Specific nutritional strategies for the female athlete

Mónica Sousa | monica.sousa@european-athletics.org

28 January 2021
Women & Sport

Before each ancient Olympic Games there was a separate women's athletic event, the Heraean
Games, dedicated to the goddess Hera

Married women were excluded, even as spectators

Women & Sport

The modern Olympics had female competitors from 1900 (Olympic Games in Paris) onward, though women at first
participated in fewer events than men

Women first made their appearance in the Olympic Games in Paris in 1900

• Out of a total of 997 athletes, 22 women (2%) competed in 5 modalities: tennis, sailing, croquet,
equestrian, and golf

• Only golf and tennis had women-only events

IOC. Factsheet: Women in the Olympic movement. 2020

Women & Sport

Since 1991, any new sport seeking to join the Olympic programme must have women’s competitions

The 2012 Games in London were the first in which women competed in all the sports (addition of
women’s boxing)
IOC. Factsheet: Women in the Olympic movement. 2016

1900 1920 1940 1960 1980 2000 2020

1900 Tennis 1924 Fencing 1948 Canoe 1964 Volleyball 1980 Hockey 2000 Weightlifting
Golf Luge Modern Pentathlon
1928 Athletics 1952 Equestrian 1984 Shooting
1904 Archery Rowing Taekwondo
Gymnastics 1976 Cycling
Basketball Triathlon
1908 Tennis* 1936 Skiing 1988 Tennis*
Skating Handball 2002 Bobsleigh
Table Tennis
1912 Aquatics Sailing 2004 Wrestling
1992 Badminton 2012 Boxing
Judo
Biathlon 2016 Golf*, Rugby

1996 Football 2018 Baseball/Softball

Softball Karate
Curling Skateboard
1998 Sports Climbing
https://www.olympic.org/women-in-sport/background Ice Hockey
Surfing
 Women & Sport

Games in Rio 2016: The Youth Olympic Games (YOG)

≈45% women Buenos Aires 2018 was the first fully
https://www.olympic.org/women-in-sport/background
gender balanced Olympic event ever
Women & Sport

Era of personalized nutritional strategies for optimal health and performance

Yet the majority of the research that supports any given strategy to enhance
health or endurance exercise performance has been conducted in men

Devries. Exp Physiol. 2016; 101(2):243-9

Physiological and nutritional differences
Menstrual cycle

Oestrogene Luteinising Hormone

Progesterone Follicule-Stimualting Hormone

01 07 14 21 28

Ovulation

Follicular phase Luteal phase

Research | Female athlete

The menstrual cycle is often cited as being ‘too difficult’ to study

Hormonal contraceptives add complexity through the introduction

of exogenous oestrogen and progesterone

Sims & Heather. Exp Physiol. 2018; 103(10):1309-1317

Menstrual cycle

Oestrogen

Progesterone

Difficulties: Methodological
• Combination of differences in timing of testing limitations
• Variability in the menstrual phases

• High inter- and intra-individual variability in oestrogen and

progesterone concentration

• The pulsatile nature of their secretion and their interaction

Jonge. Sports Med. 2003; 33(11):833-51

Menstrual cycle

↓ oestrogen ↑ oestrogen ↑ oestrogen

↓ progesterone ↓ progesterone ↑ progesterone

Oestrogen

Progesterone

01 07 14 21 28

Early Mid- Late Early Mid-luteal Late

follicular follicular follicular luteal luteal
Ovulation
Follicular phase Luteal phase

McNulty et al. Sports Med. 2020; 50(10):1813-1827

Women & Sport

The concentrations of estrogen and progesterone have an impact on

macronutrients utilization at rest and during exercise

Therefore, there might be a need to adjust the nutritional interventions

according to the menstrual cycle phase in eumenorrheic women

Rocha-Rodrigues, Sousa et al. Nutrients. 2021; Accepted for publication

Oestrogen
• ↑ whole-body insulin sensitivity

• Anorexic action in the hypothalamus

• Supress TG synthesis by:

• ↓ lipogenesis in the liver

• ↑ lipolysis in adipocytes

• Potentiate lipid accumulation in subcutaneous white adipose tissue

• Promote free fatty acids 𝛃-oxidation

• ↓ TG storage by:
• Activating AMP-activated protein kinase (AMPK)

• Stimulating the expression of peroxisome proliferation activator receptor-delta (PPAR𝞭)

Varlamov et al. Front Endocrinol (Lausanne). 2015; 5:241
Progesterone

• Interacts with estrogen to induce concerted functional and metabolic effects (Mas et al, 2015)

• Antagonize each other’s effects (Candolfi et al., 2005)

• No effect on the maximal activity of several key enzymes of lipid oxidation (Campbell & Febbraio, 2001)

• Central thermogenic effect that is responsible for the increase in the basal body temperature
(González-Alonso et al., 1999)

• Increases the appetite and food intake in the presence of estrogen (Hirschberg, 2012)

• Catabolic breakdown effect (Lamont et al, 1987)

Rocha-Rodrigues, Sousa et al. Nutrients. 2021; Accepted for publication

Energy and macronutrients
Energy expenditure

100

Thermic effect of activity (TEA)

Planned physical activity + non-exercise
activity thermogenesis (NEAT)

Spontaneous physical activity

Thermic effect of food (TEF)

50

Resting metabolic rate

(RMR)

Bourke & Deakin (ed.). Clinical Sports Nutrition. 5th edition. McGraw-Hill Education, 2015
Resting metabolic rate

Influenced by:

• Age Explain ≈ 80% of the variability in RMR

• Sex
• Body size – fat-free mass and fat mass

• Genetic

• Menstrual cycle

Bourke & Deakin (ed.). Clinical Sports Nutrition. 5th edition. McGraw-Hill Education, 2015
Resting metabolic rate

• Menstrual cycle
• RMR values are lowest during the follicular phase and highest during the luteal phase (Benton et al., 2020)

• Differences of 100–300 kcal/d – seems to be naturally compensated by  energy intake during this
phase of the menstrual cycle (Solomon et al., 1982;. Bisdee et al., 1989)

Progesterone
 appetite and food intake in the presence of estrogen (Hirschberg, 2012)

Rocha-Rodrigues, Sousa et al. Nutrients. 2021; Accepted for publication

Energy availability

𝐄𝐧𝐞𝐫𝐠𝐲 𝐢𝐧𝐭𝐚𝐤𝐞 − 𝐄𝐧𝐞𝐫𝐠𝐲 𝐞𝐱𝐩𝐞𝐧𝐝𝐢𝐝𝐞𝐝 𝐢𝐧 𝐞𝐱𝐞𝐫𝐜𝐢𝐬𝐞

𝐄𝐧𝐞𝐫𝐠𝐲 𝐚𝐯𝐚𝐢𝐥𝐚𝐛𝐢𝐥𝐢𝐭𝐲 =
𝐅𝐚𝐭 𝐟𝐫𝐞𝐞 𝐦𝐚𝐬𝐬

Melin et al. Int J Sport Nutr Exerc Metab. 2019;29(2):152-164

Energy availability

Optimal EA Subclinical LEA Clinical LEA

≥ 45 kcal/kg FFM/d (females) 30–45 kcal/kg FFM/d (females)
<30 kcal/kg FFM/d
≥ 40 kcal/kg FFM/d (males) 30–40 kcal/kg FFM/d (males)

For weight maintenance May be tolerate for short periods Health implications with
During periods with injury with during a well-constructed weight-loss impairment of many body
alternative or rehabilitation training program systems including training
at low/moderate intensity ∼1.5h/d adaptation and performance

Melin et al. Int J Sport Nutr Exerc Metab. 2019;29(2):152-164

Triad | RED-S

Female Athlete Triad → Relative Energy Deficiency in Sport

• Complexity involved

• Male athletes are also affected

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

Mountjoy et al. Br J Sports Med 2014;48:491–497

RED-S | Consequences

↓ Endurance
Immunologic
performance
Menstrual ↓ Muscle
Gastrointestinal ↑ Injury risk
Function strength

↓ Glycogen ↓ Training
Cardiovascular Bone health

RED-S stores response

(low energy
RED-S
Psychological availability) Endocrine Depression
Impaired
judgement

Growth &
Metabolic Irritability ↓ Coordination
development
↓
Haematological
Concentration

Mountjoy et al. Br J Sports Med. 2018;52:687–697

Carbohydrates

• Rely less on carbohydrate oxidation to support fuel requirements (Devries et al., 2006)

• Exercise training-induced glycogen reduction is attenuated in women in comparison

with men (Esbjörnsson-Liljedahl et al., 1999)

Lower total CHO daily amount

compared to men?

Rocha-Rodrigues, Sousa et al. Nutrients. 2021; Accepted for publication

Carbohydrates

Oestrogen (Devries et al., 2006)

• ↓ muscle glycogen use

• ↓ CHO use during exercise

• Higher glucose levels at rest in the luteal

phase compared to the follicular phase (McLay
et al. 2007)

01 07 14 21 28

Lower CHO needs at rest and during Ovulation

Follicular phase Luteal phase
exercise in the luteal phase?

Rocha-Rodrigues, Sousa et al. Nutrients. 2021; Accepted for publication

Carbohydrates
CHO loading
Endurance-trained athletes

n=6 Follicular phase

Hab: habitual diet (5.1 g/kg/d)
CHO: high carbohydrate (6.4 g/kg/d) and isoenergetic to Hab
CHO + E: extra energy (+34%) + CHO (8.8 g/kg/d)

n=7 Hab: habitual diet (6.1 g/kg/d)

CHO: high carbohydrate (7.9 g/kg/d) and isoenergetic to Hab
CHO + E: extra energy (+34%) + CHO (10.5 g/kg/d )

Females:  muscle glycogen storage with  CHO

intake only after total energy intake was increased
Tarnopolsky et al. J Appl Physiol (1985). 2001; 91(1):225-30
Carbohydrates

Impact of a CHO loading protocol on muscle glycogen concentration (Rehrer,

McLay-Cooke, & Sims, 2017):

• Follicular phase: 17–31%

• Luteal phase: 0–13%

• Men: 18–47%

01 07 14 21 28
CHO loading: >8 g CHO/kg/d +
30% energy in the follicular phase Ovulation
Follicular phase Luteal phase

Rocha-Rodrigues, Sousa et al. Nutrients. 2021; Accepted for publication

Carbohydrates

Impact of a CHO loading protocol on muscle glycogen concentration (Rehrer,

McLay-Cooke, & Sims, 2017):

• Follicular phase: 17–31%

• Luteal phase: 0–13%

• Men: 18–47%

01 07 14 21 28
Need for CHO loading during
the luteal phase? Ovulation
Follicular phase Luteal phase

Rocha-Rodrigues, Sousa et al. Nutrients. 2021; Accepted for publication

Lipids

Oxidize proportionately more lipid than men at all exercise intensities (Chenevière et
al, 2011; Devries, 2016)

Have a greater content of intramyocellular lipids and a greater capacity

to use these lipid stores (Devries, 2016; Devries et al, 2017)
• Sex-based differences may be more apparent with increasing exercise duration

Less CHO intake during

exercise compared to men?

Rocha-Rodrigues, Sousa et al. Nutrients. 2021; Accepted for publication

Lipids

Oestrogen
• ↑ fat oxidation during exercise (Isacco & Boisseau
2017)

• ↓ CHO dependence during exercise (Hamadeh,

Devries, & Tarnopolsky, 2005)

01 07 14 21 28
Less CHO intake during
exercise in the luteal phase? Ovulation
Follicular phase Luteal phase

Rocha-Rodrigues, Sousa et al. Nutrients. 2021; Accepted for publication

Protein

Systematic review (Mercer et al., 2020) on daily protein requirements of athletic women (18–45 y):

• Similar requirements for recreational and/or competitive women undertaking ~60–90 min exercise:

• Aerobic endurance (1.28–1.63 g/kg/d)

• Resistance (1.49 g/kg/d)

• Intermittent exercise (1.41 g/kg/d)

Aligned with the current sports nutrition guidelines for

all athletes (1.2–2.0 g/kg/d) (Thomas et al, 2016)
Protein

Anabolic sensitivity (West et al. 2012)

Beneficial physiological effect of 0.32–0.38 Upper range of the general amount of protein
g/kg pre- and post- resistance and recommended per meal: 0.25–0.4 g/kg/meal
intermittent exercise (Mercer et al., 2020) (Morton et al., 2015)

Daily recommendation: 1.2 – 2.0 g/kg/d

0.3 – 0.4 g/kg/meal

Rocha-Rodrigues, Sousa et al. Nutrients. 2021; Accepted for publication
Protein

Progesterone: seems to increase catabolism in the

luteal phase (Oosthuyse & Bosch, 2010; Kriengsinyos et al, 2004)
• At rest and during exercise

< protein catabolism during endurance exercise on

the luteal phase when a CHO supplement (≈ 35 g/h)
was ingested

01 07 14 21 28
Different protein needs
Ovulation
across menstrual phase?
Follicular phase Luteal phase

Protein during exercise?

Rocha-Rodrigues, Sousa et al. Nutrients. 2021; Accepted for publication

Practical nutritional strategies
Menstrual cycle phase
General
Follicular Phase (FP) Luteal Phase (LP)
Daily: optimal energy availability ≥45 kcal/kg
Energy Daily: + 100 – 300 kcal
fat-free mass/d

Daily: lower total amount compared to men Daily: ↓ total CHO intake

During exercise: Less CHO intake during During exercise: 60 g/h for exercise events up to 2 h
Carbohydrates exercise compared to men During exercise: ↓ need of CHO
(evidence is limited to data on FP for a 2 h cycling bout at ≈ 60%
V̇O2max)

CHO loading: >8 g/kg/d. An increase in the total energy

CHO loading: an increase in CHO intake might not be
intake (≈ 30%) may be needed to achieve this amount of
needed
CHO intake.

Daily: 1.2 – 2.0 g/kg/d for the majority of the

Daily: ↑ total protein intake
situations regarding athletic performance

Protein Amount per meal: 0.3 – 0.4 g-1.kg pre- and post-
Amount per meal: ↑ needs of protein
resistance and intermittent exercise

During exercise: beneficial effect of protein?

Lipids Daily: 20 – 35% of the total energy value

Rocha-Rodrigues, Sousa et al. Nutrients. 2021; Accepted for publication

 Thank you for your attention!
Mónica Sousa | monica.sousa@european-athletics.org
28 January 2021