Energibrist. Anna Melin Department of Nutrition, Exercise and Sports University of Copenhagen

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1 Energibrist Anna Melin Department of Nutrition, Exercise and Sports University of Copenhagen

2 Department of Nutrition, Exercise and Sports Energibrist Lipolys Proteolys Glukos Ketoner GnRH neurons GnRH Aptit Energidensitet = kcal/g mat Maskerad trötthet Metabol adaptation: Viloämnesomsättning (RMR) Menstruations rubbningar (0-70 %) Hypothalamus Leptin Hypofys Adipocyt TSH ACTH Ghrelin PYY, GLP-1 Magtarm kanal FSH LH Sköldkörtel Äggstock/ testickel Binjurar T 3 / T 4 Östrogen Progesteron Testosteron Kortisol Adrenalin Noradrenalin Warren J Clin Endocrinol Metab 2011; 96: , Gordon N Engl J Med 2010;363: Friedl et al J Appl Physiol 2000;88: , Bonci et al J Athletic Training 2008; 43(1): Loucks and Thuma J Clin Endocrinol Metab 2003; 88: , Larson-Meyer J Obesity, Vol 2012, Article ID Horvath et al J Am Coll Nutr 2000;19(1):52-50, Deuster et al Fertile Sterile:1986;46(4):

3 Response of Luteinizing Hormone Pulsatility to 5 Days of Low Energy Availability Disappears by 14 Years of Gynecological Age Loucks AB. J Clin Endocrinol Metab. 91(8): , 2006 Paired 24 h LH pulse profiles *=LH pulses, black bar=lights turned off. Arrows=meals

4 Department of Nutrition, Exercise and Sports GnRH neurons Energibrist Lipolys Proteolys Glukos Ketoner GnRH Aptit Maskerar trötthet Metabol adaptation Rubbad reproduktionsförmåga Nedsatt skelett hälsa (0-40%) Nedbrytning (resorption) Formation Leptin Adipocyt Hypofys TSH FSH LH ACTH Ghrelin PYY, GLP-1 Magtarm kanal Sköldkörtel Äggstock/ testicklar Binjurar T 3 / T 4 Östrogen Progesteron Testosteron Kortisol Adrenalin Noradrenalin Warren J Clin Endocrinol Metab 2011; 96: Gauillaume et al J Clin Densitometry 2012; 15(1): , Dolan et al J Bone Miner Metab 2012; 30: Gordon N Engl J Med 2010;363:365-71, Bonci et al J Athletic Training 2008; 43(1): Loucks and Thuma J Clin Endocrinol Metab 2003; 88: , Larson-Meyer J Obesity, Vol 2012, Article ID , Horvath et al J Am Coll Nutr 2000;19(1):52-50, Deuster et al Fertile Sterile:1986;46(4):

5 Cross-sectional evidence of suppressed bone mineral accrual among female adolescent runners Barrack MT, Rauh MJ and Nichols JF J Bone Mineral Research. 25(8): , 2010 Comparison of (A) total-body and (B) lumbar spine BMD Z-score values between female runners (black, n=93) and non-runner (gray, n=90) at each age group. a: P<0.01, b: P<0.05, ANOVA

6 Bone Related Health Status in Adolescent Cyclists Olmedillas H et al PLoS ONE 6(9):e24841 Group and age interaction for femoral neck volumetric BMD, P<0.01 in young and old adolescent cyclists and controls. * P<0.05 between control and cyclists groups 17 yrs.

7 Department of Nutrition, Exercise and Sports GnRH neurons Energibrist Lipolys Proteolys Glukos Ketoner GnRH Aptit Maskerar trötthet Metabol adaptation Rubbad reproduktions förmåga Nedsatt skelett hälsa Endotel dysfunktion Förhöjda kolesterol halter Leptin Adipocyt Hypotalamus Hypofys TSH ACTH Ghrelin PYY, GLP-1 Mag- Tarm kanal FSH LH Sköldkörtel Äggstock/ testicklar Binjurar T 3 / T 4 Östrogen Progesteron Testosteron Kortisol Adrenalin Noradrenalin Warren J Clin Endocrinol Metab 2011; 96: Gordon N Engl J Med 2010;363:365-71, Bonci et al J Athletic Training 2008; 43(1): Loucks and Thuma J Clin Endocrinol Metab 2003; 88: , Larson-Meyer J Obesity, Vol 2012, Article ID Horvath et al J Am Coll Nutr 2000;19(1):52-50, Deuster et al Fertile Sterile:1986;46(4):

8 Amenorrhea in Female Athletes is Associated with Endothelial Dysfunction and Unfavorable Lipid Profile Rickenlund A et al J Clin Endocrinol Metab. 90(3): , 2005 Correlations between the number of menstruations the last year vs. LDL and Apo B and correlations between LDL and Apo B vs. percent FMD in athletes with menstrual disturbance.

9 Department of Nutrition, Exercise and Sports GnRH neurons Energibrist Lipolys Proteolys Glukos Ketoner Aptit Maskerar trötthet Metabol adaptation Rubbad reproduktionsförmåga Nedsatt skelett hälsa Endotel dysfunktion Förhöjda kolesterol halter Prestation och återhämtning: - Muskel trötthed - Nedbrytning av muskelmassa, senor, bindväv och ligament - Blodgenomströmning och därmed sämre aerob substratutnyttjande - Glykogenlager - Risk för skador Hypotalamus Leptin Hypofys Adipocyt TSH Sköldkörtel GnRH FSH LH Äggstock/ testicklar ACTH Binjurar Ghrelin PYY, GLP-1 Mag- Tarm kanal T 3 / T 4 Östrogen Progesteron Testosteron Kortisol Adrenalin Noradrenalin Warren J Clin Endocrinol Metab 2011; 96: Gordon N Engl J Med 2010;363:365-71, Bonci et al J Athletic Training 2008; 43(1): Loucks and Thuma J Clin Endocrinol Metab 2003; 88: , Larson-Meyer J Obesity, Vol 2012, Article ID Horvath et al J Am Coll Nutr 2000;19(1):52-50, Deuster et al Fertile Sterile:1986;46(4):

10 Relationships among injury and disordered eating, menstrual dysfunction and low BMD a prospective study Rauh et al J Athletic Training 2010;45(3): Aim: To investigate the interrelationship between restricted eating behavior, menstrual dysfunction, reduced BMD and injuries Design: 163 female athletes were monitored for 1 year frequency and type of injuries Primary outcome: Daily injury reports from coaches, eating disorder examination, BMD and self-reported menstrual status Table 1. Selected Demographic and Physical Characteristics of Participants by Musculoskeletal Injury Status Characteristics Total (N=163) Injured (n=61) Uninjured (n=102) P-value Age 15.7 ± ± ± Height, cm ± ± ± Weight, kg 59.2 ± ± ± Body mass index, kg m ± ± ± Lean tissue mass, kg 39.7 ± ± ± Body fatness, % 26.2 ± ± ± Age at menarche, y 12.4 ± ± ± Gynecologic age, y 3.3 ± ± ± Menses past year, No ± ± ± Independent t test used to compare injured and uninjured mean values

11 Figure 1. Incidence of muscoskeletal injury (n=90) by body site in 61 female high school athletes 35 33,3 Total Injuries, % ,6 1,1 2,2 Shoulder Wrist Lower back 21,1 11,1 11,1 7,8 6,7 Hip/pelvis Thigh Knee Lower leg Ankle Foot 37% hade en eller flera skador under året 69% överbelastning eller kroniska skador 31% akuta skador Body site Figure 2. Relationship among dietary behaviour, menstrual status, BMD and major injuries. Athletes with a major injury, % Normal eating / DE 5,1 19,2* 40 * Eumenorrheic/MD 12,2 6,3 5,7 3,1 22,2 ** *p<0.05 **P< ,3 7,1 0 Normal eating/ Dietary restraint Characteristic Normal BMD /osteopenia Normal BMD /osteoporosis

12 Relative Energy Deficiency in Sports (RED-S) Eating disorders Reproductive function Bone health The Triad Cardiovascular Endocrine Low EA Injuries Metabolic Immunological Gastrointestinal Haematological Growth and Development The IOC consensus statement: beyond the Female Athlete Triad Relative Energy Deficiency in Sport (RED-S). Mountjoy M, Sundgot-Borgen J, Burke L et al. Br J Sports Med 2014;48:

13 Energy availability and reproductive function in female endurance athletes dietary characteristics and impact on energy and bone metabolism, health, performance and recovery Anna Melin & Anders Sjödin, NEXS, Copenhagen University, Denmark Åsa Tornberg, Lund University, Sweden Sven Skouby, the Fertility Clinic, Herlev Hospital, Denmark Jorunn Sundgot-Borgen, Norwegian School of Sport Sciences, Norway

14 Health Sciences Lab, Lund University Day 1 Herlev Hospital, Denmark DXA Orthostatic BP Gynecological examination Day 2 Lund University, Sweden 50W 100W 7.30 RMR 0W 6 50W 50W 6 Neuromuscular 9.00 Neuromuscular EDE-16 6 Questionnaires 6 tests Meal tests Meal Work efficiency Maximal Incremental Exercise test 1 Maximal Incremental Exercise test 2 Neuromuscular tests

15 Department of Nutrition, Exercise and Sports Descriptive details Variable All Eumenorrhea Oligomenorrhea/ (n = 40) (n = 16) FHA (n = 24) Age (y) 26.3 ± ± ±5.7 Height (cm) ± ± ±0.05 Weight (kg) 58.4 ± ± ±6.6 BMI (kg/m 2 ) 20.5 ± ± ±1.8 VO 2peak (l/min) 3.16 ± ± ±0.4 VO 2peak (ml/kg/min) 55.4 [ ] 55.0 [ ] 55.4 [ ] Body fat (kg) 11.9 ± ± ±3.1 Relative FM (%) 20.0 ± ± ±3.4 FFM (kg) 46.1 [ ] 48.8 [ ] 45.5 [ ] Exercise (h/week) 11.4 ± ± ±4.7 Data are presented as mean ±SD for normal distributed data and as median and interquartile range for skewed data. For comparison of mean levels between eumenorrhea subjects vs. oligomenorrhea/fha, a two-sample t-test was used. BMI: body mass Index FFM: fat free mass

16 Energibrist bland kvinnliga uthållighets idrottare Ätstörning 24% Oligomenorrhea/ Amenorré 60% Magproblem 38% Nedsatt benhälsa 45% Triaden 23% LDL kolesterol 25% Leptin 78% T 3 3% Cortisol 3% Energibrist 63% Skador 63% Allvarlig skada 35% Låg ämnesomsättning 53% Hypotension 18% Immunologi? Melin A et al. Scand J Med Sci Sports 2014 Melin A et al. Brit J Sport Med 2014 Järnbrist 28% Blodsocker 38 % Växt och utveckling

17 Department of Nutrition, Exercise and Sports Konklusion IOC s Consensus Statement; introducerar en ny utvidgad modell; RED-S som omfattar både män och kvinnor, andra än bara idrottare, flera fysiologiska konsekvenser än reproduktion och benhälsa. Energibrist (oftast utan en ätstörning), menstruationsrubbningar, nedsatt ben mineral densitet, hyperkolesterolemi, hypoglykemi, nedsatt ämnesomsättning etc. är vanligt bland kvinnliga idrottare trots normalvikt. Därför viktigt att screena for både energibrist och ätstörningar. Hög förekomst av låg ben mineral densitet visar stort behov för preventiva strategier, tidig upptäckt och behandling.

18 Tack för er uppmärksamhet!