IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update

Relative Energy Deficiency in Sport (RED-S) and Knee Injuries: Current Concepts for Female Athletes

In athletes, a mismatch between caloric intake and energy expended in exercise can result in Low Energy Availability (LEA). LEA can lead to Relative Energy Deficiency in Sport (RED-S), where the athlete suffers from physiological derangements and decreased sport performance. The prevalence of RED-S is higher in females than males. RED-S more comprehensively describes the syndrome originally known as "Female Athlete Triad" (FAT). FAT encompasses the triad of LEA (with or without disordered eating), menstrual dysfunction and low bone mineral density. RED-S includes other physiological derangements such as poor cardiovascular health, abnormalities of metabolic rate, immunity, and protein synthesis. Females are already at a higher risk of knee injuries, which has been attributed to a multitude of factors such as hormonal influences, differences in musculoskeletal anatomy and neuromuscular control compared to males. The literature demonstrates an even higher risk of knee injuries in female athletes with symptoms of RED-S. We propose the various factors that influence this risk. A reduction in anabolic hormones can affect muscle development and tendon repair. A relationship between poor neuromuscular control and knee injury has been established, and this can be further worsened in patients with menstrual dysfunction. Chronic deficiency in nutrients such as collagen and vitamin D can result in poorer recovery from microtrauma in tendon and ligaments. All these factors may contribute to increasing the risk of knee injuries, which may include anterior cruciate ligament tears, patella tendinopathy and patellofemoral pain syndrome. This review aims to educate sports clinicians to have a high index of suspicion when treating knee injuries in females; to screen and then manage for RED-S if present, for holistic patient care.

Patterns of energy availability and carbohydrate intake differentiate between adaptable and problematic low energy availability in female athletes

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.

Risk of low energy availability and nutrition knowledge among female team sport athletes

BACKGROUND

Nutrition knowledge influences adequate dietary intake in athletes. Inadequate dietary intakes can result in low energy availability (LEA) which can lead to relative energy deficiency in sport (RED-S). To date, there is little information on the relationship between nutrition knowledge and the risk of LEA in female team sport athletes. This study investigates if general and sports nutrition knowledge are associated with the risk of LEA in female team athletes.

METHODS

A cross-sectional design was used. Female athletes (>16 years) who participate in team sports in New Zealand were asked to complete an online questionnaire. The LEA in Females Questionnaire and the Abridged Sport Nutrition Knowledge Questionnaire were included. LEA risk and general/sports nutrition knowledge were assessed. The relationship between LEA risk and knowledge was analyzed using the Kruskal-Wallis Test of independent variables and χ2 tests.

RESULTS

Among 100 female athletes, 53% were at-risk for LEA, and 70% (N.=67) had poor nutrition knowledge. Athletes who were "at-risk" for LEA and those who were "not at-risk" for LEA did not differ statistically in terms of age (P=0.350) or BMI (P=0.576). Of those "not at risk" 54% had an A-NSK score between 50 and 60% (i.e., average knowledge), whereas 54% of the athletes who were "at risk" for LEA had poor nutrition knowledge. There was no statistical difference between the groups (P=0.273).

CONCLUSIONS

The poor nutrition knowledge and the high rates of those "at risk" of LEA among team sports athletes indicates the need for more nutrition education in this population.

Factors Associated With High-Risk and Low-Risk Bone Stress Injury in Female Runners: Implications for Risk Factor Stratification and Management

Background

Bone stress injury (BSI) is a common overuse injury in active women. BSIs can be classified as high-risk (pelvis, sacrum, and femoral neck) or low-risk (tibia, fibula, and metatarsals). Risk factors for BSI include low energy availability, menstrual dysfunction, and poor bone health. Higher vertical load rates during running have been observed in women with a history of BSI.

Purpose/Hypothesis

The purpose of this study was to characterize factors associated with BSI in a population of premenopausal women, comparing those with a history of high-risk or low-risk BSI with those with no history of BSI. It was hypothesized that women with a history of high-risk BSI would be more likely to exhibit lower bone mineral density (BMD) and related factors and less favorable bone microarchitecture compared with women with a history of low-risk BSI. In contrast, women with a history of low-risk BSI would have higher load rates.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Enrolled were 15 women with a history of high-risk BSI, 15 with a history of low-risk BSI, and 15 with no history of BSI. BMD for the whole body, hip, and spine was standardized using z scores on dual-energy x-ray absorptiometry. High-resolution peripheral quantitative computed tomography was used to quantify bone microarchitecture at the radius and distal tibia. Participants completed surveys characterizing factors that influence bone health-including sleep, menstrual history, and eating behaviors-utilizing the Eating Disorder Examination Questionnaire (EDE-Q). Each participant completed a biomechanical assessment using an instrumented treadmill to measure load rates before and after a run to exertion.

Results

Women with a history of high-risk BSI had lower spine z scores than those with low-risk BSI (-1.04 ± 0.76 vs -0.01 ± 1.15; P < .05). Women with a history of high-risk BSI, compared with low-risk BSI and no BSI, had the highest EDE-Q subscores for Shape Concern (1.46 ± 1.28 vs 0.76 ± 0.78 and 0.43 ± 0.43) and Eating Concern (0.55 ± 0.75 vs 0.16 ± 0.38 and 0.11 ± 0.21), as well as the greatest difference between minimum and maximum weight at current height (11.3 ± 5.4 vs 7.7 ± 2.9 and 7.6 ± 3.3 kg) (P < .05 for all). Women with a history of high-risk BSI were more likely than those with no history of BSI to sleep <7 hours on average per night during the week (80% vs 33.3%; P < .05). The mean and instantaneous vertical load rates were not different between groups.

Conclusion

Women with a history of high-risk BSI were more likely to exhibit risk factors for poor bone health, including lower BMD, while load rates did not distinguish women with a history of BSI.

Assessment of Relative Energy Deficiency in Sport (REDs) Risk among Adolescent Acrobatic Gymnasts

Energy imbalance exposes athletes to relative energy deficiency in sports (REDs) syndrome. Data on energy consumption, REDs, and bone mineral density (BMD) in adolescent acrobatic gymnasts, especially in males, are scarce. Our aim was to examine the eating habits, energy balance, body composition, and BMD of these athletes. In this study, 18 healthy adolescents participating in competitive acrobatic gymnastics completed a questionnaire, underwent a dual-energy X-ray absorptiometry scan (DXA), received a food log, and had their activities monitored for 3 days. Eighteen acrobats were enrolled (mean age: 14.3 ± 1.2 years; males: 6/18). The mean total body BMD Z-score was 0.4 ± 1.0. Top-position acrobats (7/18) had significantly lower total body BMD Z-scores than base-positioned acrobats (-0.2 ± 0.3 vs. 0.8 ± 0.3, p = 0.032), though their forearms were not significantly different (0.2 ± 0.5 vs. 0.8 ± 0.7, p = 0.331). No sex differences were found for BMD Z-scores, BMI, or energy availability. The BMD parameters of the acrobats were within the normal range for a healthy pediatric population, although three had low BMDs (<-1 SD) for healthy athletes. Total body and LS BMD Z-scores were significantly lower in top-position athletes compared to base-position athletes. These findings suggest personalized (top vs. base) training programs (high-impact training) that may achieve better health outcomes.

Relative energy deficiency in dance (RED-D): a consensus method approach to REDs in dance

Relative energy deficiency in sport (REDs) is a potentially severe, challenging, broad-spectrum syndrome with potential negative health and performance outcomes. The numerous research publications and International Olympic Committee consensus statements relating to REDs testify to the challenges faced in early identification or screening, diagnosis and management. Like sport, dance, in its simplest form, can be identified as an activity resulting in physiological energy demands and, as such, requires appropriate energy availability concerning energy expenditures. However, the specificity of physiological and psychological demands in dance must be considered when considering REDs. An environment where physical activity can exceed 30 hours per week and where culture may instil a value that thinness is required puts dancers at increased risk for REDs. The purpose of this study was to provide dance-specific guidance dance on this complex condition. An RAND/UCLA Delphi Panel method with nominal group technique was used to review the literature from REDs to evaluate how it may relate to dance. In addition to the EP, which was assembled from a multidisciplinary background with expertise in REDs and multiple genres of dance, six focus groups were commissioned. Four of the focus groups were drawn from the EP members and two additional focus groups formed by dancers and artistic leaders. These panels were used to guide the development of a RED-D diagnosis pathway, management plan and risk stratification and return to dance pathway. The dance-specific pathways are designed to be a practical tool for guiding and supporting clinicians managing RED-D. Furthermore, this paper represents an important focus of this area in dance and serves to stimulate discussion and further research within the sector.

Development and Feasibility of an Adolescent Dancer Screen

Background

Adolescent dancers are at high risk for injuries due to the physical demands of dance training and the physiological changes that occur during adolescence. Though studies report high injury rates, there are few standardized screening tools available for adolescent dancers.

Hypothesis/Purpose

To develop and describe a standardized, feasible, evidence-based, and clinically relevant screen for adolescent dancers.

Study Design

Descriptive Epidemiology Study.

Methods

Dancers at two suburban pre-professional dance studios, in two cohorts, participated in the Columbia Adolescent Dancer Screen (CADS) that includes dance injury history, health questionnaires (EAT-26, SF-36, DFOS), aerobic capacity, range of motion, strength, balance/orthopedic special tests, and dance technique. Participants were asked to complete a weekly injury surveillance questionnaire derived from the Dance-Specific Oslo Sports Trauma Research Centre Questionnaire on Health Problems for 14 weeks following the screening. Feasibility was assessed using process and content analysis in four areas: practicality, demand, implementation, and adaptation.

Results

Descriptive data were collected from 32 female dancers aged 11-17 with cohort one averaging 18.57 dance hours per week and cohort two averaging 10.6 dance hours per week. The screen was practical, able to screen seven to eight dancers per hour utilizing nine assessors and requiring a one-hour commitment from dancers. Cost and space requirements were considered and kept to a minimum while utilizing portable equipment. All screening slots were filled with all dancers agreeing to follow-up injury surveillance, indicating high demand. The screen was implemented with two cohorts with revisions to improve efficiency applied for the second cohort.

Conclusion

The CADS is a feasible screening tool for adolescent dancers that overcomes barriers by being pragmatic, evidence-based, and efficient. Screening can be implemented to obtain baseline values, inform wellness recommendations, and establish relationships with medical professionals.

Level of Evidence

Level 3b.

Primary Care Considerations for the Pediatric Endurance Athlete

PURPOSE OF REVIEW

This study aimed to provide an overview of some of the medical concerns surrounding the care of the pediatric endurance athletes and add to the limited literature specific to the pediatric endurance athlete.

RECENT FINDINGS

Endurance athletes are at risk for overtraining, relative energy deficiency in sport (RED-S), overuse injuries, nutritional deficiencies, and sleep dysfunction. Youth runners and female endurance athletes are particularly high-risk populations for RED-S; nutritional deficiencies and their care should involve thoughtful mitigation of modifiable risk factors. The growing endurance athlete may experience slightly different cardiac adaptations than the adult endurance athlete with the long-term implications of these changes still unclear. Endurance sports are common among youth athletes. Multidisciplinary care that includes screening and early intervention for high-risk areas is critical to optimize their care and promote, safe lifelong sport participation.

Low Energy Intake Leads to Body Composition and Performance Decrements in a Highly-Trained, Female Athlete: The WANDER (Woman's Activity and Nutrition during an Extensive Hiking Route) Case Study

OBJECTIVE

This case study's purpose was to quantify energy intake vs energy expenditure during a thru-hiker's trek and assess its relationship to performance and health.

METHODS

A highly trained, female thru-hiker (Age (yrs): 62, Ht (cm): 157, Wt (kg): 53.5, BMI (kg/m2): 21.7, %BF: 26.0) embarked on a 4-month journey through the Pacific Crest Trail, USA. The athlete's body composition and 3-day diet record were assessed before (PRE) and after the hike (POST). During the hike, she tracked her diet and performance daily and completed a wellness survey each time she reached a town-check point. Data were analyzed for descriptive (weekly averages, means ± SD) and frequency statistics.

RESULTS

She spent 10 wk (∼70 days) on the trail and hiked 1,506.35 km (26.1 ± 3.2 km/day) with an estimated energy expenditure of ∼2334 ± 351 kcal/day. During the hike, she under consumed calories (1285.3 ± 103 kcal) and dietary carbohydrate (169.5 ± 19.5g), fat (49.7 ± 5.8g), protein (41.9 ± 4.8g; 0.8 g/kg), fiber (11.8 ± 2.1g) and sodium (1642.4 ± 298.6 mg) when compared to ultra-endurance nutrition recommendations. She was unable to complete the trail due to fatigue and anthropometric changes. By POST, she had decreased total mass (PRE: 53.5 kg vs POST: 48.4 kg), BMI (PRE 21.6 vs POST: 19.5), fat-free mass (PRE: 39.6 vs POST: 38.8), and body fat (PRE: 26% vs POST: 19.6%) when compared to PRE.

CONCLUSION

Trail-related challenges combined with high energy expenditures led to low nutrient intake which contributed to trail-ending injuries and performance decrements. Research aimed at addressing the barriers associated with thru-hike fueling is needed to identify nutritional opportunities to support hikers' performance and reduce injury risks.

Epidemiology of bone injuries in elite athletics: A prospective 9-year cohort study

OBJECTIVES

To describe bone injury patterns in elite track and field athletes. To investigate relationships between bone injury and athlete characteristics to inform future injury prevention strategies.

DESIGN

Descriptive epidemiology study.

SETTING

Elite athletics training centres across the United Kingdom and internationally, observed between 2012 and 2020.

PARTICIPANTS

207 Olympic programme senior track and field athletes.

MAIN OUTCOME MEASURES

Injury number, Incidence, Severity, Burden, Time Loss.

RESULTS

There were 78 fractures during the study period. Gradual repetitive bone injuries were the most common type of injury mode. The foot, pelvis and the lumbar spine were the regions with the highest number of bone stress injuries. Stress fractures had a higher burden overall compared to stress reactions. Average return to full training was 67.4 days (±73.1) for stress reactions and 199 (±205.2) days for stress fractures. There was no relationship between bone injury type and age, sex, ethnicity, side dominance or event group.

CONCLUSION

Bone stress injuries in athletics have a high severity and burden warranting continued efforts to prevent their occurrence and optimize management. Age, sex, ethnicity, side dominance and event region do not have any relationship with bone injury occurrence and are therefore unlikely to increase risk in this cohort.

The "Young Athlete Body Project"-A pilot study evaluating the acceptability of and results from an eating disorder prevention program for adolescent athletes

BACKGROUND

The high frequency of eating disorders (EDs) in sports speaks of a need for early-stage preventive measures.

OBJECTIVES

This study evaluated the acceptability of an age, sex, and sports adapted version of the "Body Project" and changes in mental health symptoms.

METHODS

This noncontrolled pilot study included a class of athletes from 18 sports (N = 73, 13-14 years) at a sport-specialized junior high school in six small-group workshops. We interviewed 34 athletes on program acceptability, and all athletes responded to questionnaires at pretest, posttest, and 6-month follow-up including the Body Appreciation Scale 2-Children, Social Attitudes towards Appearance Questionnaire-4 revised, Eating Disorder Examination Questionnaire Short form-12 modified, and questions about body appearance pressure (BAP).

RESULTS

Athletes found the program acceptable and beneficial, but some missed physically oriented activities or did not identify with the focus, particularly boys. There were acceptable levels in mental health constructs before the workshops. There were temporary changes in the percentage of boys experiencing "BAP in society" by -14.8% points (95% CI: -.6 to .0, p = .04), % in total group experiencing "BAP at school" by +11% points (95% CI: .0-.2, p = .05), thinness idealization by girls (g = .6, p = .002) and total group (g = .4, p = .006), and muscularity idealization by boys (g = .3, p = .05) and total group (g = .23, p = .04).

DISCUSSION

Athletes experienced benefits from the Young Athlete Body Project. Seeing stabilization in outcomes may mean a dampening of the otherwise expected worsening in body appreciation and ED symptoms over time.

PUBLIC SIGNIFICANCE

Adolescent athletes are at risk for developing EDs. Due to lack of prevention programs for this group, we adapted and evaluated a well-documented effective program, the Body Project, to fit male and female athletes <15 years. The athletes accepted the program and experienced participation benefits, with stronger acceptance among girls. Our promising findings encourage larger scaled randomized controlled trials to further evaluate a refined version this program among very young athletes.

Clinical and exercise professional opinion on designing a postpartum return-to-running training programme: an international Delphi study and consensus statement

Returning to running postpartum presents challenges such as musculoskeletal pain and pelvic floor dysfunction for some females, but there is little guidance on developing and progressing postpartum training programmes. This study aims to establish expert consensus recommendations on designing and modifying a postpartum return-to-running training programme, highlight costs and access to qualified professionals as potential barriers and discuss clinical, research and sports policy implications.A three-round Delphi survey of clinical and exercise professionals working with postpartum runners was conducted. Round I consisted of open-ended questions related to designing the training plan, modifications based on biopsychosocial factors, key muscle groups to train and referral and payment sources. Rounds II and III involved Likert-scale voting to identify consensus (≥75% agreement).118 participants completed Round I, 107 completed Round II (response rate 90.6%) and 95 completed Round III (response rate 80.5%). Consensus was reached in 42/47 (89%) statements, including recommendations for a period of relative rest, gradual increases in duration and intensity, starting with a walk-run protocol and incorporating strength training. Training should be modified based on musculoskeletal or pelvic symptoms, sleep, mental health, lactation or energy availability concerns. Cost and access to experienced postpartum running professionals were identified as potential barriers for runners to receive care.Consensus recommendations for a postpartum return-to-running programme include an individualised exercise prescription, gradual increases in physical activity, walk-run protocols and targeted muscle strengthening. Further research and improved access to clinical and exercise professionals are needed to inform and facilitate best practices.

Body Composition Changes in Male and Female Elite Soccer Players: Effects of a Nutritional Program Led by a Sport Nutritionist

BACKGROUND

Soccer is a game in constant evolution and the intensity of play is increasing. Nutrition can play a role in the physical performance of elite players, maintaining their health and facilitating recovery. It is important to cover players' energy demands, and low energy availability may therefore result in impaired performance. This study aimed to evaluate alterations in body composition to determine the effects of a nutritional program led by a sport nutritionist.

METHODS

A group of 88 elite soccer players from a Serie A club in Italy (44 males aged 26.5 ± 3.0 years and 44 females aged 27.1 ± 5.2 years) were enrolled. To evaluate changes in body composition, bioimpedance and anthropometric measurements were obtained following the protocol of the International Society for the Advancement of Kinanthropometry (ISAK).

RESULTS

Compared with females, males had more muscle mass and less fat mass in both seasons evaluated. Comparing the first and last seasons, the male soccer players showed increased muscle mass and decreased fat mass while the female soccer players only showed decreased fat mass.

CONCLUSIONS

The presence of a specialist sport nutritionist on the staff of professional soccer clubs could be important to ensure energy availability and evaluate body composition during the season.

Nutrition knowledge, weight loss practices, and supplement use in senior competition climbers

Introduction

Sport climbing has gained increased scientific attention, including studies investigating the dietary habits and nutritional requirements of climbers; however, significant gaps in the literature remain. An assessment of nutritional knowledge, weight loss for competition, and supplement use has not been previously reported in senior competition climbing athletes.

Methods

Fifty climbers (26 male, 24 female; BMI 21.6 ± 1.9; 23.7 ± 5.2 years) participated in the study. Participants answered a 72-item questionnaire, comprised of demographic data and three main sections to assess general and sports nutrition knowledge, weight loss strategies, and supplement use.

Results

The mean nutrition knowledge score was 'average', with considerable individual variation (53.5 ± 11.1 %). There were no significant sex differences in the general (GNK) or sport (SNK) nutrition knowledge scores, or effect of age. Significantly higher knowledge was demonstrated by national vs. international athletes for the GNK scores (11.09 ± 1.58 vs. 9.58 ± 1.75; p = 0.028). Participants scored well in questions concerning protein, carbohydrates, alcohol, and supplements, and conversely, performed poorly in hydration and micronutrient related questions. Less than one-fifth of respondents had access to a dietitian. Forty-six percent of males and 38% of female climbers reported intentional weight loss for competition on at least one occasion. Of those, ~76% reported utilizing concerning practices, including methods that conform with disordered eating and/or eating disorders, dehydration, vomiting, and misuse of laxatives. Approximately 65% of athletes reported using at least one nutritional supplement in the previous 6 months, with 44% reporting multiple supplement use. There was no significant difference in supplement use between sexes or competition level.

Discussion

Due to the established importance of nutritional intake on athlete health and performance, educational support should be employed to improve knowledge in climbers and address shortcomings. Moreover, intentional weight loss for climbing competition is common, with most athletes achieving ~3-8% body weight loss over ≥2 weeks. It is crucial that professionals working with competitive climbers are vigilant in identifying athletes at risk of concerning weight management and establish referral pathways to the appropriate specialist services. High quality intervention trials to assess the efficacy of ergogenic aids in climbing remains inadequate.

Impact of Equation Choice on Resting Metabolic Rate Ratio in High-Level Men and Women Athletes

Objective: To examine the impact of the RMR ratio cutoff point selected on the categorization of prevalence/absence of low energy availability among predictive equations in high-level athletes (n = 241 [99 women]; 52% competed at the World Championship and Olympic Games), and whether this categorization is influenced by sex and the predictive equation used.Methods: We assessed RMR using indirect calorimetry, predicted the RMR using the equations proposed by Harris-Benedict, FAO/WHO/UNU, de Lorenzo, ten Haaf and Wejis, Wong, Jagim, Cunningham, and Freire, and computed the RMR ratio for each equation.Results: We observed that the cumulative percentage of RMR ratio values increased at a faster rate using Jagim, ten Haaf and Wejis, and Cunningham equations compared to the other equations. At the 0.90 value (the most used cutoff point in literature), the Jagim equation categorized ≥ 50% of the athletes into "low energy availability". No Sex × Equation × Sport interaction effect was observed (F = 0.10, p = 1.0). There was a significant main effect to Sex (F = 11.7, p < 0.001, ES = 0.05), Sport (F = 16.4, p < 0.001, ES = 0.01), and Equation (F = 64.1, p < 0.001, ES = 0.19). Wong and FAO/WHO/UNU equations yielded the largest errors (assessed vs. predicted RMR) in men and women, respectively.Conclusion: The selected RMR ratio cutoff point influences the prevalence/absence of low energy availability characterization in high-level athletes and suggests that certain equations could bias its assessment.

Direct and indirect impact of low energy availability on sports performance

Low energy availability (LEA) occurs inadvertently and purposefully in many athletes across numerous sports; and well planned, supervised periods with moderate LEA can improve body composition and power to weight ratio possibly enhancing performance in some sports. LEA however has the potential to have negative effects on a multitude of physiological and psychological systems in female and male athletes. Systems such as the endocrine, cardiovascular, metabolism, reproductive, immune, mental perception, and motivation as well as behaviors can all be impacted by severe (serious and/or prolonged or chronic) LEA. Such widely diverse effects can influence the health status, training adaptation, and performance outcomes of athletes leading to both direct changes (e.g., decreased strength and endurance) as well as indirect changes (e.g., reduced training response, increased risk of injury) in performance. To date, performance implications have not been well examined relative to LEA. Therefore, the intent of this narrative review is to characterize the effects of short-, medium-, and long-term exposure to LEA on direct and indirect sports performance outcomes. In doing so we have focused both on laboratory settings as well as descriptive athletic case-study-type experiential evidence.

Perspectives on the role of nutrition in influencing academy soccer player development and performance: A qualitative case study of key stakeholders from an English category one soccer academy

This study aimed to explore player and stakeholder perceptions of the role of nutrition in influencing the development of male academy soccer players. Semi-structured interviews (28 ± 13 mins in length) were conducted with 31 participants from an English category one academy, including players (Youth Development Phase, YDP: n = 6; Professional Development Phase, PDP: n = 4), parents/guardians (n = 10), coaches (n = 3), sport scientists (n = 3), physiotherapists (n = 3), and catering (n = 2). Via reflexive thematic analysis, data demonstrate an apparent lack of understanding and awareness on the role of nutrition in influencing player development, especially in relation to growth, maturation and reducing injury risk. Players highlighted the influence of their parents on their dietary behaviours, whilst parents also called for education to better support their sons. Notably, players and stakeholders perceived that the daily schedule of an academy soccer player presents as "too busy to eat", especially in relation to before school, and before and after training. The results demonstrate the necessity for the co-creation of player and stakeholder specific nutrition education programmes as an initial step towards positively impacting the nutrition culture associated with the academy soccer environment.

Depressive Disorders in Athletes

Depressive disorders in athletes are thought to be at least as common as the general population. However, athletes have a unique set of risk factors that can affect the likelihood of developing depression. Screening tools have been developed specifically for athletes such as the Sport Mental Health Assessment Tool (SMHAT). The management of the depressed athlete should involve an individualized approach, with methods such as counseling, interpersonal therapy, or cognitive behavioral therapy being used. Some may require antidepressant medication. Depressive disorders are also linked to sucidality in athletes, and the team physician and sporting organisation should have a crisis management plan in place for mental health emergencies. Tackling the stigma that remains in sport is a key part to improving mental wellbeing for all athletes.

Overtraining Syndrome as a Risk Factor for Bone Stress Injuries among Paralympic Athletes

Background and Objectives: In this review, we have explored the relationship between overtraining syndrome (OTS) and bone stress injuries among paralympic athletes. OTS is a complex condition that arises from an imbalance between training volume, nutrition, and recovery time, leading to significant negative effects on paralympic athlete's performance and overall well-being. On the other hand, bone stress injuries occur when abnormal and repetitive loading is applied to normal bone, resulting in microdamage accumulation and potential. The prevalence of overtraining syndrome and bone stress injuries among athletes highlights the need for a better understanding of their relationship and implications for prevention and management strategies. Methods: A literature review from the PubMed, Web of Science, and Google Scholar databases including the MeSH keywords "overtraining syndrome", "bone", and "paralympic athletes". Results: Studies have consistently shown that athletes engaged in endurance sports are particularly susceptible to overtraining syndrome. The multifactorial nature of this condition involves not only physical factors, but also psychological and environmental determinants. In addition, the diagnosis and management of OTS and bone stress injuries present challenges in clinical practice. Conclusions: Currently, there are no definitive biochemical markers for overtraining syndrome. The diagnosis is based on a combination of subjective measures such as questionnaires, symptoms checklists, and objective biomarkers, including hormone levels, inflammatory markers, and imaging studies. However, these diagnostic approaches have limitations regarding their specificity and sensitivity.

Short-term effects and long-term changes of FUEL-a digital sports nutrition intervention on REDs related symptoms in female athletes

Female endurance athletes are at high risk for developing Relative Energy Deficiency in Sport (REDs), resulting in symptoms such as menstrual dysfunction and gastrointestinal (GI) problems. The primary aim of this study was to investigate effects of the FUEL (Food and nUtrition for Endurance athletes-a Learning program) intervention consisting of weekly online lectures combined with individual athlete-centered nutrition counseling every other week for sixteen weeks on REDs related symptoms in female endurance athletes at risk of low energy availability [Low Energy Availability in Females Questionnaire (LEAF-Q) score ≥8]. Female endurance athletes from Norway (n = 60), Sweden (n = 84), Ireland (n = 17), and Germany (n = 47) were recruited. Fifty athletes with risk of REDs (LEAF-Q score ≥8) and with low risk of eating disorders [Eating Disorder Examination Questionnaire (EDE-Q) global score <2.5], with no use of hormonal contraceptives and no chronic diseases, were allocated to either the FUEL intervention (n = 32) (FUEL) or a sixteen-week control period (n = 18) (CON). All but one completed FUEL and n = 15 completed CON. While no evidence for difference in change in LEAF-Q total or subscale scores between groups was detected post-intervention (BFincl < 1), the 6- and 12-months follow-up revealed strong evidence for improved LEAF-Q total (BFincl = 123) and menstrual score (BFincl = 840) and weak evidence for improved GI-score (BFincl = 2.3) among FUEL athletes. In addition, differences in change between groups was found for EDE-Q global score post-intervention (BFincl = 1.9). The reduction in EDE-Q score remained at 6- and 12- months follow-up among FUEL athletes. Therefore, the FUEL intervention may improve REDs related symptoms in female endurance athletes.

Clinical Trial Registration

www.clinicaltrials.gov (NCT04959565).

Body composition as a marker of performance and health in military personnel

Introduction

Body composition standards are set to ensure operational readiness in active-duty military personnel. To meet body composition standards, some individuals, however, may engage in unhealthy weight control behaviors (i.e., weight cycling and disordered eating). The objectives of this review are to: (1) evaluate the evidence regarding body composition and the associations to physical and military specific performance; (2) discuss body composition and potential health consequences; and (3) examine the evidence of weight cycling and disordered eating behaviors in military personnel for weight control.

Methods

A systematic search to identify peer-reviewed research articles was conducted in PubMed on 2/20/2023 using Medical Subject Headings (MeSH) including but not limited to "Military Personnel", "Tactical Athlete", "Weight Loss", "Body Composition", and "Weight Cycling".

Results

A total of 225 research articles were identified. The list was narrowed down to articles from the last 20 years (2003-2023) in military personnel. Only studies in which percent body fat was directly measured were included resulting in 17 research articles for this review.

Discussion

Evidence-based research is limited on the relationship between body composition and operational readiness. Weight cycling and disordered eating behaviors also has been reported for weight control, yet additional research is needed. Specifically, future research should focus on female service members, racial and ethnic differences, age, and postpartum status and include other service branches (i.e., Air Force and Navy). A comprehensive survey on weight cycling, disordered eating, and weight management would be valuable to determine the prevalence and extent of this issue. This information along with performance data would guide policy makers on the relevance and appropriateness of existing body composition standards.

Sleep, Nutrition, and Injury Risk in Adolescent Athletes: A Narrative Review

This narrative review explores the impact of sleep and nutrition on injury risk in adolescent athletes. Sleep is viewed as essential to the recuperation process and is distinguished as an active participant in recovery through its involvement in growth, repair, regeneration, and immunity. Furthermore, the literature has shown that the sleep of athletes impacts elements of athletic performance including both physical and cognitive performance, recovery, injury risk, and mental well-being. For sleep to have a restorative effect on the body, it must meet an individual's sleep needs whilst also lasting for an adequate duration and being of adequate quality, which is age-dependent. The literature has suggested that athletes have increased sleep needs compared to those of the general population and thus the standard recommendations may not be sufficient for athletic populations. Therefore, a more individualised approach accounting for overall sleep health may be more appropriate for addressing sleep needs in individuals including athletes. The literature has demonstrated that adolescent athletes achieve, on average, ~6.3 h of sleep, demonstrating a discrepancy between sleep recommendations (8-10 h) and actual sleep achieved. Sleep-wake cycles undergo development during adolescence whereby adaptation occurs in sleep regulation during this phase. These adaptations increase sleep pressure tolerance and are driven by the maturation of physiological, psychological, and cognitive functioning along with delays in circadian rhythmicity, thus creating an environment for inadequate sleep during adolescence. As such, the adolescent period is a phase of rapid growth and maturation that presents multiple challenges to both sleep and nutrition; consequently, this places a significant burden on an adolescent athletes' ability to recover, thus increasing the likelihood of injury. Therefore, this article aims to provide a comprehensive review of the available literature on the importance of sleep and nutrition interactions in injury risk in adolescent athletes. Furthermore, it provides foundations for informing further investigations exploring the relation of sleep and nutrition interactions to recovery during adolescence.

Using a socioecological approach to explore healthy lifestyle in elite sport: a qualitative study of French athletes', coaches', and managers' perspectives

Elite athletes are continually subjected to a range of constraints specific to high performance, and these can have a negative impact on their health. Although many studies have explored the individual factors related to risky behaviours and disorders in elite sport contexts, few have focused on health promotion. Consequently, the interpersonal, institutional, and policy factors of the health-related behaviours of elite athletes are still poorly explored. Based on the socioecological model, this study aimed to identify the factors involved in the health-related lifestyle of elite athletes. Semi-structured interviews were conducted with 45 participants: athletes (N = 32), their coaches (N = 6) and the managers of elite sport centres (N = 7). Both deductive and inductive thematic analyses were performed. Our results highlight the views of the actors. Regarding intrapersonal factors, resilience qualities and health literacy appeared as key factors in influencing the health-related lifestyle of elite athletes. At the interpersonal level, parents and coaches emerged as the main sources of educational support. Regarding institutional factors, the health policies of the elite sport centres were key factors in supporting the athletes' healthy lifestyle. These results encourage the development of health promotion programs at different levels of intervention.

The development and test-retest reliability of the periodic health evaluation for female athletes (PHE FA) survey

OBJECTIVES

To develop and assess the test-retest reliability of a survey exploring Australian high-performance female athlete's perspectives toward the periodic health evaluation and their perceived health needs.

METHODS

A structured three-phase method for survey development was used to develop the periodic health evaluation for female athletes (PHE FA) survey. Initially, a literature review and gap analysis was performed to identify themes and questions (Phase 1). Survey questions were developed covering demographic information (n = 9); sports-related medical screening (n = 19) and health needs and information (n = 7) (Phase 2). Test-retest reliability of the survey was then assessed (Phase 3). The survey was administered to a purposeful sample of seven high-performance level female athletes who completed the survey, on two separate occasions, 3 weeks apart via Checkbox© survey software (Checkbox Technology Inc., San Francisco, CA). Test-retest reliability was assessed using the intraclass correlation coefficient (ICC).

RESULTS

The mean age of the athletes was 29 years (SD 4 years, range 24-34 years). All were able-bodied athletes and 71% participated in team sports. Eighty-six percent of athletes have competed in world championships and 71% were Olympians. The average ICC of all items was 0.998 (95% CI 0.997-0.998, p = 0.000) demonstrating excellent consistency of measures between the two time points.All the athletes preferred a Sport and Exercise Medicine Physician to conduct their PHE and 86% preferred a female doctor. The key topics of interest were pelvic floor health including incontinence (100%); fertility (86%); pregnancy (71%); and mental and emotional wellbeing (71%). Face-to-face education was the preferred option to receive health information.

CONCLUSIONS

The PHE FA survey was co-created with an athlete and other key stakeholders. Excellent consistency of measures between the two time points was indicated by the high test-retest reliability of the PHE FA survey. Data collected using the PHE FA survey can contribute to informed evidence-based policies, and processes to support the health and wellbeing of female athletes.

Comparative analysis between a brief nutrition screening survey and validated food frequency questionnaire among physically active college students

OBJECTIVE

To evaluate the agreement between a 61-item Nutrition Screening Survey (NSS) and 127-item validated Food Frequency Questionnaire (FFQ).

PARTICIPANTS

Forty-seven college students (male, n = 29; female, n = 18), age 21.7 ± 0.4 years, BMI of 23.5 ± 0.4 kg/m2.

METHODS

Participants completed the NSS, Block FFQ, and anthropometric measurements. Pearson's correlation, paired sample t test, and Bland-Altman plot evaluated agreement between the assessments.

RESULTS

Moderate to strong associations between assessments (0.61-0.89, p < 0.001) were identified for meals/day, snacks/day, calories, carbohydrate, fiber, grains, non-starchy vegetables, potatoes, legumes, fruit, yogurt, cheese, and eggs. Mean daily meals/day, calories, fat, fiber, grains, fruit, milk, and eggs did not significantly differ between surveys. The Bland-Altman plot analyses indicated no proportional bias for calories, fat, fiber, grains, fruit, milk, and eggs.

CONCLUSIONS

The NSS and Block FFQ display reasonable agreement, supporting use of the NSS for evaluating a range of dietary components among physically active college students.

Prevalence of low energy availability in 25 New Zealand elite female rowers - A cross sectional study

OBJECTIVES

To quantify energy availability (EA) in elite female rowers, determine its association with bone mineral density (BMD), and examine the ability of the low energy availability in females-questionnaire (LEAF-Q) and brief eating disorder in athletes-questionnaire (BEDA-Q) to distinguish between low and normal EA.

DESIGN

Observational cross-sectional study.

METHODS

Twenty-five elite female rowers participated in the study. EA was calculated by means of a 4-day food intake diary and analysis of training load. Low energy availability (LEA) was defined as EA <30 kCal * kg-1 * FFM-1 * day-1. Dual-energy X-ray absorptiometry (DXA) was used to assess fat free mass (FFM) and BMD Z-scores. LEA risk was assessed using the LEAF-Q and BEDA-Q.

RESULTS

The mean EA was 23.2 ± 12.2 kCal * kg-1 * FFM-1 * day-1. Prevalence of LEA was 64 %. The mean BMD Z-score was 1.6 ± 0.6 (range: 0.7 to 2.9). Athletes with LEA had a significantly higher BEDA-Q score than the group with normal EA (mean 0.30 ± 0.17 vs. 0.09 ± 0.11, P < 0.05), but LEAF-Q score was not different between groups (mean 10.4 ± 4.6, 8.2 ± 4.5, P = 0.29).

CONCLUSION

Low energy availability is common amongst elite female rowers in New Zealand and is positively correlated with higher scores on the BEDA-Q. Bone mineral density was normal irrespective of EA status.

Acute and Chronic Injury Patterns in Competitive Paraclimbing Sports

OBJECTIVE

This is the first study to evaluate sport-related injuries in competitive Paraclimbing athletes with the aim of creating a medical database for future research on injury prevention.

DESIGN

This was a descriptive epidemiology study. Data collection took place in two parts. In the first part, an online survey ( n = 81) was conducted. The second part was undertaken during three competitions ( n = 273) of the 2021 International Federation of Sport Climbing Paraclimbing competitions. Injury severity grading was determined using the Climbing Injury Score of the International Federation of Sport Climbing.

RESULTS

In the online survey, 76 injuries were reported: 62% acute and 38% chronic injuries. Injury severity was as follows: 21 scored 1, 34 scored 2a, 19 scored 2b, and 2 scored 3. The most injured body regions were the upper extremity (66%) with shoulder injuries (29%) most common; 53% reported regular pain/discomfort during training/competition and 16% used nonsteroidal anti-inflammatory drugs regularly to prevent pain/discomfort when training. In the 2021 International Federation of Sport Climbing Paraclimbing competitions, eight injuries were recorded. Injury severity was as follows: seven scored 1 and one scored 2a. The most injured body region was the upper extremity (47%). Overall, the calculated climbing time was 975 hrs, and injury incidence risk was 8.21 per 1000 hrs.

CONCLUSION

Compared with nondisabled climbers, the injury pattern seems to be sport dependent but influenced by the unique impairments of the athletes. In Paraclimbing competitions, the injury severity is mostly mild, with an overall low injury incidence. A concern is the number of athletes with pain/discomfort during training/competition with regular nonsteroidal anti-inflammatory drug intake.

The general nutrition practices of competitive powerlifters vary by competitive calibre and sex, weight, and age class

PURPOSE

To characterise self-reported nutrition practices and beliefs of powerlifters.

METHODS

Actively competing male (n = 240) and female (n = 65) powerlifters completed a cross-sectional online survey of self-reported nutrition practices across the competitive cycle, within specific competitive phases, and hard and easy training days. Data are presented as number (n) and percentage (%) of all powerlifters practicing a given strategy followed by a % of responses reporting various practices or beliefs within this strategy. Differences in categorical sub-groups (sex, age, and weight class; and competitive calibre) were analysed with a chi-square test and denoted where significant (p ≤ 0.05).

RESULTS

Most powerlifters reported following a specific diet long-term (n = 203, 66.6%) of which If It Fits Your Macros (IIFYM)/flexible dieting was most common (n = 159, 78.3%). Over half reported introducing a special diet for a competitive phase (n = 162, 53.1%), of which IIFYM/flexible dieting was most followed for competition preparation (n = 80, 63%) and off-season (n = 48, 71.6%). Compared to normal dietary intake, most reported eating more on harder training days (n = 219, 71.8%) and refraining from eating less on easier training days (n = 186, 61%).

CONCLUSIONS

IIFYM/flexible dieting is commonly followed by powerlifters to support performance and body composition goals. Females seemed to report more often restricting energy and dieting for body composition reasons than males. Powerlifters tailor their energy intake on harder training days to the higher training demands but refrain from reducing energy intake on rest/easier training days.

Low Energy Availability and Increased Risk of Relative Energy Deficiency in Sport (RED-S) During a 3767-km Thru-Hike on the Pacific Crest Trail: A Case Study

Long-distance "thru-hiking" has extraordinary physical demands and has become increasingly popular. This report describes a man (55 y) who thru-hiked the Pacific Crest Trail in 2021 and was at risk of developing the relative energy deficiency in sport (RED-S) syndrome. Hiking distance was 3767 km over 128 d. Eighty-eight days (69%) were full days of hiking, covering 38±8 km/d (mean±SD) in 7.9±1.6 h/d. Exercise energy expenditure above rest (heart rate vs indirect calorimetry regression method) was 2834±1518 kcal/d, total energy expenditure was 5702±1323 kcal/d, and energy intake was 4141 kcal/d. Body mass decreased by 9%, and fat mass (dual-energy X-ray absorptiometry) decreased by 46%. Energy availability (energy intake minus exercise energy expenditure) was 19.3 kcal/d/kg fat-free mass, indicating low energy availability (defined as <30 kcal/d/kg). Dual-energy X-ray absorptiometry-measured spine bone mineral density (BMD) decreased by 8.6%, with little to no decrease in total hip (-1.0%) and femoral neck (-1.5%) BMD. Total cholesterol, low-density lipoprotein cholesterol, and triglycerides increased by 24, 39, and 57%, respectively. Within 8 mo after the hike, BMD and serum lipids nearly or fully returned to baseline. No changes in high-density lipoprotein cholesterol, glycemia, or blood pressure were observed. According to guidelines, these observations are consistent with a moderate risk of RED-S, and a medical evaluation and treatment plan are advisable in order to avoid clinical manifestations (eg, stress fractures, anemia, psychological disturbances). To minimize RED-S risk, it may be prudent for thru-hikers to optimize energy availability by moderating daily hiking distances and/or increasing food intake.

Nutritional intake and anthropometric characteristics are associated with endurance performance and markers of low energy availability in young female cross-country skiers

BACKGROUND

Low energy availability (LEA) can have negative performance consequences, but the relationships between LEA and performance are poorly understood especially in field conditions. In addition, little is known about the contribution of macronutrients to long-term performance. Therefore, the aim of this study was to evaluate if energy availability (EA) and macronutrient intake in a field-based situation were associated with laboratory-measured performance, anthropometric characteristics, blood markers, training volume, and/or questionnaire-assessed risk of LEA in young female cross-country (XC) skiers. In addition, the study aimed to clarify which factors explained performance.

METHODS

During a one-year observational study, 23 highly trained female XC skiers and biathletes (age 17.1 ± 1.0 years) completed 3-day food and training logs on four occasions (September-October, February-March, April-May, July-August). Mean (±SD) EA and macronutrient intake from these 12 days were calculated to describe yearly overall practices. Laboratory measurements (body composition with bioimpedance, blood hormone concentrations, maximal oxygen uptake (VO_2max), oxygen uptake (VO₂) at 4 mmol·L^-1 lactate threshold (OBLA), double poling (DP) performance (time to exhaustion), counter movement jump (height) and the Low Energy Availability in Females Questionnaire (LEAF-Q)) were completed at the beginning (August 2020, M₁) and end of the study (August 2021, M₂). Annual training volume between measurements was recorded using an online training diary.

RESULTS

The 12-day mean EA (37.4 ± 9.1 kcal·kg FFM^-1·d^-1) and carbohydrate (CHO) intake (4.8 ± 0.8 g·kg^-1·d^-1) were suboptimal while intake of protein (1.8 ± 0.3 g·kg^-1·d^-1) and fat (31 ± 4 E%) were within recommended ranges. Lower EA and CHO intake were associated with a higher LEAF-Q score (r  = 0.44, p  = 0.042; r  = 0.47, p  = 0.026). Higher CHO and protein intake were associated with higher VO_2max (r  = 0.61, p  = 0.005; r  = 0.54, p  = 0.014), VO₂ at OBLA (r  = 0.63, p  = 0.003; r  = 0.62, p  = 0.003), and DP performance at M₂ (r  = 0.42, p  = 0.051; r  = 0.44, p  = 0.039). Body fat percentage (F%) was negatively associated with CHO and protein intake (r = -0.50, p  = 0.017; r = -0.66, p  = 0.001). Better DP performance at M₂ was explained by higher training volume (R²  = 0.24, p  = 0.033) and higher relative VO_2max and VO₂ at OBLA at M₂ by lower F% (R²  = 0.44, p  = 0.004; R²  = 0.47, p  = 0.003). Increase from M₁ to M₂ in DP performance was explained by a decrease in F% (R²  = 0.25, p  = 0.029).

CONCLUSIONS

F%, and training volume were the most important factors explaining performance in young female XC skiers. Notably, lower F% was associated with higher macronutrient intake, suggesting that restricting nutritional intake may not be a good strategy to modify body composition in young female athletes. In addition, lower overall CHO intake and EA increased risk of LEA determined by LEAF-Q. These findings highlight the importance of adequate nutritional intake to support performance and overall health.

Sports Nutrition Knowledge Questionnaires Developed for the Athletic Population: a Systematic Review

PURPOSE OF REVIEW

Sports nutrition (SN) is pivotal in aiding athletes to reach peak performance, minimize sport-related injuries, enhance career longevity, and improve general health. An accurate assessment of athletes' sports nutrition knowledge (SNK) is required to design targeted nutrition education programs aimed at enhancing both nutritional knowledge and dietary practices. This review systematically evaluates studies that use questionnaires to assess the SNK of athletes engaged in athletics.

RECENT FINDINGS

The literature search was conducted in PubMed®, Web of Science®, and Scopus®, and 375 potentially relevant articles were identified. The total number of articles included in the present review is 11, with eight studies involving only athletic disciplines and three involving athletics and other sports. The majority (n = 8) of the questionnaires included general and SN aspects, with SN covering endurance athletes' knowledge of competition carbohydrate guidelines, gastrointestinal symptoms associated with exercise, and ultra-endurance athletes' sodium beliefs and practices. Questionnaires were either delivered online (n = 7) or self-administered in hard copy (n = 1). The three major strategies identified for developing questionnaires were based on previous literature and recent SN guidelines (n = 6), consultation with a panel of experts (n = 7), and the use of a previously developed sports nutrition knowledge questionnaires (SNKQ) (n = 4), with more than one approach used in five studies. Similarly, up to three validation approaches were used, including content, face, and construct validity. Seven studies used a test-retest procedure to ensure external reliability, and eight used Cronbach's alpha or kappa coefficient to assess internal consistency. Endurance and ultra-endurance athletes are the populations of interest for the majority of questionnaires developed for athletics, with most questionnaires incorporating general and SNK topics.

Equations for smartphone prediction of adiposity and appendicular lean mass in youth soccer players

Digital anthropometry by three-dimensional optical imaging systems and smartphones has recently been shown to provide non-invasive, precise, and accurate anthropometric and body composition measurements. To our knowledge, no previous study performed smartphone-based digital anthropometric assessments in young athletes. The aim of this study was to investigate the reproducibly and validity of smartphone-based estimation of anthropometric and body composition parameters in youth soccer players. A convenience sample of 124 male players and 69 female players (median ages of 16.2 and 15.5 years, respectively) was recruited. Measurements of body weight and height, one whole-body Dual-Energy X-ray Absorptiometry (DXA) scan, and acquisition of optical images (performed in duplicate by the Mobile Fit app to obtain two avatars for each player) were performed. The reproducibility analysis showed percent standard error of measurement values < 10% for all anthropometric and body composition measurements, thus indicating high agreement between the measurements obtained for the two avatars. Mobile Fit app overestimated the body fat percentage with respect to DXA (average overestimation of + 3.7% in males and + 4.6% in females), while it underestimated the total lean mass (- 2.6 kg in males and - 2.5 kg in females) and the appendicular lean mass (- 10.5 kg in males and - 5.5 kg in females). Using data of the soccer players, we reparameterized the equations previously proposed to estimate the body fat percentage and the appendicular lean mass and we obtained new equations that can be used in youth athletes for body composition assessment through conventional anthropometrics-based prediction models.

Nutritional counseling in athletes: a systematic review

Many studies report poor adherence to sports nutrition guidelines, but there is a lack of research on the effectiveness of nutrition education and behavior change interventions in athletes. Some studies among athletes demonstrate that nutrition education (NE), often wrongly confused with nutritional counseling (NC), alone is insufficient to result in behavior change. For this reason, a clear distinction between NC and NE is of paramount importance, both in terms of definition and application. NE is considered a formal process to improve a client's knowledge about food and physical activity. NC is a supportive process delivered by a qualified professional who guides the client(s) to set priorities, establish goals, and create individualized action plans to facilitate behavior change. NC and NE can be delivered both to individuals and groups. To our knowledge, the efficacy of NC provided to athletes has not been comprehensively reviewed. The aim of this study was to investigate the current evidence on the use and efficacy of nutritional counseling within athletes. A systematic literature review was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method. The search was carried out in: PubMed, Scopus, Web of Science, Science Direct, Cochrane Library between November 2022 and February 2023. Inclusion criteria: recreational and elite athletes; all ages; all genders; NC strategies. The risk of bias was assessed using the RoB 2.0 Cochrane tool. The quality of evidence checking was tested with the Mixed Methods Appraisal Tool system. From 2,438 records identified, 10 studies were included in this review, with athletes representing different levels of competition and type of sports. The most commonly applied behavior change theory was Cognitive Behavioral Theory. NC was delivered mainly by nutrition experts. The duration of the intervention ranged from 3 weeks to 5 years. Regarding the quality of the studies, the majority of articles reached more than 3 stars and lack of adequate randomization was the domain contributing to high risk of bias. NC interventions induced positive changes in nutrition knowledge and dietary intake consequently supporting individual performance. There is evidence of a positive behavioral impact when applying NC to athletes, with positive effects of NC also in athletes with eating disorders. Additional studies of sufficient rigor (i.e., randomized controlled trials) are needed to demonstrate the benefits of NC in athletes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022374502.

Clinical assessment, treatment, and referral trends for adolescent runners seeking care at an injured runners' clinic

PURPOSE

Over a 10-year time frame, this study aimed to evaluate diagnosis, treatment, and referral trends for adolescent runners seeking care for running-related injuries (RRIs) at a clinic that specializes in running medicine.

METHODS

This study was a retrospective chart review of 392 adolescent runners (2,326 encounters) who sought care for RRIs between the years 2011 and 2021. Descriptive statistics were used to summarize clinical assessments, referrals, assistive devices, and medications prescribed or administered overall and by injury type. Chi-square analyses were used to compare proportions of services rendered across the 10-year time frame.

RESULTS

Patients most frequently received manual evaluations or special tests during clinic visits. Most visits resulted in at least one referral (91%), primarily for physical therapy or gait-training. Assistive devices and medications/supplements were offered at only 18% of patient visits. The majority of assessments (X2 = 69.7, p = 0.002), treatments (X2: 23.6-43.8, p: <  0.001-0.003), and referrals (X2 = 132, p <  0.001) were for shin injuries. Larger proportions of nutrition assessments (X2 = 40.7, p <  0.001), interventions (X2 = 26.8, p = 0.003), and referrals (X2 = 27.5, p = 0.002) were performed in or after the year 2015.

CONCLUSION

Clinic visits for shin injuries required the most clinical resources per episode of care. There were observed shifts in clinical assessment and treatment approaches to include more expanded nutritional and physiologic considerations.

High prevalence of low bone mineral density but normal trabecular bone score in Norwegian elite Para athletes

Background

Low bone mineral density (BMD) increases the risk of bone stress injuries (BSI) and is one of several clinical concerns in Para athlete sports medicine. However, whether bone microarchitecture is altered in Para athletes is not known.

Objective

We aimed to investigate BMD, bone microarchitecture and incidence of bone stress injuries in Norwegian elite Para athletes.

Design

In this cross-sectional study in Para athletes, Dual energy x-ray absorptiometry (iDXA, Lunar, GE Health Care) derived areal BMD, trabecular bone score (TBS), a surrogate marker for bone microarchitecture, and body composition (body weight (BW), lean body mass (LBM), fat mass (FM), fat percentage) were investigated and compared between ambulant and non-ambulant athletes. Also, the association between BMD, TBS and body composition variables was investigated. Incidence of BSI was assessed with a questionnaire and confirmed by a sports physician in a clinical interview. BMD Z-score <-1 was defined as low and ≤-2 as osteoporotic. TBS ≥ 1.31 was normal, 1.23-1.31 intermediate and <1.23 low.

Results

Among 38 athletes (26 ± 6 yrs, 14 females), BMD Z-score was low in 19 athletes, and osteoporotic in 11 athletes' lumbar spine (LS) or femoral neck (FN). BMD was lower in non-ambulant vs. ambulant athletes both in LS (1.13 ± 0.19 vs. 1.25 ± 0.14 g/cm2, p = 0.030) and FN (0.90 ± 0.15 vs. 1.07 ± 0.16 g/cm2, p = 0.003). TBS was normal for all athletes. BMD Z-score in LS was positively associated with TBS (r = 0.408, p = 0.013), body weight (r = 0.326, p = 0.046) and lean body mass (r = 0.414, p = 0.010), but not with fat mass or fat percentage. None of the athletes reported any BSI.

Conclusions

Half of the Norwegian elite Para athletes had low BMD, and 29% had BMD Z-score <-2 suggesting osteoporosis. Non-ambulant athletes were more prone to low BMD than ambulant athletes. However, despite high prevalence of low BMD, TBS was normal in all athletes, and BSI was absent in this young population.

An intervention mapping adaptation framework to develop a self-help intervention for athletes with eating disorder symptoms

OBJECTIVE

This research forum describes the use of the intervention mapping for adaptation (IMA) framework to develop and evaluate a novel intervention for athletes with mild eating disorder (ED) symptoms.

METHODS

The six IMA steps were followed. In step 1 (needs assessment), we conducted a systematic review of athlete ED interventions and held interviews/focus groups with athletes and sports professionals to inform intervention format and delivery. In step 2 (intervention search), needs assessment information guided the search for an evidence-based intervention suitable for adaptation to athletes. In steps 3 and 4 (intervention development), the identified intervention was adapted and feedback sought from athletes and sport professionals. In steps 5 and 6 (implementation and evaluation), a feasibility study was conducted with athletes (n = 35; females: n = 27; Mage  = 27.1).

RESULTS

The review highlighted poor evidence for the acceptability and relative efficacy of existing interventions, which were all delivered face-to-face in groups. Interview/focus group data suggested a need for more accessible intervention formats (e.g., self-help). One non-athlete self-help intervention was determined suitable for adaptation to athletes, and adaptations were made. Initial feedback suggested the adapted intervention was relevant within sport settings. The feasibility study revealed that the intervention (MOPED-A: Motivational and Psycho-Educational Self-Help Programme for Athletes with Mild Eating Disorder Symptoms) can be feasibly implemented, is acceptable to athletes and shows potential for reducing ED symptoms.

DISCUSSION

IMA is a useful framework for developing participant-centered and evidence-based interventions. The findings and approach taken provide a framework for other researchers and clinicians in developing similar interventions in the ED domain.

PUBLIC SIGNIFICANCE

The novel self-help intervention described in this article was developed using intervention mapping and provides promise as a tool for reducing eating disorder symptoms in athletes. We describe how adopting and systematically following a health intervention development approach, such as intervention mapping, can ensure that eating disorder interventions are participant-centered, contextually relevant, and evidence-based, which in turn could help to maximize their reach and effectiveness.

Energy balance and energy availability of female basketball players during the preparation period

OBJECTIVE

To determine the level of energy balance and energy availability (EA) in female basketball players during the preparation period.

METHODS

Fifteen basketball players (age: 19.53 ± 1.3 years; height: 173.6 ± 8.95 cm; weight: 67.55 ± 14.34 kg; training experience: 9.6 ± 2.7 years) and 15 age and body mass index-matched controls (age: 19.53 ± 1.1 years; height: 169.4 ± 5.06 cm; weight: 63.10 ± 6.14 kg) participated in the study. Resting metabolic rate (RMR) and body composition were measured by the indirect calorimetric method and dual-energy x-ray absorptiometry, respectively. A 3-day food diary was used to determine macronutrients and energy intake while a 3-day physical activity log was used to determine energy expenditure. Independent Samples t-test was used for data analysis.

RESULTS

The daily energy intake and expenditure of female basketball players were 2136.5 ± 594.9 kcal·day-1 and 2953.8 ± 614.5 kcal·day-1, respectively, indicating 817 ± 779 kcal·day-1 of negative energy balance. One hundred percent and 66.6% of the athletes failed to meet the carbohydrate and protein intake recommendations, respectively. EA of female basketball players was 33.04 ± 15.69 kcal·fat free mass-1·day-1 and the percentages of athletes who had negative energy balance, low EA, and reduced EA were 80%, 40%, and 46.7%, respectively. However, despite the low and decreased EA, the measured RMR to predicted RMR ratio (RMRratio) was 1.31 ± 0.17 and the body fat percentage (BF%) was 31.00 ± 5.21%.

CONCLUSION

This study shows that female basketball players have a negative energy balance during the preparation period which can be partly explained by insufficient carbohydrate intake. Although most of the athletes experienced low or reduced EA during the preparation period, the physiologically normal RMRratio and relatively high BF% indicate that this is a transient situation. In this regard, strategies to prevent the development of low EA and negative energy balance during the preparation period will contribute to positive training adaptations throughout the competition period.

[High-risk stress fractures in competitive athletes]

Bone stress injuries are chronic overload reactions of the bone, which are characterized by the load-dependent occurrence of locally perceived pain and tenderness on palpation at the site of the injury. Structurally normal bone becomes fatigued as a result of repetitive submaximal loading and/or inadequate regeneration. Certain stress fractures of the femoral neck (tension side), patella, anterior tibial cortex, medial malleolus, talus, tarsal navicular bone, proximal fifth metatarsal, and sesamoid bones of the great toe tend to develop complications (complete fractures, delayed union, pseudarthrosis, dislocation, arthrosis). These injuries are classified as high-risk stress fractures. Aggressive diagnostics and treatment are recommended when a high-risk stress fracture is suspected. Treatment is frequently different from low-risk stress fractures, including prolonged non-weight-bearing immobilization. In rare cases, surgery is indicated when conservative treatment fails, when a complete or non-healing fracture develops, or in cases of dislocation. The outcomes of both conservative and operative treatment are described as less successful compared with low-risk stress injuries.

Practical Application and Methodological Considerations on the Basics of Sports Nutrition in Basketball: A Comprehensive Systematic Review of Observational and Interventional Studies

The current systematic review (PROSPERO registration no. CRD42022334707) of observational (OS) and interventional studies (IS) aimed at evaluating the state of scientific knowledge on the basics of sports nutrition, framing discipline-specific dietary recommendations, and indicating potential directions for future studies in various age, experience level, and able-bodied abilities groups of basketball players (BP). A systematic search of PubMed, SPORTDiscus, and Web of Science ended on 20 December 2022. Records were excluded if reporting studies on animals, sport disciplines other than basketball, or supplementation protocols other than those related to macronutrients and hydration manipulations. Risk of bias (RoB) was evaluated using Cochrane RoB_2 tools, 'JBI checklist for prevalence studies', and 'Quality assessment tool for before-after (pre-post) studies with no control group'. The relevant data was synthesized in tables and a narrative review was performed. Seventy-two records were included (2581 participants): 63 were on able-bodied BP (2433 participants) and 9 on para-athlete players (148 participants); 45 records were OS and 27 IS. The review disclosed widespread poor nutritional habits and knowledge and shortages in applying adequate nutritional and hydration practices in BP. Moreover, the systematic review revealed the lack of a sufficient number of investigations delivering reliable proof for framing discipline-specific and evidence-based recommendations on the basics of sports nutrition in basketball.

Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review

The purpose of this narrative review is to identify health and performance consequences associated with LCA in female endurance athletes. The intake of carbohydrates (CHO) before, during, and after exercise has been demonstrated to support sport performance, especially endurance activities which rely extensively on CHO as a fuel source. However, low energy availability (LEA) and low carbohydrate availability (LCA) are common in female athletes. LEA occurs when energy intake is insufficient compared to exercise energy expenditure, and LEA-related conditions (e.g., Female Athlete Triad (Triad) and Relative Energy Deficiency in Sport (RED-S)) are associated with a myriad of health and performance consequences. The RED-S model highlights 10 health consequences and 10 performance consequences related to LEA. The independent effect of LCA on health and performance has been under-researched, despite current CHO intake being commonly insufficient in athletes. It is proposed that LCA may not only contribute to LEA but also have independent health and performance consequences in athletes. Furthermore, this review highlights current recommendations for CHO intake, as well as recent data on LCA prevalence and menstrual cycle considerations. A literature review was conducted on PubMed, Science Direct, and ResearchGate using relevant search terms (i.e., "low carbohydrate/energy availability", "female distance runners"). Twenty-one articles were identified and twelve met the inclusion criteria. The total number of articles included in this review is 12, with 7 studies illustrating that LCA was associated with direct negative health and/or performance implications for endurance-based athletes. Several studies included assessed male athletes only, and no studies included a female-only study design. Overall, the cumulative data show that female athletes remain underrepresented in sports science research and that current CHO intake recommendations and strategies may fail to consider female-specific adaptations and hormone responses, such as monthly fluctuations in estrogen and progesterone throughout the menstrual cycle. Current CHO guidelines for female athletes and exercising women need to be audited and explored further in the literature to support female athlete health and performance.

The accuracy of ten common resting metabolic rate prediction equations in men and women collegiate athletes

Predictive resting metabolic rate (RMR) equations are widely used to determine total daily energy expenditure (TDEE). However, it remains unclear whether these predictive RMR equations accurately predict TDEE in the athletic populations. The purpose of this study was to examine the accuracy of 10 commonly used RMR prediction equations (Cunningham, De Lorenzo, Freire, Harris-Benedict, Mifflin St. Jeor, Nelson, Owen, Tinsley, Watson, Schofield) in collegiate men and women athletes. One-hundred eighty-seven National Collegiate Athletic Association Division III men (n = 97) and women (n = 90) athletes were recruited to participate in one day of metabolic testing. RMR was measured using indirect calorimetry and body composition was analyzed using air displacement plethysmography. A repeated measures ANOVA with Bonferroni post hoc analyses was selected to determine mean differences between measured and predicted RMR. Linear regression analysis was used to assess the accuracy of each RMR prediction method (p<0.05). All prediction equations significantly underestimated RMR (p<0.001), although there was no difference between the De Lorenzo and Watson equations and measured RMR (p = 1.00) for women, only. In men, the Tinsley and Freire equations were the most agreeable formulas with the lowest root-mean-square prediction error value of 404 and 412 kcals, respectively. In women, the De Lorenzo and Watson equations were the most agreeable equations with the lowest root-mean-squared error value of 171 and 211 kcals, respectively. The results demonstrate that such RMR equations may underestimate actual energy requirements of athletes and thus, practitioners should interpret such values with caution.Highlights All prediction equations significantly underestimated RMR in men athletes.All prediction equations, except for the De Lorenzo and Watson equations, significantly underestimated RMR in women athletes.Although a significant underestimation of RMR in men athletes, the Freire and Tinsley equations were the most agreeable prediction equations.In women athletes, the De Lorenzo and Watson equations were the most agreeable prediction equations.

Mental Health in Ultra-Endurance Runners: A Systematic Review

BACKGROUND

Among ultra-endurance runners (UER), the mental, behavioral, and physical demands of training/competition can result in maladaptive outcomes. Mental health issues are common in athletes and can impact psychology, physical health, and performance.

OBJECTIVE

To synthesize information regarding the incidence/prevalence and factors associated with mental health issues among UER.

METHODS

Systematic searches were performed in PubMed, SPORTDiscus, Scopus, Cochrane databases, CINAHL, Web of Science, and Medline Ovid using key terms related to UER (e.g., trail running, road running) and psychological issues (e.g., exercise addiction, depression). Inclusion criteria included original articles published in peer-reviewed journals in English, using qualitative or quantitative approaches. We considered papers reporting incidence/prevalence and associated factors with mental health outcomes in UER of both sexes, all ages, and levels of competition (e.g., elite, nonprofessional runners). The Joanna Briggs Institute Analytical Cross-Sectional Studies critical appraisal tool was used for quality assessment.

RESULTS

A total of 282 studies were identified, and 11 studies were included in the final selection. A total of 3670 UER were included in the studies. The prevalence of mental health issues among UER ranged between 32.0% and 62.5% for eating disorders, from 11.5% to 18.2% for exercise addiction, 18.6% for depressive symptoms, and 24.5% for sleep disturbance. Exercise addiction was not related to weekly volume, but a strong relationship with exercise in an unstructured space, age, and body mass index was shown.

CONCLUSION

Mental health issues among UER are common, especially eating disorders, exercise addiction, sleep disturbances, and depressive symptoms. Further high-quality studies are needed to examine underlying factors and find preventative strategies to protect UER.

REGISTRATION

The protocol of this systematic review was registered at the PROSPERO-CRD42022338743.

The Women's Soccer Health Study: From Head to Toe

OBJECTIVES

Women are under-represented in the sports literature despite increasing rates of sports participation. Our objective was to investigate the risks and benefits of an elite women's soccer career in five health domains: general, musculoskeletal, reproductive endocrinology, post-concussion, and mental.

METHODS

An online survey was distributed to retired US college, semi-professional, professional, and national team soccer players using personal networks, email, and social media. Short validated questionnaires were used to evaluate the health domains, including the Patient-Reported Outcomes Measurement Information System (PROMIS), Single Assessment Numerical Evaluation (SANE), Post-Concussion Symptom Scale (PCSS), and Patient Health Questionnaire (PHQ).

RESULTS

A total of 560 eligible players responded to the survey over a 1-year period. The highest competitive levels were 73% college, 16% semi-professional, 8% professional, and 4% national team. The mean number of years since retirement was 12 (SD = 9), and 17.0% retired for involuntary reasons. The mean SANE scores (0-100 scale as percentage of normal) were knee = 75% (SD = 23), hip = 83% (SD = 23), and shoulder = 87% (SD = 21). The majority (63%) reported that their current activity level included participation in impact sports. A substantial proportion of players reported menstrual irregularities during their careers: 40% had fewer periods with increasing exercise and 22% had no periods for ≥ 3 months. The players (n = 44) who felt that post-concussion symptoms were due to soccer reported more time-loss concussions (F[2] = 6.80, p = 0.002) and symptom severity (F[2] = 30.26, p < 0.0001). Players who recently retired (0-5 years) reported the highest anxiety/depression scores and lowest satisfaction rates compared with those who retired 19+ years ago.

CONCLUSION

Health concerns include musculoskeletal injuries, post-concussion symptoms, and lower mental health in the early years following retirement. This comprehensive survey provides initial results that will lay the foundation for further analyses and prioritize research studies that can help all female athletes.

Signs of low energy availability in elite male volleyball athletes but no association with risk of bone stress injury and patellar tendinopathy

Relative Energy Deficiency in Sport (RED-S) syndrome is associated with undesirable health and performance outcomes. The aetiology of RED-S syndrome is low energy availability (LEA). LEA has been reported in male athletes in various sports, but there is little information in team sports. Therefore, the aims of this study were to assess the point-prevalence of surrogate markers of LEA in elite male volleyball players and examine the association between low and normal total-testosterone (TES) on endocrine markers, resting metabolic rate, bone mineral density (BMD), and history of injury/illness. Using a cross-sectional design, 22 elite male volleyball players underwent anthropometric, dual-energy X-ray absorptiometry (DEXA or DXA) and resting metabolic rate testing, bloodwork, dietary analysis, the three-factor eating questionnaire-R18, injury/illness questionnaire and Victorian Institute of Sport Assessment - patellar tendon questionnaire. The primary finding of this investigation was that 36% of athletes had ≥2 surrogate markers of LEA. Although fasted insulin was lower and cortisol was higher in players with low-total TES, low BMD, low RMR and various other endocrine markers linked to LEA were not observed. More research is required to define surrogate markers of LEA in male athletes.HIGHLIGHTS Thirty-six percent of volleyball players had ≥2 surrogate markers of LEA.The Cunningham, 1991 predictive RMR equation and/or the cut-off point (<0.9) may be unsuitable for detecting energy conservation associated with LEA in large male athletes.There was no association between total-TES and risk of bone stress injury, illness and patellar tendinopathy.

Surfboard riders are at risk of low energy availability - A pilot study

BACKGROUND

Surfing is a rapidly growing sport and recreational activity. The previously reported, intermittent high-intensity energetics of surfing place athletes and recreational participants at risk of low energy availability (LEA).

AIM

As such, this pioneering study aims to be the first to investigate LEA risk and the second to investigate dietary intake in surfers.

METHODS

Twenty-one intermediate and advanced surfers (female - 5, male - 16) were recruited to complete an online self-administered questionnaire and 4 consecutive 24-hour food logs to establish LEA risk and asses dietary intake. The Low Energy Availability in Female Questionnaire and Eating Disorder Examination Questionnaire were used to identify at-risk individuals in females and males, respectively, with respective cut-off's of ≥8 and ≥2.3.

RESULTS

Fifty-seven percent were classed as at-risk of LEA (50% and 80% in males and females, respectively). No significant relationship of competitive status, surfing ability and body mass index on risk classification was found. However, a non-significant medium effect of age was observed (p = 0.338, R = 0.549). And 77% of the 70 total analysed food records showed inadequate carbohydrate (CHO) consumption.

CONCLUSION

In summary, an alarmingly high portion of surfers are at risk of LEA and dietary inadequacy. Future studies should confirm whether surfing organisations need to intervene, by addressing limitations of the present study including a small sample, which was heavily biased away from female and high-level competitors.

Mechanisms and predictors of menses resumption once normal weight is reached in anorexia nervosa

BACKGROUND

In cases of Anorexia Nervosa (AN), achieving weight gain recovery beyond the lower limits set by the World Health Organization and normalizing classical nutritional markers appears to be essential for most patients. However, this is not always adequate to restore menstrual cycles. This discrepancy can cause concern for both patients and healthcare providers, and can impact the medical management of these individuals. Thus, the purpose of this study was to assess the ability of anthropometric and hormonal factors to predict the resumption of menstrual cycles in individuals with anorexia nervosa upon reaching a normal body weight.

METHOD

Patients with AN who had achieved a normal Body Mass Index but had not yet resumed their menstrual cycles (referred to as ANRec) were evaluated on two occasions: first at visit 1 and then again 6 months later, provided their body weight remained stable over this period (visit 2). Among the 46 ANRec patients who reached visit 2, they were categorized into two groups: 20 with persistent amenorrhea (PA-ANRec) and 26 who had regained their menstrual cycles (RM-ANRec). Anthropometric measurements, several hormone levels, Luteinizing Hormone (LH) pulsatility over a 4-h period, and LH response to gonadotropin-releasing hormone injection (LH/GnRH) were then compared between the two groups at visit 1.

RESULTS

Patients in the RM-ANRec group exhibited higher levels of follicular stimulating hormone, estradiol, inhibin B, LH/GnRH, and lower levels of ghrelin compared to those in the PA-ANRec group. Analysis of Receiver Operating Characteristic curves indicated that having ≥ 2 LH pulses over a 4-h period, LH/GnRH levels ≥ 33 IU/l, and inhibin B levels > 63 pg/ml predicted the resumption of menstrual cycles with a high degree of specificity (87%, 100%, and 100%, respectively) and sensitivity (82%, 80%, and 79%, respectively).

CONCLUSIONS

These three hormonal tests, of which two are straightforward to perform, demonstrated a high predictive accuracy for the resumption of menstrual cycles. They could offer valuable support for the management of individuals with AN upon achieving normalized weight. Negative results from these tests could assist clinicians and patients in maintaining their efforts to attain individualized metabolic targets.

TRIAL REGISTRATION

IORG0004981.

Nutritional Considerations for Elite Golf: A Narrative Review

Golf is predominantly a skill-based sport where technical aspects are regarded as a priority area for improving performance. At present, most of the existing literature has focused on improving a player's physicality, endurance and technical attributes in an effort to enhance performance. While important, the role of nutrition in elite golf has received little attention to date. The energy demands of the sport can vary depending on the level of the individual (recreational-professional), with distances of up to 20 km being covered and the time spent on the course ranging approximately 4-8 h each day. Like other sports, a focus on pre-game, during and post-game nutrition, including hydration, is integral to ensuring that individuals are adequately fuelled, hydrated and optimally recovered. For the elite athletes who travel extensively to international tournaments, it is important to understand the additional impact of travel on the body and consider the role nutrition can play in preventing illness and ensuring minimal disruption to golf performance. Lastly, the role of dietary supplements to enhance the performance of golfers is also important to consider. This review aims to consolidate the findings of the existing research focusing on nutrition strategies for golf performance and identify areas for potential future research.