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2023 International Olympic Committee’s (IOC) Consensus Statement on Relative Energy Deficiency in Sport (REDs)

Abstract

  • Relative Energy Deficiency in Sport (REDs) introduced in 2014 identifies a syndrome impacting both male and female athletes, resulting from Low Energy Availability (LEA) due to inadequate energy intake relative to exercise energy expenditure.
  • The field has advanced significantly since the 2018 REDs consensus, with over 170 original research publications, highlighting issues such as the role of low carbohydrate availability, mental health interplay, and LEA impacts on males.
  • New Health and Performance Models developed to understand complex outcomes from LEA exposure.
  • A Novel REDs Clinical Assessment Tool-Version 2 (IOC REDs CAT2) has been developed to improve detection and diagnosis of REDs with training and competition recommendations.
  • Guidelines for body composition assessment to prevent REDs outlined.
  • Methodological best practices for REDs research mentioned to encourage future studies.

Introduction

  • Athletes often face pressures affecting energy intake (EI) and exercise energy expenditure (EEE), leading to LEA.
  • Energy Availability (EA) calculated using the formula: EA = rac{EI - EEE}{FFM} Where:
    • EA: Energy Availability
    • EI: Energy Intake (kcal)
    • EEE: Exercise Energy Expenditure (kcal)
    • FFM: Fat-Free Mass (kg/day)
  • Various scenarios including extreme EEE and desire for leaner physiques can lead to LEA, resulting in REDs implications.

What is REDs?

  • Defined as a syndrome of physiological and/or psychological impairments arising from prolonged problematical LEA:
    • Includes negative health implications like decreased metabolism, reproductive function, musculoskeletal health, immunity, glycogen synthesis, cardiovascular health.
    • Can result individually or synergistically in decreased performance and increased injury risk.

Definitions Box 1

  • Energy Availability (EA): Dietary energy left for body function after accounting for exercise energy.
    EA = rac{(EI - EEE)}{FFM} ext{ (kcal/kg FFM/day)}
  • Low Energy Availability (LEA): Any mismatch between EI and EEE that compromises body’s energy needs, impacting health and performance.
  • Adaptable LEA: Temporary reductions leading to benign physiological adaptations.
  • Problematic LEA: Persistent reductions leading to adverse health impacts and performance impairments.

Moderating Factors

  • Factors that can affect the outcome of LEA exposure including gender, age, and genetics.

Methodology and Consensus Results

  • Consensus Methodology: Using RAND-UCLA Appropriateness Method (RAM) with a diverse group of experts discussing, voting, and validating statements to achieve consensus on REDs.
  • Three levels of agreement established:
    1. Agreement: ≥80% agree without disagreement.
    2. Agreement with minority disagreement: ≥80% agree but with some disagreement.
    3. Disagreement: <80% agree.

Key Scientific Advances Since the 2018 REDs Consensus Statement

  • Emerging themes include:
    1. Combined effects of low carbohydrate availability (LCA) and LEA.
    2. Overlapping symptoms of REDs and Overtraining Syndrome (OTS).
    3. Understanding time-course effects of LEA in developing REDs outcomes.
    4. Mental health associations with REDs.
    5. Increased knowledge regarding REDs in male and para athletes.

The Magnifying Impact of LCA

  • Several interventions show that LCA worsens REDs outcomes even in absence of LEA, leading to detrimental consequences on bone health, immunity, and biochemical markers.

Mental Health Outcomes of REDs

  • Prioritization of mental health in sports; awareness of REDs as a contributing factor has risen along with discussions around the psychological risk factors associated with LEA.

REDs in Male and Para Athletes

  • Growing awareness that males can also suffer from REDs, often misrecognized or studied less, while parasport athletes may experience greater pressures leading to LEA.

REDs Conceptual Models

  • Newly developed models focus on:
    • Health outcomes and performance issues arising from various degrees of LEA exposure.
    • A model that integrates physiological responses and moderating factors.

Clinical Applications

  • Assessment of EA:
    • Risk zones established, guiding practitioners in identifying athletes at risk for health deterioration due to LEA.
  • Body composition assessments should be medical, focusing on health rather than aesthetic pressures.

IOC REDs Clinical Assessment Tool-Version 2 (IOC REDs CAT2)

  • A new, validated tool for assessing the severity and risk of REDs using a three-step process, allowing for stratification from green (healthy) to red (critical).
  • Recommended approaches for treatment and management identified, focusing on restoration to optimal EA.

Prevention and Treatment of REDs

  • Primary prevention through education; focusing on nutrition knowledge among athletes and coaches, utilizing screening and intervention methods for early identification of REDs symptoms.
  • Tertiary prevention for diagnosed cases based on stratified severity.

Conclusion

  • This consensus statement captures significant advancements in REDs research including new operational frameworks and clinical tools for assessment, diagnosis, and management aimed at promoting athlete health and performance integrity.
  • Encouragement for stakeholders across the sports system to implement findings to protect athletes from REDs.