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Relative Energy Deficiency in Sport

(RED-S)

Erik Sesbreno MSc (c), RD, CBDT, Dip Sport Nutrition IOC

Lead Sport Dietitian at INS

Certified Bone Densitometry Technologist & ISAK level 3 Anthropometrist

Disclosure

• I, Erik Sesbreno, have no actual or potential conflict of interest in relation to this

program/presentation.

RED-S

History & Definition

Physiological Disruptions

Performance & Injuries

Screening

Treatment

Return to Play

Female Athlete Triad

2005 – IOC Consensus Statement

…”combination of disordered eating and irregular

menstrual cycle eventually leading to a decrease on

hormones resulting in low bone mineral density (BMD)”

2007 – AMERICAN COLLEGE OF SPORT MEDICINE

• …”relationship between three inter-related

components: energy availability (EA), menstrual

function and bone health”

Female Athlete Triad

• Introduced by the IOC expert working group in 2014

• Replaces “Female Athlete Triad”

• Greater complexity

• Male athletes are affected

Relative Energy Deficiency in Sports

Considerations: Energy Availability

Mountjoy, et al., 2014

Considerations: Energy Availability

Mountjoy, et al., 2014

Estimating Energy Availability

• Energy Availability (EA)

= Energy Intake (kcal) - Energy Cost of Exercise (kcal)

Fat Free Mass (kg)

• In healthy adults, 45 kcal/ kg FFM per

• Low EA causes adjustments to body systems

– Disruptions to hormonal, metabolic and functional characteristics

RED-S

History & Definition

Physiological Disruptions

Performance & Injuries

Screening

Treatment

Return to Play

Hormonal Disruptions

EA 45kcal/kg FFM/d vs EA 10kcal/kg FFM/d

• Low EA reduced LH pulse frequency by 10% (p <0.01) and

• Low EA increased LH pulse amplitude by 36%(P = 0.05)

• The stress of exercise neither reduced LH pulse frequency nor increase LH pulse amplitude (all p>0.4)

Loucks et al., 1998

Hormonal Disruptions

Endocrine Alterations

Endocrine Alterations

Loucks et al., 1994

ANOVA (threshold) model (solid line)

- p < 000001; R^2 (threshold)

- 61%

ANOVA (threshold) model (solid line)

- p < 004; R^2 (threshold)

- 29%

Metabolic Alterations

• Energy intake = 2770 kcal day

• Exercise energy expenditure = 840 kcal day

• Energy availability = 30 kcal kg FFM/day)

were constant

• Magnitude of “-“ E balance decreased

• Rate -90kcal/d

• May have recovered 0 E balance in 3 weeks

Effects on Fat Free Mass

Fagerberg et al., 2017

-20

-15

-10

-5

0

5

Rossow etal., 2013

Kistler etal., 2014

Robinson etal., 2015

kg Weight (kg)

FFM (kg)

FM (kg)

Effects on Fat Free Mass

National Level Diver

Training: Hypertrophy Block

Test Method: DXA

Effects on Fat Free Mass

Junior Elite Middle Distance Runner

Test Method: ISAK Surface Anthropometry

RED-S

History & Definition

Physiological Disruptions

Performance & Injuries

Screening

Treatment

Return to Play

Reasonable Weight Change Goals

SR: 0.7%/wk FR: 1.4%/wk

• N: 2 males

• Artic hike– 95d

– 10hr/d

– 2300km

Effects on Performance

Stroud et al., 1997

Effects on Performance

Effects on Performance

• N: 10 (female)

• 15-17 yo

• 12wk training block

• CYC vs OVS

• Max TT 400m swim

Effects on Performance

VanHeest et al., 2014

EUM (n=16)Mean (SD)

SFHA (n=14)Mean (SD)

Unadjusted for FFM(kg)P-value

Reaction Time (ms) 57 (4) 61 (5) 0.025

Bone Metabolism Alterations

Ihle et al., 2004

1. Bone Formation

• Osteocalcin (OC)

• Pro collagen carboxyl-terminal propeptide (PICP)

2. Bone Resorption

• N-Terminal telopeptide (NTX)

Bone Metabolism Alterations

Risk of Bone Injuries

Odds of Bone Stress Injury

Moderate Risk High Risk

2x more likely 4x more likely

Energy Availability and Injury Risk

Disordered Eating (DE) may underpin a large

proportion of cases of low EA, but…

• mismanaged programs to quickly reduce body mass/fat

• inability to track energy intake with an extreme exercise

commitment

… may occur without such a psychological overlay.

Reflect and Digest

RED-S

History & Definition

Physiological Disruptions

Performance & Injuries

Screening

Treatment

Return to Play

Disordered Eating Continuum

Prevalence of ED and DE in Elite Athletes

Affects Both Genders

WEIGHT SENSITIVE SPORTS MALE FEMALE

AESTHETIC - 40%

WEIGHT CATEGORY 18% 30%

GRAVITATIONAL 24% -

Sundgot-Borgen et al., 2013

Sundgot-Borgen et al., 2010

Prevalence of ED and DE in Elite Athletes

Affects Both Genders

Prevalence of DE over Time

Sundgot-Borgen et al.,2010

Screening and Diagnosis

Screening should be undertaking through annual health exams and/or

1. presence of DE/ED

2. weight loss

3. lack of normal growth and maturation

Mountjoy et al.,2014

4. menstrual dysfunction

5. recurring injuries and

illnesses

6. decrease performance

7. mood changes

Mountjoy et al.,2014

Screening and Diagnosis

Screening and DiagnosisAssess EA (No standard guidelines to determine)

1. Energy Intake

• Food intake recall or prospective methods

2. Energy Expenditure

• Exercise log and tables of energy expenditure

• Supplemented with GPS units, HR monitors or power meters

3. Fat free mass

• DXA

• Surface anthropometry

• (population specific regression equations)

Assess Menstrual Dysfunction• Diagnosis of exclusion

Assess Bone Health• Athletes with low EA, DE, ED or amenorrhoea of

over 6 months, BMD should be measured by DXA

Mountjoy et al.,2014

Screening and Diagnosis

RED-S

History & Definition

Physiological Disruptions

Performance & Injuries

Screening

Treatment

Return to Play

• Improve energy availability• Increase energy intake (~500kcal/d)

• Reduce energy expenditure

• or both

• Weight gain is strongest predictor of recovery of normal menstrual function

Treatment Strategies

Mountjoy et al.,2014

• Optimize bone health• Increasing energy intake = +1-10% bone mass in

anorexics

• Restore energy and estrogen dependent mechanisms of bone loss

• Resistance training and high impact loading

• Calcium and vitamin D supplementation

• Psychological support

Mountjoy et al.,2014

Treatment Strategies

RED-S

History & Definition

Physiological Disruptions

Performance & Injuries

Screening

Treatment

Return to Play

Return to Play Framework

Mountjoy et al.,2014

Return to Play Framework

• Underlying problem of RED-S is inadequate energy to support a range of body functions involved in health and sport performance

• Disordered Eating (DE) may underpin a large proportion of cases of low EA, but it could occur without a psychological overly

Summary

• It could affect male and female athletes across various ages

• The prevalence could vary across a variety of sport disciplines

• Clinical competency is important in RED-S management, but it takes a team approach and the ability to develop a trusting relationship with the athlete to be successful

Summary

Case Study Background

• Nov 2015 referral from CSIO physiologist

• Female; 18 y.o.; 1st yr university

• No CSIO nutrition support

• No CSIO IST support

Evaluation of Health Status

• No medical illnesses or training injuries

• Bone mineral density within normal limits

• Menstrual dysfunction in 2014 & 2015

• Started OCP in 2015

• RED-S likely ongoing

Sport Assessment

• Provincial elite program

• International competitions

• Great emphasis on leanness for P:W ratio

• No standardized performance test data

Decision Modifiers

• Preseason around the corner

• Performance excellence a BIG priority in 2016

• No professional relationship established

• Confident with self directed nutrition planning

elephant pic / Blind

2016 Pre & In-Season: Monitor – Educate - Build

• Protein availability and distribution

– Currently ~ 1.8g/kg, but bolus was <20g or > 30g

• Periodize CHO availability across week and training blocks

– Limited fuelling on the ride; restricted variety of CHO based foods

2016 Pre & In-Season: Monitor – Educate - Build

• Monitor body composition changes

• Bone mineral content

• Aim to monitor sex hormones

2016 Pre & In-Season: Monitor – Educate - Build

(mm·kg-0.15)MTB Pre/In

Season

MTB Off

Season MTB Pre/In

Season

MTB Off

Season

Assess Impact: Protein Availability (g) and Distribution

0

10

20

30

40

50

60

70

1-3h PreTraining

FuellingDuring

120m Ride

Recovery(<30min

PostTraining)

Recovery(1-2hrs

PostTraining)

Fuel Up(<30min

PreTraining)

FuellingDuring SCSession

Recovery(<30min

PostTraining)

Supper BedtimeSnack

Training Training

Assess Impact: Carbohydrate Availability (g/kg) and Distribution

0

0.5

1

1.5

2

1-3h PreTraining

FuellingDuring

120m Ride

Recovery(<30min

PostTraining)

Recovery(1-2hrs

PostTraining)

Fuel Up(<30min

PreTraining)

FuellingDuring SCSession

Recovery(<30min

PostTraining)

Supper BedtimeSnack

Training Training

2016 Off Season: Monitor – Educate - Build

(mm·kg-0.15)MTB Pre/In

Season

MTB Off

Season MTB Pre/In

Season

MTB Off

Season

Incorporate Physique Enhancement Tactics and Support Good Energy Availability

• Periodize macronutrients across the year

• Enhance tactical nutrition approaches for competition and training camps (altitude)

• Ongoing monitoring across the In-season

• Increase circle of support (Coach and IST members)

Nutrition Support: New Approach to YTP

Pre/In

Season

Off

Season

Pre/InSeason Off

Season

2016 20162017 2017

(mm·kg-0.15)

Nutrition Support: Monitoring Effects

0

2

4

6

8

0

1

2

3

4

01-S

ep-1

6

01

-Oct-

16

01

-No

v-1

6

01-D

ec-1

6

01

-Ja

n-1

7

01

-Fe

b-1

7

01-M

ar-

17

01

-Ap

r-1

7

01

-Ma

y-1

7

01-J

un-1

7

01

-Ju

l-17

01

-Au

g-1

7

LH and FSH

LH

FSH

40

60

80

100

120

01

-Sep

-16

01

-Oct-

16

01

-No

v-1

6

01

-De

c-1

6

01

-Jan

-17

01

-Fe

b-1

7

01

-Ma

r-1

7

01

-Apr-

17

01

-Ma

y-1

7

01

-Jun

-17

01

-Jul-

17

01

-Aug

-17

Estradiol - 17

2016 20172016 2017

(IU/L) (pmol/L)

Event Placement

Event 2016 2017

UCI MTB World U23 30 16

UCI MTB World Cup U23 1 10 DNS

UCI MTB World Cup U23 2 25 38

UCI MTB World Cup U23 3 32 35

Canada Cup Series (Elite) 13 1

National Championship (U23) 4 4

elephant pic / Blind

Paralympian: Hockey

• Men’s national team sledge hockey

• Paralympic and world championship medalist

• Goal: S4FS <55mm in 2 months

Anthropometry and Baseline DXA

• Use DXA to enhance observations

• Use lean mass to monitor EA

• Aim -1.0kg/wk (fat)

• Feb 16: Plan

• Weight: -3.1kg

• Lean mass stable

• Fat mass: -3.3kg

• Rate: -1.1kg/wk

• S4SF: -5.2mm

• Weight: -3.1kg

• Rate: -1.1kg/wk

• S4SF: -5.8mm

• S4SF: 54.4mm

• Target: <55.0mm

Summary

• Build trust and relationship

• Careful design

• Nutrition Support

Thank You!

Erik Sesbreno MSc (c), RD, CBDT, Dip Sport Nutrition IOCLead Sport Dietitian INS

Certified Bone Densitometry Technologist & ISAK level 3 Anthropometrist

647-457-8668

esesbreno@insquebec.org