorrhea/amenorrhea) cannot be determined; (ii) objectively defined dietary restriction for use in the CRA tool; and (iii) explored proxy measures of energy deficiency. This cross-sectional investigation of exercising women (n = 166) utilized an existing database derived from multiple studies designed to assess health, exercise, and menstrual function. Data from the screening/baseline period of each study included: anthropometrics, dual-energy X-ray absorptiometry, disordered eating questionnaires, descriptive data, and proxy measures of energy deficiency (total triiodothyronine (TT₃) and ratio of measured-to-predicted resting metabolic rate (mRMR/pRMR)). Substituting delayed menarche for BMD was the best-fit replacement resulting in 15 (9%) participants being categorized in different clearance categories. When menstrual status cannot be assessed, such as during hormonal contraceptive use, low energy availability (EA) determined using self-report and disordered eating questionnaires was the best substitution, resulting in 34 (20%) participants being categorized in different clearance categories. Based on original clearance categorizations, the provisional group had lower TT₃ (78.3 ± 2.2 ng/dL; 92.7 ± 2.7 ng/dL) and Harris-Benedict mRMR/pRMR (0.85 ± 0.01; 0.90 ± 0.01) than the full group. Until an updated risk assessment tool is developed, delayed menarche can substitute for low BMD and low EA for oligomenorrhea/amenorrhea. Novelty This investigation addresses previous limitations of the Triad CRA tool. Disordered eating questionnaires can be used to objectively identify dietary restriction for the low EA risk factor. When a risk factor cannot be assessed, delayed menarche can substitute for low BMD and low EA for oligomenorrhea/amenorrhea.