Notes on Relative Energy Deficiency in Sport (RED-S) and Disordered Eating

Relative Energy Deficiency in Sport (RED-S)

  • Definition: RED-S is a condition characterized by impaired physiological function and encompasses various health issues related to insufficient energy availability (EA).

  • Background:

    • 2005: The International Olympic Committee (IOC) defines the Female Athlete Triad, which includes disordered eating, irregular menstrual cycles, and low bone mineral density.

    • 2007: The American College of Sports Medicine (ACSM) redefines the triad focusing on the interplay between energy availability, menstrual function, and bone health.

    • 2014: The term RED-S is established to encompass a broader range of health implications, including metabolic rate, immunity, and cardiovascular function.

Energy Availability (EA)

  • Calculation:

    • Formula: EA = EI - EEE

    • Where EI = Energy intake (kcals)

    • EEE = Exercise energy expenditure (kcals)

    • Fat Free Mass (FFM) = Weight of the body minus fat.

    • Optimal EA: 45 ext{ kcal/kg FFM/day}

    • Low EA Cutoff: < 30 ext{ kcal/kg FFM/day}

Consequences of Low Energy Availability (LEA)

  • Physical Effects:

    • Reduced muscle strength and endurance performance.

    • Increased risk of injuries.

    • Decreased glycogen stores, which may negatively affect athletic performance and recovery.

    • Poor recovery between training sessions and chronic fatigue.

  • Psychological Effects:

    • Increased irritability and depression.

    • Reduced concentration and coordination leading to impaired judgment.

  • Menstrual Function:

    • Regular cycles (Eumenorrhea) occur every 21-35 days.

    • Amenorrhea:

    • Primary: No menarche by age 15.

    • Secondary: Absence of 3 consecutive cycles post-menarche.

    • Oligomenorrhea: Cycle lengths greater than 45 days.

Health Implications of RED-S

  • Bone Health:

    • Low EA is linked to altered bone structure and increased risk of stress fractures, particularly affecting males and females equally.

    • Peak bone mass is achieved at ~19 years (females) and ~20.5 years (males).

  • Endocrine Disruption:

    • Hormonal imbalances lead to decreased testosterone in men and altered hypothalamic-pituitary-gonadal axis in women.

  • Immunological Effects:

    • Increased incidence of upper respiratory infections and gastrointestinal issues due to reduced immune response.

Disordered Eating Patterns Among Athletes

  • Prevalence:

    • Significant rates of disordered eating in athletes, particularly in sports that emphasize leanness (e.g., gymnastics, dance).

    • It affects 13-20% of female athletes and 3-8% of male athletes.

  • Types of Disorders:

    1. Anorexia Nervosa:

    • Characterized by severe caloric restriction and distorted body image.

    1. Bulimia Nervosa:

    • Recurrent binge eating followed by compensatory behaviors (vomiting, laxatives).

    1. Binge Eating Disorder:

    • Binge eating without compensatory behavior.

Screening and Treatment

  • Screening:

    • Use tools like LEAF-Q (for females) and BEDA-Q (shorter & not gender-specific).

    • Important identifiers include changes in menstrual cycles, preoccupation with food, and signs of hormonal disruption.

  • Treatment Approach:

    • Increase energy intake to stabilize EA above 45 kcal/kg FFM.

    • Decrease excessive exercise output.

    • Multidisciplinary teams are crucial, including physicians, registered dietitians, and mental health professionals.

Prevention Strategies

  • Raising Awareness:

    • Normalize menstrual regularity and educate about the effects of low EA on performance and overall health.

  • Resources Available: Websites like #Trainbrave and SCAN for guidance and support.

Key Takeaway

  • RED-S is a multi-faceted issue that affects both male and female athletes, emphasizing the importance of energy availability, monitoring, and a comprehensive approach to treatment and prevention. Regular assessment and education can mitigate the risks associated with low energy availability and promote sustainable athletic performance across all sports.

Components of Female Athlete Triad

The Female Athlete Triad includes three interrelated components:

  1. Disordered Eating: Involves unhealthy eating behaviors including extreme dieting, restrictive eating, and binge eating.

  2. Menstrual Dysfunction: Irregular menstrual cycles, including amenorrhea (absence of menstruation) or oligomenorrhea (infrequent periods).

  3. Low Bone Mineral Density: Decreased bone strength leading to increased risk of fractures.

Female Athlete Triad vs. RED-S

  • Female Athlete Triad focuses on three main components.

  • RED-S (Relative Energy Deficiency in Sport) expands on this by addressing the broader systemic effects of low energy availability on metabolic rate, immunity, cardiovascular health, and psychological well-being.

Calculating Energy Availability (EA)

  • Formula: EA = EI - EEE

    • EI = Energy intake (kcals)

    • EEE = Exercise energy expenditure (kcals)

  • Optimal Energy Availability: 45 \text{ kcal/kg FFM/day}

  • Low Energy Availability Cutoff: < 30 \text{ kcal/kg FFM/day}

Low EA Effects on Hormones

  • For Females: Low EA can lead to hormonal imbalances, particularly affecting the menstrual cycle and overall hormone regulation.

  • For Males: Reduced testosterone levels and irregularities in hormone secretion can occur due to low EA.

Low EA Effect on Menstrual Function

  • Normal Menstrual Function: Regular cycles (Eumenorrhea) occur every 21-35 days.

  • Low EA can contribute to menstrual dysfunction, leading to primary or secondary amenorrhea along with other irregularities.

Low EA Effect on Bone Health

  • Low EA is linked to diminished bone mineral density, consequently increasing the risk of stress fractures in both male and female athletes.

Low EA Effect on Metabolism, Immune System, and GI System

  • Disruption of metabolic rate and energy balance, leading to fatigue and poor athletic performance.

  • Increased vulnerability to infections and gastrointestinal issues, due to compromised immune function.

Low EA Effect on Psychology

  • Psychological impacts include increased anxiety, depression, irritability, and a decline in concentration and cognitive function.

Disordered Eating vs. Eating Disorders

  • Disordered Eating: General term for a range of harmful eating behaviors.

  • Eating Disorders: Clinically diagnosed conditions like Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder.

Defining Characteristics of Eating Disorders

  1. Anorexia Nervosa: Severe caloric restriction, intense fear of gaining weight, distorted body image.

  2. Bulimia Nervosa: Episodes of binge-eating followed by compensatory actions such as vomiting or using laxatives.

  3. Binge Eating Disorder: Frequent episodes of eating large amounts of food without purging behaviors.

Risk Factors for Low EA & Disordered Eating/Eating Disorders

  • Factors can include pressure to maintain low weight, the emphasis on leanness in certain sports, and psychological factors such as low self-esteem.

Considerations for Return to Play after RED-S Diagnosis

  • Evaluate physical recovery, stabilization of energy availability, and psychological support prior to resuming athletic activities.

  • Emphasize a multidisciplinary approach for a safe return to sport, including support from healthcare professionals, nutritionists, and psychologists.