Here is our update on what we feel is important to know about COVID-19 at this time. We will try to send these updates daily, or as we learn more information that we feel is helpful to pass along.

As you are aware, cases are increasing throughout the United States including the Denver metro area, but we are here to help you stay informed and safe during this time of uncertainty.

You probably already feel overloaded with information on the 2019 coronavirus disease, but the medical team at the Gaudiani Clinic wants to make sure that our patients, providers, and general community have the latest, most up-to-date, and most accurate information about the coronavirus. Today, we are going to go through general information about what is known right now about this coronavirus, but please know that this information may change quite rapidly as we learn more about the virus so stay tuned to our social media feed and website for updates.

Many athletes from recreational to professional go through periods of higher training volumes in order to enhance performance. (1) These high intensity periods should then be followed by periods of lower intensity and lower volume of training. This practice of high intensity cycles followed by lower intensity cycles is called periodization.(1) Periodization is one way to optimize performance while reducing risk of overtraining. Athletes that maintain high training volumes year-round and/or do not incorporate adequate rest and recovery into their training cycles are at risk for over training syndrome (OTS). Recovery is an essential part of any training program. Recovery involves not only physical recovery such as days off from training, but also good hydration, nutrition, sleep, and mental recovery. Today, we are going to do a general overview of OTS including terminology, symptoms, diagnosis, treatment, and prevention. Keep in mind that OTS can happen to any active person not just high level or elite athletes!

For someone like me who likes to get things right the first time, “hindsight is 20/20” has never been a particularly comforting phrase. I like to imagine I have some control over my life, that I can anticipate how something might go, and that my efforts have an impact on the outcome…

The story of how I came to be a physician with a specialty in eating disorders is really one of chance. Like many doctors in training, I learned little about eating disorders, particularly the medical aspects of them, while in medical school. Then I decided to pack my bags, move from sunny Florida, to sunny (surprise, it is really sunny here too!) Denver, Colorado for my internal medicine training and that single decision altered my career path to what it is today. This, however, is not a story about how I came to have this expertise, but rather a reflection on the gratitude I have for working in this field. For those who do not know me well, I also love pop culture. In the fashion of David Letterman, here is my top 3 list of reasons I love working in this field…

Type I diabetes mellitus (DMT1) is an autoimmune disease in which the immune system attacks cells in the pancreas that are responsible for making insulin leading to insulin deficiency. (1) Therefore, DMT1 treatment always involves the administration of exogenous insulin. Before getting into the rest of the blog, let’s review some basic physiology around insulin. After every meal, blood sugar or glucose levels rise. As our cells need glucose for energy, the pancreas releases insulin, which functions to “open” cells to let glucose in. In DMT1, the lack of insulin leads to a rise in blood glucose levels and essentially starvation of the body’s cells. Our body also likes to keep the level of glucose in our blood within a specified range. Blood glucose that is too high, called hyperglycemia, or too low, called hypoglycemia, can cause dangerous medical complications both in the short and long term. Now that we have covered some of the basics, let’s shift to focus on eating disorders in those with DMT1.

Dr. Elissa Rosen specializes in treating athletes, from the recreational to the elite. She writes about all things RED-S (Relative Energy Deficiency in Sport) and loves discussing the many issues athletes may face when balancing physical health and their sport. Here is a round-up of some of her most popular blogs focusing on athletes…

Today’s blog is geared toward what would be helpful for coaches and other sports team staff to know about relative energy deficiency in sports (RED-S). A key component in prevention and earlier recognition of athletes with RED-S is increased awareness by coaches and other professionals that work with athletes. (1) To start, let’s define what RED-S means and how the word came to be. The term RED-S was coined by the International Olympic Committee (IOC) to describe the physiologic and performance consequences of under fueling in athletes. (2) RED-S literally means what the term spells out in its name – insufficient nutritional intake in an athlete leading to too little energy for both general life and sports demands. So now that you know the basis for the term, let’s dive into more important details to know about RED-S.

Kidneys are able to perform remarkably complex functions in order to maintain homeostasis in our bodies. One of the major functions of the kidneys is to filter our blood in order to balance electrolytes, maintain optimal fluid levels, and excrete toxins. While this process is exquisitely fine-tuned and complex, the kidneys also must be treated well in order to function well. Many things can disrupt kidney function including medications, dehydration, and imaging contrast materials to name a few. In certain types of eating disorders, kidney failure is more common. For purposes of this blog we are going to talk about acute kidney failure (now better known as acute kidney injury), generally defined as developing over 48 hours or less, and chronic kidney disease, which develops over greater than 48 hours and many times over a period of months to years.

Electrolyte abnormalities are frequently seen in eating disorders associated with purging behaviors. (1) Electrolytes are minerals found in the body that can also be measured by blood tests. Our body is quite particular about the amount of electrolytes it needs to function properly and has different organ systems, such as the kidneys, that are designed to help maintain a narrow range of electrolyte levels in the blood.

 All types of purging behaviors including vomiting, laxative use, and diuretic use can be associated with both dehydration and abnormal electrolytes. The mode and frequency of purging behaviors can certainly impact the type and degree of electrolyte derangements. With the exception of low sodium in the blood, or hyponatremia, restrictive only eating disorders, such as anorexia nervosa restrictive type, are generally not associated with electrolyte abnormalities or dehydration (unless extreme restriction of fluid is part of someone’s restrictive eating disorder behaviors).

There is a lot of talk of menstrual cycles in female athletes. Why? Menstruation is an easy marker to follow for possible signs of insufficient energy intake. A female athlete with low energy availability may develop irregular or absent menstrual cycles. While there is no direct equivalent marker in male athletes, insufficient fueling can impact hormone levels in male athletes, in particular testosterone.

Energy deficiency in male athletes has been much less discussed both in the scientific literature and in the athletic world in general. Since the term “female athlete triad” was coined in the 1990s, much of the focus has centered on the health consequences of insufficient energy intake in female athletes, namely as it relates to menstrual dysfunction and bone health. (1) Recognizing that male athletes can suffer health and performance consequences due to low energy availability, the International Olympic Committee (IOC) published a consensus statement in 2014 to broaden the term “female athlete triad” to “relative energy deficiency in sport” (RED-S).

Myth 4: Bradycardia, or slow heart rate, is always a sign of good fitness in a female athlete.

Truth: The medical definition of bradycardia is a heart rate less than 60 beats per minute. While an athlete’s heart rate may slow some as they gain fitness, a very low heart rate at rest (especially under 50) may be a clue that there is more to the story. Excluding other serious causes of bradycardia, there are two scenarios that are the most common to explain a slow heart rate in an athlete– an athlete’s heart vs a starving heart.

Myth 3: The only medical problems that can be found in athletes with low energy intake are amenorrhea and bone density loss.

Truth: In the 1990s the ACSM coined the term female athlete triad. (4) This term describes the relationship between low energy intake in athletes, loss of menstrual cycle, and low bone density. The scope of the problem of low energy intake as it relates to the female body is actually broader than amenorrhea and low bone density…

Myth 2: Oral contraceptive pills (OCPs) can be used to maintain bone health in athletes with amenorrhea and should be used to “jump start” periods.

Truth: It seems logical that if the low estrogen found in those with amenorrhea is part of the reason why bone density decreases then if we give an athlete hormone pills with estrogen then the bones would be protected. Unfortunately…

Myth 1: Amenorrhea in a female athlete is an expected consequence of sport participation and is nothing to be concerned about.

Gastroparesis is felt to be nearly universal in those who have restricted calories resulting in significant weight loss (generally 10-20% of body weight). (1) It is worth emphasizing that gastroparesis can occur in those of all body shapes and sizes and one does not need to be clinically underweight to develop gastroparesis. (2) The most common symptoms are early satiety (meaning feeling very full even after just a small amount of food) and bloating. For those with an eating disorder, specifically those who have body image concerns that focus on the appearance of their abdomen, a distended and bloated stomach can certainly challenge even the most recovery motivated person.

It was OCD Awareness Week last week. It was timely that the Sunday, October 7th evening broadcast of “60 Minutes” featured an interview with John Green, author of The Fault in Our Stars. Before the interview, I only knew that he was a good writer, and that he has a great sense of humor. What I didn’t know, before this interview, was that he suffers from OCD as does approximately two percent of the population. Often, when we think of OCD, we imagine an individual who is incessantly washing hands due to contamination fears or flipping a light switch eight times to ward off a disaster of some type. However, there are many ways OCD can show up and affect a person’s life.

Now let’s focus on some of those myths.

Myth 1: It is normal for an athlete to stop menstruating during periods of heavy training.

It is NEVER normal for an athlete to stop menstruating. Yes, you read that right. Amenorrhea should never be considered an acceptable consequence of any level of athletic or fitness training. Amenorrhea is a red flag that the body is not functioning to its full potential. Amenorrhea again can be due to exercising too much for your body, under-fueling, high stress, or a combination of these factors.

Myth 2: Amenorrhea in athletes is unique to only endurance or high-level athletes.

Amenorrhea can be seen in females from any sport and at any level from recreational to elite. Even those without sport specific goals and that exercise for health/fitness/enjoyment can develop amenorrhea. It is likely true that higher intensity and frequency of exercise might make someone more prone to FHA than those who exercise at a lower intensity, frequency. 

Iron deficiency is common in athletes. Nearly half of females who exercise may experience iron deficiency.1  While females are at higher risk for iron deficiency due to monthly loss of blood with menstruation, male athletes can also suffer from it. The International Olympic Committee 2009 Consensus Statement on periodic health evaluation of elite athletes even recommended routine screening for iron deficiency.2 Please note, unless otherwise specified, the term iron deficiency in this article solely refers to low iron and not resultant anemia, or low red blood cells. This article is also focused on adult athletes and the information discussed may not apply to children.