Relative Energy Deficiency in Sport (RED-S): Difference between revisions

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[[File:Health and Performance Implications of RED-S.png|thumb|Health and Performance Implications of RED-S]]'''Health implications''' are multi-system, affecting the endocrine, metabolic, skeletal, cardiovascular and immune systems; and in women, the menstrual cycle is disrupted. Not infrequently are also significant ramifications on the psychological state of the individual, given the prevalence of disordered eating in this population.
[[File:Health and Performance Implications of RED-S.png|thumb|Health and Performance Implications of RED-S]]'''Health implications''' are multi-system, affecting the endocrine, metabolic, skeletal, cardiovascular and immune systems; and in women, the menstrual cycle is disrupted. Not infrequently are also significant ramifications on the psychological state of the individual, given the prevalence of disordered eating in this population.


* Menstrual Dysfunction
* Menstrual Dysfunction - Stress and low energy availability cause suppression of the hypothalamic–pituitary–axis (HPA) and subsequent reduction in the volume of GnRH secreted from the hypothalamus<ref>Gordon, C., Ackerman, K., Berga, S., Kaplan, J., Misra, M., Murad, H., Santoro, N., Wareen, M. 2017. Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology and Metabolism. 102(5). Pp. 1413 – 1439. </ref>. As a result, the menstrual cycle is disrupted, in a condition called hypothalamic amenorrhea.The degree to which the HPG axis is affected, directly dictates the severity of menstrual dysfunction. For example, oligomenorrhea may develop into amenorrhea with further disuprtion to the HPA axis and reductions to GnRH, LH and FSH levels<ref>Koltun KJ, Williams NI, Scheid JL, De Souza MJ. Discriminating hypothalamic oligomenorrhea/amenorrhea from hyperandrogenic oligomenorrhea/amenorrhea in exercising women. Appl Physiol Nutr Metab. 2020 Jul;45(7):707-714. doi: 10.1139/apnm-2019-0640. Epub 2019 Dec 9. PMID: 31815525.</ref>
* Bone Health  
* Bone Health  
* Endocrine health
* Endocrine health
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* Immunological  
* Immunological  
* Psychological - This correlation between MCD and eating disorders has significant implications for psychological well-being, by potentially exacerbating low self-esteem, anxiety and depression (Nazem and Ackerman, 2012)  
* Psychological - This correlation between MCD and eating disorders has significant implications for psychological well-being, by potentially exacerbating low self-esteem, anxiety and depression (Nazem and Ackerman, 2012)  
'''Performance implications''' are significant and are the result of the negative influences on training adaptations, coordination, endurance performance, muscle strength, worsened concentration, irritability, impaired judgement, and the increased risk of injury.
'''Performance implications''' are significant and are the result of the negative influences on training adaptations, coordination, endurance performance, muscle strength, worsened concentration, irritability, impaired judgement, and the increased risk of injury.


Revision as of 10:07, 16 February 2023

Introduction[edit | edit source]

Relative Energy Deficiency in Sport (RED-S) (the updated model of the female athlete triad) was defined by the International Olympic Committee in 2014 as: ‘impaired physiological functioning caused by relative energy deficiency, and includes but is not limited to impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health’[1]

This term has replaced the female athlete triad as we are now aware that this syndrome impacts both female and male individuals experiencing low energy availability.

Glossary[edit | edit source]

  • Amenorrhea - An abnormal absence of menstruation[2]
  • Dysmenorrhea - Painful menstruation, typically involving abdominal cramps[2]
  • The Female Athlete Triad – The interrelationship of menstrual cycle dysfunction, reduced energy availability and reduced bone mineral density[3]
  • Hypomenorrhea – Abnormally light menstrual bleeding[4]
  • Menarche – ‘The occurrence of the first menstrual period in the female adolescent’ [5]
  • Menorrhagia – Heavy menstrual blood loss[6]
  • Menstrual cycle - The process of ovulation and menstruation[2]
  • Menstruation - The process of discharging blood and other material from the lining of the uterus at intervals of about one lunar month from puberty to the menopause, except during pregnancy[2]
  • Oligomenorrhea - Menstrual cycle length of greater than 45 days[7]
  • Osteopenia - A medical condition in which the protein and mineral content of bone is reduced, but less severely than in osteoporosis[2]
  • Relative Energy Deficiency in Sport (RED-S) - This is impaired physiological function including, but not limited to impairment of: metabolic rate; menstrual function; bone health; immunity; protein synthesis; and cardiovascular health, caused by energy deficiency[1]

Low Energy Availability (LEA)[edit | edit source]

LEA underpins RED-S, and is the instance in which there is a chronic mismatch between nutritional intake and energy expenditure, thus leaving insufficient energy available for essential physiological functions [1]. As a result, physiological functions are down-regulated in order to preserve energy for more essential functions and for movement, thus leading to detrimental health and performance implications for the athlete[8].

LEA may be intentional, with the athlete intentionally restricting their dietary intake, or unintentional, in which the athlete's nutrition simply does not meet the demand of their training load [8]. Whether the LEA is intentional or unintentional, there remain the same significant implications to the health and performance of the athlete, but it is essential to recognise which form of LEA an athlete may be suffering, as management for each differs.

  • Intentional LEA - the athlete is intentionally restricting their dietary intake to control body weight and/or body composition [9].This is more commonly seen in sports in which their is a weight category such as light-weight boxing and rowing due to the additional external pressure and emphasis on aesthetics or appearance [10].
    • Management - management is complex because relationship with food and psychology must be addressed. This requires a multidisciplinary team approach with medical, dietary and mental health support[11]
  • Unintentional LEA - the athlete is not meeting the demands of their sport, commonly during periods with increased training volume or when engaging in sports with high energy expenditure [8]
    • Management - this is easier to manage, and it may be sufficient to simply educate the patient on the nutritional demands of their training load

Prevalence of RED-S[edit | edit source]

The prevalence of RED-S is not well documented due to the inherent methodological difficulties in diagnosing true low energy availability. A narrative review conducted in 2020 found prevalence varies between sports, and ranges in the literature between 22-58%[12]. There is significant difficulty in estimating LEA due to the wide variety of methods used to estimate LEA, and therefore comparing data across studies proves challenging.

Additionally, the understanding of RED-S and its symptoms are poorly known by athletes and coaches, and therefore it is also not commonly recognised[12]. A further review identified that fewer than 50% of physicians, coaches, physiotherapists and athletic trainers could identify the triad components (Low energy availability +/- disordered eating, menstrual dysfunction, low bone mineral density)[1]. As a result, fewer cases will be recognised, diagnosed, and therefore highlighted as suffering from RED-S.

Health and Performance Implications of RED-S[edit | edit source]

Health and Performance Implications of RED-S

Health implications are multi-system, affecting the endocrine, metabolic, skeletal, cardiovascular and immune systems; and in women, the menstrual cycle is disrupted. Not infrequently are also significant ramifications on the psychological state of the individual, given the prevalence of disordered eating in this population.

  • Menstrual Dysfunction - Stress and low energy availability cause suppression of the hypothalamic–pituitary–axis (HPA) and subsequent reduction in the volume of GnRH secreted from the hypothalamus[13]. As a result, the menstrual cycle is disrupted, in a condition called hypothalamic amenorrhea.The degree to which the HPG axis is affected, directly dictates the severity of menstrual dysfunction. For example, oligomenorrhea may develop into amenorrhea with further disuprtion to the HPA axis and reductions to GnRH, LH and FSH levels[14]
  • Bone Health
  • Endocrine health
  • Metabolic implications
  • Cardiovascular implications
  • Gastrointestinal impact
  • Immunological
  • Psychological - This correlation between MCD and eating disorders has significant implications for psychological well-being, by potentially exacerbating low self-esteem, anxiety and depression (Nazem and Ackerman, 2012)

Performance implications are significant and are the result of the negative influences on training adaptations, coordination, endurance performance, muscle strength, worsened concentration, irritability, impaired judgement, and the increased risk of injury.

  • Adaptations associated with LEA are known to negatively influence muscular adaptations in both endurance and strength and power athletes. Endurance athletes, because of a negative impact on mitochondrial protein synthesis and strength, and power athletes, because of a negative impact on muscle protein synthesis. [8]

Red Flags for RED-S[edit | edit source]

The health and performance implications – cardiac abnormalities, recent weight loss, stress fractures, overuse injuries, anxiety/depression, oligomenorrhea/amenorrhea, poor concentration, restrictive eating, worsened performance, and body dysmorphia – are the red flags for RED-S.

Screening tools[edit | edit source]

  1. RED-S CAT - Relative Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT) https://bjsm.bmj.com/content/bjsports/49/7/421.full.pdf [15]
    • Can assess males and females
    • Assesses risk and return to play
    • Is a more functional model using a traffic light system
  2. LEAF-Q - Low Energy Availability in Females Questionnaire http://www.diva-portal.org/smash/get/diva2:1303041/FULLTEXT02.pdf [16]
    • High Sensitivity (78%) and specificity (90%)
    • For female athletes only

Management[edit | edit source]

Non-pharmacologic – When a patient is diagnosed with RED-S, the following management strategies should be implemented: education; optimising energy availability; modification of exercise and nutrition; supplementation of vitamin D and calcium; and CBT[1]. An MDT approach should be adopted, including mental health support. Sport participation may be used as leverage.

Pharmacologic – oral contraceptive is not recommended as it creates false menstruation or a ‘pseudo-period’. They are currently reviewing the use of recombinant parathyroid hormones and its role in improving bone mineral density [1]

RED-S in Men[edit | edit source]

Author and Affiliations[edit | edit source]

Catherine Stanislas

Physiotherapist at Isokinetic Medical Centre, Harley Street

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Mountjoy, M., Sundgot-Borgen, J., Burke, L. M., Carter, S., Constantini, N., Lebrun, C., ... Ljungqvist, A. (2014). The IOC consensus statement: beyond the female athlete triad--relative energy deficiency in sport (red-s). British Journal of Sports Medicine, 48(7), 491–497. https://doi.org/10.1136/bjsports-2014-093502
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Ferin, M., Jewelewicz, R., Warren, M. (1993) The Menstrual cycle. Oxford: Oxford University Press (pp. 186-187)
  3. ↑ Nazem and Ackerman, 2012. The Female Athlete Triad. Sports Health. 4(4). [Online].
  4. ↑ Yaffe, H., Ron, M., Polishuk, W. Amenorrhea, Hypomenorrhea, and Uterine Fibrosis. American Journal of Obstetrics and Grynaecology. 130(5): 599-601
  5. ↑ Lacroix, A., Gondal, H., Langaker, M., 2020. Physiology, Menarche. StatPearls Publishing. Treasure Island (FL)
  6. ↑ National Institute for Health and Care Excellence 2018. Menorrhagia: What is it? Clinical Knowledge Summaries
  7. ↑ Riaz Y, Parekh U. Oligomenorrhea. [Updated 2022 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560575/
  8. ↑ 8.0 8.1 8.2 8.3 Wasserfurth, P., Palmowski, J., Hahn, A. et al. Reasons for and Consequences of Low Energy Availability in Female and Male Athletes: Social Environment, Adaptations, and Prevention. Sports Med - Open 6, 44 (2020). https://doi.org/10.1186/s40798-020-00275-6
  9. ↑ Burke L, Lundy B, Fahrenholtz L et al, & Melin. Pitfalls of conducting and interpreting estimates of energy availability in free-living athletes. International Journal of Sport Nutrition and Exercise Metabolism2018; 28(4):350–363
  10. ↑ Gillbanks L, Mountjoy M, Filbay SR. Lightweight rowers' perspectives of living with Relative Energy Deficiency in Sport (RED-S). PLoS One. 2022 Mar 17;17(3):e0265268. doi: 10.1371/journal.pone.0265268. PMID: 35298499; PMCID: PMC8929546.
  11. ↑ De Souza, M. J., Williams, N. I., Nattiv, A., Joy, E., Misra, M., Loucks, A. B., ... Rauh, M. J. (2014). Misunderstanding the female athlete triad: refuting the IOC consensus state- ment on relative energy deficiency in sport (red-s). British Journal of Sports Medicine, 48(1461–1465), 1461–1465. https://doi.org/10.1136/bjsports-2014-093958
  12. ↑ 12.0 12.1 Logue DM, Madigan SM, Melin A, Delahunt E, Heinen M, Donnell SM, Corish CA. Low Energy Availability in Athletes 2020: An Updated Narrative Review of Prevalence, Risk, Within-Day Energy Balance, Knowledge, and Impact on Sports Performance. Nutrients. 2020 Mar 20;12(3):835. doi: 10.3390/nu12030835. PMID: 32245088; PMCID: PMC7146210.
  13. ↑ Gordon, C., Ackerman, K., Berga, S., Kaplan, J., Misra, M., Murad, H., Santoro, N., Wareen, M. 2017. Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology and Metabolism. 102(5). Pp. 1413 – 1439.
  14. ↑ Koltun KJ, Williams NI, Scheid JL, De Souza MJ. Discriminating hypothalamic oligomenorrhea/amenorrhea from hyperandrogenic oligomenorrhea/amenorrhea in exercising women. Appl Physiol Nutr Metab. 2020 Jul;45(7):707-714. doi: 10.1139/apnm-2019-0640. Epub 2019 Dec 9. PMID: 31815525.
  15. ↑ Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A, Ackerman K. RED-S CAT. Relative Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT). Br J Sports Med. 2015 Apr;49(7):421-3. doi: 10.1136/bjsports-2015-094873. PMID: 25896450.
  16. ↑ Melin A, Tornberg ÅB, Skouby S, et al. The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad. British Journal of Sports Medicine 2014;48:540-545.
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