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Relative Energy Deficiency in Sport

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Relative Energy Deficiency in Sport, RED-S

  • See Also
  1. Female Athlete Triad
  • Definitions
  1. Relative Energy Deficiency in Sport (RED-S)
    1. Relative energy deficiency
    2. Results in impaired physiologic functioning
      1. Impaired metabolic rate, Protein synthesis
      2. Amenorrhea or Oligomenorrhea
      3. Impaired cardiovascular health
      4. Low Bone Mineral Density
  • Background
  1. Female Athlete Triad was originally defined by American College of Sports Medicine (1984)
    1. Disordered Eating
    2. Amenorrhea
    3. Premature Osteoporosis
  2. International Olympic Committee renamed Female Athlete Triad as RED-S (2014)
    1. Relative energy deficiency
    2. Results in impaired physiologic functioning affecting multiple systems beyond original definition
      1. Impaired metabolic rate, Protein synthesis
      2. Amenorrhea or Oligomenorrhea
      3. Impaired cardiovascular health
      4. Low Bone Mineral Density
    3. Associated with multi-system complications
      1. See below
  • Epidemiology
  1. More common in female gender, but also occurs in males
  • Risk Factors
  1. Eating Disorder (e.g. Anorexia Nervosa)
  2. Sport type
    1. Judged sports (appearance, aesthetics)
    2. Weight category sports
    3. Endurance sports
  • Pathophysiology
  1. Low energy availability
  2. Dietary Energy Intake is insufficient for Energy Expenditure needs (given sports activity)
  • Evaluation
  • Screening
  1. Low Energy Availability in Females Questionnaire (LEAF-Q)
  2. RED-S Low Risk Criteria (Green)
    1. Appropriate BMI and body habitus
    2. Appropriate energy availability and healthy eating
    3. Normal cardiovascular exam
    4. Normal mood and affect
    5. Normal Menstrual Cycles (may be altered by contraceptives)
    6. Healthy bone density for cohort (Z-Score) without recurrent Stress Fractures
    7. Healthy musculoskeletal system without frequent or persistent injury
  3. RED-S Moderate Risk Criteria (Yellow)
    1. Significant recent weight loss (5 to 10% of BMI) or prolonged low BMI
    2. Low energy availability or disordered eating that is severe or prolonged
      1. Associated physical complications of disordered eating
    3. Abnormal Menstrual Cycle
      1. No Menarche by age 15 years
      2. Functional Hypothalamic Amenorrhea >3 months
    4. Stress Fractures (at least one) due to endocrine dysfunction or low energy availability
    5. Decreased bone density by DEXA Scan (Z-Score <1 S.D. or decreased from prior)
    6. Disordered eating refractory to management or impacting other team members
  4. RED-S High Risk Criteria (Red)
    1. Anorexia Nervosa or other serious condition related to low energy availability
    2. Extreme weight loss techniques
  • Signs
  1. Decreased glycogen stores
  2. Decreased Motor Strength
  3. Decreased endurance Exercise performance
  4. Increased Musculoskeletal Injury risk
  5. Fatigue and difficult recovery from Exercise
  6. Impaired concentration, judgement and coordination
  7. Increased irritability and depressed mood
  • Differential Diagnosis
  1. Endocrine abnormalities (e.g. Hypothyroidism, Adrenal Insufficiency)
  2. Female Athlete Triad (similar syndrome with overlapping definition, preceded RED-S Definition)
  3. Eating Disorder
  • Management
  1. Multi-disciplinary team
    1. Sports medicine provider
    2. Sports dietician and nutritionist
    3. Sports psychologist
  2. Goals
    1. Restore balance between Caloric Intake and expenditure
  3. Treatment Plan (expectations for continued sports participation)
    1. Regular follow-up
    2. Meal Plan adherence
    3. Individualized weight gain plan adherence
  4. Return-To-Play
    1. RED-S Low Risk (Green)
      1. Full sports participation without restriction
    2. RED-S Moderate Risk (Yellow)
      1. May continue to train as long as following above treatment plan
      2. May compete under supervision if medically cleared
    3. RED-S High Risk (Red)
      1. No competition or training
      2. Follow treatment plan as above (under a written contract signed by patient)
      3. Adherence to a minimum BMI
  5. Other measures
    1. Antidepressant use is limited to typical indications for psychiatric conditions (e.g. Major Depression)
    2. Oral Contraceptives are not recommended to correct Menstrual Cycles
      1. Does not correct the underlying energy deficiency, and masks the endocrinopathy
  • Resources
  1. Dietary Analysis Tool for Athletes
    1. https://www.gssiweb.org/docs/default-source/education-resources/toolbox/gssi-dietary-analysis-tool-for-athletes.pdf?sfvrsn=14
  2. Athlete Diet Index (University of Sidney)
    1. https://sportsnutritionassessment.com/adi/
  • References
  1. MacDonald (2021) Am Fam Physician 103(9): 539-46 [PubMed]
  2. Mountjoy (2015) Br J Sports Med 49(21): 1354 [PubMed]
  3. Wojnowich (2022) Am Fam Physician 106(1): 52-60 [PubMed]