A live conversation between Alan D Rogol (Charlottesville) and Robert M Malina (Austin) Moderated by Martin Ritzén (Stockholm).
Contributors: Jan-Maarten Wit, Abiola Oduwole, George Chrousos, Ze’ev Hochberg, Ivo Arnhold, Mark Sperling
Transcription: Shira Rappoport
Martin Ritzén: This conversation is about pubertal maturation and its influence on sports, which is really quite an interesting field. Think about the 13-14 years old boy who has not entered puberty, he has flunked out of his ice- hockey team because he is too short and too light. Should we do something about it? He may want to have testosterone to get stronger; is that acceptable? Children of same age but vast differences in physical maturation; should they compete with each other? That is the question for Alan or Bob. What about the health aspects of hard physical training during maturation; is that good or is it bad for a child? Is it acceptable to subject a boy who is completely prepubertal to the same degree of training as one who has advanced puberty, or even an adult? As for the degree of maturation, we have the extreme example of DSDs: XY females, e.g. 5alpa reductase type II deficiency who start to respond to their high testosterone in puberty. You could call that extreme maturation. They will become very muscular and compete very well in sports.
We have two excellent conversers. Alan Rogol, who has done a lot of work on sports and on endocrinology of sports. We have Bob Malina, who is unique in the contributions of scientific work on the relation of puberty to sports and physical maturation. So we have an excellent team to start the discussion, then I hope to have a free discussion with the rest of you.
Alan Rogol: I am happy to be the warm-up player to my longtime friend and colleague, Bob Malina. You’ll hear from him. Bio-Banding that’s what it’s called in sport. It actually is not a new concept at all although it’s relatively new to sport as Bob will discuss, but mainly from the point of view of his former students and himself.
Sean Cumming and the University of Bath in the UK will be major players. I sent around at least one paper that he wrote [J Sports Sci 2017; 19:1-9]. In fact, this concept fell out of issues related to the human as a work machine.
This concept goes back a hundred years or probably even more than that. In general, all of us in this room understand at least the outward signs of pubertal maturation leaving pubertal development or the psycho-social aspects aside, although Bob will bring up some of those aspects as part of his training in that area.
Sport at least at the pubertal age selects those who mature early especially in those sports for which chronological age groups are prominent, around the world of football, soccer for us, and basketball – those are the prominent ones. Within any age group the players’ birthdates are not randomly distributed, but those in the first quarter of the year are more prominent, likely due to maturity status. And so that is January to March, if it’s a whole year, that quarter is enriched in the kids. Why is this so? At least for boys sports strength and power are critical and maturity status and strength and power are causally related. We are all more familiar with the growth aspects than we are with the strength and power aspects. I have copied several papers which I will open up but one of the papers that people ought to read is David Handelsman Sex difference in athletic performance emerge coinciding with the onset of male puberty. Clin Endocrinol 2017; 87(1):68-72.
What about girls? We don’t talk about them so much except Bob and I and a few others were part of FIG which is the French for Federation Internationale de Gymnastic. Do you know why the girls in gymnastics are so little? Too much training, how much is too much? It turns out that they’re prisoners of their genes.
We’ve written about that [Sports Med 2013; 43(9):783-802].
One of the things we don’t talk so much about when we talk about training is the volume of training: “we’ve been training for 16 hours a week, 32 hours a week… ” What does that mean in terms of energy expenditure? Yet some sports scientists have actually looked frame by frame at every 15 seconds or every minute what the girls do during four hours of gymnastics training. A lot of it is stretching; a lot of it is learning dance moves etc. It’s not all strength and power. And so although they train 30 hours a week, that’s not really necessarily at a heart rate that is 70, 80, or 90 percent of heart rate max.
So I think that those issues will be brought out. Although in fairness if you look at the adult data Ann Loucks, who is the most prominent, talks about energy balance [J Clin Endocrinol Metab 2006; 91(8):3158-64]. Pulsatile LH release, menstrual function depends on the net energy balance. If one does enough exercise or not eat enough one has disturbed hypothalamic-pituitary-gonadal dysfunction. Essentially it’s calories no matter how the calories are distributed (accrued or spent) that one works so hard or one does not eat enough so, on the one hand one has anorexia nervosa but on the other and one has perfectly well eating athletes, but not enough for the amount of energy that they expend.
Thus, what is important for athletic success? Number one on the list, genes. Not exercise; not anything else. And so one might say you better pick your parents (actually a few generations before your parents) very carefully, if you want to be a successful athlete.
Part of the training issue of course is both physical and psychological stress. George Chrousos will speak about that aspect. So in part of the discussion we will need to wait for what George has to say.
Bob Malina will now continue with the specific issue of bio banding.
Robert (Bob) Malina: Thank you Alan for the introduction and thanks for the opportunity to be here. Of course this is all a very different community for me to be interacting with. But I’ll do my best to give you a fair shake as to some of the issues involved. Bio-banding is now the in-word. Specifically, what they’re doing with it in UK is using a non-invasive estimate of maturity status-percentage of predicted adult height attained at the time of observation. And they’re applying it in the context of soccer. But as Alan said this is not a new concept. Perhaps the first person to talk about grouping boys by maturity status was a man named Ward Crampton back in 1908. His paper was published in the American Physical Education Review. In fact, Jim Tanner thought he was talking about sport, but Crampton never once mentioned sport. It was aimed at how boys should be grouped s for work? Crampton used pubic hair-prepubertal, pubertal or adult. But a year later (1909) a man named Rotch began using hand-wrist bone age; he called it Anatomical Age, and indicated its potential relevance for sport. So this (maturity-matching or bio-banding) is not a new concept; it has been with us for a while.
Historically it has focused mostly on boys and it makes perfect sense. Sport is ruthlessly selective, whether it’s voluntary (dropping out), cutting you’re (excluded because you’re not good enough or not big enough and so on). But sport is in many ways a business and in boys more so than girls’ sports are dominated by early maturing boys. American football, soccer or football, ice hockey, baseball, swimming, track and field athletics (except for distance runners) sports are dominated by early maturing boys.
So this is not new. My major professor of anthropology Dr. Krogman published a paper back in 1959 on skeletal age of little league baseball players: participants the World Series that are held every year in the summer. His conclusion was that men are beating the boys. The age limit for little league is 12. So not yet 13 years by a specific cut-off date. Krogman used Todd’s method of assessing skeletal maturation (1937) and several years earlier (1956) the president of the Little League (Creighton Hale) used maturing assessments, specifically did it with pubic hair with Crampton’s criteria and showed the same results. . Clearly the men were beating the boys and this has since been verified in other sports.
To put things in perspective one of the first studies of young girls was from Sweden- work on swimmers (1963), where he found that girls in swimming were in general average maturing with no dominance of early or late maturers. In fact, the best swimmers were slightly maturing except for small samples. The exception for boys is gymnastics, where you still see the late maturing boy t and some average maturing boys persist, but by and large it’s late maturers. In girls in the aesthetic sports: late maturers dominate-artistic gymnastics, figure skating, also ballet. Otherwise most girls in sport tend to be average in their pubertal maturation. You get a few late maturers in distance running and related sports. So, it is hard to generalize from one sex to the other.
So, why is there such concern for this bio-banding now? Well, historically in the sports sciences there’s been a reluctance to use invasive methods of assessing maturity – skeletal age or pubic hair. Also most in the sports science don’t know how to assess maturity status. One of the big limitation is when you provide a skeletal age, only a bone age, many in sports sciences have no idea what’s involved in doing it. Of course assessment of secondary sex characteristics is very, very difficult. It’s considered personally invasive. That’s an interesting paper Medicine and Science in Sports and Exercise several years ago (2013) which evaluated how well orthopedists could assess the pubertal status of their patients; the conclusion was that the assessments were unreliable. So, just because you’re a physician is no guarantee you know what you’re talking about when it comes to pubic hair assessment. I do not say that negatively, but this is a problem in the literature.
So, there’s been interest in noninvasive methods, and back in the early 80s Alex Roche (1983) from the Fels Institute, who just died earlier this year, e proposed the use of the percentage of predicted adult height as a potential noninvasive estimate of maturity status. Hypothetically, the youngster closer to his or her adult height is more mature than a youngster of the same age who is not there. And Roche and a colleague proposed a series of equations to predict adult height based on age, height and weight of the child and mid-parent height. And of course, if you go back to the longitudinal growth studies of the University of California, Berkeley by Nancy Bailey Harold Jones and colleagues the percentage of adult height attained at each age is reported for the total sample and also for early, average, and late maturing boys and girls in Bayer and Bailey’s monograph back in the late 50s. So, there is a long tradition of using percentage of adult height and Alex proposed it as a maturity indicator. Several individuals used it in the studies of physical activity. I applied it in a study of young American football players, and it worked reasonably well. It had moderate concordance with the skeletal age, which we did in a separate study. And Sean Cumming applied it in his doctoral thesis at Michigan State University. When he got to England colleagues from soccer (football) asked him to give it a try with soccer. There was a group in England concerned with how can we modify the system to give all boys a more equal chance?
Now to put it in perspective, any of you ever heard of Alex Ferguson the coach at Man U? One of my colleagues was a trainer at Man U. And they appealed to the English Premier League to hold two or three boys back to let them play down based on skeletal age to give them a chance to catch up. That’s how perceptive he (Ferguson) was. I can’t mention names but the three youngsters are now playing professionally. So this is something was on the back of their minds. So there was I think fertile ground to try this approach.
So, what have they tried in England, and they have been working with boys, 12 to 14 years. They have done a series of what they call bio-banded tournaments, where the boys were grouped by percentage of predicted adult height using Alec Roche’s equations. They tried several categories, but the one they used was grouping players between 85 and 90 % of predicted adult height. Most boys are about 91-92 percent of adult height at the time of peak height velocity that comes from the Polish and other studies. Putting that band into perspective I used it with a group of soccer players for whom I had data. And most players below 85 percent were pubic hair stage 1 (prepubertal) or 2 (early puberty). In the 85 % to 90 % band, you had mostly pubic hair 2 and 3 a few 4s and maybe a few 1s. And these are actually boys who play soccer in Portugal. The tournaments were very well received by the coaches and especially by the boys. This is the work of Sean Coming a sports psychologist by training and he was interested in how did early and late maturing boys react. And it was amazing: reactions were very favorable in terms that there was more emphasis on technique and skill than sheer physical size because you take a group of 13 to 14-year-old boys, the defenders will dominate because they are physically big and so on. This was the highlight I think of it as the youngsters received the bio-banded tournament very well. The coaches generally perceived the tournament as well and the feedback from the youngsters in terms of learning the skills and proficiency in the sport was the most important thing. And it has been very successful in UK. You will probably see this applied in US because the man now running U.S. youth soccer came from England and he worked with Sean and he was the one to help adapt it. So you’ll probably see that soon in us.
So, this is what the bio banding at present and right now it is actually well-received. Sure it is not perfect. There’s always error involved, but this is being done.
Rogol: Bob you mentioned, tournaments, what about training? Different training for those who are more mature vs less mature?
Malina: That’s a different issue. Sure. Many people will have you modify your training programs for the late maturing boy as opposed to early maturing boy. Typically, if the boy is early maturing – strength and power, early on it is a lot more focused on skill and so on. But I would like to add one more method that is out there now. It is being used mostly in US and now worldwide: it is predicting maturity offset time, time before or after peak height velocity.
It is predicted from age, height, sitting height, estimate leg length and weight. The original equations have since been modified. For boys. There are two equations with age and height, and age and sitting height. For girls one equation with age and height. Chronological age minus maturity offset provides an estimate of predicted age at peak height velocity. It is widely used and widely misused. We have done three validation studies two with the Wroclaw Growth Study (Poland) and one with the Fels Longitudinal Study (US). Predicted maturity offset depends on chronological age and body size at prediction. If applied longitudinally, predicted offset/age at PHV varies from age-to-age in the same child. The protocol does not work with early maturing boys and girls. It’s good for average maturing boys close to the time of peak height velocity meaning between about 13.5 to 14.5 years I’ll be happy to share those papers with you; one is still in press.
Studies tend to group youngsters as pre PHV, around PHV and post PHV But why predict peak height velocity in a 16 year old boy? He’s already been past it. But the sports scientists don’t understand. I’m sorry I say that critically but they need to be educated on what they’re looking for a quick fix.
A couple of comments: Alan mentioned about training. Time does not equal training. They spent X hours in gymnastics in the study you mentioned. They actually spent more time resting between repetitions than training. Now only sports like swimming where you know what the distance is swimming or they’re running and so on this is somewhat different. Nevertheless, time training is often misrepresentative of what’s actually going on. And I honestly think if I were to study the effects of training on children nowadays I would study the adults involved. If there’s a problem with intensive training; it is not the youngsters, it is not the training, it is the adults! And I say from experience working with women athletes at the University of Texas we had several with disordered eating problems in the early 90s. You could trace every one of them to the coach. In case of swimming, the coach wanted them at weights at which they swam their best times, i.e., when they were teenagers. But now they are adult women. And in the case of track and field athletics it was the coach; she wanted them at less than12 percent body fat. So to me if I were to go back and study sport I would study the adults and the environments in which the youngsters train and that’s vastly overlooked.
So at that to open floor for discussion.
George Chrousos: About 30 years ago we did the big exercise study with the human performance laboratory at the Naval Hospital, which is excellent. And we studied young men mostly from the Navy who ran or didn’t ran daily. First, we did their VO2 max, and found that If you stress people, the amount of VO2 max was the one that correlated with the hormones elevations. Let me remind you that ACTH, cortisol, prolactin, growth hormone; a large number of hormones go up when you exercise. So, there were three groups of people – sedentary, very little exercise; running I think 25 miles a week; and running over 40 miles a week. When we analyzed the data, So what do you see was all or none effect with the high exercise. No it was the people who ran over 40 miles a week had high urinary free cortisol, and had suppressed ACTH responses to CRH. So the conclusion is that if you exceed the certain amount of exertion you become hypercortisolemic. And it fits very well with what people are finding in these athletes. They develop osteoporosis, have suppressive immune system and so forth. So the first question that was mentioned here the amount of exercise. I think there is a level for each one of us. If you go beyond that who will be stressed chronically stressed, and we will damage our body.
We did another study with a psychology group at the NIH. Middle class boys and girls from around the Bethesda area where we examined them with Tanner staging and so forth and did a number of psychological – psycho medical tests, such as the CBCL test. That shows degrees of adjustment or maladjustment to the environment. What was very clear was that girls that matured early had a lot of problems; not boys. Boys that matured early were the best, and exactly the opposite with boys that delayed their puberty had many more problems than boys that started earlier – problems that you pick up at the CBCL – the standard testing for these ages. There is one for the patient and one for the mother, evaluation of behaviors feelings. A standardized test. And of course these people were children who were within the normal range but you could pick up the correlation between the test and the maturation.
Let me tell you another thing. We tried to examine the people who exercise a lot over 40 miles a week psychologically. Nobody would stop doing it. They didn’t want to stop. And they actually scored very high. They were very well adjusted. One had a damage in one of the muscles and stopped. And while he stopped he was depressed. We just couldn’t convince him to stop. So there is a degree of addiction to exercise. So it’s also quantitative exercise. You cannot exceed a certain level, which is different for each one of us.
Ritzén: Does hard endurance exercise cause damage to children psychologically or physically. Who would like to comment?
Chrousos: I think that if you exceed a certain level you will damage the people. Now I remember that we had a good opportunity to study exhaustive exercise in young men and women. There is a so-called Spartathon where people come from all over the world and they run from Athens to Sparta. It’s like a marathon but it’s a quick walking basically. So, they have to do it within 36 hours. And when they arrive the ones that don’t stop in the middle. There are people waiting for them from the Sparta hospital, and take them directly to the hospital. And we had to measure everything in them. And I have to tell you I’ve never seen this high levels of interleukin 6. The amount of inflammation and proteolysis in their muscle was unbelievable. Cortisol was sky high. And then we had the two days later to do the same. And they were completely corrected. It was amazing. Everything went down. So exercise can be quite an inflammatory response. This is an inflammatory state but obviously the body can overcome it. All these people the Spartans they’re all very well fit right. They run the whole year you have to be ready for that. So as there is a certain level we manage very well actually it may even be beneficial. But beyond a certain level of constant inflammation you’re going to be damaged. You need the time in between to repair.
Question: Was there a difference between pubertals and adults?
Chrousos: Well we didn’t study that. They were all young adults.
Jan-Maarten Wit: I have a question on this bio banding. Why don’t you use serum testosterone instead of this complicated formula – in the boys of course? I’s not so invasive to take a blood sample for testosterone levels, I would say.
Malina: I do not think they’ve got the facilities and the technology for the coaches and trainers to do it in-situ. That’s part of the problem.
Wit: There are of course doctors with each football team, and they can just order the testosterone. That’s just not such a big issue. It’s even possible to measure testosterone in saliva or urine.
Malina: Perhaps, but I’m just not sure of the variations in hormones. And when you work with adolescent boys if you’re going to be able to do so. I don’t know enough about the endocrinology of it. And I’m not sure the sports scientists know that either.
Ritzén: It seems that all the different ways of assessing maturity is set up in order to avoid blood testing. Blood testing would be the ideal method. But that may not be practically feasible.
Chrousos: If you get two saliva samples let’s say 8 a.m. and 8 p.m. and measure cortisone alpha-amylase and testosterone, then you get a tremendous amount of information twice a day to show circadian variation.
Wit: Early morning is more informative than an evening sample.
Ze’ev Hochberg: I didn’t do any research myself on that, but I see my patients. And my patients tell me about their life, and sport is part of their life. When you talk about biobanding, do you limit your ideas to boys and girls who train to become professional and take part in competing teams? Or this has also to do with sport activity at school or socially.
My second question: you talk mostly about physical maturation, physical puberty. What about the mental part of adolescence? Some kids show a discrepancy between their physical and the mental maturity. How do you band them? Do you bioband them by their physique only?
And lastly, you mentioned girls who do gymnastics, and you mentioned that they rest a lot during the training, they do not exercise the whole time. But the girls I see who come to me with delayed puberty and train, they spend like six hours a day six times a week going to the training center, which put them into tremendous stress in terms of their school performance. They never manage to do their homework. And then after training they take the bus to go back home etc. So, these girls spend six seven hours a day, seven times a week in gym. What do you think is the impact of that life style?
Malina: I hope I get all the parts of the question. All the work done on biobanding in England right now is based on youngsters in soccer academies. They are 12, 13, 14 years so they already are select in many ways before the major selections are going to come up. I know of nobody who has done it in a social context. But there’s a very rich literature on maturation and behavior that goes back to the Berkeley studies. I would recommend if you ever get a chance go back and read those papers by Harold Jones and colleagues talking about the behavioral characteristics of early late maturing boys and girls. These all go back to the 40s and 50s and are incredibly good studies because Jones also studied muscular strength. And clearly the early maturing boy is strong and is also really behaviorally way ahead of the game.
Now, athletes of course are a unique sample. They are selected, ruthlessly selected. And as a rule the behavioral characteristics of youth athletes have not been systematically studied especially in a bio behavioral context. So, the unique thing that I think Sean Cumming is coming up with is the perceptions of the early and late maturing boys; the early maturing boys 12 year old playing up and the late maturing 14 year old boy playing down.
That is what I believe they are pursuing right now. So those results are in but the extremes of maturity forced to play up or down their Reactions of the players to the biobanding being have been very favorable in the context of that sport (soccer). In terms other behavioral dimensions, it has not been study.
Your question about the young athletes who may spend six hours a day or eight hours or X hours a week in training gymnastics, I agree with you, but I think it is more important to study the gymnastics environment, because if there’s a negative effect it’s the adults who run the sport. Why are these children there for that many hours? Are they driven or are the parents driven? That is the issue that has not been studied. I find it hard to believe that children do this by themselves. Because in youth sports in US right now, parents are investing so much money in their children’s sport; They are expecting future prospects and perhaps big returns.
Hochberg: Has anybody studied the consequences?
Malina: Not yet. I say if there’s a problem in youth sport it is the adults it is not the sport. If you let children in sport do it on their own, you have no trouble. Trouble is that sport for youngsters right now is so over organized. And there are at least three or four newspaper articles in the last month about how much parents are investing in their child’s sport to the point some are spending a thousand or two thousand dollars a month. Something is inherently wrong with that. And the expectation for the children is unreal. And to put it in perspective the probability of getting a scholarship in the US (that’s the motivation) – less than 2 percent of high school athletes get a college scholarship, and in US the only full scholarships are for American football and basketball- in basketball both sexes; in football obviously men. Every other scholarship is partial. Give you an example about baseball. Baseball teams in college have 25 players. There are 11 scholarships that are divided among 25 athletes. So the notion of a full scholarship is a pie in the sky; it may or may not exist.
Ritzén: We’re talking about sport and the influence of sport. Has anyone compared the parents of young children being trained pianists? They’re probably training many hours a day, even more than sports. Are they equally hampered by their being away from school work or being away from peers or whatever, training all the time? That comparison might be interesting.
Mark Sperling: There was a study by the author, whose name escapes me right now but will come, who studied the home environments of youngsters who did music. I think also youngsters who became mathematicians and swimmers, and they all had very common environments in terms of the emphasis on training.
Abiola Oduwole: I saw it never in Africa. Our own problem is not the younger ones wanting to be like an adult. But what we have is an older boy wanting to play in the younger age group. Usually when you do the born age, when you look at them physically they actually do look young and they’re not tall. So would you say it could be used vice versa if somebody is not yet mature could he play in a younger age group? If the person is more mature should he play in the older age group; they are being penalized and fined and sometimes jailed for moving through the age groups. And you have some 12 years old who are looking as mature as 16 and yet they’re not being allowed to play and they can’t. And so they play with 12 year old and they override everybody and they’re the best. And yet you have these 17 who is better in that younger age group but not good if you look at it in the older age. So what do we do here. Can we apply that?
Malina: That is a tough call and it’s a good question on Africa because the big issue they have had in soccer is specifically is age verification. I asked a colleague, Tom Riley, about age verification and they say he’s an African 12 which means he could be 13 or 14 because this is part of the problem in parts of Africa.; he indicated that the boy is an African 12 which means he could be 13 or 14; this is part of the problem in parts of Africa.. The youngsters who were very talented in soccer had no birth certificates or verification of their birth dates. And so that was an issue. And that is still an issue for FIFA verifying the ages of some of the players in some tournaments. They know it’s a problem. And youngsters playing up or playing down. And especially in developing countries it’s a different issue. And I don’t know how to control it because in the case of soccer if you are talented they’re going to find you and they’re going to do everything they can to get you into the system whether your age is correct or not correct. FIFA now is using MRI of the distal radius to verify chronological age.
I could give you a 14-year-old boy whose distal radius is fused. He would be eliminated by FIFA even though he is of the right age.
Rogol: On the same point I have a paper here I brought it on purpose. Its title is an essential approach to the age assessment in undocumented minors in conflict with the law (Rev Ital Med Adoles 2016(April); 14(1):5-11. So, exactly the same issue without a birth certificate. And Bob has shown and others have shown that a 12 years old can have a 16-year-old bone age and a 16-year-old can have a 12 year bone age. And remember when we say 12 it’s not 12.00 it’s 12 plus or minus.
Ritzén: At the moment in Sweden we have very current discussion about asylum seekers. If they are below 18 years old, they are treated in a much nicer way and they are allowed to stay in the country etc. If they’re above 18 they are like adults. So that has become a big issue. The legislation has now accepted that there is an error with the current methods to determine the “true” chronological age, using bone age. “dental age” and MRI of the knee. But you have to accept that there are errors when you go by these cutoffs.
Rogol: One other point that I wanted to make about stress that was talked about there are people in the U.S. Army who do what’s called Ranger training, so they jump out of perfectly good airplanes, they’re in swamps, they’re not eating, bullets are going over their heads. And if you evaluate Ranger training: hard training, marching, little for a week or two. Their testosterone levels are very low and their gonadotropins are low as well, so they’re hypogonadotropic. You let them out of that training, feed them and in three days they’re back to normal [J Appl Physiol 2000;88(5):1820–30.].
George Werther: Can I just ask to comment on the role of androgen abuse in this situation. Talk about how it’s a huge advantage for children with early puberty, boys with early puberty. How much of an issue is that say in the in the soccer situation in the UK and elsewhere with people wanting to be elite athletes. How much of an issue is androgen abuse? Obviously, covert androgen abuse in males and possibly even in females.
Malina: I’ve only heard it in the context of track and field athletics with older teenagers. I’ve not heard of it much at the younger ages and I have not heard of it much in soccer. So, it is a potential issue because someone is always looking for an edge.
Oduwole: Are they testing for androgen in the younger age groups?
Malina: I believe they do not.
Oduwole: In Africa, a lot of parents want their child to play football because it’s big money. So I’m sure that they’re attracted to androgens, not necessary the ones that we are familiar with. Student had been given androgen to advance their peak height velocity so that they can start making money.
Rogol: On the same issue, in both Texas and in New Jersey the high school athletic authorities decided to test high school athletes, (American football) and detected vanishingly few, if any. The cost of doing it in America is about $100 for androgens, not for other drugs, but for androgens. They’ve stopped testing and these are people who are really at risk for taking anabolic steroids because they’re in sports in which are either contact sports or even worse, collision sports like ice hockey and football. So it’s been tried. It’s been found to be economically infeasible. Not to say anything about practically infeasible as well.
Wit: You said there’s a big role of adults actually in this whole issue. In Holland, and I think in other countries, over the last two years there was a lot of speaking about sexual abuse and harassment of young athletes actually by the trainers. That has also something to do maybe to pubertal stage of these children and adolescents. Are there some ideas in your field about that issue?
Malina: There’re many ideas because they are in the news on a regular basis. The most recent one in US is a physician at Michigan State who was molesting young female gymnasts who come into his clinic. And I never realized it when I was at Michigan State at the time why he was so seemingly threatened by the fact we were studying youth gymnasts. I guess we were “invading his territory”, and we were doing routine anthropometry and there was another adult in the room with me preferably a young woman too. We were going to measure the young girls. But then I realize in retrospect that he really did not want me there. So, this is a big issue and this “a very private issue”, and it is surfacing more and more in the newspapers. We need to look at these environments. Many accept the medical doctors – people inherently trust medical doctors. And so you’ve got to watch the situation. But it needs to be done.
Ritzén: I would like to make an analogy between pre pubertal children in sport and men and women in sport. I’ve been heavily involved in trying to define the conditions when hyper androgenic women are allowed to compete in the female category. The only difference that we find that defined a wide gap between the two genders is testosterone levels in blood. So, looking at physical characteristics will be very difficult and also intimidating if you have what was called “nude parade” that was used a long time ago. That’s when a number of doctors were checking undressed women if they were female enough. But we found testosterone to be the only simple dividing measure. If proper reference ranges for salivary testosterone in men and women are established, then in future it may not be so difficult to come by. Essays are becoming easier and less expensive. Testosterone is a very important factor when it comes to performance in sport –at least middle distance running.
Hochberg: So what is the bottom line? Is biobanding now the standard for sports for youngsters?
Malina: Good point. No I don’t think biobanding is going to be the answer to everything. It is now very much an experimental stage in the UK. It has not been applied elsewhere that I am aware of yet. It is very much in the news and it’s been well received by a number of academies in England and specifically in soccer. I have not seen or talked about any other sport to date and the whole issue is maturity status. I honestly don not think that most people who work with athletes they see it every day but they don’t know what to do about it.
And many of them accept that as the nature of sport. As I said at the expense of repetition. Sport is ruthlessly selective. This this is going to go on and in all sports. Many start, but very few make it to the top.
And when you study the elite athlete keep in mind yes you’re studying a very select sample. You’re missing out on everybody who dropped out along the way. We also need to study the dropouts because they can tell us a lot, but we do not study them. We are interested in the successful ones. And that is a big part of the issue. And then another thing in sport is that many people looking for the magic bullet-what is going to give me the answer. One examination is not going to tell you anything. You need to follow the youngsters over time. And this is typically not done. So it is multifaceted.
To get back to the question of age verification. Those of you who work with skeletal age are aware of Tanner Whitehouse (TW) 2 or 3. TW3 skeletal ages are systematically younger by about a year or more beginning about 10 years in boys. So if I have an early maturing boy with TW2, he may be average with TW3. What does that have to do the training? The differences are systematic. But have has not received that much attention, yet.
Ivo Arnhold: So, we have heard that sport is very selective and that too much sports is prejudicial to your health. So, what would be the flags? or what should we do if we want the parents and society to know if their children are doing enough sport that is good for their health, but not too much? that may be different from one boy to the other. What measures could we look for in terms of ensuring this?
Malina: I personally think is the question you raise very important but more for the general population. We confuse sport with physical activity. They are not equal. Sport is one form of physical activity and most children do not get enough activity. That’s where I think our focus should be. But then you have a very small percentage who are the elite athletes who are getting a lot of activity in perhaps a highly stressful context. And that is a very special group to study. So it is a two edged sword. They are almost at the one extreme and so on, and you just got to be very careful with them, and there is no simple answer. But we cannot go from the athlete to the general population because the athletes are off the curve. And often we make that mistake and in public. Now of course your good athletes are at so many different levels. If you go to local high schools here, you have many athletes but you are lucky maybe one will get out of there to the next level. So this is part of the issue with the generalization across sport, and in news media they generalize. This is potentially misleading. So you have got to be very careful with that and hopefully translate for the public.
Wit: We have not spoken yet about that question. That’s also an important issue in the young athletes. So, are there other elements in the diets that can increase muscular power, like extra proteins or proteins from various products that have a positive influence on either one. So is there any relationship there?
Malina: I’m not a nutritionist. I do not know for sure. But for most young kids who train in sport, at least in the U.S., their diets are fairly adequate. If you’re training in sport academies, your diet is monitored for you.
But, this is just part of the issue. Keep in mind eating is a social behavior influenced by many other things. We eat foods we do not eat nutrients. And many people miss that point that our elite athletes are monitored fairly regularly, at least at the University level; everything is regulated. At the high school level they are eating at home unless they attend a special academy or special swim clubs in U.S. or gymnastics academies. The IMG Academy in Florida, is a big business now. It is basically a school for athletes, and they live there. That is where many elite tennis players went to school, but for the general athlete I do not think we have such control over their diets because they are eating at home. And that is an altogether different environment. If you’re in a club, you perhaps are monitored; at home, forget it. You’re eating what your family eats and that is 99 percent, if not more of the youngsters who do sports.
Wit: And they don’t take extra nutrients like amino acid, vitamins or that kind of stuff? I had the impression that a lot of athletes believe actually in the role of vitamins etc. It’s not really sure that that has any effect.
Ritzén: I think the parents believe it. It is time to try to summarize:
We covered a few aspects on sports and maturation. One is the safety issue. Is it safe for children to do a lot of endurance training? George Chrousos pointed out that inflammatory markers are very high in athletes that practice that kind of training, and we should be aware of that. Psychological effects: Ze’ev pointed out that a lot of time spent on sports takes the same amount of time away from other activities. Is that good for the kid? Or not? I haven’t really been convinced that there are obvious negative health effects except for the rise in inflammatory markers in hard intensive training.
Then we brought up a different question, trying to create a level playing field for those competing with each other. Looking at the year of birth is not very good. Definitely bad, especially at the ages of 12 to 15 or so, when some have entered puberty and some have not.
Biobanding has been one such attempt to create such level playing field. The variation is very large and is not a very sharp a scientific instrument. If you really want to assess one factor that has proven to be important for performance, I would come back to testosterone, and may be measuring testosterone in saliva is acceptable to the child. The major drawback is the practical management and the assays that at present are rather expensive. Maybe for a selected group of people and maybe in future that might be one way of creating a level playing field for those that compete with each other. In order to give those born in December an equal opportunity to those born in January.
Malina: I just read a paper the other day, reporting Fels’ skeletal ages on soccer players from an English academy and from Aspire in Qatar. The paper –stated that skeletal age overrules the relative age effect. Relative age effect means month of birth – those born in the first three months. Once you adjust the relative age for skeletal age variation, skeletal age rules.
Ritzén: That’s not very surprising. The bad thing is about X-ray. It will not be accepted by society to take X-rays of children in order to do sports. So, I think we have to leave many good methods for assessing maturity trying to get something that is acceptable for society and acceptable for the child and acceptable for the competitors.
COMMENTS TO THIS CONVERSATION ARE TO BE MAILED TO MARTIN RITZEN Martin.Ritzen@ki.se