Relative Energy Deficiency in Sport (RED-S)

Relative Energy Deficiency in Sport (RED-S) is a condition that affects athletes when they do not consume enough energy to meet the demands of their training and competition. This can lead to a range of physical and mental health issues, impacting performance and overall well-being. Understanding RED-S is crucial for athletes, coaches, and health professionals to prevent its negative consequences and promote a healthier sports environment.

Key Takeaways

• RED-S is a condition that affects both male and female athletes.

• It can lead to serious health issues, including hormonal imbalances and decreased bone density.

• Awareness and education about RED-S are essential for prevention and early intervention.

• Coaches and trainers play a key role in monitoring athletes' energy intake and overall health.

• Ongoing research is needed to better understand RED-S and develop effective management strategies.

Understanding RED-S

Definition and Overview

Relative Energy Deficiency in Sport (RED-S) is a syndrome that happens when athletes don't get enough energy from their diet to support the energy they use during training and everyday life. It's more than just not eating enough; it's about the mismatch between energy intake and energy expenditure [1]. This energy deficiency messes with many body functions, affecting health and performance. It's important to spot RED-S early to avoid serious health problems [2].

Historical Context

RED-S is actually an update to the Female Athlete Triad. Originally, the Triad focused on the connection between energy availability, menstrual function, and bone health in female athletes. But, it became clear that energy deficiency affects male athletes too, and it impacts way more than just those three things. So, the International Olympic Committee came up with RED-S to show how widespread the effects of low energy can be [3]. It's a more complete way to look at the problem.

Physiological Implications

When an athlete has RED-S, lots of body systems can be affected. This includes:

• Metabolic rate

• Menstrual function

• Bone health

• Immunity

• Protein synthesis

• Cardiovascular health

Basically, when you don't have enough energy, your body starts shutting down or slowing down processes to save energy. This can lead to things like weaker bones, getting sick more often, and not being able to build muscle properly. It's a big deal for both health and athletic performance [4].

References

1. Mountjoy M, Sundgot-Borgen JK, Burke LM, Ackerman KE, Blauwet C, Constantini N, et al. IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. British Journal of Sports Medicine. 2018;52(11):687–97.

2 .Stellingwerff T, Morton JP, Burke LM. A Framework for Periodized Nutrition for Athletics. International Journal of Sport Nutrition and Exercise Metabolism [Internet]. 2019 Mar;29(2):141–51. Available from: https://journals.humankinetics.com/doi/full/10.1123/ijsnem.2018-0305

‌3. McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvořák J, Echemendia RJ, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sports Medicine [Internet]. 2013 Mar 11 [cited 2019 Oct 2];47(5):250–8. Available from: https://bjsm.bmj.com/content/47/5/250

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Prevalence Among Athletes

Gender Differences

It's interesting how RED-S doesn't play favourites; it affects both male and female athletes, but the way it shows up can be quite different. For female athletes, you often hear about the Female Athlete Triad, which involves energy deficiency, menstrual problems, and bone issues [1]. But, it's not just a female problem. Male athletes also face significant risks, though it might present differently, such as lower testosterone levels, reduced muscle mass, and also bone health problems [2].

Sports Most Affected

Certain sports seem to have a higher risk of RED-S, and it often boils down to the pressure to maintain a certain body type or weight. Endurance sports like long-distance running and cycling, weight-class sports such as wrestling and boxing, and aesthetic sports like gymnastics and dancing are particularly risky [3]. In these sports, athletes might feel pressured to restrict their diet to improve performance or meet certain appearance standards, which can then lead to RED-S. It's not just about dieting, though; overtraining without enough fuel can also cause problems, no matter the sport.

Demographic Considerations

RED-S doesn't discriminate when it comes to age, level of competition, or background. However, younger athletes might be more at risk because they're still growing and developing, so any energy deficiency can really mess with that [4]. Also, athletes at any level, from amateur to elite, can be affected. It's easy to think that only elite athletes face these pressures, but that's not the case. Even recreational athletes who are super focused on their performance or body image can develop RED-S. Different cultural or socioeconomic backgrounds can also play a role, influencing attitudes towards food, body weight, and training habits.

It's important to remember that RED-S is complex, and there's no one-size-fits-all explanation. A combination of factors, including sport-specific pressures, individual psychology, and social environment, all contribute to the risk.

References:

1. Torstveit, M. K., & Sundgot-Borgen, J. (2005). The female athlete triad: are elite athletes at increased risk? Medicine and Science in Sports and Exercise, 37(2), 184–193.

2. Hoch AZ, Pajewski NM, Moraski L, Carrera GF, Wilson CR, Hoffmann RG, et al. Prevalence of the female athlete triad in high school athletes and sedentary students. Clinical Journal of Sport Medicine: Official Journal of the Canadian Academy of Sport Medicine [Internet]. 2009 Sep 1;19(5):421–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19741317

3. ‌BBC News. (2018). The athletes starved themselves for success. BBC News.

4. Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, et al. The IOC Consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine. 2014 Mar 11;48(7):491–7.

Symptoms and Consequences

Physical Health Effects

When athletes don't get enough energy from their diet to match their activity levels, it can mess with their bodies in many ways. This energy imbalance, at the heart of RED-S, can lead to a cascade of physical health problems [d9e8].

• Metabolic Rate: The body might slow down its metabolism to conserve energy, which can make it harder to lose or maintain weight. It's like the body is trying to survive on less fuel.

• Bone Health: Low energy availability can mess with bone density, increasing the risk of stress fractures and osteoporosis. Bones need enough nutrients to stay strong, and RED-S can rob them of that.

• Cardiovascular Health: There can be heart problems, including issues with how the heart functions and its rhythm. The heart needs enough energy to pump efficiently.

• Immune System: The immune system can weaken, making athletes more prone to illness and infections. A body under stress from RED-S can't defend itself as well.

Psychological Impact

RED-S isn't just about the body; it hits the mind too. The psychological impact can be significant, affecting an athlete's mental well-being and performance. Low energy availability can lead to:

• Mood Changes: Increased irritability, anxiety, and depression are common. It's tough to feel good when your body is running on empty.

• Decreased Concentration: It can be hard to focus and make decisions, which is bad news for training and competition. The brain needs fuel to work well.

• Eating Disorders: RED-S can sometimes be linked to disordered eating patterns or full-blown eating disorders. It's a complex relationship, but energy deficiency can play a big role.

Athletes might feel pressure to maintain a certain body weight or composition, leading to unhealthy behaviours. This pressure, combined with the physical stress of training, can create a perfect storm for mental health issues.

Long-term Health Risks

Ignoring RED-S can lead to some serious long-term health problems. It's not just about short-term performance dips; it's about the future health of the athlete. These risks include:

• Reproductive Health: In women, irregular or absent periods (amenorrhoea) can lead to fertility problems and other hormonal imbalances. In men, it can affect testosterone levels and sperm production.

• Bone Health: Long-term bone loss can increase the risk of fractures later in life. Building strong bones early is important, and RED-S can mess that up.

• Cardiovascular Disease: There's a higher risk of heart problems down the road. Taking care of your heart early is key, and RED-S can put it at risk.

| Long-Term Risk | Description * Long-term health risks [d9e8] can include cardiovascular issues and decreased bone density.

Diagnosis and Assessment

Clinical Evaluation

Clinicians typically begin by taking a detailed history and conducting a thorough physical examination. They gather information on dietary intake, training load and general well-being to detect signs suggestive of energy deficiency. A full clinical evaluation involves not only physical assessments but also discussions about lifestyle and nutritional habits [1]. This practical approach allows practitioners to spot early warning signs that might otherwise be ignored [2].

Diagnostic Criteria

When it comes to establishing a diagnosis, practitioners rely on clear diagnostic criteria. This usually includes comparing energy intake with expenditure, checking hormonal profiles, and evaluating bone density through tests. Regular laboratory tests and body mass index measurements contribute to determining whether an athlete meets the criteria for RED-S. In this setting, lab testing also provides objective evidence to support clinical findings [3]. The criteria help in distinguishing this condition from other similar disorders by adhering to established guidelines in sports medicine [3].

Role of Screening Tools

Screening tools are an important component in identifying athletes who may be at risk before more serious health issues manifest. These tools generally include a range of assessments outlined below:

• A detailed self-report questionnaire focusing on dietary and physical activity habits.

• Functional fitness tests that measure strength and endurance.

• Psychological assessments aimed at evaluating mental well-being.

A small table summarises some common screening components:

Screening Tool	Purpose	Reference
Dietary Questionnaire	Assess caloric intake and timing	[3]
Functional Fitness Testing	Measure musculoskeletal strength and endurance	[4]
Psychological Inventory	Evaluate stress levels and mental fatigue	[4]

When screening tools highlight potential concerns, this early detection is a key factor that can prompt further detailed assessments and timely intervention [2].

Overall, combining clinical evaluations, established diagnostic criteria, and accessible screening tools creates a robust framework for diagnosing RED-S in a sporting context [1, 2, 3, 4].

Management Strategies

Alright, so you've figured out someone's got RED-S. What's next? It's not a quick fix, but a bunch of things working together. Think of it as getting a car back on the road – you need fuel, the engine needs to be okay, and the driver needs to know where they're going.

Nutritional Interventions

First up, nutrition. It's not just about calories but about getting the right stuff in. We need to look at their diet and see if they're getting enough energy, especially carbohydrates, to match what they're doing. It's about modifying the fuelling strategy and training load. Sometimes, people think they're eating enough, but it's not the right balance assessment of RED-S. It's like putting diesel in a petrol engine – won't work, will it?

• Increase overall energy intake to match energy expenditure.

• Ensure adequate carbohydrate intake, especially around training.

• Optimise macronutrient ratios to support training and recovery.

Psychological Support

RED-S isn't just physical; there's a mental side too. Athletes might have issues with body image, or maybe they're pushing themselves too hard because of pressure. Talking to someone – a therapist or counsellor – can help. It's about finding a way to deal with the stress and change their mindset. It's like having a sat nav for your brain – guiding you in the right direction.

It's important to create a safe space where athletes feel comfortable talking about their struggles. Encouraging open communication can help them address underlying issues and develop healthier coping mechanisms.

Coaching and Education

Coaches and trainers need to be clued up about RED-S. They're the ones who see the athletes every day, so they can spot the early signs and help prevent things from getting worse. Education is key – making sure everyone knows what RED-S is, what the risks are, and what to do about it. It's like giving everyone a first-aid kit – they know what to do in an emergency. Modifying the fuelling strategy and training load is important. It's about creating a supportive environment where athletes can thrive without pushing themselves to breaking point.

Research and Future Directions

Current Studies

Research into Relative Energy Deficiency in Sport (RED-S) is constantly evolving. Current studies are focusing on several key areas. One major area is improving our understanding of the long-term health consequences of RED-S, particularly concerning bone health, cardiovascular function, and mental well-being [1]. Another focus is on developing more sensitive and specific diagnostic criteria to aid in early detection. There's also a push to explore the effectiveness of different intervention strategies, including nutritional, psychological, and exercise-based approaches, to find the best ways to support athletes recovering from RED-S. Finally, researchers are investigating the prevalence of RED-S in various sports and athlete populations to better understand the scope of the problem.

Emerging Trends

Several emerging trends are shaping the future of RED-S research. One is the increasing use of technology, such as wearable sensors and mobile apps, to monitor athletes' energy balance and identify those at risk. Another trend is the growing recognition of the importance of a multidisciplinary approach to RED-S, involving collaboration between sports medicine physicians, nutritionists, psychologists, coaches, and athletes themselves. There's also a growing interest in personalised interventions, tailored to the individual athlete's needs and circumstances. The role of the gut microbiome in energy regulation and overall health is also an area of increasing interest [2].

Need for Further Research

Despite significant progress, there's still a considerable need for further research into RED-S. Key areas that require more attention include:

• Developing more effective screening tools to identify athletes at risk.

• Conducting longitudinal studies to fully understand the long-term health consequences of RED-S.

• Investigating the impact of RED-S on different athlete populations, including para-athletes and masters athletes.

• Exploring the role of genetics and other individual factors in susceptibility to RED-S.

• Developing and evaluating interventions to prevent RED-S in young athletes [3].

Further research should focus on translating research findings into practical strategies that can be implemented by coaches, trainers, and athletes to promote energy balance and prevent RED-S [4]. This includes developing educational resources, implementing policy changes, and creating supportive environments that prioritise athlete health and well-being.

Preventive Measures in Sport

Education and Awareness

Raising awareness about RED-S is the first step in prevention. Athletes, coaches, parents and medical staff need to understand what RED-S is, how it develops, and what the potential consequences are. This can be achieved through workshops, seminars, and the distribution of educational materials. It's about creating a culture where athletes feel comfortable discussing their energy balance and seeking help when needed.

Education should cover the importance of adequate fuelling, not just for performance, but also for overall health. It should also address the dangers of excessive training and restrictive dieting.

Policy Changes

Sports organisations can play a big role by implementing policies that protect athlete health. This includes things like regular screening for RED-S risk factors and guidelines for safe training loads. Policies might also address weight-related pressures and promote a more balanced approach to nutrition and body image. For example, some sports are moving away from weigh-ins or focusing less on body composition [1].

Here are some potential policy changes:

• Mandatory education for coaches and athletes

• Guidelines for training load management

• Access to registered dietitians and sports psychologists

• Confidential reporting mechanisms for suspected RED-S cases

Role of Coaches and Trainers

Coaches and trainers are often the first point of contact for athletes, so they're in a great position to spot early warning signs of RED-S. They need to be educated on how to identify athletes at risk and how to approach the subject sensitively. It's also important for them to understand their limitations and know when to refer an athlete to a medical professional [2]. Coaches should promote a healthy training environment that prioritises athlete well-being over short-term performance gains [3, 4].

References:

1. Mountjoy M, Sundgot-Borgen J, Burke L, Ackerman KE, Blauwet C, Constantini N, et al. International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update. International Journal of Sport Nutrition and Exercise Metabolism. 2018 Jul 1;28(4):316–31.

2. Mountjoy M, Sundgot-Borgen J, Burke L, Ackerman KE, Blauwet C, Constantini N, Lebrun C, Lundy B, Melin A, Meyer N, Sherman R. International Olympic Committee (IOC) consensus statement on relative energy deficiency in sport (RED-S): 2018 update. International journal of sport nutrition and exercise metabolism. 2018 Jul 1;28(4):316-31.

3. Nicholls AR, Madigan DJ, Backhouse SH, Levy AR. Personality traits and performance enhancing drugs: The Dark Triad and doping attitudes among competitive athletes. Personality and Individual Differences. 2017 Jul 1;112:113-6.

4. Currie A. Sport and eating disorders - understanding and managing the risks. Asian J Sports Med. 2010 Jun;1(2):63-8. doi: 10.5812/asjsm.34864. PMID: 22375193; PMCID: PMC3289170

In conclusion, understanding Relative Energy Deficiency in Sport (RED-S) is essential for athletes, coaches, and health professionals alike. This condition, which can affect both male and female athletes, highlights the importance of maintaining a proper balance between energy intake and expenditure. Ignoring the signs of RED-S can lead to serious health issues, including hormonal imbalances, decreased bone density, and impaired performance. It is crucial to promote awareness and education around this topic, ensuring that athletes receive the support they need to maintain their health while pursuing their sporting goals. By fostering a culture that values overall well-being over mere performance, we can help prevent RED-S and its associated risks.

Frequently Asked Questions

What is RED-S?

Relative Energy Deficiency in Sport (RED-S) happens when athletes do not eat enough food to match the energy they use. This can affect both men and women, and it leads to various health issues.

Who is affected by RED-S?

RED-S can affect anyone who is very active, but it is especially common in athletes, particularly those in sports that focus on being lean or light.

What are the signs of RED-S?

Some signs of RED-S include feeling tired all the time, having irregular periods in women, and getting injured more often. It can also lead to problems with bones and heart health.

How is RED-S diagnosed?

Doctors diagnose RED-S through a combination of talking about symptoms, checking medical history, and sometimes using tests to measure energy levels and other health factors.

What can be done to manage RED-S?

Managing RED-S often includes improving nutrition, getting support for mental health, and educating athletes about healthy practises in sports.

How can RED-S be prevented?

Preventing RED-S involves educating athletes on the importance of proper nutrition, encouraging open conversations about health, and ensuring that coaches support healthy body images.