{"id":7831,"date":"2018-05-30T08:01:01","date_gmt":"2018-05-30T07:01:01","guid":{"rendered":"https:\/\/blogs.bmj.com\/bjsm\/?p=7831"},"modified":"2021-02-12T10:37:27","modified_gmt":"2021-02-12T09:37:27","slug":"2018-update-relative-energy-deficiency-in-sport-red-s","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bjsm\/2018\/05\/30\/2018-update-relative-energy-deficiency-in-sport-red-s\/","title":{"rendered":"2018 UPDATE: Relative Energy Deficiency in Sport (RED-S)"},"content":{"rendered":"

What updates are presented in the IOC consensus statement on RED-S 2018?<\/strong><\/p>\n

Prevention<\/strong><\/p>\n

Awareness is the key to prevention, yet RED-S continues to go unrecognised. Less than 50% of clinicians, physiotherapists and coaches are reported as able to identify the components of the female athlete triad.\u00a0In a survey of female exercisers in Australia, half were unaware that menstrual dysfunction impacts bone health. Note that these concerning statistics relate to the female athlete triad and the lack of awareness of RED-S in\u00a0male athletes<\/a>\u00a0is even more marked. RED-S as a condition impacting males, as well as females, was described in the initial IOC consensus statement published in 2014. However there is evidence of the occurrence of RED-S in\u00a0male athletes<\/a>\u00a0pre-dating this.<\/p>\n

Identification<\/strong><\/p>\n

Identifying an athlete\/dancer with RED-S is not always straight forward. In dance or sports where being light weight confers a performance or aesthetic advantage, how can a coach\/teacher distinguish between athletes who have this type of physique \u201cnaturally\u201d and those who have disordered eating and are at risk of RED-S?\u00a0 Equally, low energy availability could be a result either of intentional nutrition restriction to control body weight and composition, or an unintentional consequence of not matching an increase in energy expenditure (due to increased training load), with a corresponding increase in energy intake.<\/p>\n

Performance effects<\/strong><\/p>\n

Performance is paramount to any athlete or dancer. Apart from physical ability, being driven and determined are important characteristics to achieve success. If weight loss is perceived as achieving a performance advantage, then this can become a competitive goal in its own right: in terms of the individual and amongst teammates. This underlies the interactive effect of\u00a0psychological factors<\/a>\u00a0in the development and progression in the severity of RED-S.<\/p>\n

There is both theoretical and practical evidence that short term low energy availability impairs\u00a0athletic performance<\/a>\u00a0as the body is less able to undertake high quality sessions and benefit from the physiological adaptations to exercise.\u00a0Within day energy deficits<\/a>\u00a0have been shown to have adverse effects in both male and female athletes in terms of impact on oestradiol\/testosterone and cortisol concentrations. Failure to refuel with carbohydrate and protein promptly after a training session in male runners has been shown to have an adverse effect on\u00a0bone turnover markers<\/a>.<\/p>\n

To underline the adverse performance effect of low energy availability, a recent study demonstrated that in female athletes, those with functional hypothalamic amenorrhea displayed decreased\u00a0neuromuscular performance<\/a>\u00a0compared to their eumenorrhoeic counterparts. This adverse effect on performance is of particular concern where such skills are crucial in precisely those sports\/dance where RED-S is most prevalent. Clearly this situation puts such athletes at increased injury risk, especially if associated with adverse bone mineral density (BMD) due to low energy availability.<\/p>\n

Ironically the\u00a0long term consequences of low energy availability<\/a>\u00a0produce adverse effects on body composition: increased fat\/lean and reduction in BMD. In other words, the precise opposite effects of what an energy restricted athlete is trying to achieve. In terms of\u00a0bone health<\/a>, the lumbar spine is most sensitive to nutrition\/endocrine factors (apart from rowers where mechanical loading can attenuate BMD loss at this site in RED-S). Suboptimal BMD is associated with an increased risk of bone injury and therefore impaired performance.<\/p>\n

\"\"<\/p>\n

Medical Assessment<\/strong><\/p>\n

Low energy availability is the fundamental issue driving the multi-system dysfunction in the endocrine, metabolic, haematological, cardiovascular, gastrointestinal, immunological and psychological systems in RED-S. However, there are practical issues with directly quantifying energy availability as this is subject to the inaccuracies of reliably measuring energy intake and output. Endocrine and metabolic markers have been shown to more\u00a0objective indicators of low energy availability<\/a>, which in turn are correlated to performance outcomes such as bone stress injury in male and female athletes. In the case of female athletes there is an obvious clinical indicator of sufficient energy availability: menstrual cycles. As there is no such obvious clinical sign in male athletes is this why RED-S is less frequently recognised? In both female and male athletes there is some degree of clinical variation: there is no absolute threshold cut off with a set temporal component of low energy availability resulting in amenorrhoea or low testosterone in males. Therefore the IOC recoomends that individual clinical evaluation include discussion of nutrition attitudes and practices, combined with menstrual history for females and endocrine markers for male and female athletes will give a very clear indication if an athlete is at risk of\/has RED-S.<\/p>\n

Management<\/strong><\/p>\n

RED-S is a diagnosis of exclusion. Once medical conditions per se have been excluded, RED-S presents a multi-system dysfunction caused by a disrupted\u00a0periodisation of nutrition\/training\/recovery<\/a>. For an athlete the motivation to address these imbalances is to be in a position reach their full athletic potential. This attainment is compromised in RED-S.<\/p>\n

Pharmacological interventions are not recommended as first line management in amenorrhoeic athletes. Oral contraception (OCP) masks amenorrhoea with withdrawal bleeds. OCP does not support bone health and indeed may exacerbate bone loss by suppressing further IGF-1. Although transdermal oestrogen, combined with cyclic progesterone does not down regulate IGF-1, nevertheless any hormonal intervention cannot be a long term solution, as bone loss will continue if energy availability is not addressed as a priority.<\/p>\n

What next?<\/strong><\/p>\n

The IOC statement suggests further research should include studies with allocation of athletes to intervention groups, with assessment of effects over a substantial time period. Currently a\u00a0study of competitive male road cyclists<\/a>\u00a0over a training\/competition season is being undertaken to evaluate the effects of nutrition advice and off bike skeletal loading exercise. Crucially outcome measures will not only be based on bone health and endocrine markers, but measures of performance in terms of power production and race results.<\/p>\n

To raise awareness and build support pathways as recommended in the IOC statement,\u00a0 this is an on going process which requires\u00a0communication\u00a0<\/a>between athlete\/dancers, coaches\/teachers, parents and healthcare professionals both medical and non medical working with male and female athletes.<\/p>\n

References<\/strong><\/em><\/p>\n

IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update<\/a>\u00a0BJSM 2018<\/p>\n

Male Cyclists: bones, body composition, nutrition, performance<\/a>\u00a0BJSM 2018<\/p>\n

Male Athletes: the Bare Bones of Cyclists<\/a><\/p>\n

Addiction to Exercise \u2013 what distinguishes a healthy level of commitment from exercise addiction?<\/a>\u00a0BJSM 2017<\/p>\n

Sports Endocrinology \u2013 what does it have to do with performance?\u00a0<\/a>BJSM 2017<\/p>\n

Within\u2010day energy deficiency and reproductive function in female endurance athletes<\/a>\u00a0Scandinavian Journal of Science and medicine in Sports 2017<\/p>\n

The Effect of Postexercise Carbohydrate and Protein Ingestion on Bone Metabolism<\/a>\u00a0Translational Journal of the American College of Sports Medicine 2017<\/p>\n

Reduced Neuromuscular Performance in Amenorrheic Elite Endurance Athletes<\/a>\u00a0Medicine & Science in Sports & Exercise. 49(12):2478\u20132485, DEC 2017<\/p>\n

Cumulative Endocrine Dysfunction in Relative Energy Deficiency in Sport (RED-S)<\/a>\u00a0BJSM 2018<\/p>\n

Cyclists: Make No Bones About It<\/a>\u00a0BJSM 2018<\/p>\n

Low Energy Availability is Difficult to Assess But Outcomes Have Large Impact on Bone Injury Rates in Elite Distance Athletes<\/a>\u00a0Sports Nutrition and Exercise Metabolism 2017<\/p>\n

Part 2: Health, Hormones and Human Performance take centre stage<\/a>\u00a0BJSM 2018<\/p>\n

Cyclists: How to Support Bone Health?<\/a><\/p>\n

Healthy Hormones<\/a>\u00a0BASEM 2018<\/p>\n","protected":false},"excerpt":{"rendered":"

What updates are presented in the IOC consensus statement on RED-S 2018? Prevention Awareness is the key to prevention, yet RED-S continues to go unrecognised. Less than 50% of clinicians, physiotherapists and coaches are reported as able to identify the components of the female athlete triad.\u00a0In a survey of female exercisers in Australia, half were […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":7832,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[16069,3040],"class_list":["post-7831","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized","tag-featured-list","tag-red-s"],"yoast_head":"\n2018 UPDATE: Relative Energy Deficiency in Sport (RED-S) - BJSM blog - social media's leading SEM voice<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bjsm\/2018\/05\/30\/2018-update-relative-energy-deficiency-in-sport-red-s\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"2018 UPDATE: Relative Energy Deficiency in Sport (RED-S) - BJSM blog - social media's leading SEM voice\" \/>\n<meta property=\"og:description\" content=\"What updates are presented in the IOC consensus statement on RED-S 2018? 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