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.

Hormonal contraception for female athletes presents special needs and concerns.

PURPOSE: Oral contraceptives (OCs) are commonly used by female athletes raising concerns regarding the possible adverse effects of OCs on physical performance, musculoskeletal injuries, and bone density. We aimed to review all current studies on the physiological effects of OCs in physically active women. MATERIALS AND METHODS: A review of literature in electronic search in PubMed and Google Scholar databases from December 2002 to December 2022 using relevant keywords. The reference lists of the articles found eligible were also reviewed. RESULTS: Out of 344 articles in the initial database, 54 clinical studies were eligible for inclusion in our literature review. OCs are used by about two-thirds of female athletes. Current research suggests that OCs' effects on endurance performance and muscle strength are mostly reassuring. OCs do not seem to have a major negative impact on bone health or sports injuries. In fact, new data suggests that they may even significantly reduce the risk of anterior cruciate ligament (ACL) injury. CONCLUSIONS: OCs can be safely used by young female athletes, who may also benefit from better menstrual cycle control. OCs offer newly realised protection from ACL injuries. The use of OCs must be carefully individualised according to their preferences, expectations, and experience.

Hormonal contraception can be safely prescribed to active women. The International Olympic Committee advocates a new and wider definition for the 'athlete triad', where low energy availability presents a special challenge for these athletes. New data suggests that the use of oral contraceptives may protect against ACL injury.

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.

Best practice recommendations for body composition considerations in sport to reduce health and performance risks: a critical review, original survey and expert opinion by a subgroup of the IOC consensus on Relative Energy Deficiency in Sport (REDs).

BACKGROUND: The assessment of body composition (BC) in sport raises concern for athlete health, especially where an overfocus on being lighter or leaner increases the risk of Relative Energy Deficiency in Sport (REDs) and disordered eating. METHODS: We undertook a critical review of the effect of BC on performance (29 longitudinal, prospective or intervention studies) and explored current practice related to BC considerations via a follow-up to a 2013 internationally distributed survey. RESULTS: The review found that a higher level of body fat was negatively associated with endurance performance, while a gain in muscle mass resulted in performance benefits across sports. BC did not contribute to early talent identification, and no unique cut-off to signify a performance advantage for BC was identified. BC appears to be one of an array of variables impacting performance, and its influence should not be overstated. The survey (125 practitioners, 61 sports and 26 countries) showed subtle changes in BC considerations over time, such as an increased role for sport dietitian/nutrition practitioners as BC measurers (2013: 54%, 2022: 78%); less emphasis on reporting of body fat percentage (2013: 68%, 2022: 46%) and reduced frequency of BC assessment if ≥every fourth week (2013: 18%, 2022: 5%). Respondents remained concerned about a problematic focus on BC (2013: 69%, 2022: 78%). To address these findings, we provide detailed recommendations for BC considerations, including an overview of preferable BC methodology. CONCLUSIONS: The 'best practice' guidelines stress the importance of a multidisciplinary athlete health and performance team, and the treatment of BC data as confidential medical information. The guidelines provide a health focus around BC, aiming to reduce the associated burden of disordered eating, problematic low energy availability and 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.

Global Alliance for the Promotion of Physical Activity: the Hamburg Declaration.

Non-communicable diseases (NCDs), including coronary heart disease, stroke, hypertension, type 2 diabetes, dementia, depression and cancers, are on the rise worldwide and are often associated with a lack of physical activity (PA). Globally, the levels of PA among individuals are below WHO recommendations. A lack of PA can increase morbidity and mortality, worsen the quality of life and increase the economic burden on individuals and society. In response to this trend, numerous organisations came together under one umbrella in Hamburg, Germany, in April 2021 and signed the 'Hamburg Declaration'. This represented an international commitment to take all necessary actions to increase PA and improve the health of individuals to entire communities. Individuals and organisations are working together as the 'Global Alliance for the Promotion of Physical Activity' to drive long-term individual and population-wide behaviour change by collaborating with all stakeholders in the community: active hospitals, physical activity specialists, community services and healthcare providers, all achieving sustainable health goals for their patients/clients. The 'Hamburg Declaration' calls on national and international policymakers to take concrete action to promote daily PA and exercise at a population level and in healthcare settings.

Elevated cfDNA after exercise is derived primarily from mature polymorphonuclear neutrophils, with a minor contribution of cardiomyocytes.

Strenuous physical exercise causes a massive elevation in the concentration of circulating cell-free DNA (cfDNA), which correlates with effort intensity and duration. The cellular sources and physiological drivers of this phenomenon are unknown. Using methylation patterns of cfDNA and associated histones, we show that cfDNA in exercise originates mostly in extramedullary polymorphonuclear neutrophils. Strikingly, cardiomyocyte cfDNA concentration increases after a marathon, consistent with elevated troponin levels and indicating low-level, delayed cardiac cell death. Physical impact, low oxygen levels, and elevated core body temperature contribute to neutrophil cfDNA release, while muscle contraction, increased heart rate, ß-adrenergic signaling, or steroid treatment fail to cause elevation of cfDNA. Physical training reduces neutrophil cfDNA release after a standard exercise, revealing an inverse relationship between exercise-induced cfDNA release and training level. We speculate that the release of cfDNA from neutrophils in exercise relates to the activation of neutrophils in the context of exercise-induced muscle damage.

[PHYSICAL ACTIVITY DURING PREGNANCY AND AFTER BIRTH].

INTRODUCTION: Physical activity (PA) decreases morbidity, improves quality of life and elongates life span. PA during pregnancy is safe and decreases complications. Physical inactivity during pregnancy is an independent risk factor for maternal weight gain and complications. Pregnancy is a golden opportunity to promote a healthy lifestyle. OBJECTIVES: This article aims to review the latest recommendations regarding PA in pregnancy. In this article we focused on the following: The joint guidelines of the Society of Obstetricians and Gynaecologists of Canada's (SOGC) and the Canadian Society for Exercise Physiology (CSEP), the American College of Obstetricians and Gynecologists (ACOG) committee opinion, and the ACSM's (American College of Sports Medicine) Guidelines for Exercise Testing and Prescription, the 11th Edition published in 2019, 2020 and 2022 respectively. CONCLUSIONS: PA during pregnancy is safe and essential. Every pregnant woman without contraindications should perform 150 weekly minutes of aerobic exercise and resistance training. DISCUSSION: A weekly goal of 150 medium intensity aerobic exercise minutes spread over at least 3 separate days combined with resistance training is recommended for every pregnant woman, including women who were inactive prior to the pregnancy, those diagnosed with gestational diabetes and overweight or obese women. Pregnant women with absolute contraindication can continue to perform their daily activities but avoid more intense activities, those with relative contraindications should discuss the advantages and risks of PA with their attending physician. After birth, women can return to PA gradually depending on the mode of delivery and complications encountered.

Iron Deficiency and Anemia in Male and Female Adolescent Athletes Who Engage in Ball Games.

The aim of this study was to assess the prevalence of iron deficiency (ID) and iron deficiency anemia (IDA) among male adolescent athletes who participate in non-calorie-restricting sports, and to compare the results with female athletes of the same age and sports. Data of the hemoglobin concentration (Hb) and serum ferritin (sFer) levels of male (n = 350) and female (n = 126) basketball and football players, aged 11-18, from two sport medicine centers in Israel were gathered and analyzed. Mild ID was defined as sFer ≤ 30 µg/L, moderate as sFer ≤ 20 µg/L, and severe as sFer ≤ 10 µg/L. IDA was defined as sFer ≤ 20 µg/L and Hb < 13 g/dL for males and sFer ≤ 20 µg/L and Hb < 12 g/dL for females. The prevalence of mild ID was 41.1% and 53.2%, moderate was 17.4% and 27.8%, and severe was 2% and 4.8% in males and females, respectively. The prevalence of IDA was 2.6% in males and 4% in females. Mild and moderate ID was significantly higher among females. In conclusion, non-anemic ID, which is known to be common among female athletes, especially in sports requiring leanness, is also highly prevalent among adolescent males playing ball games. Therefore, screening for hemoglobin and sFer is recommended for young athletes of both genders and in all sports.

Age Differences in Recovery Rate Following an Aerobic-Based Exercise Protocol Inducing Muscle Damage Among Amateur, Male Athletes.

Purpose: Compare recovery rates between active young (Y) and middle-aged (MA) males up to 48H post aerobically based, exercise-induced muscle damage (EIMD) protocol. A secondary aim was to explore the relationships between changes in indices associated with EIMD and recovery throughout this timeframe. Methods: Twenty-eight Y (n = 14, 26.1 ± 2.9y, 74.5 ± 9.3 kg) and MA (n = 14, 43.6 ± 4.1y, 77.3 ± 12.9 kg) physically active males, completed a 60-min downhill running (DHR) on a treadmill at -10% incline and at 65% of maximal heart rate (HR). Biochemical, biomechanical, psychological, force production and muscle integrity (using MRI diffusion tensor imaging) markers were measured at baseline, immediately-post, and up to 48H post DHR. Results: During the DHR, HR was lower (p < 0.05) in MA compared to Y, but running pace and distance covered were comparable between groups. No statistical or meaningful differences were observed between groups for any of the outcomes. Yet, Significant (p < 0.05) time-effects within each group were observed: markers of muscle damage, cadence and perception of pain increased, while TNF-a, isometric and dynamic force production and stride-length decreased. Creatine-kinase at 24H-post and 48H-post were correlated (p < 0.05, r range = -0.57 to 0.55) with pain perception, stride-length, and cadence at 24H-post and 48H-post. Significant (p < 0.05) correlations were observed between isometric force production at all time-points and IL-6 at 48H-post DHR (r range = -0.62 to (-0.74). Conclusion: Y and MA active male amateur athletes recover in a comparable manner following an EIMD downhill protocol. These results indicate that similar recovery strategies can be used by trainees from both age groups following an aerobic-based EIMD protocol.

[RECOMMENDATIONS FOR CHANGING CARDIOVASCULAR SCREENING OF ATHLETES WHO ARE REQUIRED FOR PRE-PARTICIPATION SCREENING UNDER THE SPORTS LAW - A POSITION PAPER ON BEHALF OF THE ISRAEL HEART SOCIETY].

INTRODUCTION: For many years routine screening of athletes in Israel includes frequently performed ECGs and exercise tests that overload the system with questionable benefits. The purpose of the current document is to reevaluate the need for pre-participation testing and establish new evidence-based guidelines. It should be noted that our proposal for a change of approach relates only to subjects whose health questionnaire is normal, who do not have a family history of sudden and unexpected death at an early age, or a family history of hereditary heart disease and whose physical examination from a cardiovascular point of view is normal.

Rare Cause of Syncope in an Athlete, Matter of Brain and Heart Electricity.

ABSTRACT: A 17-year-old elite triathlete presented with recurrent loss of consciousness events. Implantable loop recorder (ILR) documented sinus node asystoles of up to 21 seconds. She underwent cardiac neuromodulation ablation. After ablation, a generalized tonic-clonic seizure (GTCS) occurred, without concomitant asystole on the ILR. Temporal lobe seizures were diagnosed and supported by interictal epileptic activity on electroencephalogram. We assumed that the syncope episodes were ictal asystole (IA) and that the IA terminated the epileptic seizures early after their onset. The cardiac ablation prevented IA, enabling spread of seizure activity and development of GTCS. To the best of our knowledge, this is the first case of IA treated with cardiac ablation, allowing avoidance of cardiac pacing. This case raises the awareness to epileptic seizures as a cause of asystole in athletes, with an elusive and atypical presentation.

Activity Tracking After Surgery: Does It Correlate With Postoperative Complications?

BACKGROUND: Postoperative ambulation is an important tenet in enhanced recovery programs. We quantitatively assessed the correlation of decreased postoperative ambulation with postoperative complications and delays in gastrointestinal function. METHODS: Patients undergoing major abdominal surgery were fitted with digital ankle pedometers yielding continuous measurements of their ambulation. Primary endpoints were the overall and system-specific complication rates, with secondary endpoints being the time to first passage of flatus and stool, the length of hospital stay, and the rate of readmission. RESULTS: 100 patients were enrolled. We found a significant, independent inverse correlation between the number of steps on the first and second postoperative days (POD1/2) and the incidence of complications as well as the recovery of GI function and the likelihood of readmission (P < .05). POD2 step count was an independent risk factor for severe complications (P = .026). DISCUSSION: Digitally quantified ambulation data may be a prognostic biomarker for the likelihood of severe postoperative complications.

Walking to a better future? Postoperative ambulation after cesarean delivery and complications: A prospective study.

OBJECTIVE: To assess the correlation between maternal mobility after cesarean delivery and postoperative morbidity. METHODS: A prospective study was conducted in a tertiary hospital among patients after cesarean delivery. The women were recruited after surgery and before ambulation. Each participant received an accelerometer and routine instructions for mobilization. The patients were asked to wear the accelerometer constantly. It was collected at discharge. Electronic files were reviewed and patients' outcomes were analyzed. The Mann-Whitney U test was used to compare groups and a receiver operating characteristic curve was calculated for the threshold of number of steps. RESULTS: Data were analyzed for 199 patients, among which 107 (54.4%) deliveries were urgent and 90 (45.6%) were elective. The median number of steps was higher for multiparous women compared to nulliparous women (P = 0.035). Patients who developed complications after discharge walked significantly less during their hospitalization compared to those who did not. There was a trend toward increased risk for in-hospitalization complications among patients who walked less while hospitalized. A threshold of more than 9716 steps per hospitalization was found to be associated with fewer post-discharge complications. CONCLUSION: There is a significant correlation between the extent of ambulation after cesarean delivery and fewer postoperative complications.

Methodological Considerations for Studies in Sport and Exercise Science with Women as Participants: A Working Guide for Standards of Practice for Research on Women.

Until recently, there has been less demand for and interest in female-specific sport and exercise science data. As a result, the vast majority of high-quality sport and exercise science data have been derived from studies with men as participants, which reduces the application of these data due to the known physiological differences between the sexes, specifically with regard to reproductive endocrinology. Furthermore, a shortage of specialist knowledge on female physiology in the sport science community, coupled with a reluctance to effectively adapt experimental designs to incorporate female-specific considerations, such as the menstrual cycle, hormonal contraceptive use, pregnancy and the menopause, has slowed the pursuit of knowledge in this field of research. In addition, a lack of agreement on the terminology and methodological approaches (i.e., gold-standard techniques) used within this research area has further hindered the ability of researchers to adequately develop evidenced-based guidelines for female exercisers. The purpose of this paper was to highlight the specific considerations needed when employing women (i.e., from athletes to non-athletes) as participants in sport and exercise science-based research. These considerations relate to participant selection criteria and adaptations for experimental design and address the diversity and complexities associated with female reproductive endocrinology across the lifespan. This statement intends to promote an increase in the inclusion of women as participants in studies related to sport and exercise science and an enhanced execution of these studies resulting in more high-quality female-specific data.

Relative energy deficiency in sports (RED-S): elucidation of endocrine changes affecting the health of males and females.

The purpose of this review is to present a different perspective of the relative energy deficiency syndrome, to improve understanding of associated endocrine alterations, and to highlight the need for further research in this area. The term "female athlete triad" was coined over 25 years ago to describe three interrelated components: disordered eating, menstrual dysfunction, and low bone mass. The syndrome's etiology is attributed to energy intake deficiency relative to energy expenditure required for health, function, and daily living. Recently, it became clear that there was a need to broaden the term, as the disorder is not an issue of only three interrelated problems but of a whole spectrum of insults resulting from low energy availability (LEA; i.e., insufficient energy availability to cover basic physiological demands) that can potentially affect any exerciser, irrespective of gender. The new model, termed relative energy deficiency in sport (RED-S), has received greater scrutiny in sports medicine due to its effects on both health and performance in athletes of both sexes. RED-S results from low-energy diets (intentional or unintentional) and/or excessive exercise. Energy deficiency reduces hypothalamic pulsatile release of gonadotropin-releasing hormone, this impairing anterior pituitary release of gonadotropins. In women, reduced FSH and LH pulsatility produces hypoestrogenism, causing functional hypothalamic amenorrhea and decreased bone mass. In men, it reduces testosterone and negatively affects bone health. Moreover, LEA alters other hormonal pathways, causing physiological consequences, such as alteration of the thyroid hormone signaling pathways, leptin levels, carbohydrate metabolism, the growth hormone/insulin-like growth factor-1 axis, and sympathetic/parasympathetic tone. This review explains and clarifies the effects of RED-S in both sexes.

Exercise Performance Is Impaired during the Midluteal Phase of the Menstrual Cycle.

PURPOSE: This study aimed to test the hypothesis that aerobic exercise performance is impaired in the midluteal (ML) compared with the midfollicular (MF) phase of the menstrual cycle. METHODS: Twelve recreationally active eumenorrheic women (25 ± 6 yr) completed exercise sessions during the MF and the ML phases. Each session consisted of an 8-km cycling time trial that was preceded by 10 min of cycling performed at a constant power below and above gas exchange threshold. Heart rate, ventilation, and oxygen uptake were continuously measured. RPE and ratings of fatigue were assessed during the time trial using visual analog scales. Total mood disturbance was calculated from the POMS questionnaire administered before and 20 min postexercise. RESULTS: Salivary progesterone concentration was 578 ± 515 pg·mL-1 higher in ML compared with MF phase (P < 0.01), whereas estradiol concentration did not differ between phases (167 ± 55 vs 206 ± 120 pg·mL-1, P = 0.31). Total mood disturbance before exercise was greater during the ML phase compared with the MF phase (P < 0.01), but this difference was abolished postexercise (P = 0.14). Mean power output was lower during the ML phase (115 ± 29 vs 125 ± 28 W, P < 0.01), which led to a slower time trial in the ML phase (18.3 ± 2.0 min) compared with the MF phase (17.8 ± 1.7 min, P = 0.03). Ratings of fatigue were greater during the ML phase from 2 to 8 km (P ≤ 0.01), whereas no differences in RPE were observed. Heart rate (P = 0.85), minute ventilation (P = 0.53), and oxygen uptake (P = 0.32) did not differ between phases during the time trial. CONCLUSION: Aerobic exercise performance is worse in the ML phase compared with the MF phase in recreationally active women, which was accompanied by a more negative mood state preexercise and increased ratings of fatigue.

Myokine levels after resistance exercise in young adults with Prader-Willi syndrome (PWS).

Individuals with PWS require marked caloric restriction and daily exercise to prevent morbid obesity. Lower energy expenditure, hypotonia, decreased muscle mass, and cognitive impairment make exercise challenging for this population. Exercise guidelines include resistance training as an important component. Myokine responses to resistance exercise may mediate beneficial metabolic effects. We aimed to determine if young PWS adults can perform a resistance exercise program and to measure myokine responses in PWS versus age- and BMI-matched controls. Each group included 11 participants (7M/4F). Ages and BMI for PWS and controls were 30.7 ± 4.6 versus 30.1 ± 4.3 years and 28.3 ± 4.3 versus 28.2 ± 4.2 kg/m2 , respectively. Glucose, creatine kinase (CK), lactate, and myokines were measured before, after, 30, and 60 min after completing eight resistance exercises. Myokines were assayed using a multiplex myokine panel (Merck Millipore). CK was lower in PWS versus controls (62 ± 16 vs.322 ± 100 U/L, p < .04). Peak lactate was 3.7 ± 0.7 in PWS versus 7.3 ± 0.7 mmol/Lin controls (p < .001). The increase in interleukin-6 was similar in PWS and controls (41 ± 16% and 35 ± 10%, respectively). Pre- and post-exercise levels of the six myokines assayed showed no consistent differences between the PWS and control participants. PWS young adults are capable of performing resistance/strength-building exercise. The lower CK and peak lactate levels in PWS may reflect decreased muscle mass in this population. Further studies are needed to determine optimal exercise regimens and assess the role of myokines incontributing to the metabolic phenotype of PWS.