NUTRITIONAL CONSEQUENCES AND TREATMENT OF RELATIVE ENERGY DEFICIENCY IN SPORT RED-S JESSICA LAROCHE, MS, RD, CSSD US SPEEDSKATING DIETITIAN

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1 NUTRITIONAL CONSEQUENCES AND TREATMENT OF RELATIVE ENERGY DEFICIENCY IN SPORT RED-S JESSICA LAROCHE, MS, RD, CSSD US SPEEDSKATING DIETITIAN

2 OBJECTIVES Distinguish differences between Female Athlete Triad and RED-S Define energy availability Identify screening strategies of RED-S Nutritional treatment of RED-S (Triad vs RED-S guidelines) Return to play model Prevention of RED-S

3 FEMALE ATHLETE TRIAD A medical condition often observed in physically active girls and women, and involves any one of the three components: (1) low energy availability (EA) with or without disordered eating (DE), (2) menstrual dysfunction and (3) low bone mineral density (BMD) De Souza MJ, et al. Br J Sports Med 2014;48:289.

4 RELATIVE ENERGY DEFICIENCY IN SPORT (RED-S) 2014: IOC consensus statement: beyond the Female Athlete Triad Relative Energy Deficiency in Sport Expands on the Triad to show wider range of outcomes Affects metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular, and psychological health Application to male and female athletes

5 HEALTH CONSEQUENCES OF RED-S VS De Souza MJ, et al. Br J Sports Med 2014;48:289.

6 POTENTIAL PERFORMANCE EFFECTS OF RED-S

7 ENERGY AVAILABILITY Underlying cause of RED-S (and Triad) is low ENERGY AVAILABILITY (EA) Amount of dietary energy remaining for other body functions AFTER exercise training expenditure EA = (EI EEE) / kg FFM EA = Energy Availability EI = Energy Intake EEE = Exercise Energy Expenditure FFM = Fat Free Mass* *Need body composition test to determine

8 LOW ENERGY AVAILABILITY Energy balance = 45 kcal/kg FFM in healthy adults EA level that affects menstrual function, disrupts bone mineralization, and decreases muscle protein synthesis <30 kcal/kg FFM Energy Availability Example EI = 2400 kcal EEE = 800 kcal 140 lb female with 18% body fat FFM = lb (52.2 kg) EA = ( ) / 52.2 = 30.7 kcal/kg

9 CAUSES OF LOW ENERGY AVAILABILITY Not necessarily eating disorder or disordered eating that leads to low EA Increased EEE above EI (changes in training volume) Inadvertent low EI: Poor meal planning skills/lack of time for meal prep Short time period between training sessions Lack of money or culinary skills Poor understanding of energy needs for sport Intentional but mismanaged efforts to reduce weight Dysfunctional eating patterns Subclinical and clinical ED Dieting including fasting, diet pills, laxatives, diuretics, etc Loucks AB, et al. J Sports Sci 2011;29:sup1, S7-S15

10 SCREENING FOR RED-S Screening as part of annual Periodic Health Examination (PHE) Some DE/ED screening tools for athletes exist, but no consensus on best tool currently Female Athlete Screening Tool (FAST): 33-item questionnaire, ~15 minutes to complete, can also identify subclinical ED Athletic Milieu Direct Questionnaire (AMDQ): 119 questions, self-report Physiologic Screening Test (PST): 14 self-report items and 4 physiological measurements meant to be given in medical exam format to hide true purpose of test Brief Eating Disorders in Athletes Questionnaire (BEDA-Q): athletes who score at risk for ED undergo a full Eating Disorder Examination interview Knapp J, et al. Current Sports Med Reports 2014;13:214

11 TRIAD CONSENSUS PANEL SCREENING QUESTIONS Have you ever had a menstrual period? How old were you when you had your first menstrual period? When was your most recent menstrual period? How many periods have you had in the last 12 months? Are you presently taking any female hormones (estrogen, progesterone, birth control pills)? Do you worry about your weight? Are you trying to or has anyone recommended that you gain or lose weight? Are you on a special diet or do you avoid certain types of foods or food groups? Have you ever had an eating disorder? Have you ever had a stress fracture? Have you ever been told you have low bone density (osteopenia or osteoporosis)? De Souza MJ, et al. Br J Sports Med 2014;48:289.

12 SCREENING FOR LOW ENERGY AVAILABILITY Stable body weight DOES NOT indicate adequate EA Need to measure EI, EEE, and FFM to determine EA All measurements are generally imprecise!! Energy Intake Food logs (electronic or written) Retrospective food recall Exercise Energy Expenditure Exercise logs and MET calculations Sports technology devices (GPS, HR, power meters) Fat Free Mass DXA Anthropometry (ISAK, skinfolds) BIA, BodPod

13 SCREENING FOR MENSTRUAL DYSFUNCTION AND BONE HEALTH Menstrual dysfunction Menstrual history (age of menarche, regularity of menses, hormonal medication, presence of other health issues, family menstrual hx) Physical exam including assessment of body comp, pubertal stage, signs of ED Lab testing including hemoglobin, luteinizing hormone, follicle stimulating hormone, prolactin, estradiol, T4, thyroid stimulating hormone, pregnancy, and androgen profile) Bone Health Measure BMD in athletes with low EA, ED, or amenorrhea of more than 6 months Z-score <-1.0 warrants further attention

14 TREATMENT FOR LOW EA RED-S Increase EI, reduction in exercise, or combo of both Increase current EI by ~ kcal/day Address suboptimal practices related to energy spread over the day and around exercise sessions, dietary composition and food-related stress Triad Increase EI, reduction in exercise, or both Gradual increase in EI to meet body weight goal ~20-30% increase in caloric intake over baseline energy needs, or amount of energy required to gain ~0.5 kg every 7-10 days If EA can be estimated Weekly weighing when initiating treatment program De Souza MJ, et al. Br J Sports Med 2014;48:289.

15 TREATMENT FOR MENSTRUAL DYSFUNCTION AND LOW BMD RED-S Increasing EA and weight gain for resumption of menses 1500 mg calcium Maintain vitamin D levels above ng/ml, with IU/day of vitamin D High impact loading and resistance training 2-3 days/week for athletes in non-weight bearing sports and/or those with decreased BMD Triad Increasing EA and weight gain for resumption of menses Adequate calcium intake ( mg/day) Adequate vitamin D ( IU/day, possibly more if deficient) Adequate vitamin K (60-90 mcg/day) Protein needs may be higher than average population ( g/kg/day) Weight-bearing exercise 2-3 days/week De Souza MJ, et al. Br J Sports Med 2014;48:289.

16 RED-S Risk Assessment Model for Sport Participation (modified from Skarderud et al 2012)

17 RED-S DECISION-BASED RETURN TO PLAY MODEL (modified from Creighton et al 2010) Steps Risk Modifiers Criteria RED-S specific criteria Step1: Evaluation of health status Medical factors Patient demographics Symptoms Medical history Signs Laboratory results Psychological health Potential seriousness Age, sex (see Yellow light column in Table 1) Recurrent dieting, menstrual health, bone health Weight loss/fluctuations, weakness Hormones, electrolytes, ECG, and DXA Depression, anxiety, disordered eating/eating disorder Abnormal hormonal and metabolic function Stress fracture Step 2: Evaluation of participation risk Sport risk modifiers Type of sport Position played Competitive level Weight sensitive, leanness sport Individual vs team sport Elite vs recreational Step 3: Decision modification Decision modifiers Timing and season Pressure from athlete External pressure Conflict of interest Fear of litigation Creighton DW,, et al. Clin J Sport Med 2010;20: In/out of season, travel, environmental factors Desire to compete Coach, team owner, athlete family and sponsors If restricted from competition

18 PREVENTION OF RED-S Within Sport: Comprehensive nutrition education RED-S, EA, healthy eating, risks of dieting and how it affects performance Reduction of emphasis on weight, emphasis on nutrition and health as means to enhance performance Avoidance of critical comments related to weight and body composition Awareness of athlete and staff that good performance does not always mean athlete is healthy

19 PREVENTION OF RED-S Healthcare Professional Recommendations Multidisciplinary athlete health support team: physician, dietitian, psychologist, athletic trainers, strength and conditioning, sport physiologist Education of medical team in detection and treatment of RED-S Implementation of RED-S Risk Assessment Model in PHE and RED-S Return to Play Model

20 PREVENTION OF RED-S Sport Organization Recommendations Rule modifications/changes to address weight-sensitive issues in sport Policies for coaches on the healthy practice of managing athlete eating behavior, weight, and body composition Preventative educational programs

21 MULTIDISCIPLINARY APPROACH Athlete health is everyone s responsibility! Medical team PHE, illness/injury visits Blood result analysis Sport Dietitian Nutrition assessments, including menstrual history and estimate of EA Body composition testing Coaches Athlete performance Athlete mood, comments about body satisfaction

22 FUTURE RESEARCH Validation of screening tools and treatment programs, such as RED-S Risk Assessment Model and RED-S Return to Play Model Expansion of research on etiology and treatment of RED-S in males, ethnic and disabled populations Validation of ED/DE screening tools in athletic population

23 RESOURCES Creighton DW, Shrier I, Shultz R, et al. Return-to-play in sport: a decision-based model. Clin J Sport Med 2010;20: De Souza MJ, Nattiv A, Joy E, et al Female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad: 1 st International Conference held in San Francisco, CA, May 2012 and 2 nd International Conference held in Indianapolis, IN, May Br J Sports Med 2014;48:289. De Souza MJ, Williams NI, Nattiv A, et al. Misunderstanding the female athlete triad: refuting the IOC consensus statement, beyond the female athlete triad relative energy deficiency in sport (RED-S). Br J Sports Med 2014;48: Knapp J, Aerni G, Anderson J. Eating disorders in female athletes: use of screening tools. Curr Sports Med Reports 2014;13:214 Loucks AB, Kiens B, Wright HH. Energy availability in athletes. J Sports Sci 2011;29(Suppl 1):S7-S15 Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the female athlete triad relative energy deficiency in sport (RED-S). Br J Sports Med 2014;48: Mountjoy M, Sundgot-Borgen J, Burke L, et al. Author s 2015 additions to the IOC consensus statement: relative energy deficiency in sport (RED-S). Br J Sports Med 2015;49(7): Nattiv A, Loucks AB, Manore MM, et al. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc 2007;39: