Pilot Study: Metabolic Activity Patterns

(MAP) as a Potential Tool to Identify

Overtraining in Male Collegiate Runners
Student Investigator:
Allana Boone
Research Preceptors:
Lynn Cialdella-Kam, Stephanie Harris
Co-Investigator:
Amy Sheon
NTRN 561
Fall 2014

Project Summary:
Background: Although there is a large body of research done looking at the effects
of training on the male athlete, most of the data has been indicative of nonfunctional overreaching (NFO). No research has been completed determining
signature metabolic activity patterns (MAPs) for over-training syndrome (OTS).
Purpose: To determine if OTS in male runners is associated with a unique MAPs
using BodyMedia.
Methods: Undergraduate male runners (n=10) who are a part of both the Case
Western Reserve University Cross Country and Track and Field teams will be
monitored during two training seasons. At the beginning and end of each season,
athletes will be asked to complete 3-d weighed food and physical activity log and
wear a BodyMedia Fit armband. In addition, they will be requested to complete two
questionnaires Eating Disorder Inventory-2 (EDI-2) to assess disordered eating
patterns and Profile of Mood State (POMS) to assess mood state. During the
season, athletes will be asked to wear the BodyMedia Fit armbands daily and to
complete POMS on a bi-weekly basis.
Hypothesis: We hypothesize that there will be a difference in MAPs measured by
the BodyMedia Fit armbands among training states (normal, overreaching and
overtraining) during the season.
Significance of Research: The results of this study will determine if the Metabolic
Activity Patterns (MAPs) may be used to detect overtraining in male collegiate
runners. The overtraining syndrome leads to serious health complications including
recurrent injuries and infections, depressed mood state, sleep disorders, fatigue
and underperformance. No practical measurements exist that are valid and reliable
in determining the existence of overtraining. Due to the danger associated with
overtraining in endurance athletes, a tool that can be used to determine
overtraining is imperative. The results of further research can be used to prevent
overtraining in future male runners through the monitoring of MAPs throughout the
training season. In addition, this research will help to determine whether these
BodyMedia Fit armbands should be used in all male runners throughout their
training season due to the fact that athletes reach overtraining at different

intensities and frequencies of training. Upon completion of this pilot study, we

intend to apply for funding for a larger study.
Specific Aims:
Athletes experience periods of increased training to increase performance
followed by periods of recovery. When adequate rest is not allowed for recovery,
athletes can experience natural common symptoms of functional over-reaching (FO)
that can ultimately lead to overtraining without adequate recovery between training
periods2. Non-functional over-reaching (NFO) and overtraining syndrome (OTS)
occur when athletes do not recover despite adequate periods of rest and differ only
by the amount of time needed to recover. Athletes experiencing NFO may recover
after two weeks while those with OTS require longer than two weeks for full
recovery1. Most of the research on the proposed subject focuses on over-reaching
rather than the overtraining syndrome. Due to this there is a need for more
evidence as to whether NFO leads to OTS, or if they are two distinct diagnoses and
how to identify them.
Multiple theories for the underlying cause(s) of the over-training syndrome exist,
yet there is no evidence supporting one theory over another. Prior research testing
these theories explored changes in glycogen muscle stores, serotonin levels,
glutamine levels, oxidative stress, cytokine levels, hormones related to
hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal axes. Although
there are many theories, no laboratory values or data have been determined to
diagnose individuals with overtraining1. Rate of perceived exertion (RPE) and Profile
of Mood State (POMS) questionnaires have been shown to correlate with symptoms
of NFO and OTS. With an increase in training endurance there is an increase in RPE
at the same training intensity4. POMS scores for tension, depression, fatigue, anger,
and confusion increase with increased with overtraining while scores for vigor
decrease. Research supports the notion that vigor scores are more specific to
identifying NFO and OTS than fatigue, due to fatigue being evidenced as a normal
side effect of exercise regardless of adequate recovery 1,2.
The proposed pilot study will help to determine if Metabolic Activity Patterns
collected from the BodyMedia Fit armbands can be used as a tool to identify

athletes at risk for overtraining. BodyMedia Fit armbands are popular devices used
currently by athletes because of their accuracy and validity in measuring Metabolic
Activity Patterns (MAP) and energy expenditure patterns throughout the day. These
devices are portable and consumer-based5.
Specific Aim 1:
Determine whether Metabolic Activity Patterns (MAP) can be used as a
tool to detect overtraining in collegiate runners. Energy balance (3-day food
and physical activity logs), MAP as measured by BodyMedia Fit armbands,
mood disturbances using POMS, and disordered eating using EDI-2 will be
analyzed in male collegiate runners over two training seasons to achieve this
aim.
We hypothesize that MAP measures by BodyMedia Fit armbands will be
different among training states (normal, over-reaching and over-training) in
male runners.
If the data collected from these armbands show significant differences between
individuals who are normally trained, over-reached, and over-trained, then more
research can be done to determine if these armbands can be used as a reliable and
valid tool for diagnosing individuals with NFO or OTS.
This research is beneficial to the field of nutrition because it can distinguish
whether there is a pattern between nutritional intake and the development and/or
prevention of NFO and OTS in collegiate runners. Further research could then be
carried out in other endurance athletes, such as swimmers, as well as other
physically active individuals and possibly even the general public. There is no record
of research on the assessment of MAP by wearable devices and their usefulness in
early detection of overtraining. Ultimately, the goal of this research is in recognizing
individuals who are at risk for overtraining throughout the season, and preventing
this syndrome with decreased intensity of training and periods of recovery.
Background and Significance:
Sixty percent of U.S. male elite runners have reported being over-trained at
some point throughout their running career6. Fatigue, depressed mood state,
frequent respiratory infections, weight loss, sleep disturbances and

underperformance are all serious and common signs and symptoms seen in athletes
experiencing non-functional over-reaching (NFO) and over-training syndrome
(OTS)1,2,3,4,7. NFO is a normal adaptation to an increase in training load that is
necessary for increasing overall performance once the training level has returned to
normal1,2,3. OTS is observed in individuals who have spent an extended period of
time at these high training levels which ultimately leads to an adverse effect on
performance1,2,3. OTS is characterized by the inability to perform at the rate that
they were performing before the increased load was introduced and can lead to
total loss of drive. Over-reaching has been the focus of research with very little
research on OTS. Thus, a diagnostic criteria and tools for identifying OTS have yet
to be identified5.
Biochemical data and their use as markers of OTS have been explored, and
no single biochemical marker has been proven as an accurate marker for presence
of overtraining8,9,10,11. POMS is considered to be the best available tool thus far in
identifying NFO and OTS6. A correlation between changes in POMS and an increase
in symptoms of NFO and OTS1,2,3,12,. A distinct inverse relationship between vigor
and fatigue has been shown, as fatigue increases, vigor decreases 4,13,14,15,16.
POMS is the best tool available for determining a correlation between training
state and the symptoms of NFO and OTS. Changes in POMS can occur with minimal
increases in training, but most studies using this method have looked at overreaching, as opposed to overtraining. Although this tool is the best tool available
and is inexpensive, it is also inconvenient and time consuming 8,10,12. The use of
POMS will be incorporated in this study to identify changes in mood state in order to
help better identify and correlate OTS with changes in MAPs. Further research after
the completion of this pilot study will help to identify the BodyMedia Fit armbands
as a valid and reliable tool in identifying overtraining in athletes. With this research,
coaches will be able to detect risk of overtraining early and decrease training
intensity in those individuals who are at risk for overtraining before that state is
reached.
BodyMedia Fit armbands are a technological device that can be used to
determine Metabolic Activity Patterns (MAP) through the use of multiple sensors;
accelerometer, temperature, heat flux and galvanic skin response. The

accelerometer is used to measure motion and steps of the individual while the
temperature sensor is used to measure the surface temperature of the individuals
body. The heat flux sensor measures the rate the heat is leaving the body and the
galvanic skin response sensor measure the amount of perspiration leaving the
individuals body17. With the help of this pilot study and further research, these
devices could soon be proposed as a tool to detect overtraining. The purpose of this
study is to determine if these devices can detect changes in MAP between training
states that can be further used for the early detection of overtraining in athletes.
Prior research has not determined a 100% valid and reliable tool in
determining overtraining in athletes. Previous research has looked at changes in
biochemical data and mood states, but many have not taken into consideration
energy intake and energy expenditure in the sense of energy balance. The studies
that looked at energy intake and saw increased overtraining symptoms in
individuals with lower energy intakes when exercise intensity was increased 12,18,19.
Another research study looked at exercise in the fasted stated and in the fed state
and determined that the fasted state there were increased risk of recurrent injuries
and fractures20. Past researchers have also failed to utilize devices such as these to
help accurately determine energy expenditure and monitor MAPs.
About one-third of young athletes have experienced NFO or OTS6 which
raises a need for more research on how to quickly identify and prevent it from
manifesting. This small pilot study will determine whether further research needs to
be carried out in this direction. If the hypothesis of this research is proven then we
will propose a large-scale research study of the same nature. With the completion
of this study, it is hoped that these devices can be used in the future to detect the
risk of overtraining early in athletes and reverse the progression with a decrease in
training intensity.
Research Design and Methods:
The following study is a pilot study that will be conducted at Case Western
Reserve University (CWRU) with men from the cross-country and track and field
teams. We have hypothesized that BodyMedia Fit bands are a good tool for
detecting differences in MAPs in male athletes throughout their training season. We

hope that the results from this pilot study will lead to a larger study, and we intend
to fund a future study by applying for a grant.
Investigators:
The researchers of this study share an interest in nutrition focusing in the
areas of exercise physiology, energy regulation, health and clinical research.
Allana Boone is a Masters student at Case Western Reserve University
(CWRU), studying Food and Nutrition, and dietetic intern at the Louis Stokes
Cleveland Veteran Affairs Medical Center. She received a Bachelors of Science
degree in Dietetics at Bowling Green State University (BGSU). This researcher is
passionate about the physiology of the body in relation to physical activity and
exercise. Her senior capstone project analyzed the three components of the Female
Athlete Triad (FAT) and the prevalence and medical/ nutrition care for an individual
diagnosed with this triad of conditions.
Lynn Cialdela-Kam is a professor at Case Western University and co-director
of the correlated Masters/Dietetic Intern Program. Dr. Kam has a PhD in Nutrition
with a double minor in exercise physiology and statistics. Dr. Kam received her PhD
at Oregon State University out of Corvallis, OR and her dissertation was "Reversing
Menstrual Dysfunction: The Impact of Menstrual Status on Musculoskeletal and
Hormonal Health. Dr. Kam has done prior research in this field, especially looking
at the physiological, and psychological effects of increased training on female
athletes.
Stephanie Harris is a professor at Case Western University and a Registered
and Dietitian of Ohio. She has her PhD in Clinical Nutrition with a double minor in
Nutritional Biochemistry and Human Metabolism. Dr. Harris is a Clinical Dietitian
and Research Associate at University Hospital. Dr. Harris has done clinical research
in the fields of metabolomics and human metabolism.
Amy Sheon is the Executive Director of the Urban Health Initiative at Case
Western Reserve University. Dr. Sheon recently co-directed the Childhood Obesity
Prevention Mission Project which was done in Ann Arbor Michigan. Prior to
returning, Dr. Sheon helped in the establishment of three different centers at the
University of Michigan, focused on clinical research, ethical issues in the life

sciences, and on improving educational outcomes for disadvantaged youth.

Currently she is hoping to make an impact on the health of the individuals of
Cleveland, Ohio.
Participants:
Permission has been received from the Director of Athletics at CWRU to invite
male athletes from the CWRU mens varsity cross country and track and field teams
to participate in this study. Our goal for this pilot study is to recruit a minimum of
10 adult male athletes, 18-23 y. The purpose of the study and the procedures that
the athletes will undergo throughout this study will be explained, and the
individuals who wish to participate will be required to sign consent documentation
per CWRU IRB protocol. These documents will be held in the primary investigators
office, Dr. Kam, in a locked file cabinet for confidentiality. WG-34 Wood Building,
School of Medicine, CWRU.
Questionnaires Used:
EDI-2
Disordered eating will be identified using two subscales of the Eating Disorder
Inventory 2 (EDI-2); Drive for Thinness and Body Composition. A protocol is in
place and will be followed for individuals who are identified to have disordered
eating issues or disordered eating behaviors. Participants will also be provided
information on resources such as the University Health Services and Counseling
Services provided to students on CWRU campus.
POMS:
A Profile of Mood State questionnaire containing 65-items will be used to
assess mood states in six different categories (fatigue, anger, vigor, depression,
confusion, and anxiety) of mood states. The participants will complete the POMS
test via REDCap) based on the previous week as accurately and honestly as they
can. An overall measure of global effective state will be determined by the
calculated total mood disturbance score with a maximum of 60.
Collection of Data:

Participants will be expected to report to WG-34 Wood Building, School of

Medicine, CWRU, weekly over the course of the Cross Country season and the Track
and Field season, for a total of 16 visits, eight per season. During these sessions
data will be extracted from the BodyMedia Fit devices. The participant will also be a
required to report to this same office for study instructions and assessment on
seven other occasions.
Early Season (week 0):
Visit 1: Participants weight, height, and body composition will be measured. RMR
will be calculated using indirect calorimetry. Participants will be asked to refrain
from exercise and drive to the test if possible. They will also be asked to be fasting
for 8 hrs. prior to the visit. After all testing is completed, the participants will be
provided a snack and information on the BodyMedia Fit armbands and how they are
expected to be used.
Visit 2: A second RMR test will be conducted under the same circumstances as the
previous meeting. Breakfast will be given along with instructions on how to
complete a 3-day food record/physical activity log. A scale will also be provided for
the participants to weigh their food for accuracy.
Visit 3: Participants will turn in their 3-day food record/activity logs as well as their
BodyMedia Fit armbands. The link and instructions for how to use REDCap, a secure
electronic research application, will be provided and participants will be required to
complete two surveys: 1) Eating Disorder Inventory 2 (EDI-2); 2) Profile of Mood
State (POMS).
Mid-Season (8 weeks):
Bi-weekly, participants will be asked to complete POMS and report injury and tempo
run times online via REDCap. Weekly, BodyMedia Fit armband data will be collected
by visiting WG-34, Wood Building, School of Medicine, CWRU.
Visit 4: Instructions for 3-day food records/activity logs will be provided again.
Visit 5: Records will be collected.

Late Season (week 8):

Visit 6: Participants will undergo anthropometric and RMR testing again, same as
Visit 1.
Visit 7: Participants will undergo a second RMR test and receive instructions on how
to record a 3-day food record and physical activity logs.
Visit 8: Food records/physical activity logs will be collected. Participants will be
instructed to complete the two surveys from Visit 3. Participants will undergo a
timed run. BodyMedia Fit armbands will be collected.
Visits 9-16: Repeat of procedures from the previous Track and Field Season (Weeks
1-8).
Data Analysis:
Food Processor (Food Processor SQL, version 9.91, 2006; ESHA Research,
Salem, OR) will be used to analyze the energy and nutrient content of the collected
food records and physical activity logs. Microsoft Excel will be used to analyze deidentified data downloaded from the information participants completed on REDCap.
By examining the mean and median number of calories burned per minute during
sleeping, times of rest and times individuals were physically active and the amount
of time spent in each of these areas, Metabolic Activity Patterns can be
characterized. A determination of association between MAP and POMS scores,
running performance and energy balance (energy intake energy expenditure =
+/- energy balance) will be determined through simple linear regression analysis
with a significance level of 0.05. This is a pilot study and ideal sample size and
power will be determined in the future through analysis of mean data collected.
Potential Limitations:
Some potential limitations to this study branch from human error and errors
from devices and tools. Human error could be related to errors that the researchers
make extracting, analyzing or recording data. Participants could also contribute to
human error by answering questions incorrectly through the online questionnaire
system, REDCap, in recording food intakes and by forgetting to wear their devices.

The REDCap questionnaire system could malfunction, as well as, the BodyMedia Fit
armbands. The accuracy of the BodyMedia Fit armbands may also not be 100%
accurate and could vary from device-to-device in % accuracy.
Project Timeline:
IRB application was approved 11.3.14. Recruitment was finished while waiting for
IRB acceptance. The proposed start of the research study will be 11.10/14 and will
run through 4.25.14. Consent will be received from all participants prior to the start
of the study from 11.3.14-11.10.14. Analysis of data will start 4.28.14. The
manuscript for this research study is proposed to be near completion by 10.1.14.
Event
IRB Approval
Consent from Participants
Data Collection
Analysis
Manuscript Write-Up

References:

Start Date
11.3.14
11.3.14
11.10.14
4.28.14
7.23.14

End Date
11.3.14
11.10.14
4.25.14
7.23.14
10.1.14

1. Kreher JB, Schwartz JB. Overtraining syndrome: a practical guide. Sports health.
2012;4:128-138.
2. Budgett R. Fatigue and underperformance in athletes: the overtraining
syndrome. Br J Sports Med. 1998;32:107-110.
3. Budgett R, Newsholme E, Lehmann M, et al. Redefining the overtraining
syndrome as the unexplained underperformance syndrome. Br J Sports Med.
2000;34:67-68.
4. Main L, Grove JR. A multi-component assessment model for monitoring training
distress among athletes. European Journal of Sport Science. 2009;9:195202.
5. Lee, J.M.; Kim, Y.; Welk, G.J., Validity of consumer-based physical activity
monitors. Medicine and science in sports and exercise 2014, 46, 1840-1848.
6. Matos NF, Winsley RJ, Williams CA. Prevalence of nonfunctional
overreaching/overtraining in young English athletes. Med Sci Sports Exerc.
2011;43:1287-1294
7. Reid VL, Gleeson M, Williams N, Clancy RL. Clinical investigation of athletes with
persistent fatigue and/or recurrent infections. Br J Sports Med. 2004;38:4245.
8. Halson SL, Lancaster GI, Jeukendrup AE, et al. Immunological responses to
overreaching in cyclists. Med Sci Sports Exerc. 2003;35(5):854-861.
9. Meeusen R, Nederhof E, Buyse L, Roelands B, de Schutter G, Piacentini MF.
Diagnosing overtraining in athletes using the two-bout exercise protocol.
South African Journal of Sports Medicine. 2010;22:99.
10. Slivka DR, Hailes WS, Cuddy JS, Ruby BC. Effects of 21 days of intensified
training on markers of overtraining. Journal of strength and conditioning
research. 2010;24:2604-2612.

11. Meeusen R, Nederhof E, Buyse L, et al. Diagnosing overtraining in athletes

using the two-bout exercise protocol. Br J Sports Med. 2010;44:642-648.
12. Snyder AC, Kuipers H, Cheng B, et al. Overtraining following intensified training
with normal muscle glycogen. Med Sci Sports Exerc. 1995;27(7):1063-1070.
13. Fry RW, Morton AR, Keast D. Overtraining in athletes: an update. Sports Med.
1991;12(1):32-65.
14. Morgan WP, Costill DL, Flynn MG, et al. Mood disturbance following increased
training in swimmers. Med Sci Sports Exerc. 1988;20(4):408-414.
15. Tobar DA. Trait anxiety and mood state responses to overtraining in men and
women college swimmers. International Journal of Sport and Exercise
Psychology. 2012;10:135
16. Snyder AC, Kuipers H, Cheng B, et al. Overtraining following intensified training
with normal muscle glycogen. Med Sci Sports Exerc. 1995;27(7):1063-1070.
17. http://www.bodymedia.com/sensors.html
18. Bock KD, Derave W, Eijnde BO, et al. Effect of training in the fasted state on
metabolic responses during exercise with carbohydrate intake. J Appl Physiol.
2008;104:1045-1055.
19. Achten J, Halson SL, Moseley L, Rayson MP, Casey A, Jeukendrup AE. Higher
dietary carbohydrate content during intensified running training results in
better maintenance of performance and mood state. J Appl Physiol.
2004;96:1331-1340
20. Hawley JA, Burke LM, Phillips SM, Spriet LL. Nutritional modulation of traininginduced skeletal muscle adaptations. J Appl Physiol. 2011;110:834-845.