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.

Primary, secondary and tertiary prevention of Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the IOC consensus on REDs.

Relative Energy Deficiency in Sport (REDs) is common among female and male athletes representing various sports at different performance levels, and the underlying cause is problematic low energy availability (LEA). It is essential to prevent problematic LEA to decrease the risk of serious health and performance consequences. This narrative review addresses REDs primary, secondary and tertiary prevention strategies and recommends best practice prevention guidelines targeting the athlete health and performance team, athlete entourage (eg, coaches, parents, managers) and sport organisations. Primary prevention of REDs seeks to minimise exposure to and reduce behaviours associated with problematic LEA. Some of the important strategies are educational initiatives and de-emphasising body weight and leanness, particularly in young and subelite athletes. Secondary prevention encourages the early identification and management of REDs signs or symptoms to facilitate early treatment to prevent development of more serious REDs outcomes. Recommended strategies for identifying athletes at risk are self-reported screening instruments, individual health interviews and/or objective assessment of REDs markers. Tertiary prevention (clinical treatment) seeks to limit short-term and long-term severe health consequences of REDs. The cornerstone of tertiary prevention is identifying the source of and treating problematic LEA. Best practice guidelines to prevent REDs and related consequences include a multipronged approach targeting the athlete health and performance team, the athlete entourage and sport organisations, who all need to ensure a supportive and safe sporting environment, have sufficient REDs knowledge and remain observant for the early signs and symptoms of REDs.

2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs).

Relative Energy Deficiency in Sport (REDs) was first introduced in 2014 by the International Olympic Committee's expert writing panel, identifying a syndrome of deleterious health and performance outcomes experienced by female and male athletes exposed to low energy availability (LEA; inadequate energy intake in relation to exercise energy expenditure). Since the 2018 REDs consensus, there have been >170 original research publications advancing the field of REDs science, including emerging data demonstrating the growing role of low carbohydrate availability, further evidence of the interplay between mental health and REDs and more data elucidating the impact of LEA in males. Our knowledge of REDs signs and symptoms has resulted in updated Health and Performance Conceptual Models and the development of a novel Physiological Model. This Physiological Model is designed to demonstrate the complexity of either problematic or adaptable LEA exposure, coupled with individual moderating factors, leading to changes in health and performance outcomes. Guidelines for safe and effective body composition assessment to help prevent REDs are also outlined. A new REDs Clinical Assessment Tool-Version 2 is introduced to facilitate the detection and clinical diagnosis of REDs based on accumulated severity and risk stratification, with associated training and competition recommendations. Prevention and treatment principles of REDs are presented to encourage best practices for sports organisations and clinicians. Finally, methodological best practices for REDs research are outlined to stimulate future high-quality research to address important knowledge gaps.

Body appreciation and body appearance pressure in Norwegian university students comparing exercise science students and other students.

BACKGROUND: Body image is considered a core issue for public health and associates with university students' overall health. Due to positive associations between exercise and body image, it has been suggested that students within an exercise science program might be more body appreciative compared to other students. On the other hand, the strong societal idealization of the athletic body may expose them to a pressure of having a specific body appearance, which may result in unfavorable health consequences. Nevertheless, studies investigating these hypotheses are lacking. We therefore aimed to explore the level and associations of body appreciation, body appearance pressure, body image related mental health constructs, physical activity, and exercise, in Norwegian university exercise science and non-health reference students. METHOD: Male and female exercise science students (n = 517) and reference students (n = 476), from nine large universities in Norway took part in this cross-sectional study. Participants responded to the Body appreciation scale-2, a self-developed questionnaire on body appearance pressure, Physical Appearance Comparison Scale-Revised, Sociocultural attitudes towards appearance questionnaire-4R, Rosenberg Self-Esteem Scale, Satisfaction with Life Scale, and questions about physical activity and exercise. Between group differences were analyzed using student independent t-test and ANCOVA for parametric data and Chi-square test for categorical data, and associations were evaluated by Person's correlation. P-values ≤0.05 were defined as significant. RESULTS: Female exercise science students had higher scores on body appreciation compared to reference students. No group difference was found in males. A high percentage of students reported experiencing body appearance pressure, with 69 and 85% among male and female exercise science students, and 57 and 83% among male and female reference students. Fitness centers were the settings where most respondents experienced body appearance pressure. Body appreciation was strongly associated with favorable scores on body image related mental health constructs, while personally experienced body appearance pressure associated with destructive scores on the same constructs. CONCLUSION: Body appearance pressure is an issue among university students regardless of study program. Actions to promote body appreciation and prevent body appearance pressure may include an implementation of media literacy, body functionality, and exercise as topics within the education program to safeguard students' health and well-being. CLINICAL TRIAL REGISTRY: No. NCT04256967 .

Prevalence of Surrogate Markers of Relative Energy Deficiency in Male Norwegian Olympic-Level Athletes.

The syndrome of Relative Energy Deficiency in Sport (RED-S) includes wide-ranging effects on physiological and psychological functioning, performance, and general health. However, RED-S is understudied among male athletes at the highest performance levels. This cross-sectional study aimed to investigate surrogate RED-S markers prevalence in Norwegian male Olympic-level athletes. Athletes (n = 44) aged 24.7 ± 3.8 years, body mass 81.3 ± 15.9 kg, body fat 13.7% ± 5.8%, and training volume 76.1 ± 22.9 hr/month were included. Assessed parameters included resting metabolic rate (RMR), body composition, and bone mineral density by dual-energy X-ray absorptiometry and venous blood variables (testosterone, free triiodothyronine, cortisol, and lipids). Seven athletes (16%) grouped by the presence of low RMR (RMRratio < 0.90) (0.81 ± 0.07 vs. 1.04 ± 0.09, p < .001, effect size 2.6), also showed lower testosterone (12.9 ± 5.3 vs. 19.0 ± 5.3 nmol/L, p = .020) than in normal RMR group. In low RMRratio individuals, prevalence of other RED-S markers (-subclinical-low testosterone, low free triiodothyronine, high cortisol, and elevated low-density lipoprotein) was (N/number of markers): 2/0, 2/1, 2/2, 1/3. Low bone mineral density (z-score < -1) was found in 16% of the athletes, all with normal RMR. Subclinical low testosterone and free triiodothyronine levels were found in nine (25%) and two (5%) athletes, respectively. Subclinical high cortisol was found in 23% of athletes while 34% had elevated low-density lipoprotein cholesterol levels. Seven of 12 athletes with two or more RED-S markers had normal RMR. In conclusion, this study found that multiple RED-S markers also exist in male Olympic-level athletes. This highlights the importance of regular screening of male elite athletes, to ensure early detection and treatment of RED-S.

Healthy and sustainable diet and physical activity: the rationale for and experiences from developing a combined summary score.

Aims: First, to describe the rationale for developing a combined summary score, the Healthy and Sustainable Dietary and Physical Activity habits (HSDPA) score, incorporating four selected dietary and physical activity aspects: (a) the New Nordic Diet, (b) local and sustainable foods, (c) active transportation and (d) non-exercise outdoor activities. Secondly, to describe the experiences from constructing the HSDPA score. Methods: Relevant literature covering the four aspects of interest was reviewed to secure a well-grounded rationale and a theory-based approach. To measure compliance with such a broad approach targeting diet, physical activity, health and environmental sustainability, the HSDPA score was constructed including one subscale for each aspect. The four subscales were constructed from questionnaire items and were equally weighted, entailing a range from 0-10 points, hence the total HSDPA score ranged from 0-40 points. Results: In retrospect, we believe that the rationale for creating the HSDPA score is reasonable. Still, emphasizing fewer, but the most relevant aspects, such as reduced meat consumption and active transportation, may represent a more functional solution than the broad approach suggested herein, both for promoting public health and environmental sustainability, and for developing a feasible measurement tool. Conclusions: Our experiences illustrate the importance of methodological perspectives and scrutiny related to both the development and testing of complex summary scores. Nevertheless, we think that combined summary scores could be applicable for use within epidemiological studies and for measuring the effects of interventions, if accounting for the methodological limitations as far as possible.

Participation in organized sports is associated with decreased likelihood of unhealthy lifestyle habits in adolescents.

Adolescence is a pivotal time for investing in both present and future health. Thus, it is important to identify arenas for promoting positive adolescent health behaviors and preventing negative ones. The aim of this study was to investigate the associations between organized sports participation (OSP) and a broad range of lifestyle habits in Norwegian adolescents. A comprehensive survey was completed by 13 269 junior high and high school students in southern Norway. Multivariable binary logistic regression models, adjusted for gender, age, and parental education, were used to investigate the associations between OSP and adolescent substance use, dietary habits, physical activity level, passive vs active transportation, screen time, and sleep duration. Inverse associations were found between OSP and adolescent substance use (odds ratio 0.40 [95% confidence interval 0.30-0.52] to 0.68 [0.61-0.76]), irregular consumption of main meals (0.58 [0.53-0.63] to 0.78 [0.70-0.89]), high intake of unhealthy food and beverages (0.55 [0.47-0.65] to 0.86 [0.75-0.98]), low intake of healthy food items (0.57 [0.51-0.63] to 0.77 [0.70-0.84]), low physical activity level (0.15 [0.14-0.17]), high screen-based activity (0.61 [0.55-0.67]), passive vs active transportation (summer; 0.79 [0.72-0.86] and winter; 0.84 [0.77-0.92]), and short sleep duration, during both weekdays (0.57 [0.52-0.63]) and weekends (0.79 [0.69-0.89]). In conclusion, adolescents participating in organized sports had decreased odds for engaging in several unhealthy lifestyle habits compared with non-participants, indicating that organized sports may be a relevant setting for promoting healthy behaviors among adolescents. Future studies are, however, needed to confirm a possible causal relationship.

Within-Day Energy Deficiency and Metabolic Perturbation in Male Endurance Athletes.

Endurance athletes are at increased risk of relative energy deficiency associated with metabolic perturbation and impaired health. We aimed to estimate and compare within-day energy balance in male athletes with suppressed and normal resting metabolic rate (RMR) and explore whether within-day energy deficiency is associated with endocrine markers of energy deficiency. A total of 31 male cyclists, triathletes, and long-distance runners recruited from regional competitive sports clubs were included. The protocol comprised measurements of RMR by ventilated hood and energy intake and energy expenditure to predict RMRratio (measured RMR/predicted RMR), energy availability, 24-hr energy balance and within-day energy balance in 1-hr intervals, assessment of body composition by dual-energy X-ray absorptiometry, and blood plasma analysis. Subjects were categorized as having suppressed (RMRratio < 0.90, n = 20) or normal (RMRratio > 0.90, n = 11) RMR. Despite there being no observed differences in 24-hr energy balance or energy availability between the groups, subjects with suppressed RMR spent more time in an energy deficit exceeding 400 kcal (20.9 [18.8-21.8] hr vs. 10.8 [2.5-16.4], p = .023) and had larger single-hour energy deficits compared with subjects with normal RMR (3,265 ± 1,963 kcal vs. -1,340 ± 2,439, p = .023). Larger single-hour energy deficits were associated with higher cortisol levels (r = -.499, p = .004) and a lower testosterone:cortisol ratio (r = .431, p = .015), but no associations with triiodothyronine or fasting blood glucose were observed. In conclusion, within-day energy deficiency was associated with suppressed RMR and catabolic markers in male endurance athletes.

The association between time scarcity, sociodemographic correlates and consumption of ultra-processed foods among parents in Norway: a cross-sectional study.

BACKGROUND: Use of ultra-processed foods has expanded rapidly over the last decades and high consumption has been positively associated with risk of e.g. overweight, obesity and type 2 diabetes. Ultra-processed foods offer convenience as they require minimal time for preparation. It is therefore reasonable to assume that such foods are consumed more often among people who experience time scarcity. The main aim of this study was to investigate the association between time scarcity and consumption of ultra-processed foods among parents of 2-year olds in Norway. A secondary aim was to investigate the association between sociodemographic correlates, weight status and consumption of ultra-processed foods. METHODS: This cross-sectional study included 497 participants. Chi-square and cross tabulations were used to calculate proportions of high vs. low consumption of ultra-processed foods in relation to time scarcity, sociodemographic correlates and weight status. Binary logistic regression analyses were performed to test the relationship between independent variables and consumption of ultra-processed foods. RESULTS: Participants reporting medium and high time scarcity were more likely to have a high consumption of ultra-processed dinner products (OR = 3. 68, 95% CI = 2. 32-5.84 and OR = 3.10, 1.80-5.35, respectively) and fast foods (OR = 2.60, 1.62-4.18 and OR = 1.90, 1.08-3.32, respectively) compared to those with low time scarcity. Further, participants with medium time scarcity were more likely to have a high consumption of snacks and soft drinks compared to participants with low time scarcity (OR = 1.63, 1.06-2.49). Finally, gender, ethnicity, educational level, number of children in the household and weight status were identified as important factors associated with the consumption of certain types of ultra-processed foods. CONCLUSIONS: Results from the present study showed that time scarcity, various sociodemographic factors and weight status was associated with consumption of processed foods. Future studies with a longitudinal design are needed to further explore these patterns over a longer period of time.

Postmenopausal women with osteopenia and a healed wrist fracture have reduced physical function and quality of life compared to a matched, healthy control group with no fracture.

BACKGROUND: Fractures lead to reduced physical function and quality of life (QOL), but little is known about postmenopausal women with osteopenia and a healed wrist fracture. The purpose was to evaluate physical function in terms of quadriceps strength, dynamic balance, physical capacity and QOL in postmenopausal women with osteopenia and a healed wrist fracture compared to a matched, healthy control group with no previous fracture. METHODS: Eighteen postmenopausal women with osteopenia (patients) (mean age 59.1 years, range 54 - 65) and a healed wrist fracture were matched to 18 healthy control subjects on age (mean age 58.5 years, range 51 - 65), height, weight and body mass index (BMI). We measured quadriceps strength at 60°/sec and at 180°/sec with Biodex 6000, dynamic balance with the Four Square Step Test (FSST), physical capacity with the six-minute walk test (6MWT) followed by the Borg's scale (BS), and QOL with the Short Form 36 (SF-36), bone mineral density (BMD) with dual x-ray absorptiometry (DXA) and physical activity level with the Physical Activity Scale for the Elderly. RESULTS: The patients had 17.6% lower quadriceps strength at 60°/sec (p = 0.025) at left limb and 18.5% at 180°/sec (p = 0.016) at right limb, and 21% lower at 180°/sec (p = 0.010) at left limb compared to the controls. Impaired performance for the patients was found with 2.4 seconds (p = 0.002) on the FSST, 74 metres (p < 0.001) on the 6MWT, and 1.4 points (p = 0.003) on the BS compared to the controls. The patients scored lower on the sub-scales on the SF-36 role limitations-physical (p = 0.014), bodily pain (p = 0.025) and vitality (p = 0.015) compared to the controls. CONCLUSIONS: The patients with osteopenia and a healed wrist fracture scored significantly lower on quadriceps strength, dynamic balance, physical capacity and QOL compared to the matched controls. Greater focus should be put on this patient group in terms of rehabilitation and early prevention of subsequent fractures.

Disordered eating and eating disorders in aquatic sports.

Disordered eating behavior (DE) and eating disorders (EDs) are of great concern because of their associations with physical and mental health risks and, in the case of athletes, impaired performance. The syndrome originally known as the Female Athlete Triad, which focused on the interaction of energy availability, reproductive function, and bone health in female athletes, has recently been expanded to recognize that Relative Energy Deficiency in Sport (RED-S) has a broader range of negative effects on body systems with functional impairments in both male and female athletes. Athletes in leanness-demanding sports have an increased risk for RED-S and for developing EDs/DE. Special risk factors in aquatic sports related to weight and body composition management include the wearing of skimpy and tight-fitting bathing suits, and in the case of diving and synchronized swimming, the involvement of subjective judgments of performance. The reported prevalence of DE and EDs in athletic populations, including athletes from aquatic sports, ranges from 18 to 45% in female athletes and from 0 to 28% in male athletes. To prevent EDs, aquatic athletes should practice healthy eating behavior at all periods of development pathway, and coaches and members of the athletes' health care team should be able to recognize early symptoms indicating risk for energy deficiency, DE, and EDs. Coaches and leaders must accept that DE/EDs can be a problem in aquatic disciplines and that openness regarding this challenge is important.

Risk and prevalence of Relative Energy Deficiency in Sport (REDs) among professional female football players.

A high prevalence of low energy availability (LEA) has been reported in female football players. This is of concern as problematic LEA may evolve into a syndromic pattern known as relative energy deficiency in sport (REDs). Given the difficulties in accurately assessing LEA, our study shifts emphasis to measurable indicators of REDs, serving as proxies for health detriments caused by LEA. The present cross-sectional study aimed to quantify the risk of REDs and to assess the prevalence of indicators indicative of the syndrome. 60 players (tiers 3 and 4) from three Norwegian football teams were analyzed as a single cohort but also stratified based on player position and menstrual status. The proportion of players at risk for REDs was 22%, that is, 17% with mild, 3% with moderate to high, and 2% with very high/extreme risk, respectively. The majority of the cohort (71%) presented with no primary indicators, while 20%, 7%, and 2% presented with one, two, and three primary indicators, respectively. Regarding secondary indicators, 57% had none, 33% had one, and 10% had two indicators. For associated indicators, 30% had none, 42% had one, 18% had two, 8% had three, and 2% had four indicators. Player position did not affect the prevalence of REDs indicators. Among noncontraceptive users (n = 27), secondary amenorrhea (AME) was reported by 30%. These findings indicate that health and performance teams should prioritize universal health promoting strategies rather than selective or indicative strategies. Particularly, focus on nutritional periodization to secure sufficient energy availability, mitigating the risk of problematic LEA and REDs should be addressed.

Risk factors for sexual harassment and abuse victimization among adolescent athletes and non-athletes: A one-year follow-up study.

BACKGROUND: The association between SHA and negative mental health increases the need to understand risk factors for SHA victimization, which is important for future development of prevention programs. OBJECTIVE: To examine which combinations of demographic- and mental health factors were associated with subsequent SHA victimization, and the prevalence of elite athletes, recreational athletes, and reference students who experienced sexual revictimization. PARTICIPANTS AND SETTING: Norwegian elite athletes and recreational athletes attending sport high schools, and reference students attending non-sport high schools (mean age: 17.1 years) were eligible for participation. METHODS: The participants answered an online questionnaire at two measurement points one year apart, T1 and T2 (n = 1139, 51.1 % girls). After testing for measurement invariance, data were analyzed with Classification and Regression Tree analysis (CRT) using demographic- and mental health variables from T1 as independent variables, and SHA at T2 as outcome. RESULTS: The combination of being a girl with high level of symptoms of eating disorders and other psychological symptoms was associated with subsequent reporting of SHA. Among the students with lifetime experience of SHA at T1 (n = 533, 58.3 %), 49.5 % reported revictimization at T2 (60.9 % girls, 32.2 % boys, p ≤ .001). The prevalence of SHA revictimization was lower among elite athletes (44.3 %) compared with recreational athletes (49.1 %) and reference students (59.4 %, p = .019). CONCLUSION: The combination of female gender and mental health symptoms are risk factors for subsequent SHA victimization. These findings, and the high prevalence of SHA revictimization is important knowledge for developing preventive programs targeting elite athletes, recreational athletes, and reference students.

FIDES Athlete Development Programme: project background and study protocol of an embedded multiple case study.

Most sports science research revolves around male subjects. As a result, most of the knowledge and practices within sports are male-centric. Failing to take the biological, psychological and social (biopsychosocial) particularities of females into account is believed to hinder optimal sports participation, development and performance, with potential negative effects on the health and well-being of females. To close the knowledge gap and alleviate these issues, we aim to develop and evaluate a 12-video educational intervention that addresses female-specific subject matter: the FIDES Athlete Development Programme. The study is designed as an embedded multiple case study where at least 1320 Swedish female athletes aged 13-16 will participate, in addition to their parents and their coaches. The girls will be recruited through their sports clubs, with half being exposed to the FIDES Athlete Development Programme and the other half serving as control cases. The primary outcomes are well-being and sporting experience. To further increase our understanding of the intervention and its implications, interviews and focus group interviews with a reference group of girls and focus group interviews with a randomly selected subsample of coaches and parents will also be performed. The project is approved by the Swedish ethics committee (number: 2023-05264-01) and will be carried out in compliance with the Declaration of Helsinki. Results from the project will be published open access in peer-reviewed journals, at national and international conferences, in mass media, and a PhD thesis. The anonymised data will be made openly available in a data repository.

Relative Energy Deficiency in Sport (REDs) Indicators in Male Adolescent Endurance Athletes: A 3-Year Longitudinal Study.

Longitudinal measurements of Relative Energy Deficiency in Sport (REDs) among adolescent male elite athletes are lacking. We aimed to monitor REDs indicators and their possible impact on performance in elite high-school cross-country skiing and biathlon athletes (n = 13) (16.3 ± 0.4 years, 179.4 ± 7.6 cm, 63.6 ± 8.2 kg body mass (BM), and peak oxygen uptake (VO2peak): 61.5 ± 5.3 mL/kg BM/min) every 6 months for 3 years. Protocols included assessments of energy availability (EA), body composition and bone mineral density (BMD), resting metabolic rate (RMR), disordered eating behavior, exercise addiction, VO2peak, and muscle strength. Data were analyzed using a linear mixed model. At baseline, 38% had low lumbar BMD (Z-score ≤ -1), and overall, bone health increased only slightly. VO2peak and muscle strength improved (p < 0.001), RMR decreased (p = 0.016), and no change was observed in EA or physiological or psychological REDs indicators. Conclusively, many of these young male athletes had poor bone health at baseline, and most either lost or did not achieve the expected pubertal bone mineral accrual, although no other indication of REDs was observed, while performance improved during the study period. Our findings highlight the importance of elite sports high schools focusing on screening for early detection of impaired bone health in male athletes.

Sexual harassment and abuse; disclosure and awareness of report- and support resources in Norwegian sport- and non-sport high schools: a prospective exploratory study.

Purpose: To examine high school students' disclosure of sexual harassment and abuse (SHA), and awareness of reporting systems and support mechanisms in school among students, leaders, and coaches. Method: Norwegian 17-year-old high school elite athletes (n = 630), recreational athletes (n = 307), and reference students (n = 263) responded to an online questionnaire at two measurement points, 1 year apart (T1 and T2). Leaders and coaches (n = 249) at the participating high schools responded to an adapted version of the questionnaire at T1. Data were analyzed using ANOVA or Welch test, Pearson Chi-Square test, and McNemar test. Results: In total, 11.4 and 34.0% of the adolescents were aware of reporting systems and support mechanisms, respectively, in their schools. Nearly all the leaders, and half of the coaches were aware of these resources. Among the adolescents with lifetime experience of SHA, 20.1% had disclosed their experiences to someone. Girls disclosed more frequently than boys. The elite- and recreational athletes disclosed less often compared with the reference students. A negative change from T1 to T2 was found in disclosure of SHA and awareness of support mechanisms. At T2, 6.5% of the adolescents reported that their school had implemented measures against SHA during the last 12 months. Conclusion: The results emphasize a need for institutional effort to improve information about available report- and support resources and increase the relevance of use of such systems for adolescents.