Clinical MDT approach to supporting exercisers with RED-S Dr. Nicola Keay BA, MA (Cantab), MB, BChir, MRCP Sports/Dance Endocrinologist
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1 Clinical MDT approach to supporting exercisers with RED-S Dr. Nicola Keay BA, MA (Cantab), MB, BChir, MRCP Sports/Dance Endocrinologist Member British Association Sport and Exercise Medicine National Institute of Dance Medicine and Science Honorary Fellow Department Sport and Exercise Sciences, Durham University
2 Clinical Challenges of RED-S Identification of exercisers/athletes/dancers at risk of Low Energy Availability (LEA) RED-S diagnosis of exclusion MDT management of exercisers with RED-S
3 How to Optimise Health and Performance? Integrated periodisation of lifestyle choices (Keay BJSM 2017)
4 Matching Energy Intake with Energy Demand Energy intake Insufficient energy intake Energy intake matched with energy demand Excessive training load Energy requirement for life processes Energy demand for training load Energy demand for training load Energy demand for training load Reduced energy available for life processes Sufficient energy available for life processes Reduced energy available for life processes
5 Female Athlete Triad Drinkwater (1984 NEJM) study of female athletes Disordered eating Amenorrhoea Reduced bone mineral density (BMD) Clinical spectrum De Souza et al BJSM 2014
6 RED-S as broader clinical model of LEA RED-S clinical model multisystem effects, includes female athlete triad (IOC BJSM 2014, update 2018) RED-S not exclusive to female athletes Associated sports/dance where low body weight confers performance/aesthetic advantage Fundamental issue Low Energy Availability Quality of diet: micronutrients Absorption issues (leaky gut) and gut microbiota Psychological aspects (cause/effect) Low Energy Availability cascade of network effects on multiple systems
7 Implications of RED-S on Athletic Performance Endocrine system dysfunction: deceased training response Motivation for athlete to implement change Decreased neuromuscular skills in amenorrhoeic athletes where most valuable (Melin et al, Med Sc Spots & Exercise 2017) Compounded low BMD: injury risk! Quantification of health and performance outcomes LEA as per RED-S clinical model (Ackerman, BJSM 2018) RED-S health and sport performance consequences (Mountjoy BJSM 2014, 2018)
8 RED-S Diagnosis of Exclusion History Individual interview (IOC update BJSM 2018) training, injury, nutrition, LEAF-Q, SEAQ-I Examination HR, BP, other signs Investigations: Primary amenorrhoea: karyoptype Beta hcg (female amenorrhoea) FBC, U&Es, LFTs TFTs, Prolactin, FSH, LH, E2, Testosterone, SHBG, (17 hydroxyprogesterone, DHEA) (9am cortisol) Haematinics: Fe, B12, Folate Vit D Metabolic: BG, HbA1c, lipid profile CRP and autoantibodies? DXA U/S Ovaries (primary amen/pcos) Exclude underlying medical condition per se (endocrine, metabolic, systemic inflammatory, autoimmune) Risk stratification RED-S
9 Functional Hypothalamic Amenorrhoea All women of reproductive age (menarche to menopause) whether athlete or not, regular hormonal cycles, characterised by regular menstrual cycles Menstruation barometer of healthy hormones. Vital top performing athletes. Possible: triathlete Gwen Jorgensen (Training Peaks). Training metric Amenorrhoea definitions RCOG Primary 16 years Secondary >= 6 months Oligo < 9 per year Functional H-P amenorrhoea diagnosis exclusion: Pregnancy Ovary: PCOS pathophysiology, diagnosis, unique profile Pituitary: prolactinoma Other: thyroid disorders, CAH, Cushing s, acromegaly Functional H-P amenorrhoea diagnosis of exclusion
10 Functional Hypothalamic Amenorrhoea: a diagnosis of exclusion Primary amenorrhoea Secondary amenorrhoea Oligo amenorrhoea Karyotype Height/Weight Centile U/S Pelvis Beta hcg ê FSH, LH é Pregnancy Primary ovarian failure? -> U/S pelvis Prolactinoma? -> MRI pituitary fossa Primary Hyperthyroidism? -> T4 raised éé Prolactin êê TSH éé Functional Hypothalamic Amenorrhoea Testosterone é SHGB, FAI Primary Hypothyroidism? -> T4 low, Anti TPO Ab PCOS or CAH? -> U/S pelvis, DHEA 17OH Progesterone
11 Energy Availability Energy Availability under behavioural control of athlete/dancer Contrast energy balance (complex measure, physiological control) Quantification EA Energy Input: diet diaries Energy Output: activity FFM from DXA Limitations in free living athletes Inaccuracies Temporal aspect Interpretation Kcal/Kg FFM Not all/nothing threshold applicable all individuals. What clinical effect? (Pitfalls of conducting and interpreting estimates energy availability in free living athletes. Burke, Melin IJSNEM 2018) Other methods: Resting Metabolic Rate actual v predicted surrogate for energy deficiency (Melin, IJSNEM 2018) What alternatives?
12 Endocrine markers indicative EA & clinical outcome bone stress injury Male and female distance runners categorised on clinical & Endocrine markers sex steroids More reliable & objective indication optimal EA for health v EA calculation intake/output 4.5 times more bone injuries and 10 times more days off training Burke et al, Sport Nutrition & Exercise Metabolism 2017
13 Effects of LEA on endocrine networks Sleepê Other Stressors é Blood Glucose ê Hypothalamus Insulin ê TRHê GnRHê CRHé Pancreas Leptin ê Low Energy Availability Glucagon é Insulinê Adipose tissueê Pituitary Hypothalamic releasing factors CRH: corticotrophin releasing hormone GnRH: gonadotrophic releasing hormone TRH: thyrotropin releasing hormone Cholesterol uptakeê Pituitary trophic hormones TSH: thyroid stimulating hormone ACTH: adrenocorticotropic hormone FSH: follicle stimulating hormone LH: luteinising hormone Hormones produced by target organs E2: oestradiol T3+T4: thyroid hormones
14 Effects of LEA on endocrine networks Sleepê Other Stressors é Blood Glucose ê Hypothalamus Insulin ê TRHê GnRHê CRHé Low Energy Availability Pancreas Glucagon é Insulinê Leptin ê Adipose tissueê Pituitary TSHê FSHê LHê ACTHé Adrenal gland Thyroid T3+T4ê Hypothalamic releasing factors CRH: corticotrophin releasing hormone GnRH: gonadotrophic releasing hormone TRH: thyrotropin releasing hormone Cholesterol uptakeê Gonads Pituitary trophic hormones TSH: thyroid stimulating hormone ACTH: adrenocorticotropic hormone FSH: follicle stimulating hormone LH: luteinising hormone Hormones produced by target organs E2: oestradiol T3+T4: thyroid hormones
15 Effects of LEA on endocrine networks Sleepê Other Stressors é Blood Glucose ê Hypothalamus Insulin ê TRHê GnRHê CRHé Low Energy Availability Pancreas Glucagon é Insulinê Leptin ê Adipose tissueê Pituitary TSHê FSHê LHê ACTHé Adrenal gland Cortisolé Immunityê Basal Metabolic Rate ê Cholesterol uptakeê Thyroid T3+T4ê Gonads Hypothalamic releasing factors CRH: corticotrophin releasing hormone GnRH: gonadotrophic releasing hormone TRH: thyrotropin releasing hormone Pituitary trophic hormones TSH: thyroid stimulating hormone ACTH: adrenocorticotropic hormone FSH: follicle stimulating hormone LH: luteinising hormone Hormones produced by target organs E2: oestradiol T3+T4: thyroid hormones
16 Effects of LEA on endocrine networks Sleepê Other Stressors é Blood Glucose ê Hypothalamus TRHê GnRHê CRHé Insulin ê Pancreas Low Energy Availability Glucagon é Insulinê Leptin ê Adrenal gland Pituitary Adipose tissueê ACTHé GH ê TSHê Immunityê Cortisolé FSHê LHê Thyroid Δ Body composition Basal Metabolic Rate ê Hypothalamic releasing factors CRH: corticotrophin releasing hormone GnRH: gonadotrophic releasing hormone TRH: thyrotropin releasing hormone T3+T4ê Pituitary trophic hormones TSH: thyroid stimulating hormone ACTH: adrenocorticotropic hormone FSH: follicle stimulating hormone LH: luteinising hormone Gonads Cholesterol uptakeê Bone Densityê E2ê Testosteroneê E2ê Aromatisationê IGF-1 ê Hormones produced by target organs E2: oestradiol T3+T4: thyroid hormones
17 Sale NTU 2017, Bone 2017, Loucks 2003, 2011, Christo 2008, Ackerman 2012, Melin 2017, Barrack 2008, Duetz 2000, Jones 2013, Ackerman 2014/6 Cumulative Low Energy Availability and Endocrine Dysfunction (Keay BJSM 2018)
18 Clinical Value of Endocrine markers Indicative of individual response to combination training load, nutrition and recovery Reflect temporal aspect of LEA Monitoring changes for individual: insights into effects of periodisation Objective and quantifiable Practical Clinical relevance: hormones drive adaptations to exercise Endocrine system key player in health and performance (Keay BJSM 2017)
19 RED-S risk stratification Based on Clinical Assessment Tool (Mountjoy et al BJSM 2015)
20 Clinical Management of RED-S Identification of exercisers/athletes/dancers at risk of LEA RED-S diagnosis of exclusion Risk Stratification MDT healthcare professionals in collaboration with coach/ teacher/parent Pharmacological intervention in selected cases NOT OCP! Transdermal oestradiol and cyclic progesterone (Ackerman BJSM 2018) Endocrine system key player in health and performance (Keay BJSM 2017)
21 Health4Perforamnce.co.uk Educational website Key determinants of health and human performance
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