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ACSM Female Athlete Webinar — Transcript

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0:01So, hi everyone. Um, thank you so much
0:04for joining this webinar. Um, I'm
0:07Rebecca and I'll be presenting today
0:09with Caroline and we are both scientists
0:12at the Gatorade Sport Science Institute.
0:15We're really excited to present to you
0:18all today and a huge thank you to ACSM
0:21for this opportunity. Um, we welcome any
0:25questions throughout our presentation.
0:27um please just write them in the chat
0:29and we'll leave some time at the end to
0:32answer
0:34them. So today we're going to cover
0:37three main topics um during which
0:39Caroline and I will be tag teaming.
0:42Firstly an overview of the menstrual
0:45cycle which will go a bit deeper in
0:48menstrual cycle variability, nutrition
0:51and hydration considerations and
0:54menstrual cycle dysfunction. This will
0:57link nicely onto low energy availability
1:01or under fueling with a focus on
1:04potential indicators of low energy
1:07availability data on um low energy
1:10availability in different sports and how
1:13to measure it. And then finally,
1:16carbohydrate intake for female athletes.
1:19We're also really excited to share with
1:21you today our newly launched interactive
1:25ebook on female athlete health and
1:27performance and we'll be showing some
1:30previews of this throughout the
1:33webinar. So let's start with the
1:36menstrual
1:37cycle. The menstrual cycle is defined as
1:41the time between the first day of
1:43bleeding known as a period or menration
1:47and the day before the next period. Now,
1:50on average, the duration of a typical
1:53menstrual cycle is around 28 days.
1:56However, we know from data in female
1:59athletes and maybe observations that
2:01you've had from yourself or from the
2:03athletes that you work with that it
2:05differs between individuals. So it might
2:08range from 21 days in duration to around
2:1240
2:13days each period. So that's the day of
2:16bleeding has an average length of 2 to 7
2:19days. And again that differs within and
2:22between females for month to month. So
2:26this means that females have
2:28approximately 480 periods during their
2:31lifetime. and as they occur on a monthly
2:35basis. Menration is a significant part
2:38of a female's life. Yet, the
2:40conversation around periods is often a
2:43taboo
2:45topic. The menstrual cycle can be split
2:48into three different phases. So starting
2:51at the beginning of the cycle which is
2:53the follicular phase, the ovulatory
2:56phase which is in the middle of the
2:58cycle and then the lutal phase at the
3:01latter part and it's the brain which
3:04controls the menstrual cycle by
3:06initiating fluctuations in female sex
3:09hormones throughout the whole of the
3:12cycle. There's changes in two main
3:15hormones known as estrogen and
3:18progesterone. And it's the rise and fall
3:20of these two hormones plus some others
3:23that determine the phase of the
3:25menstrual
3:27cycle. So here you can see the
3:29fluctuations of the hormones that I was
3:32just referring to. So in brief the
3:34estrogen. So if you look at the dark
3:36green line, estrogen repairs, thickens
3:41and maintains the lining of the uterus.
3:44And then progesterone. So that's the
3:46yellow line, the yellow bar.
3:49Progesterone maintains the lining of the
3:52uterus during the latter part of the
3:54menstrual cycle. There's two other
3:57hormones which play a key role which are
4:00the follicle stimulating hormone shown
4:03in orange and the luteinizing hormone in
4:06light green. And these stimulate the
4:09growth and repair of the follicles in
4:11the ovary and trigger ovulation
4:14respectively.
4:16And then ovulation which is right in the
4:18middle of the menstrual cycle. This is
4:20when an egg is released from the
4:23ovaries. Um as I said that's right in
4:25the middle of the menstrual cycle but
4:27it's difficult to know the exact day due
4:30to the varying of cycle
4:34lengths. Now the hormone profile which
4:37was shown on the previous slide is what
4:39we would consider a textbook example of
4:42menstrual cycle hormones. However, we
4:45know that there are variations in female
4:48sex hormones between all females and
4:51these variations also exist in our
4:53female athletes. So, this slide shows
4:57hormone data collected from three elite
5:01female soccer players in the UK with
5:04estrogen on the left column and
5:07progesterone on the right column. And
5:10you can see that the hormonal profiles
5:12from each player look very different. So
5:16this just highlights the variability in
5:18hormones from athlete to
5:22athlete. And then this data is from the
5:25same study. Um however this time showing
5:28the menstrual cycle length in female
5:31soccer players. And each bar on this
5:34chart is a different player. And you can
5:36clearly see the variation in menstrual
5:39cycle length between each of the
5:41players. So what this data shows is that
5:44there is large variation in female sex
5:47hormones and menstrual cycle duration
5:50between females and every female athlete
5:54has a unique hormonal profile and
5:56length.
6:02Now, a study by Martin Etal in 2018
6:06which included 430 elite female athletes
6:11reported that 70% use hormonal
6:14contraceptive at some point. No study
6:18has reported like the reasons why
6:20athletes use hormonal contraception.
6:23However, potential reason reasons might
6:25be to prevent pregnancy to alter
6:28menstrual cycle around competition or to
6:32prevent negative side effects of the
6:34menstrual
6:35cycle. So, contraception or sometimes
6:38referred to as birth control comes in a
6:41range of preparations, brands and
6:44delivery methods which you can see on
6:46the screen here. And definitely a health
6:49professional should be involved if an
6:51athlete wishes to use or terminate the
6:54use of hormonal contraceptives.
6:57One of the most common contraceptives is
7:00the combined pill which is taken on a 28
7:03day cycle whereby an active pill is
7:06taken for 21 days followed by an
7:09inactive pill or no pill for 7 days and
7:13during that 7-day period bleeding
7:16normally occurs. It's important to note
7:19that the bleeding experienced during
7:21this time is not actually a natural
7:23menration. It's a result of the
7:26artificial hormones. So if the inactive
7:29pills are skipped and active pills are
7:32continuously taken in their place, then
7:35bleeding does not occur.
7:39So, hormonal contraceptives reduce the
7:42amount of naturally occurring estrogen
7:45and progesterone, which you can see on
7:47the slide here in the dark green and
7:50orange lines at the bottom of this chart
7:53throughout the whole month. And that's
7:55because hormonal contraceptives provide
7:58provide artificial hormones into the
8:00body. So this results in a completely
8:03different hormonal profile to the
8:06naturally or the natural menstrual cycle
8:08which I showed on um some of the
8:10previous
8:14slides. So we should consider the
8:16symptoms that athletes experience and
8:18how this might make them feel in their
8:20daily life and when they're
8:23exercising. On the slide here you can
8:25see symptoms that a female may
8:27experience during their menstrual cycle.
8:30And this is split into the oatory phase
8:33and the days just before and during
8:35their
8:36period. Stats from elite female athletes
8:39suggest that around 75% experience
8:42negative symptoms during their menstrual
8:44cycle at some point. It's important to
8:48note that these are not exhaustive lists
8:50and the type and severity of menstrual
8:52cycle symptoms largely varies between
8:55individuals.
8:57Data also suggests that the majority so
9:00around 80% of symptoms are experienced
9:03in the first one to two days of
9:05menstruation or
9:07bleeding. It's also common for symptoms
9:10to be present in the week prior to
9:12menstruation and this is referred to as
9:15premenstrual syndrome which is often
9:17abbreviated as PMS and this can cause
9:20physical and emotional changes such as
9:23stomach cramps, back pain and mood
9:25swings.
9:27Another important factor to consider is
9:29that symptom type and severity can vary
9:32within the same individual from cycle to
9:34cycle and it won't al it won't always
9:37necessarily be the same within each of
9:41the
9:44cycles. When talking about the menstrual
9:47cycle we should also consider youth
9:49athletes. The age of first menstruation,
9:52which has been on the decline, is on
9:55average around 12 to 13 years. When
9:58females first start their menstrual
10:00cycle, it's common for their cycle
10:02length to be irregular. This is because
10:05their body is getting used to the
10:07changes in
10:08hormones. In some youth female athletes,
10:11they might may find that their menstrual
10:13cycle does not start until much later
10:15than this. This could be be related to
10:18under fueling issues if the athlete is
10:21not consuming enough fuel for the
10:23demands of the exercise they're
10:25completing. And I'll come on to talk
10:27about this shortly or it could also be
10:30an underlying medical issue.
10:33It's recommended that female athletes
10:35should seek professional medical advice
10:37if they haven't started their period by
10:40the age of 16, if their periods stop for
10:43several months, or if they experience
10:46extremely severe
10:48symptoms. It's obviously important that
10:50athletes are educated on the point shown
10:53on this slide. However, with youth
10:55athletes, it's also important to educate
10:58parents and guardians so that they can
11:00also help to notice if a youth athlete
11:03requires medical
11:08support. Around one in three exercising
11:11females experience heavy menstrual
11:13bleeding and this is when menstrual
11:16cycle bleeding is particularly heavy or
11:19prolonged. Signs that athletes are
11:21experiencing heavy menstrual bleeding
11:24include passing large blood clots,
11:27needing to use two types of sanitary
11:29products at once, bleeding through
11:31clothes, needing to change their
11:34sanitary products frequently, having
11:36periods that last longer than 7 days,
11:39and if they often feel tired.
11:42This condition can reduce well-being and
11:44confidence and create concern in
11:47clothing choices, which is a factor
11:49that's often outside of an athletes
11:52control. In addition, those that
11:54experience heavy menstrual bleeding are
11:56more likely to suffer from an iron
11:58deficiency, which could potentially
12:00impact both health and performance.
12:03Research shows that female athletes with
12:05heavy menstrual bleeding are more likely
12:07to perceive that their period negatively
12:10impacts their training and
12:13performance. Athletes with HMBB often do
12:16not feel comfortable discussing this
12:18with practitioners, coaches, medical
12:21staff, etc. However, it's important to
12:24create an environment that facilitates
12:26open conversations about this topic so
12:28that athletes can sort help which in
12:30turn will help manage the impact of
12:32heavy menstrual bleeding on both
12:34well-being and performance. And we will
12:37discuss this a little later
12:41on. So, moving on to talk about
12:44menstrual cycle and nutrition and
12:46hydration considerations. And it's
12:49important to note that nutrition advice
12:51posted online doesn't require any
12:55factchecking and there are no
12:57regulations in place on who can share
13:00health and nutrition advice on social
13:02media which can lead to a lot of
13:04articles that look like this that are on
13:07the screen as well as a lot of
13:10misinformation and this can make it
13:12misleading and confusing for our female
13:15athletes.
13:18Currently, there's little to little
13:20evidence to suggest that nutrition
13:23should be manipulated during different
13:25phases of the menstrual cycle. But there
13:28are a few things to consider. So
13:31firstly, practitioners should focus on
13:34optimizing the daily nutrition of female
13:37athletes as well as their nutrition
13:40before, during, and after exercise or
13:43training. Caroline will come on to this
13:46when talking about fueling, but when
13:49fueling is not optimal or if athletes
13:52have periods of chronic low energy
13:56availability, this could result in
13:58menstrual cycle dysfunction, which in
14:00the long term might have health and
14:02performance issues for our female
14:04athletes.
14:07Iron intake is important for our female
14:10athletes as well as Caroline just
14:12alluded to because menstrual bleeding
14:15increases blood losses and as iron is an
14:18important component of blood, it can
14:21increase the risk of iron deficiency in
14:25females. Females may also have a lower
14:28ability to absorb iron in comparison to
14:31males. And in fact, it's been reported
14:34that approximately 35% of female
14:37athletes are iron
14:39deficient. So, so therefore, it's
14:42important to monitor the iron status of
14:45female athletes as well as optimizing
14:48iron intake in the daily diet.
14:52Now, some female athletes might report
14:54changes in appetite or cravings at
14:57certain phases of their cycle, or they
15:00might report energy
15:02fluctuations. And it's these athletes
15:04that practitioners or RDS might want to
15:07focus their attention on. So in summary
15:12um with nutrition considerations the
15:15focus is on to have a balanced healthy
15:18diet making sure that fueling is there
15:21to meet the needs of the energy demands.
15:27Now there are some female specific
15:29considerations when looking at both
15:32sweat rate so the amount of fluid that
15:35is lost and also the composition so the
15:38electrolytes that are in sweat
15:41especially when we compare female
15:43athletes to male
15:45athletes. Typically, female athletes
15:48have lower sweat rates than males, and
15:51that's largely due to them having a
15:54lower body mass or a lower body
15:57size. Women also sweat more efficiently,
16:00meaning that less sweat comes out of
16:03their sweat glands. And unlike male
16:05athletes, females start sweating at
16:08hotter
16:10temperatures. Females also have a lower
16:13sweat output per gland. And when looking
16:17at sex differences in sweat composition,
16:20women tend to have lower sweat sodium
16:23and chloride
16:27concentrations. When looking at
16:29differences in sweat rate and sweat
16:31sodium across the menstrual cycle,
16:34there's no research to suggest, oh
16:36sorry, there is research to suggest that
16:39during the lutil phase, there's an
16:41increase in the threshold at which
16:44sweating occurs. But there's no
16:46differences seen in sweating rates or
16:49sweat sodium concentrations across the
16:52menstrual
16:55cycle. So to date, while there are some
16:58sex differences in sweat rate and also
17:02sweat composition, we know that sweat
17:05rate and the subsequent fluid
17:07recommendations are very individual for
17:10all athletes. So fluid recommendations
17:13should be personalized to each athlete
17:16and at the moment there is no evidence
17:19to suggest that there should be sex
17:22specific fluid recommendations or
17:25different recommendations based on
17:27menstrual cycle phase.
17:31So currently we're in a position to say
17:34that there's no data to support the
17:36notion that we should be tailoring
17:39nutrition or hydration based on
17:42menstrual cycle phase. If one day we do
17:45have the data to tailor the
17:48recommendations, it would be great to
17:50hear from practitioners or maybe
17:52yourselves on this webinar if you think
17:55it would be feasible, especially in a
17:57team sport environment when we have
18:00squads of 20 plus female athletes to be
18:04able to personalize nutrition,
18:07especially when players might be at a
18:09different phase of their menstrual cycle
18:11or on hormonal contraceptive.
18:15For now, the advice would be that
18:17practitioners should be aware of the
18:19physical demands of the sport, making
18:22sure that fueling is optimal, and
18:25working with athletes that might report
18:27any severe symptoms that are related to
18:30their menstrual cycle, as well as any
18:33athletes that might report any cravings
18:35or appetite changes across the cycle. um
18:38to make sure that um our female athletes
18:42are fueling correctly and that their
18:44females aren't losing their
18:48periods. One way that athletes can
18:51notice any disruptions to their
18:53menstrual cycle is by asking them to
18:56track it. This can help um to notice any
19:01changes in menstrual cycle length or the
19:04amount of blood that is lost. Tracking
19:07can also help athletes to empower them
19:10to become more in tune with menstrual
19:12cycle related
19:14symptoms and also give them a better
19:17understanding of the connection between
19:19menstrual cycle and other factors such
19:21as sleep, physical activity, energy,
19:25performance, and recovery.
19:29As a minimum, it's recommended for
19:32athletes to keep notes of the days of
19:36bleeding, bleeding amounts, any
19:39symptoms, and any responses to exercise.
19:43So, athletes should track symptoms um
19:46throughout the whole menstrual cycle and
19:48not just those days that they are
19:50bleeding. If athletes feel comfortable,
19:53encourage them to share this information
19:56as it might help them to inform their
19:58training. So for instance, if athletes
20:01are consistently struggling to recover
20:04from high intensity sessions during a
20:07certain phase of the menstrual cycle,
20:09training or recovery time can be adapted
20:13accordingly. There's several ways that
20:16athletes can track their menstrual
20:18cycle. This is including phone based
20:21apps, using a diary or calendar or
20:25simply by writing it down. There is some
20:28hesitancy from athletes in using
20:31menstrual cycle tracking apps because
20:34they might store data on a cloud-based
20:37software and athletes might not be aware
20:40of who sees this data.
20:43But athletes should be encouraged to
20:44track their menstrual cycle in whichever
20:46way they feel most comfortable and
20:49sharing it with whoever they feel most
20:51comfortable sharing it
20:53with. Now, some female athletes can
20:57experience disruptions to their
20:59menstrual cycle. In non-pregant
21:02pre-menopausal women, the menstrual
21:05cycle may stop or become irregular for a
21:08number of reasons, including increased
21:11stress or hormonal contraceptive
21:15use. In exercising females, menstrual
21:18cycle disruption may also occur if
21:21they're experiencing low energy
21:23availability, which Caroline is going to
21:26go on to talk about. If athletes are in
21:29a state of low energy availability for a
21:32prolonged period of time, menstrual
21:35cycle disruptions such as oligo menora
21:38or amenorhea may
21:41occur. It's important that athletes seek
21:44advice from health care professionals if
21:46they are experiencing menstrual any
21:48menstrual cycle
21:50disruptions. So, it's here that we would
21:53like to share the first preview of our
21:55interactive ebook. We have chapters on
21:59many different topics but this is the
22:01one on menstrual cycle which goes
22:03through lots of different areas lots of
22:06which we have covered today such as
22:09heavy menstrual uh bleeding types of
22:12hormonal
22:17contraceptives. It also has some
22:19important advice on how we can help
22:22support our female athletes.
22:26So with that, I will pass it over to
22:28Caroline to talk about low energy
22:30availability and under
22:34fueling. Thanks, Becca. Um, so yeah, as
22:37Becca said, I'm now going to talk about
22:39under fueling and low energy
22:41availability. Um, which as Becca
22:43mentioned is a potential cause of
22:45menstrual cycle disruption in female
22:48athletes. And we know from the research
22:50that female athletes are particularly
22:52susceptible to low energy availability.
22:55And this is due to a number of reasons
22:57which I'll touch on over the next couple
22:59of
23:01slides. First of all, let's look at the
23:04concept of energy availability itself.
23:07On this slide, you can see what the
23:09equation is for calculating energy
23:11availability, which I'm sure many of you
23:13are familiar with.
23:15It's essentially the amount of energy
23:18available to the body after accounting
23:20for energy which is expended through
23:23exercise which is used for underlying
23:25and very important physiological
23:27functions and systems within the body.
23:31As you can see energy availability is
23:33expressed relative to fat-free mass
23:36which is the body's most metabolically
23:38active
23:40tissue. If too much energy is expended
23:42through exercise and not enough fuel is
23:45consumed through food, this is when an
23:48athlete can end up in a state of low
23:50energy
23:51availability. In order for the menstrual
23:54cycle to function optimally, it requires
23:57energy. Therefore, if the athlete
23:59doesn't have enough energy available,
24:01then their menstrual cycle can become
24:04disrupted or stop completely.
24:09Many athletes will expend large amounts
24:12of energy on a daily basis through
24:14undertaking their intensive training
24:16loads. The most recent IOC consensus
24:19statement states that low energy
24:21availability occurs as a continuum
24:24between two types. So firstly, adaptable
24:28low energy availability and this is when
24:30an athlete is exposed to reduced energy
24:34availability but most likely for a short
24:36period of time. This might cause a
24:39slight impact on bodily systems but
24:41these effects are usually mild and
24:43easily reversible having little to no
24:46impact on long-term health, well-being
24:48or performance.
24:51On the other hand, if an athlete is
24:53exposed to low instead of reduced energy
24:56availability and for a longer period of
24:59time, then this can cause greater
25:01disruptions to bodily systems. In the
25:04long run, it can potentially cause
25:06long-term impairments to both health and
25:08performance.
25:12It should be noted that it can be very
25:14challenging to accurately measure all
25:17components of energy availability. That
25:19being energy intake, exercise energy
25:22expenditure, and fat-free mass. And in
25:25particular, it's very difficult to
25:27measure um energy intake and exercise
25:30energy expenditure. And this is
25:32especially when working in the field as
25:34opposed to having access to lab
25:36equipment. In turn, this can make it
25:39difficult to know the energy
25:40availability status of an athlete and to
25:43identify whether they're experiencing
25:45adaptable or problematic low energy
25:50availability. It's been shown that
25:52self-reported dietary intakes, which are
25:54typically used to estimate energy intake
25:57in the field, might actually
25:59overestimate the prevalence of low
26:01energy availability in athletes.
26:05The graph on the right hand side of the
26:07slide shows average energy availability
26:09in female soccer players when either
26:12food photography or doubly labeled water
26:15was used. As you can see, average energy
26:18availability when food photography, so a
26:21self-reported measure was used was
26:24around 37 calories per kilogram of
26:26fat-free mass per day. whereas it was
26:29around 48 calories per kilogram of
26:31fat-free mass per day when doubly
26:33labeled water. So a much more objective
26:36method was
26:38used as an alternative. There are now
26:40several screening tools which have been
26:42produced to assess low energy
26:44availability and its associated
26:47outcomes. These include tools such as
26:50the low energy availability in females
26:53questionnaire, also known as the leaf Q,
26:56and there's also now the lem Q for males
26:59as well if anyone's interested. Um, the
27:02red S specific screening tool, the
27:04exercise dependent scale, and many more.
27:07And links to all of these are within the
27:09interactive ebook.
27:14If you're able to accurately assess the
27:16different components of energy
27:18availability, then within the female
27:20athlete toolkit interactive version,
27:22we've added a calculator where you can
27:24input the values to get the energy
27:27availability output which you can see on
27:30the screen here.
27:32In addition, we also have another
27:33calculator which is an alternative more
27:36objective measure method sorry to
27:39measuring energy availability and this
27:41is called the energy availability energy
27:44balance method. It requires measurements
27:46of body mass, body
27:49composition and average daily and
27:51exercise energy expenditure. And this
27:53removes the need to directly measure
27:56energy intake itself. So you can find
27:59much more information about this within
28:01the
28:06toolkit. So now moving on to what can
28:09cause low energy availability in
28:11athletes. The two fundamental causes of
28:14low energy availability are either
28:17inadequate energy intake and or a
28:20failure to match energy intake to
28:23training or energy demands which is
28:25demonstrated in mathematical terms
28:28within this table.
28:30If we start off with adequate energy
28:33availability on the top row here, this
28:35shows the athlete to be expending 500
28:38calories per day and taking in 2,700
28:42calories per day. So this leads to an
28:44energy availability of 45 calories per
28:47kilogram of fat-free mass per day. And
28:50this is assuming that the body
28:51composition um sorry this is assuming
28:54the body composition which you can see
28:56underneath the table which is an athlete
28:58with 18% body
29:01fat. If this same athlete was to
29:03continue expending the same amount of
29:05energy through exercise but reduce their
29:08energy intake to 1900 calories per day.
29:12This would put them into low energy
29:14availability which we are assuming here
29:17to be less than 30 calories per kilogram
29:19of fat-free mass per day. And this would
29:22be through a process of consuming an
29:24inadequate amount of
29:27energy. Similarly, if their energy
29:30intake stayed at
29:322,700 calories, but their exercise
29:35energy expenditure increased to 1,300
29:38calories per day. This would also put
29:41them into low energy availability, but
29:44this time it would be through a failure
29:46to match energy intake to a high
29:49training
29:50load. And the final row demonstrates how
29:53a combination of both a slightly
29:56increased exercise energy expenditure
29:58and a slightly reduced energy intake can
30:01also result in low energy availability.
30:07There are many contributing factors to
30:09these two fundamental causes of low
30:12energy
30:13availability. For example, contributing
30:15factors to athletes having too high a
30:18volume of training can be a poorly
30:20planned training program with not enough
30:23recovery or rest days or an exercise
30:26dependence where the athlete is overex
30:28exercising causing their body to expend
30:31too much energy through exercise.
30:35on the right hand side in terms of an
30:38inadequate energy intake. You can see
30:40how this is split into three different
30:42categories that being nutritional
30:45factors for example lack of nutrition,
30:47education and knowledge or perhaps a
30:50lack of motivation to fuel properly,
30:52body image and this is particularly
30:54prevalent in aesthetically demanding
30:57sports such as gymnastics and finally
31:00disordered eating and eating disorders.
31:04This helps us to highlight situations
31:06where an athlete could potentially fall
31:09into the trap of being in low energy
31:11availability, which could cause
31:13disruptions to their menstrual cycle.
31:16Through both education and awareness,
31:19many of these barriers can be addressed
31:21to minimize the likelihood of an athlete
31:23inadvertently experiencing low energy
31:26availability.
31:30With it being difficult to accurately
31:32determine energy availability in
31:35athletes, it's important for coaches,
31:37support staff, practitioners, and
31:39athletes to all be aware of potential
31:41signs and risk
31:43factors. We've already mentioned how
31:46menstrual cycle irregularities or
31:48complete loss of menstrual cycle can be
31:51an indicator that a female athlete is
31:53under fueling and or overtraining.
31:57However, there are many other signs in
31:59addition in addition to this which can
32:01be seen here on the slide. For example,
32:05things like poor bone mineral density or
32:08history of bone stress injuries, sleep
32:11disturbances, training inconsistencies,
32:13and constant
32:15fatigue. It's important to note that the
32:18signs and risk factors shown on this
32:20slide are not an exhaustive list. And in
32:23addition, an athlete does not need to be
32:25showing all of these symptoms here in
32:28order to be experiencing low energy
32:30availability. They may only show a small
32:33amount of these, but still be
32:34experiencing
32:38it. On this slide, you can see the
32:41estimated prevalence of low energy
32:43availability in female athletes reported
32:45across the literature. And this is
32:47assuming a cutoff value of less than 30
32:50calories per kilogram of fat-free mass
32:52per day which is commonly utilized in
32:55research and
32:57practice. It's suggested that low energy
33:00availability is more likely to occur in
33:03certain types of sports. So first of
33:06all, aesthetic sports such as gymnastics
33:08which I already mentioned and weight
33:11sensitive sports such as wrestling or
33:14jockeyies and this is potentially due to
33:17eating disorders and/or disordered
33:20eating being more prevalent in these
33:22sports which of course impacts energy
33:24intake therefore increasing the risk for
33:27low energy availability.
33:30However, it should be noted that low
33:32energy availability can occur both with
33:34and without an eating disorder or
33:37disordered
33:38eating. In weight sensitive sports,
33:41adaptable low energy availability might
33:44be more common during periods of weight
33:46loss in preparation for
33:49competition. And the other type of sport
33:52where low energy availability is more
33:55likely to occur is endurancebased sport.
33:58So such as longd distance running and
34:02cycling and this is potentially due to
34:05high volumes of training resulting in an
34:08increased exercise energy expenditure
34:11which in turn increases the risk for low
34:14energy
34:17availability as well as disruptions to
34:20the menstrual cycle and reproductive
34:22function. Low energy availability can
34:24also lead to a variety of other health
34:27and performance outcomes which can be
34:30seen in the diagrams here on this
34:33slide. Low energy availability is the
34:36underlying cause of the condition which
34:38is known as reds which stands for
34:40relative energy deficiency in sport
34:43which I'm sure many of you have heard
34:45of. In terms of health outcomes, on the
34:50left hand side, low energy availability
34:52can lead to mental health issues, sleep
34:55disturbances, and reduced muscle
34:57function, which of course are all
34:59important for athletes. And then in
35:02terms of performance, which you can see
35:04on the right hand side, low energy
35:06availability can disrupt many aspects of
35:09performance, including recovery,
35:11strength, and endurance.
35:14The outcomes shown in these diagrams
35:16will occur over different time periods
35:18and with differing severities. In
35:21addition, the outcomes experience may
35:23differ between different
35:28individuals. Finally, when considering
35:30low energy availability, it's also
35:33important to consider the impacts of low
35:35carbohydrate availability. This is a
35:38separate concern independent of low
35:40energy availability although they can
35:43often occur
35:45simultaneously. The independent effect
35:47of low carbohydrate availability on
35:50health and performance has been under
35:52researched despite current carbohydrate
35:54intake being commonly insufficient in
35:57female athletes.
35:59It's been shown that low carbohydrate
36:01availability may not only contribute to
36:03low energy availability, but it can also
36:06have independent health and performance
36:09consequences in
36:11athletes. In female athletes,
36:13carbohydrate availability helps to
36:16maintain normal estrogen and
36:18progesterone levels, which as Becca
36:21mentioned are important for reproductive
36:24health.
36:26Low carbohydrate availability can also
36:28be associated with poor bone health even
36:31if energy availability is
36:34adequate. In addition, it's also
36:37associated with depressed immune
36:39function. This highlights the need for
36:41carbohydrate availability to be optimal
36:44in female athletes regardless of energy
36:47availability status.
36:51Considering this highlighted importance
36:54of carbohydrate availability in female
36:56athletes, we're now going to finish off
36:59by looking in more detail at the
37:01importance of carbohydrate intake in
37:03female athletes, whether female athletes
37:06are currently meeting the
37:07recommendations for carbohydrate intake
37:10and how we can support female athletes
37:12in achieving adequate daily carbohydrate
37:15intakes to support their training and
37:18competition needs.
37:21First of all, let's look at why
37:23carbohydrate is an important fuel source
37:25during many types of
37:27exercise. The contribution of
37:29carbohydrate to energy metabolism during
37:32exercise changes depending on exercise
37:36type. As you can see, during
37:38highintensity endurance or sprint type
37:41exercise, carbohydrates are the
37:43predominant energy source.
37:46During this type of exercise, the body
37:48will use glycogen stores and sometimes
37:50they may even become depleted. When
37:53glycogen stores run low, the body may
37:56fatigue which can result in impaired
37:59physical and cognitive performance. So
38:02this demonstrates the importance of
38:03adequate carbohydrate intake for many
38:06different kinds of
38:10exercise. Due to carbohydrate
38:12utilization varying during different
38:14exercise occasions, daily carbohydrate
38:17intake recommendations are dependent
38:20upon the intensity and duration of
38:22exercise that the athlete is performing.
38:25So as you can see, as the intensity and
38:28duration of daily exercise increases,
38:30the recommended carbohydrate intake
38:33increases too. The aim is to ensure that
38:36sufficient carbohydrate is consumed to
38:39provide energy to working muscles, the
38:41central nervous system and other bodily
38:44processes as
38:48well. Here you can see some practical
38:50examples of roughly how athletes can
38:53meet increasing carbohydrate needs.
38:56If you look across the top row, this
38:58shows approximately what would be
39:00required for breakfast, lunch, and
39:03dinner to meet the recommendation of 3
39:06to 5 g per kilogram of body mass per
39:09day. So, oatmeal with berries, chicken
39:12salad, and a banana for lunch, and fish
39:14with roasted vegetables for dinner with
39:17some snacks in between this two. Each
39:20row there on shows what could be added
39:23into each of these meals in order to
39:25take it up to the next
39:28recommendation. It can be difficult for
39:31athletes to meet the upper end of the
39:33recommendation. So 8 to 12 gram per
39:36kilogram of body mass per day especially
39:40female athletes. Therefore, providing
39:42them with practical examples of how this
39:45actually looks in food and beverage form
39:47can help them to visualize the amount
39:49that they actually need to be
39:55consuming. Just before I hand back over
39:57to Becca to finish off this
40:00presentation, I just wanted to show a
40:02sneak peek of the dietary carbohydrate
40:05section of the female athlete toolkit.
40:08And this time it's shown as the mobile
40:11version. So here you can see um some of
40:14those tools which I've just shown on the
40:16slides um and how they're demonstrated
40:19within the interactive toolkit. So for
40:22example in this section here you can
40:24input the athletes body mass and it will
40:26tell you their recommended carbohydrate
40:29intake depending on the intensity and
40:32duration of exercise that they're
40:33completing. And then at the bottom here,
40:36you can see the carbohydrate and fiber
40:38content of different foods and drinks.
40:42So this is a practical tool that of
40:45course you can use yourself, but also
40:47you could use it with athletes as well
40:49to show them their recommendations and
40:51then show them how this might
40:53practically look in food form as well.
40:57So, I'll now hand over to Becca to round
40:59us off with talking about whether the
41:01current carbohydrate recommendations are
41:04practical and achievable for female
41:06athletes.
41:08Yeah, thanks Caroline. Um, so currently
41:11there are no sex specific carbohydrate
41:16recommendations and as Caroline clearly
41:19explained, daily carbohydrate intakes
41:22are based on the type of activity that's
41:26going to be completed that day or in the
41:29upcoming days.
41:31However, from working with female
41:33athletes ourselves, as well as hearing
41:36from RDS and sports nutritionists, we
41:39know that it's often difficult for
41:41females to eat high amounts of
41:43carbohydrates.
41:45So in this example on the slide, if this
41:49runner was recommended to eat 9 g per
41:52kilogram of body mass of carbohydrate,
41:56it would equate to approximately 540 g
42:00of carbohydrate, which would look
42:02something like this. So this would
42:05ensure that she hits her carb
42:08carbohydrate
42:09recommendations. But as you can see
42:11here, this is a large amount of food and
42:15also foods contain other macronutrients,
42:19not just carbohydrate. So it would also
42:22amount to a high amount of total
42:25calories that she would have to
42:27consume. So let's look at some published
42:30data to see if female athletes are
42:33hitting the carbohydrate
42:35recommendations.
42:38And carbohydrate intakes have been
42:40reported in the literature in elite
42:43soccer players. So here you can see that
42:46average carbohydrate intakes from three
42:49different studies and all of these are
42:52on the lower end of the
42:55recommendations which suggests that in
42:57these three studies female soccer
42:59players are not adjusting their
43:01carbohydrate intake based on the
43:04training load for their sport. and this
43:07could result in the in them being
43:09routinely
43:12underfueled. The same conclusions can
43:14also be drawn from this study which
43:17measured energy intake in NCAA female
43:21and male runners during a training and
43:25competition period. So here you can see
43:28that the females on the right hand side
43:30of the table consumed less carbohydrates
43:34than their male runners. And while they
43:36do reach the recommendation for
43:39endurance athletes, it's definitely at
43:42the lower end of the range.
43:46I've already acknowledged that the
43:48larger amounts of carbohydrate can be
43:50difficult for females to consume. But we
43:54are also seeing qualitative research
43:56published highlighting that females have
43:59an inherent fear of consuming
44:03carbohydrates. So these three excerpts
44:07have been taken from focus groups in
44:10professional soccer players and sports
44:13practitioners. And one of the key themes
44:15that was drawn from this study was the
44:18fear of consuming
44:20carbohydrate. Now, I'm not going to read
44:23through all of these quotes, but you can
44:26see the quote from one player and said
44:29that it was difficult for her to eat
44:31more carbohydrates for the fear of
44:34putting on weight and making her fat.
44:38And in another quote from the sports
44:40dietician, it just said that players
44:42don't want protein shakes that have too
44:45many carbs and that there's this worry
44:47and fear about having carbs in the
44:50protein
44:52shake. Now, there are some other reasons
44:55why female athletes might struggle to
44:57reach the carbohydrate recommendations.
45:00So firstly, females are known to eat
45:03larger amounts of low energy dense foods
45:06like fresh fruit and veg. These foods
45:09have a much higher water content and
45:12fiber content which can make them feel
45:14full and you'd have to eat larger
45:17amounts of them to meet the required
45:19carbohydrate
45:22recommendations. Also, if our female a
45:24athletes are substituting sports drinks
45:28for low calorie drinks during intense
45:30training, that just means that they'll
45:32have to consume more food or more high
45:35carbohydrate foods in their diet outside
45:38of the exercise occasion.
45:42Also, social media has become a place
45:45where carbohydrates are demonized. And
45:48if coupled with a lack of credible
45:51education, this leads to a negative
45:54perception of carbohydrates, which is
45:57preventing females to fuel
46:00correctly. So, what can we do with our
46:02female athletes? Well, first and
46:04foremost, we must educate them. I think
46:08that's up to us and everyone on the call
46:11to be the voice of authority to educate
46:14female athletes on the importance of not
46:17only carbohydrate intake but also
46:19optimal
46:21fueling. We also need to work with our
46:23athletes to find different forms of
46:25carbohydrates that work for for them. So
46:28whether that's taking in more calories
46:31through different types of foods and
46:33beverages and also working with our
46:36athletes to strategically time the
46:38intake around exercise to support
46:41performance and
46:44recovery. So that's where we would like
46:47to finish today and we will happily
46:50answer any questions. And just a final
46:53plug for you to check out our toolkit on
46:56sports nutrition and hydration for
46:58female athletes. Um, as you can see on
47:01the right hand side, there's lots of
47:03different topics, including some of the
47:05ones that we've spoken about today, but
47:07also some additional topics. Um, we hope
47:10that it's a really useful resource, not
47:13only for yourself, but maybe for anyone
47:15to use with female athletes. Um, and if
47:18yeah, if you've got any feedback on the
47:20resource, we're also happy to take the
47:22feedback as well. So, we will finish
47:25there and answer any questions. Thank
47:28you for listening.

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