By Dr Nicky Keay, Sports/Dance Endocrinologist @nickyKfitness, Chair of BASEM Spring Conference 2018
Endocrine and Metabolic aspects of Sports and Exercise Medicine (SEM) are crucial determinants of health and human performance, from the reluctant exerciser through to the elite athlete and the professional dancer. This is what the recent BASEM spring conference set out to demonstrate. The audience comprised of doctors with interest in SEM, representatives from the dance world, research scientists, nutritionists, physiotherapists, coaches and trainers. In short, all were members of multi-disciplinary teams supporting aspiring athletes. The importance of the conference was reflected in CPD awarded from The Faculty of Sport and Exercise Medicine (FSEM), British Association of Sport and Exercise Sciences (BASES), Royal College of Physicians (RCP), Register of Exercise Professionals (REP-S) and endorsement for international education from BJSM and National Institute of Dance Medicine and Science (NIDMS).
Exercise is a crucial lifestyle factor in determining health and disease. Yet we see an increasing polarisation in the amount of exercise taken across the general population. At one end of the spectrum, the increasing training loads of elite athletes and professional dancers push the levels of human performance to greater heights. On the other side of the spectrum, rising levels of inactivity, in large swathes of the population, increase the risk of poor health and developing disease states. Which fundamental biological processes and systems link these groups with apparently dichotomous levels of exercise? What determines the outcome of the underlying Endocrine and metabolic network interactions? How can an understanding of these factors help prevent sports injuries and lead to more effective rehabilitation? How can we employ Endocrine markers to predict and provide guidance towards beneficial outcomes for health and human performance?
Hormones take centre stage
The opening presentation set the scene, placing hormones centre stage: outlining why having an optimally functioning Endocrine system is fundamental to health and performance. Conversely, functional disruption of Endocrine networks is caused by non-integrated periodisation of the three key lifestyle factors of exercise/training, nutrition and recovery/sleep, which can lead to adverse effects on health and athletic performance.
Male and female athletes: insufficient energy availability
An imbalance in training load and nutrition can manifest as the female athlete triad, which has now evolved into relative energy deficiency in sports (RED-S) in recognition of the fact that Endocrine feedback loops are disrupted across many hormonal axes, not just the reproductive axis. And, significantly, acknowledging the fact that males athletes can also be impacted by insufficient energy availability to meet both training and “housekeeping” energy requirements. Why and how RED-S can affect male athletes, in particular competitive road cyclists was discussed, highlighting the need for further research to investigate practical and effective strategies to optimise health and therefore ultimately performance in competition.
In situations of functional disruption of the Endocrine networks, underlying Endocrine conditions per se should be excluded. Case studies demonstrated this principle in the diagnosis of RED-S, where treatable endocrine diseases should be considered and addressed as a priority. This is particularly important in the investigation of amenorrhoea. All women of reproductive age, whether athletes or not, should have regular menstruation (apart from when pregnant!), as a barometer of healthy hormones. Indeed, since hormones are essential to drive positive adaptations to exercise, healthy hormones are key in attaining full athletic potential in any athlete/dancer, whether male or female. Evidence was presented from research studies for the role of validated Endocrine markers and clinical menstrual status in females as objective and quantifiable measures of energy availability and hence injury risk in both male and female athletes.
Tapping into our inner endocrinologist
Dr Kate Ackerman explained why we should all tap into our inner endocrinologist. SEM goes far beyond diagnosing and treating injury. Is there any underlying endocrine cause for suboptimal health, performance or injury? Be this an endocrine diagnosis that should not be missed, or a functional endocrine dysfunction due to RED-S. Dr Ackerman explained the importance of the multidisciplinary team in both identifying and supporting an athlete experiencing the consequences of RED-S. New research from Dr Ackerman’s group was presented indicating the effects of RED-S on both health and athletic performance.
Females now have combative roles alongside their male counterparts. What are the implications of this type of intensive exercise training? Dr Julie Greaves presented insightful research revealing that differences in the geometry of bone in men and women can predispose towards bone stress injury and account for increased incidence in this type of injury in female recruits. Dr Greaves herself was the embodiment of female resilience and professionalism: despite “feeling like being at altitude” due to being close to full term, delivered a comprehensive academic and practical review of bone health and the pathogenesis of stress fracture injury.
Grace, aesthetic line and ethereal quality belie the athletic prowess required in ballet. What are the Endocrine, metabolic and bone health consequences for this unique group of athletes? Dr Roger Wolman returned to the important topic of insufficient energy availability in sport/dance where being lightweight confers a performance advantage, resulting in dysfunction in multiple endocrine axes. Dr Wolman discussed his recent research studies in dancers revealing an intriguing synergistic action between oestrogen and vitamin D, which is itself a steroid hormone. Evidence was presented to demonstrate how being replete in vitamin D has beneficial effects on bone, immunity and muscle function. Thus it is key in preventing injury and supporting health in athletes, with particular relevance in premenarchal and postmenopausal women, who are in relative oestrogen deficient states. This presentation will certainly change my clinical practice and, I am sure, that of many in the audience, in ensuring that athletes/patients are vitamin D replete. This may have to be achieved in the form of strategic use of sports informed vitamin D supplementation, given that even walking naked for 5 hours a day outside during UK winter, would not produce enough vitamin D production. Therefore, to the relief of many in the audience, Dr Wolman did not recommend this strategy.
Determinants of athletic gender
Lunchtime discussion and debate was focused on the determinants of athletic gender, lead by Dr Joanna Harper and Professor Yannis Pitsiladis. Rather than relying on genetic sex, testosterone concentration was proposed as the criteria for determining whether an athlete competes in male or female events. That testosterone concentration is linked to performance was demonstrated in a study published last year in the BMJ where female athletes in the upper tertile of testosterone were shown to have a performance advantage in certain strength based track and field disciplines. This could potentially be an objective, functional metric used to determine sporting categories for transgender and intersex athletes.
Nutrition for health and performance
Nutrition is a key component in optimising health and performance through the Endocrine system. Dr Sophie Killer explained practical implications for athletes. In a study stimulating a training camp, there were distinct differences between athletes on different regimes of carbohydrate intake in terms of endocrine markers and psychological effects. Those athletes on restricted carbohydrate intake fared worse.
Exercise and blood glucose control
Insulin insensitivity is the underlying pathological process in developing T2DM and metabolic syndrome. What is the crucial lifestyle intervention to combat this? Dr Richard Bracken presented the science behind why and how exercise improves blood glucose control and therefore ultimately risk of developing the macro and microvascular complications of diabetes. T2DM is an increasing health issue in the population, which has to be addressed beyond reaching for the prescription pad for medication. Dr Bracken outlined some effective strategies to encourage the reluctant exerciser to become more active. Having worked myself in NHS diabetic clinics over many years, this was a key presentation at the conference to demonstrate that SEM goes far beyond a relatively small group of elite athletes. Highlighting the crucial role of physical activity in supporting health and performance through optimisation of endocrine networks: uniting the elite athlete and the reluctant exerciser.
Motivate2Move: dis-ease prevention
Motivate2Move initiative aims to shift the emphasis from treating disease, to preventing disease. Dr Brian Johnson presented the excellent resource for healthcare professionals to encourage, motivate and educate patients in order to consider exercise as an effective and enjoyable way to improve health.
Hormones play a key role in health and human performance, applicable to all levels of exerciser from reluctant exerciser to elite athlete.