Archive for July, 2019

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During the 1970s, researchers began to notice a higher-than-expected frequency of amenorrhea (absence of normal menstrual cycles) in ballet dancers, and that in those women there was a very high likelihood of suffering from stress fractures in the feet and lower legs.

At around the same time (with the passage of Title IX), more and more women began to participate in sports, and similar patterns began to be seen among those who performed at the highest levels. In other words, more and more female athletes who developed amenorrhea had a tendency to sustain stress fractures.

What is the Female Athlete Triad?

It was only a matter of time before a syndrome was identified that linked disordered eating with the absence of menstruation and the development of stress fractures. It was named the female athlete triad, and the triad can be conceptually visualized by the figure below that illustrates schematically how the interplay between energy availability (affected by disordered eating), hormonal processes (disrupting menstrual cycles), and bone mineral density (leading to stress fractures) are all on a spectrum.

female athlete triad explained

At its worst, women who are training hard may be sacrificing good eating habits, or affected by a distorted body image that leads them to develop a true eating disorder. With continued exertion in an underfed state, hormonal processes required for regular menstruation are interrupted. These same hormonal processes are required for healthy bone formation, and in their absence, bone mineral density begins to deteriorate leading to stress fractures.

Detecting the Onset of Symptoms

Fortunately,
the effects of the female athlete triad are, for the most part, reversible, but
the best way to manage them is to detect the onset of symptoms early to
intervene and prevent the development of injuries in the first place. Coaches
can have an important role both in precipitating some of the habits that can
lead to the triad, but also in the early detection of and intervention in the
progression of the triad by knowing what to look for and by being diligent with
their female athletes.

With respect to precipitating habits that can lead to the triad, coaches should recognize the outsized impact they may have on their female athletes by over-emphasizing weight loss. Women are subject to untold amounts of societal pressures related to their weight and appearance, and well-meaning coaches can compound this and may have the unintended effect of promoting dieting or dietary restriction—the two most common precursors to disordered eating.

Promoting healthy nutrition and overall performance over weight loss is the preferred means to discuss diet with female athletes. While some coaches may have difficulty de-emphasizing weight loss, it’s important they remember that nothing is more important than their athlete’s physical and mental well-being. Healthy nutrition will accomplish both of those ends.

Because
disordered eating is the common starting point for the triad, it’s the single
best reason for a coach to intervene early in order to prevent the more serious
effects of this relative energy deficiency.

Please note, disordered eating is NOT the same as a true eating disorder. While both exist on a spectrum, disordered eating is merely unhealthy eating in that the nutritional needs are not met by the diet of the athlete. A true eating disorder encompasses much more than this, including elements of distorted body image and true manifestations of mental illness.

Challenges for Coaches

There
are several challenges for coaches to overcome in order to identify the signs
of disordered eating in their female athletes:

Women who embody many of the habits and
characteristics of successful athletes share a lot in common with women who are
most at risk for disordered eating. They tend to put in long hours of training
and they are very compliant with their coaches’ plans for them.Female athletes who are most at risk for
disordered eating tend to be found in sports that emphasize thinness or
leanness. Consequently, coaches may not notice these women as being unwell
because they fit the stereotype of athletes in their sport.Finally, the firmly entrenched notion
that leanness and thinness are correlated with improved performance is
difficult to overcome and so coaches may not see their athletes as underfed.

For
coaches to get past these biases they must be hyper-vigilant and pay attention
to some subtle signs of poor nutrition:

Physical signs and symptoms include significant weight loss, frequent complaints of dehydration, muscle cramps, weakness, and fatigue.

Psychological signs include complaining of feeling fat despite being thin, anxiety and/or depression, difficulty concentrating, and preoccupation with weight and eating.

It
should be noted that the mere presence of any one of these signs or symptoms is
not enough to make the diagnosis of disordered eating, but should serve to at
least raise awareness of the possibility for the coach.

Later signs of disordered eating include amenorrhea and eventually, stress fractures. It’s difficult for a coach to know their athlete’s menstrual health, and this is likely not something many coaches would feel comfortable asking about.

However, if a coach is concerned about their athlete and believes that they may be at risk for the triad, knowing if they are still having periods is very important. Amenorrhea has for too long been considered ‘normal’ amongst female athletes, and it’s important that this attitude shift.

Addressing the Issue

For
a coach who is worried, a suggested approach might sound like: “I understand
there is a fine balance between performance and weight, but there are some
really clear signs when that the balance is off. Missing your period is one of
those clear signs. If this is happening or begins to happen, we need to address
it as soon as possible. I need to know this as a coach because it is indicating
to me that you are not fueling adequately and therefore not going to be able to
train optimally, and secondly, that you are putting yourself at risk of injury.”

If an athlete is identified with amenorrhea, a frank discussion with her is paramount with an emphasis on the need to get back to a healthy state. A focus on a restoration of energy balance through improved nutrition is almost always adequate to reverse the menstrual irregularities, and over time, any deficits in bone mineral density.

However, women with disordered eating, especially those at the end of the spectrum closest to true eating disorders, may refuse to recognize they have a problem and will not make the necessary changes to improve their health. Worse, they might continue their behaviors while paying lip service to making changes.

These
latter cases should be strongly encouraged to seek help from a healthcare
professional who specializes in the management of these patients. For less
seriously affected women, a registered dietician may be helpful to develop an
acceptable plan to restore an appropriate energy balance for their athlete.

Any
female athlete who sustains a stress fracture should be encouraged to see their
physician for a comprehensive evaluation of their menstrual health since this
often is a sign of the female athlete triad.

It’s important to note that in 2014 the International Olympic Committee issued a consensus statement Beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). This statement was an effort to update the science on the triad, but also to recognize that a similar syndrome had been purported to exist in male athletes. The redefinition of the female athlete triad to RED-S was met with considerable scorn in the sports medicine community and remains a topic of significant controversy.

Female Athlete Triad Versus RED-S

While it’s true that a significantly smaller number of male athletes do suffer from disordered eating, there are several problems with redefining the triad to RED-S:

While there are decades of research and
a multitude of studies on the female athlete triad, there is a scarcity of
research on any such syndrome in men. This is because the number of men
afflicted remains so small as to remain unknown.Renaming the female athlete triad shifts
the focus of this entity towards men and away from women in the minds of many
who study this problem. This, in their minds, is wholly inappropriate given how
this so disproportionately affects female athletes.Finally, another important distinction
between men and women is the absence of menstruation in men. Consequently men
are protected from the effects of disordered eating to some degree. While they
may lose weight and suffer many of the same physical and psychological effects,
they do not need to ‘fuel’ ovulation and menstruation. In the absence of
disruption of these hormonal processes they do not suffer the loss in bone
mineral density and stress fractures that women do.

For this reason, coaches should be much more concerned about their female athletes than their male athletes with regard to the presence of disordered eating and all its associated effects.

In
summary, female endurance athletes are at significant risk for disordered
eating because of the nature of the sports that they participate in. Coaches
need to be careful to de-emphasize weight loss when talking to women and
instead highlight overall healthy nutrition as an important contributor to
overall health and performance. Coaches should also be vigilant for signs of
the female athlete triad and encourage female athletes with signs of it to seek
an evaluation by a health professional.

I am deeply indebted to Kelly Phuah and Lucy Brash for their assistance in reviewing and editing this article prior to submission. In addition, I consulted the following manuscripts in the preparation of this article:

1. The Female Athlete Triad. Med Sci Sport Exerc. 2007;39(10):1867-1882. doi:10.1249/mss.0b013e318149f111

2. Matzkin E, Curry EJ, Whitlock K. Female Athlete Triad. J Am Acad Orthop Surg. 2015;23(7):424-432. doi:10.5435/JAAOS-D-14-00168

3. NCAA Coaches Handbook Managing the Female Athlete Triad. Accessed June 17, 2019.

4. Souza MJ De, Williams NI, Nattiv A, et al. Misunderstanding the Female Athlete Triad: Refuting the IOC Consensus Statement on Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014;48(20):1461-1465. doi:10.1136/BJSPORTS-2014-093958

5. Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014;48(7):491-497. doi:10.1136/bjsports-2014-093502

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The Whole Picture: Recovery Through Sleep

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This is Part Five of a five-part series on total load, the cumulative training and life stress an athlete experiences while training. Read Part One, Part Two, Part Three, and Part Four to get the full story.

No series looking at total load would be complete without an examination of the main mechanism by which the body repairs itself and recovers: sleep. While perfect sleep is quite easy to imagine (and desire!), it’s not that easy to achieve.

What are the problems with the less-than-perfect sleep that almost all of us encounter, either on a temporary or ongoing basis, and how do these affect total load?

Perfect sleep

Perfect sleep is not defined as a certain
number of hours each night, but rather it:

Has 90-minute cycles comprising
periods of light sleep, deep sleep, and REM sleep, with more deep sleep at the
start of the night, and less later on.Has a number of 90-minute
cycles per night, usually five for most people when averaged across the week.Fits in with your personal body
clock or circadian rhythm, which is reset by the daily light/dark cycle (i.e.
when your body naturally wants to be asleep).Satisfies our sleep pressure.
This is our need to sleep which has built up during the day, and which carries
over from nights of insufficient sleep.Has good sleep hygiene (i.e.
cool, dark, quiet, comfortable).Includes 20- to 30-minute naps
in the early or late afternoon, especially if training or competing later in
the day, or if night-time sleep quantity or quality has been reduced.

pre and post sleep routines

Why do we need good sleep?

There are plenty of articles out there with advice on how to prepare for effective sleep, but why do we need good sleep? In general, sleep facilitates recovery from damage accumulated during the previous period of wakefulness, and is especially important for athletes.

Good sleep is needed to maintain the performance of thinking and problem solving, carbohydrate metabolism and the appetite associated with particular blood sugar levels, and the performance of the immune system in identifying and neutralizing invading pathogens. The first four hours of sleep are especially critical, as this period has the largest amount of deep sleep when human growth hormone (HGH) and testosterone are produced. These are the hormones responsible for the compensation response to exercise when our muscles and metabolism become stronger and more powerful.

Good sleep resets the calibration of our
internal perceived exertion (RPE) scale, and maintains good sensations of
fatigue and mood. Workouts (especially high-intensity ones) feel easier when we
have slept well, so are more likely to be completed as prescribed. Extended
endurance workouts are more satisfying and our pacing strategy is also better
when we have slept well too.

With such clear benefits, you would expect
that athletes take sleep as seriously as training, but according to surveys
performed by Dr. Shona Halson at the Australian Institute of Sport, this is
seldom the case, even amongst elite athletes.

As the chart below shows, sleep efficiency
(the proportion of time spent asleep whilst in bed, often used as a rough
measure of sleep quality) and wake-up time are related, with swimmers and
triathletes having the earliest rise times, coupled with the poorest sleep
efficiency:

sleep efficiency and wake time

So, although athletes need more sleep than
their less-active peers, they often get less, resulting in daytime sleepiness
as well as reduced performance.

Less-than-perfect sleep

So, what typically prevents athletes from
getting good sleep?

Sleep hygiene: Poor bedtime routine, use of phones and TV in bed, bedding and room temperature mismatched.Body sensations: Fatigue, injury, muscle soreness, nervous system activity—especially from using caffeine or training late in the day.Travel: Jet lag, shared hotel rooms, shifts in time zone, training/competition times.

Overall, a lack of awareness of the
importance of good sleep is what prevents athletes from paying sufficient
attention to the factors they can control.

How does sleep interact with other total load components?

Nutrition

A chronic lack of sufficient sleep has
significant effects on the regulation of blood sugar levels, increasing
appetite for sweet sugary foods and the likelihood of contracting type 2
diabetes. On the other hand, an evening meal that includes high GI
carbohydrates more than one hour before bedtime has been shown to increase the
amount of REM sleep and reduce the time required to fall asleep.

Diets high in protein may improve sleep
quality slightly, but high-fat diets may negatively influence total sleep time.
Foods naturally high in amino acid tryptophan, such as turkey and pumpkin seeds,
may improve both sleep latency and quality.

Mental Stress

In Part
3 of this series, we looked at the effects of mental stress, and how high
levels of perceived stress can reduce endurance athletes’ maximum power output.
A study
by Canadian researchers used Heart Rate Variability (a sensitive marker of
stress) to evaluate the susceptibility of a group of students to stress in the
form of a demanding task. They found that the amount of reduction in HRV during
a standard stress test predicted the degree of sleep disturbance the students
experienced during the build-up to important exams.

Other
researchers found that a higher daytime HRV predicted a shorter time to
fall asleep and less arousals during the night, as well as a better sleep
questionnaire score.

This makes stress
management and stress reduction techniques such as mindfulness, meditation,
and deep breathing especially valuable at bedtime. It’s also said that a little
love at bedtime doesn’t do sleep quality any harm, even the night before
competition!

Conclusion

Sleep deprivation has significant effects on athletic performance, especially longer endurance sessions and high-intensity intervals. Most athletes don’t get enough sleep, and both napping and deliberately extending sleep on some days to get in the missing 90-minute cycles are very likely to have positive effects on performance, total load, and overall life satisfaction.

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Electronic sports (esports) racing has arrived and it’s here to stay! As coaches, you are part of the paradigm shift in the way athletes can prepare and compete on a world stage, and as athletes, the benefits are extraordinary.

When you think of esports, you might think of video games, where injuries and ailments are along the lines of carpal tunnel syndrome and vitamin D deficiencies. That landscape has shifted though, and now athletes can significantly benefit from various platforms in both cycling and running. Make no mistake, the great outdoors and fresh air will always take center stage, but this is about complimenting those pastimes.

Indoor training is nothing new—there are millions of subscribers for Peleton and SoulCycle—but we have never seen this level of connection, engagement, development, and competition in this space before. Cycling brands are scrambling to ensure they get their piece of the pie.

Zwift is
the clear front runner in this space (recently raised $120M in capital), and
has launched their professional league, the KISS Super League. Online racing
audiences remain modest at this early stage (15,000 to 20,000 people), however
you get the feeling when BBC Sport decided to live broadcast the British
National Championships, something is brewing. 

When
the one of the world’s leading cycling federations is embracing the technology
for its members, high-performance athletes, and talent identification, there
must be something to it. Could cycling esports be an Olympic event in the
future? Australia and Great Britain have already issued national champion
jerseys for esports racing.  

Consistency is critical in the world of endurance sports, so at the very least, a technology that enables athletes to train all year in any condition is a useful tool! Athletes used to dread staring at a painting on the wall for 90 minutes. But now you can wake up, suit up, and race people from all over the world in the comfort of your own living room.  

We’ve all heard the complaint, ‘I just want to race, I’m sick of training’—and it makes perfect sense, both physically and psychologically. Esports can be that bridge between the end of one season and the start of another. Or, if used at the right time, sharpen the senses during race preparations.  

For the time-crunched athlete, this emerging platform is a way to maximize precious minutes. Often athletes find an extra gear on race day (or go a little bit deeper into the abyss), so with various forms of racing now available any day of the year, it’s an incredible coaching tool.  

At Koa
Sports we offer our athletes the chance to connect and race via our Koa Sports League. We had athletes
from seven different countries in one group workout riding a structured session
based off their FTP (built using the TrainingPeaks Workout
Builder and exported as a .zwo file), suffering alongside their coach. It
was a perfect synergy, utilizing modern coaching tools and techniques.  

Much
like the biological passport for WADA, we use TrainingPeaks as a performance
passport for our athletes during racing to ensure absolute integrity in the
results. Coaches should be aware of their athletes’ capabilities (and the
TrainingPeaks platform adds an extra layer of reliability), so athletes have
the confidence they are all racing with true account settings.

Esports can’t replace that feeling of freedom on the open roads, brisk fresh air, or the shoulder-to-shoulder sprint for the criterium finish line, and it’s not trying to. But perhaps you’re a coach or an athlete who first opened a Facebook account in 2019? I’d be concerned for the coach or athlete who waited another 14 years to embrace esports.  

It’s
only a matter of time before TrainingPeaks gives coaches the option to check
the ‘esports’ box for expertise, much like IRONMAN, XTERRA or ultrarunning, or
simply ‘Indoor Cycling’ as an event option on the calendar.

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