Naama Constantini

The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S)

Protecting the health of the athlete is a goal of the International Olympic Committee (IOC). The IOC convened an expert panel to update the 2005 IOC Consensus Statement on the Female Athlete Triad. This Consensus Statement replaces the previous and provides guidelines to guide risk assessment, treatment and return-to-play decisions. The IOC expert working group introduces a broader, more comprehensive term for the condition previously known as ‘Female Athlete Triad’. The term ‘Relative Energy Deficiency in Sport’ (RED-S), points to the complexity involved and the fact that male athletes are also affected. The syndrome of RED-S refers to impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular health caused by relative energy deficiency. The cause of this syndrome is energy deficiency relative to the balance between dietary energy intake and energy expenditure required for health and activities of daily living, growth and sporting activities. Psychological consequences can either precede RED-S or be the result of RED-S. The clinical phenomenon is not a ‘triad’ of the three entities of energy availability, menstrual function and bone health, but rather a syndrome that affects many aspects of physiological function, health and athletic performance. This Consensus Statement also recommends practical clinical models for the management of affected athletes. The ‘Sport Risk Assessment and Return to Play Model’ categorises the syndrome into three groups and translates these classifications into clinical recommendations.

High prevalence of vitamin d insufficiency in athletes and dancers

Objective: Vitamin D insufficiency is prevalent in various populations worldwide but with scarce data on physically active individuals. Vitamin D is important to athletes, affecting bone mass, immunity, and physical performance. This study evaluated the prevalence of vitamin D insufficiency and deficiency among young athletes and dancers. Design: Cross-sectional study. Setting: Sport medicine clinic. Patients: Data on 98 athletes and dancers (age, 14.7 ± 3.0 years; range, 10-30 years; 53% men), who had undergone screening medical evaluations, were extracted from medical records. Independent Variable: Serum 25(OH)D concentrations. Main Outcome Measures: Serum 25(OH)D concentrations, age, sex, sport discipline, month of blood test, and serum ferritin. Vitamin D insufficiency was defined as serum 25(OH)D concentration <30 ng/mL. Results: Mean serum 25(OH)D concentration was 25.3 ± 8.3 ng/mL. Seventy-three percent of participants were vitamin D insufficient. Prevalence of vitamin D insufficiency was higher among dancers (94%), basketball players (94%), and Tae Kwon Do fighters (67%) and among athletes from indoor versus outdoor sports (80% vs 48%; P = 0.002). 25(OH)D levels adjusted for age and sex correlated with serum ferritin and season. Conclusions: In this study, conducted among young athletes and dancers from various disciplines in a sunny country, a high prevalence of vitamin D insufficiency was identified. A higher rate of vitamin D insufficiency was found among participants who practice indoors, during the winter months, and in the presence of iron depletion. Given the importance of vitamin D to athletes for several reasons, we suggest that athletes and dancers be screened for vitamin D insufficiency and treated as needed.

Exercise With and Without an Insulin Pump Among Children and Adolescents With Type 1 Diabetes Mellitus

Background. The use of insulin pumps is becoming a popular technique for insulin delivery among patients with type 1 diabetes mellitus (T1DM), but there is no consensus regarding the guidelines for proper pump use during exercise. Objective. To investigate the physiologic responses and risk of hypoglycemia among children and adolescents with T1DM when exercising with the pump on (PO) (50% of the basal rate) or pump off (PF). Methods. Ten subjects with T1DM (6 female subjects and 4 male subjects), 10 to 19 years of age, performed prolonged exercise (40–45 minutes) on a cycle ergometer ∼2 hours after a standard breakfast and an insulin (Lispro) bolus. Complex carbohydrates (20 g) were provided before and after the exercise. Each patient exercised once with PO and once with PF, in a randomized, crossover (single-blind) manner. During exercise and 45 minutes of recovery, subjects were monitored for cardiorespiratory, metabolic, and hormonal responses. Blood glucose concentrations were recorded for 24 hours after exercise, with a continuous glucose monitoring system, to document late hypoglycemic events. Results. During exercise, blood glucose concentrations decreased by 59 ± 58 mg/dL (mean ± SD: 29 ± 24%) with PF and by 74 ± 51 mg/dL (35.5 ± 18%) with PO (not significant). No significant differences were found in cortisol, growth hormone, or noradrenaline levels between PO and PF. There were no differences in cardiorespiratory parameters, blood lactate concentrations, or free fatty acids concentrations between pump modes. Hypoglycemic events during exercise were asymptomatic and occurred for 2 subjects with PO and 2 with PF. Nine subjects had late hypoglycemia after PO, compared with 6 after PF (not significant). Conclusions. We found no advantage for subjects with either PO or PF during exercise, and we noted that late hypoglycemia was more common than hypoglycemia during exercise. However, PO was associated with a trend of increased risk for late hypoglycemia. We recommend that the pump be removed or turned off during prolonged exercise and that blood glucose concentrations be monitored for several hours after exercise, regardless of the pump mode.

The Medial Longitudinal Arch as a Possible Risk Factor for Ankle Sprains: A Prospective Study in 83 Female Infantry Recruits

Background: Ankle sprains are frequent, especially in athletes, soldiers, or others who perform high levels of physical activity. Although prevention is a primary goal, little is known about the risk factors. We evaluated the association of the structure of the medial arch of the foot to the occurrence of acute and recurrent ankle sprains in 83 female infantry recruits. We found no previous studies on ankle sprains in women in the English literature. Methods: Arch height was quantified using the Chippaux-Smirak index, and each arch was classified as high, normal, or low. Retrospective data were obtained from questionnaires in which the soldiers noted whether or not they had had ankle sprains in the past, the grade of the sprain, and recurrence. Prospective data were accumulated in the 4 months of basic training, during which time every ankle sprain was documented and classified according to its grade and cause. Results: The retrospective data showed more frequent ankle sprains in the low arch group than in the normal arch group, mainly in the right foot (RR of 2.9, p < 0.05). Recurrent sprains studied retrospectively also showed that more sprains occurred in the low arch group than in the normal arch and high arch groups (RR of 10.3, p < 0.05). The prospective data suggested a pattern toward the same outcome (50% in the low arch as opposed to 36% in the normal arch group, RR, 1.3), but with no statistical significance. Conclusions: We concluded that a low arch of the foot might be a risk factor for ankle sprains. However, our study consisted of a relatively small population, and further studies are needed.

The association between adiposity and the response to resistance training among pre- and early-pubertal boys.

Resistance training has been shown to be effective in enhancing muscle strength among prepubertal and adolescent boys. Lately, it has been recommended for obese children. We hypothesized that resistance training will be similarly effective among boys of different adiposity. Thirty boys, aged 9.2 +/- 0.3 years, participated in progressive resistance training twice weekly during the first and second school years and thrice weekly during the third year. Training sessions included 1-4 sets of 3-6 exercises, with 5-30 repetitions/set. The mean load was 50-60% of 1 repetition maximum. Subjects were divided into responders (R--upper tertile) and non-responders (NR--lower tertile), according to the three-year improvement in muscle strength, as assessed by means of changes in concentric strength of knee flexors and extensors. Differences between groups were observed at baseline (p <0.05) in all variables reflecting adiposity (mean +/- SD): % body fat (14.1 +/- 2.6 vs 23.5 +/- 7.5% for R and NR, respectively), sum of four skinfolds (25.4 +/- 4.7 vs 47.8 +/- 21.6 mm for R and NR, respectively), BMI (15.5 +/- 1.1 vs 18.6 +/- 2.6 kg x m(-2) for R and NR, respectively). Additionally, the changes in adiposity were inversely related to the training effect (r = -0.60 to -0.34). No differences were observed in initial height and maturation between R and NR groups and there was no difference in linear growth and physical maturation with time between groups. These data suggest that resistance-training loads which may be appropriate to increase strength of knee flexors and extensors in normal-weight children may be insufficient to do so in overweight children. More research is required to elucidate the efficacy of resistance training among overweight children.

Urinary incontinence in physically active women and female athletes

A literature review was performed on the topic of urinary incontinence during physical activity and sports. This paper reviews the prevalence, risk factors, pathophysiology and treatment modalities of urinary incontinence in physically active women and female athletes. Urinary incontinence affects women of all ages, including top female athletes, but is often under-reported. The highest prevalence of urinary incontinence is reported in those participating in high impact sports. Pelvic floor muscle training is considered the first-line treatment, although more research is needed to determine optimal treatment protocols for exercising women and athletes. Trainers, coaches and other athletes’ caregivers should be educated and made aware of the need for proper urogynaecological assessment.

High Prevalence of Iron Deficiency and Anemia in Female Military Recruits

Iron deficiency anemia has long been known to impair physical and mental performance. Iron deficiency itself, even without anemia, may also cause such an effect. Similar to female athletes, women in active military units may have increased risks for iron deficiency and its detrimental effects. Female recruits were screened for anemia and iron store status, and a questionnaire on lifestyle habits and menstruation was completed. Iron depletion (serum ferritin level of <20 microg/L) was found for 77% of study participants. Iron deficiency (ferritin level of <12 microg/L and transferrin saturation of <15%) was found for 15% of study participants. Anemia was found for 24% of subjects, and iron deficiency anemia was found for 10% of subjects. High prevalence of iron depletion, iron deficiency, anemia, and iron deficiency anemia was found among female recruits intended for active military duty. Therefore, a recommendation can be made to screen such female recruits for anemia and iron stores.

Authors’ 2015 additions to the IOC consensus statement: Relative Energy Deficiency in Sport (RED-S)

In April 2014, the International Olympic Committee (IOC) published a Consensus Statement in this journal entitled “Beyond the Female Athlete Triad: Relative Energy Deficiency in Sport (RED-S)”.1 In reference to that Consensus Statement, Professor Mary Jane De Souza and colleagues published an editorial (July 2014).2 The editorial below expands on the original Consensus Statement and comments on the 2014 Editorial by Professor Mary Jane De Souza and colleagues. Albert Einstein said: “The important thing is to never stop questioning.” A group of 11 IOC authors have called attention, as others in the past,3 ,4 to a problem that is wider and more complex than originally identified when the term ‘Female Athlete Triad’ (Triad or FAT) was first coined in 1992. Just as knowledge evolves, so too should ideas and constructs on how to address it. Given the evolution of science since 1992, and to more accurately describe the clinical syndrome originally known as the Female Athlete Triad, the IOC introduced a more comprehensive, broader term: Relative Energy Deficiency in Sport. The syndrome of RED-S refers to impaired physiological functioning caused by relative energy deficiency, and includes but is not limited to impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health. Our April 2014 Consensus statement identifies the aetiological factor underpinning the syndrome as: an energy deficiency relative to the balance between dietary energy intake and the energy expenditure required to support homeostasis, health and the activities of daily living, growth and sporting activities. We reaffirm the principle that the IOC Consensus Statement highlights about energy deficiency/low energy availability among exercising people. De Souza and colleagues’ editorial criticises the use of the word ‘balance,’ suggesting that the IOC authors have confused the terms energy availability and energy balance. We used the term …

Short-Term Dynamics and Metabolic Impact of Abdominal Fat Depots After Bariatric Surgery

OBJECTIVE Bariatric surgery is gaining acceptance as an efficient treatment modality for obese patients. Mechanistic explanations regarding the effects of bariatric surgery on body composition and fat distribution are still limited. RESEARCH DESIGN AND METHODS Intra-abdominal and subcutaneous fat depots were evaluated using computed tomography in 27 obese patients prior to and 6 months following bariatric surgery. Associations with anthropometric and clinical changes were evaluated. RESULTS Excess weight loss 6 months following surgery was 47% in male and 42.6% in female subjects. Visceral fat and subcutaneous fat were reduced by 35% and 32%, respectively, in both sexes, thus the visceral-to-subcutaneous fat ratio remained stable. The strongest relation between absolute and relative changes in visceral and subcutaneous fat was demonstrated for the excess weight loss following the operations (r ∼0.6–0.7), and these relations were strengthened further following adjustments for sex, baseline BMI, and fat mass. Changes in waist circumference and fat mass had no relation to changes in abdominal fat depots. All participants met the criteria of the metabolic syndrome at baseline, and 18 lost the diagnosis on follow-up. A lower baseline visceral-to-subcutaneous fat ratio (0.43 ± 0.15 vs. 0.61 ± 0.21, P = 0.02) was associated with clinical resolution of metabolic syndrome parameters. CONCLUSIONS The ratio between visceral and subcutaneous abdominal fat remains fairly constant 6 months following bariatric procedures regardless of sex, procedure performed, or presence of metabolic complications. A lower baseline visceral-to-abdominal fat ratio is associated with improvement in metabolic parameters.

Differences in physical fitness of male and female recruits in gender-integrated army basic training.

PURPOSE To evaluate gender differences in physical fitness before and after a 4-month gender-integrated basic training (BT) course and to determine whether this program effectively narrowed the differences between male and female soldiers in physical fitness parameters. METHODS One hundred and thirty-seven soldiers (109 females and 28 males) successfully completed a 4-month BT course in the Israeli Defense Forces (IDF). The subjects physical fitness was evaluated pre- and post-BT by three laboratory tests [the maximal aerobic capacity (VO2max), the Leonardo Ground Reaction Force Plate, and the Wingate Anaerobic Test (WAnT)] and by the IDF physical fitness test (IDF-PT). RESULTS Females significantly improved their scores in the IDF-PT and laboratory aerobic tests, whereas males significantly improved only in the IDF-PT. After BT, gender differences narrowed by approximately 4% in all tests except upper body strength. Although fitness improvement after BT was marginally higher in females than males, resulting in a slight narrowing of the gender differences, a significant gender gap in physical fitness still exists after BT. CONCLUSIONS There was only a small overlap in physical abilities at the beginning of BT, which indicated vast differences in physical fitness between the genders. As expected, integrated combat BT improved physical fitness. Although females demonstrated marginally higher improvement in aerobic capacity, basic physiological gender differences were still evident at the end of the training regimen.