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Relative Energy Deficiency in Sport
(RED-S)
Erik Sesbreno MSc (c), RD, CBDT, Dip Sport Nutrition IOC
Lead Sport Dietitian at INS
Certified Bone Densitometry Technologist & ISAK level 3 Anthropometrist
Disclosure
• I, Erik Sesbreno, have no actual or potential conflict of interest in relation to this
program/presentation.
RED-S
History & Definition
Physiological Disruptions
Performance & Injuries
Screening
Treatment
Return to Play
Female Athlete Triad
2005 – IOC Consensus Statement
…”combination of disordered eating and irregular
menstrual cycle eventually leading to a decrease on
hormones resulting in low bone mineral density (BMD)”
2007 – AMERICAN COLLEGE OF SPORT MEDICINE
• …”relationship between three inter-related
components: energy availability (EA), menstrual
function and bone health”
Female Athlete Triad
• Introduced by the IOC expert working group in 2014
• Replaces “Female Athlete Triad”
• Greater complexity
• Male athletes are affected
Relative Energy Deficiency in Sports
Considerations: Energy Availability
Mountjoy, et al., 2014
Considerations: Energy Availability
Mountjoy, et al., 2014
Estimating Energy Availability
• Energy Availability (EA)
= Energy Intake (kcal) - Energy Cost of Exercise (kcal)
Fat Free Mass (kg)
• In healthy adults, 45 kcal/ kg FFM per
• Low EA causes adjustments to body systems
– Disruptions to hormonal, metabolic and functional characteristics
RED-S
History & Definition
Physiological Disruptions
Performance & Injuries
Screening
Treatment
Return to Play
Hormonal Disruptions
EA 45kcal/kg FFM/d vs EA 10kcal/kg FFM/d
• Low EA reduced LH pulse frequency by 10% (p <0.01) and
• Low EA increased LH pulse amplitude by 36%(P = 0.05)
• The stress of exercise neither reduced LH pulse frequency nor increase LH pulse amplitude (all p>0.4)
Loucks et al., 1998
Hormonal Disruptions
Endocrine Alterations
Endocrine Alterations
Loucks et al., 1994
ANOVA (threshold) model (solid line)
- p < 000001; R^2 (threshold)
- 61%
ANOVA (threshold) model (solid line)
- p < 004; R^2 (threshold)
- 29%
Metabolic Alterations
• Energy intake = 2770 kcal day
• Exercise energy expenditure = 840 kcal day
• Energy availability = 30 kcal kg FFM/day)
were constant
• Magnitude of “-“ E balance decreased
• Rate -90kcal/d
• May have recovered 0 E balance in 3 weeks
Effects on Fat Free Mass
Fagerberg et al., 2017
-20
-15
-10
-5
0
5
Rossow etal., 2013
Kistler etal., 2014
Robinson etal., 2015
kg Weight (kg)
FFM (kg)
FM (kg)
Effects on Fat Free Mass
National Level Diver
Training: Hypertrophy Block
Test Method: DXA
Effects on Fat Free Mass
Junior Elite Middle Distance Runner
Test Method: ISAK Surface Anthropometry
RED-S
History & Definition
Physiological Disruptions
Performance & Injuries
Screening
Treatment
Return to Play
Reasonable Weight Change Goals
SR: 0.7%/wk FR: 1.4%/wk
• N: 2 males
• Artic hike– 95d
– 10hr/d
– 2300km
Effects on Performance
Stroud et al., 1997
Effects on Performance
Effects on Performance
• N: 10 (female)
• 15-17 yo
• 12wk training block
• CYC vs OVS
• Max TT 400m swim
Effects on Performance
VanHeest et al., 2014
EUM (n=16)Mean (SD)
SFHA (n=14)Mean (SD)
Unadjusted for FFM(kg)P-value
Reaction Time (ms) 57 (4) 61 (5) 0.025
Bone Metabolism Alterations
Ihle et al., 2004
1. Bone Formation
• Osteocalcin (OC)
• Pro collagen carboxyl-terminal propeptide (PICP)
2. Bone Resorption
• N-Terminal telopeptide (NTX)
Bone Metabolism Alterations
Risk of Bone Injuries
Odds of Bone Stress Injury
Moderate Risk High Risk
2x more likely 4x more likely
Energy Availability and Injury Risk
Disordered Eating (DE) may underpin a large
proportion of cases of low EA, but…
• mismanaged programs to quickly reduce body mass/fat
• inability to track energy intake with an extreme exercise
commitment
… may occur without such a psychological overlay.
Reflect and Digest
RED-S
History & Definition
Physiological Disruptions
Performance & Injuries
Screening
Treatment
Return to Play
Disordered Eating Continuum
Prevalence of ED and DE in Elite Athletes
Affects Both Genders
WEIGHT SENSITIVE SPORTS MALE FEMALE
AESTHETIC - 40%
WEIGHT CATEGORY 18% 30%
GRAVITATIONAL 24% -
Sundgot-Borgen et al., 2013
Sundgot-Borgen et al., 2010
Prevalence of ED and DE in Elite Athletes
Affects Both Genders
Prevalence of DE over Time
Sundgot-Borgen et al.,2010
Screening and Diagnosis
Screening should be undertaking through annual health exams and/or
1. presence of DE/ED
2. weight loss
3. lack of normal growth and maturation
Mountjoy et al.,2014
4. menstrual dysfunction
5. recurring injuries and
illnesses
6. decrease performance
7. mood changes
Mountjoy et al.,2014
Screening and Diagnosis
Screening and DiagnosisAssess EA (No standard guidelines to determine)
1. Energy Intake
• Food intake recall or prospective methods
2. Energy Expenditure
• Exercise log and tables of energy expenditure
• Supplemented with GPS units, HR monitors or power meters
3. Fat free mass
• DXA
• Surface anthropometry
• (population specific regression equations)
Assess Menstrual Dysfunction• Diagnosis of exclusion
Assess Bone Health• Athletes with low EA, DE, ED or amenorrhoea of
over 6 months, BMD should be measured by DXA
Mountjoy et al.,2014
Screening and Diagnosis
RED-S
History & Definition
Physiological Disruptions
Performance & Injuries
Screening
Treatment
Return to Play
• Improve energy availability• Increase energy intake (~500kcal/d)
• Reduce energy expenditure
• or both
• Weight gain is strongest predictor of recovery of normal menstrual function
Treatment Strategies
Mountjoy et al.,2014
• Optimize bone health• Increasing energy intake = +1-10% bone mass in
anorexics
• Restore energy and estrogen dependent mechanisms of bone loss
• Resistance training and high impact loading
• Calcium and vitamin D supplementation
• Psychological support
Mountjoy et al.,2014
Treatment Strategies
RED-S
History & Definition
Physiological Disruptions
Performance & Injuries
Screening
Treatment
Return to Play
Return to Play Framework
Mountjoy et al.,2014
Return to Play Framework
• Underlying problem of RED-S is inadequate energy to support a range of body functions involved in health and sport performance
• Disordered Eating (DE) may underpin a large proportion of cases of low EA, but it could occur without a psychological overly
Summary
• It could affect male and female athletes across various ages
• The prevalence could vary across a variety of sport disciplines
• Clinical competency is important in RED-S management, but it takes a team approach and the ability to develop a trusting relationship with the athlete to be successful
Summary
Case Study Background
• Nov 2015 referral from CSIO physiologist
• Female; 18 y.o.; 1st yr university
• No CSIO nutrition support
• No CSIO IST support
Evaluation of Health Status
• No medical illnesses or training injuries
• Bone mineral density within normal limits
• Menstrual dysfunction in 2014 & 2015
• Started OCP in 2015
• RED-S likely ongoing
Sport Assessment
• Provincial elite program
• International competitions
• Great emphasis on leanness for P:W ratio
• No standardized performance test data
Decision Modifiers
• Preseason around the corner
• Performance excellence a BIG priority in 2016
• No professional relationship established
• Confident with self directed nutrition planning
elephant pic / Blind
2016 Pre & In-Season: Monitor – Educate - Build
• Protein availability and distribution
– Currently ~ 1.8g/kg, but bolus was <20g or > 30g
• Periodize CHO availability across week and training blocks
– Limited fuelling on the ride; restricted variety of CHO based foods
2016 Pre & In-Season: Monitor – Educate - Build
• Monitor body composition changes
• Bone mineral content
• Aim to monitor sex hormones
2016 Pre & In-Season: Monitor – Educate - Build
(mm·kg-0.15)MTB Pre/In
Season
MTB Off
Season MTB Pre/In
Season
MTB Off
Season
Assess Impact: Protein Availability (g) and Distribution
0
10
20
30
40
50
60
70
1-3h PreTraining
FuellingDuring
120m Ride
Recovery(<30min
PostTraining)
Recovery(1-2hrs
PostTraining)
Fuel Up(<30min
PreTraining)
FuellingDuring SCSession
Recovery(<30min
PostTraining)
Supper BedtimeSnack
Training Training
Assess Impact: Carbohydrate Availability (g/kg) and Distribution
0
0.5
1
1.5
2
1-3h PreTraining
FuellingDuring
120m Ride
Recovery(<30min
PostTraining)
Recovery(1-2hrs
PostTraining)
Fuel Up(<30min
PreTraining)
FuellingDuring SCSession
Recovery(<30min
PostTraining)
Supper BedtimeSnack
Training Training
2016 Off Season: Monitor – Educate - Build
(mm·kg-0.15)MTB Pre/In
Season
MTB Off
Season MTB Pre/In
Season
MTB Off
Season
Incorporate Physique Enhancement Tactics and Support Good Energy Availability
• Periodize macronutrients across the year
• Enhance tactical nutrition approaches for competition and training camps (altitude)
• Ongoing monitoring across the In-season
• Increase circle of support (Coach and IST members)
Nutrition Support: New Approach to YTP
Pre/In
Season
Off
Season
Pre/InSeason Off
Season
2016 20162017 2017
(mm·kg-0.15)
Nutrition Support: Monitoring Effects
0
2
4
6
8
0
1
2
3
4
01-S
ep-1
6
01
-Oct-
16
01
-No
v-1
6
01-D
ec-1
6
01
-Ja
n-1
7
01
-Fe
b-1
7
01-M
ar-
17
01
-Ap
r-1
7
01
-Ma
y-1
7
01-J
un-1
7
01
-Ju
l-17
01
-Au
g-1
7
LH and FSH
LH
FSH
40
60
80
100
120
01
-Sep
-16
01
-Oct-
16
01
-No
v-1
6
01
-De
c-1
6
01
-Jan
-17
01
-Fe
b-1
7
01
-Ma
r-1
7
01
-Apr-
17
01
-Ma
y-1
7
01
-Jun
-17
01
-Jul-
17
01
-Aug
-17
Estradiol - 17
2016 20172016 2017
(IU/L) (pmol/L)
Event Placement
Event 2016 2017
UCI MTB World U23 30 16
UCI MTB World Cup U23 1 10 DNS
UCI MTB World Cup U23 2 25 38
UCI MTB World Cup U23 3 32 35
Canada Cup Series (Elite) 13 1
National Championship (U23) 4 4
elephant pic / Blind
Paralympian: Hockey
• Men’s national team sledge hockey
• Paralympic and world championship medalist
• Goal: S4FS <55mm in 2 months
Anthropometry and Baseline DXA
• Use DXA to enhance observations
• Use lean mass to monitor EA
• Aim -1.0kg/wk (fat)
• Feb 16: Plan
• Weight: -3.1kg
• Lean mass stable
• Fat mass: -3.3kg
• Rate: -1.1kg/wk
• S4SF: -5.2mm
• Weight: -3.1kg
• Rate: -1.1kg/wk
• S4SF: -5.8mm
• S4SF: 54.4mm
• Target: <55.0mm
Summary
• Build trust and relationship
• Careful design
• Nutrition Support
Thank You!
Erik Sesbreno MSc (c), RD, CBDT, Dip Sport Nutrition IOCLead Sport Dietitian INS
Certified Bone Densitometry Technologist & ISAK level 3 Anthropometrist
647-457-8668