An Evidence-Based Approach To

Relative Energy Deficit in Sport

(RED-s)
Jennifer M. Doane, MS, RD, CSSD, LDN, ATC
Registered Dietitian
Certified Specialist in Sports Dietetics
Certified Athletic Trainer

MAATA Annual Symposium

May 20, 2016
Virginia Beach, VA
Disclosures
 Financial Partners or Donations = NONE!
 Own and operate a private practice for nutrition counseling and
consulting services for more than 16 years
 Adjunct professor for The College of St. Elizabeth in Morristown, NJ
 Adjunct professor for Moravian College in Bethlehem, PA
 Serve on the advisory board for The College of St. Elizabeth’s
Department of Food and Nutrition & Dietetic Internship programs
 Serve on advisory board for Cedar Crest College’s Department of
Nutrition Didactic Program and Dietetic Internship
Workshop Learning Objectives
Each participant will be able to :
 Identify the differing components of the female athlete triad verses
the model for relative energy deficit in sport (RED-s).
 Explain how the impacts of starvation relate to an athletic population
especially its impacts to an athlete’s physiological systems.
 Identify current best-practices for evaluating an athlete suspected of
having RED-s.
 Utilize evidence-based criteria within one’s pre-participation
assessment for RED-s.
 Institute an evidence-based decision-making process for an athlete’s
playing status and/or return to play which addresses their full
physiology to correct a relative energy deficit and eliminate further
medical implications.
In Years Past…
 Used to be considered “normal” for female athletes to lose their
menstrual cycles
 Loss of menses was supposed to be a good measure that you were
training “hard enough”
 In 1997…
o The Task Force on Women's Issues of the
American College of Sports Medicine (ACSM)
released the Female Athlete Triad Position Stand
o Components of the triad were identified as:
 Disordered Eating
 Amenorrhea
 Osteoporosis

Otis, Carol L., et al. "ACSM position stand: the female athlete triad.“ Medicine & Science in Sports & Exercise 29.5 (1997): i-ix.
Key Updates To The Triad in 2007
 A Continuum
o Energy availability, menstrual function, and bone health status
o Impacts to each in response to training volume, intensity of training, stress
level, and nutritional status.
 Low percent body fat is not always a reliable indicator
 Clinical eating disorder diagnosis not always present
 Functional hypothalamic amenorrhea due to insufficient energy
availability is often inadvertent yet impacts occur rapidly
o Absence of menses due to the suppression of the hypothalamic–pituitary–
ovarian axis, in which no anatomical or organic disease is identified
o There are three types of FHA: weight loss-related, stress-related, and
exercise-related amenorrhea

Nattiv A., et al. ACSM position stand: the female athlete triad. Med Sci Sports Exerc. 2007: 1867 – 1882.
Meczekalski, B. et al. Functional hypothalamic amenorrhea and its influence on women’s health. J Endocrinol Invest. 2014; 37(11): 1049–1056.
Key Updates To The Triad in 2007
 Measurable changes in bone mineral density, and bone fractures,
take time to develop, present, treat and resolve
 Hormonal replacement therapy does not resolve bone mineral
density issues in most cases and definitely does not correct energy
availability

Nattiv A., et al. ACSM position stand: the female athlete triad. Med Sci Sports Exerc. 2007: 1867 – 1882.
2007 The Updated Female Athlete Triad
Position Stand, ACSM

Nattiv A., et al. ACSM position stand: the female athlete triad. Med Sci Sports Exerc. 2007: 1867 – 1882.
What’s Missing…
 We need a means of assessment:
o For energy balance not solely based on
menstrual cycles in females
o Which does not exclude male athletes
o Which includes a comprehensive look at
total body physiology & functions
Health
Consequences
of RED-s
Showing an expanded
concept of the Female
Athlete Triad to
acknowledge a wider
range of outcomes and the
application to male &
female athletes

*Psychological
consequences can either
precede RED-S or be
the result of RED-S

Mountjoy M, et al. “The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S)”. Br J Sports Med 2014;48:491–497.
Conflict…
o Female Athlete Triad Coalition
 After the IOC 2014 Consensus Statement was released, the Female Athlete Triad
Coalition refuted the IOC’s consensus statement in a published article in the British
Journal of Sports Medicine
 The coalition feels that there is insufficient emphasis placed on the female athlete
triad model which has been thoroughly researched and improves the health
outcomes of all female athletes

o International Olympic Committee

 The IOC stand by their recommendations which recommend the sports medicine
team work cohesively to increase the understanding an awareness of RED-s to
broaden our efforts and connect with all athletes

DeSouza MJ, Williams NI, Nattiv A, et al. 2014 Misunderstanding the Female Athlete Triad: Refuting the IOC Consensus Statement on Relative Energy Deficiency in Sport (RED-S). Br J Sports
Med. 2014; 48(20): 1461-1465.
Mountjoy M, et al. “The IOC consensus statement: Beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S)”. Br J Sports Med 2014;48:491–497.
Mountjoy M, Sundgot-Borgen J, Burke L, et al. Authors’ 2015 additions to the IOC consensus statement: Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2015; 49(7): 417-420.
But, It All Comes Down To Energy Balance…
 Energy: Defined as the capacity to do work, and in the case of the
human body, this work is of a biological and physical nature
o Cellular processes
o Synthesis of compounds
o Growth & Development
o Reproduction
o Activities of Daily Living
o Exercise (Skeletal muscle contractions)
 The Energy Balance Equation
o “Simple” version = Energy In vs. Energy Out
o Hypothalamus integrates a host of signals from the liver, gut, and
adipose tissue to regulate energy expenditure and the initiation,
termination, and frequency of eating
o Adaptations!
Energy Expenditure
 Three components to total daily energy expenditure
o Resting Metabolic Rate (RMR) The energy expended while lying supine in a post-
absorptive, awakened state for cellular processes necessary to maintain life
 70-75% of daily energy expenditure
o Thermic Effect of Food (TEF) Energy expenditure above RMR in response to the
ingestion of food
 Approx 10% of energy ingested; Fats have lowest TEF 3%, Carbohydrates 5-10% TEF and
Protein 20-30% TEF
o Physical Activity
 Non-Exercise Activity Thermogenesis (NEAT) The Energy expenditure from
physical activity which is not considered exercise, such as ADL or fidgeting

 Exercise Energy Expenditure (ExEE) Most variable component which is defined

as volitional movement done for the purpose of improving or maintaining one or
more features of either health or performance-related physical fitness
 Up to 30% of daily energy expenditure however in athletes this factor can increase
greatly
Energy Availability (EA)
The amount of dietary energy remaining
for other body functions AFTER exercise training

(EI – EEE) / kg FFM

EI = Dietary Energy Intake
EEE = Exercise Energy Expenditure
FFM = Fat Free Mass (*body comp needed)
Calculating Fat Free Mass Bioelectrical Impedance Analysis (BIA)
(Opposite of Fat Mass) BodPod
Girth measurement body fat equations
Calipers

Nattiv A., et al. “ACSM position stand: the female athlete triad.” Medicine & Science in Sports & Exercise (2007): 1867 – 1882.
Energy Availability (EA) Example

(EI – EEE) / kg FFM

EI = Dietary Energy Intake 1800kcal/day
EEE = Exercise Energy Expenditure 1200 kcal/day “practice”
FFM = Fat Free Mass 140# with body fat% 20%
112# FFM / 2.2 kg = 50.91 kg

(1800 – 1200) / 50.91 kg FFM

11.79 kcal/kg energy availability

Nattiv A., et al. “ACSM position stand: the female athlete triad.” Medicine & Science in Sports & Exercise (2007): 1867 – 1882.
Energy Availability is reduced by…
 Increased EEE above EI
o Changes in training volume

 Inadvertent impacts on energy intakes

o Nutrition as an afterthought
o Timing of training session conflicting with eating opportunities
 Short time between training sessions
 Time, money constraints
 Back loading intakes

 Dysfunctional Eating Behaviors

o Dieting, Sub-clinical and clinical eating disorders

Nattiv A., et al. “ACSM position stand: the female athlete triad.” Medicine & Science in Sports & Exercise (2007): 1867 – 1882.
Causes of Low Energy Intakes

Unintentional Low Intakes

DSM-V Eating Disorder
Intentional meeting Disordered Eating
body composition or
weight loss goal
Starvation State:
Minnesota Starvation Study
 World War II
 November 1944 to December 1945
 “After you’ve not had food for a while your
state of being is just numb. I didn’t have any
pain. I was just very weak. One’s sexual
desires disappeared“ says Sutton
 Men lost 25% of their body weight
 Anxiety and Depression

Kalm, L.M., & Semba, R.D. (2005). They starved so that others be better fed: Remembering Ancel Keys and the Minnesota Experiment. Journal of Nutrition, 135, 1347–1352.
Keys, A., Brozek, J., Henshel, A., Mickelson, O., & Taylor, H.L. (1950). The biology of human starvation, (Vols. 1–2). Minneapolis, MN: University of Minnesota Press.
Tucker, T. (2007). The great starvation experiment: Ancel Keys and the men who starved for science. Minneapolis, MN: University of Minnesota Press.
Starvation and Fuel Use

I II III IV
Origin of Exogenous Hepatic Glycogen; Hepatic & Renal &
Blood Gluconeogenesis Renal Hepatic
Glucose Gluconeo- Gluconeo-
genesis genesis

Tissues All All except liver. Brain and Brain at a

Using Muscle & Adipose RBCs; Small diminished
Glucose tissue at amount by rate; RBCs
diminished rates muscle normal

Major Fuel Glucose Glucose Glucose; Ketone

of Brain Ketone Bodies;
Bodies Glucose

A. http://www.nbs.csudh.edu/chemistry/faculty/nsturm/CHE452/24_Glucose%20Homeostas.html
B. Annu. Rev. Nutr. 2006.26:1-22. Downloaded from arjournals.annualreviews.org by jmd on 10/29/15
Humans Adapt to Fuel Deprivation
 A) Before a fast
B) Following three weeks of
starvation
 The process of keto-adaption
prevents the ongoing
catabolism of lean mass to
provide glucose
 Even a small amount of glucose
infusion decreases ketoacid
and ammonia nitrogen
excretion
 Down regulation of metabolic
rate
 Assess for urinary ketones

Cahill, George F, Jr. “Fuel Metabolism in Starvation” Annual Review of Nutrition 2006 AUG; 26: 1-22.
Ketones
 Ketone bodies are three water-soluble molecules that are produced by
the liver from fatty acids during periods of low food intake (fasting)
or carbohydrate restriction for cells of the body to use as energy
instead of glucose
o Inefficient back up energy
 The three endogenous ketone bodies: acetone
acetoacetic acid
beta-hydroxybutyric acid
 Acetoacetate and beta-hydroxybutyrate can be
reconverted to acetyl-CoA to produce energy,
via the citric acid cycle
 Uses in the heart, brain and muscle
(but not the liver)
Brain Adaptation

 Brain adapts to using ketones as fuel –

but not in the short run
 Keto-adaption starts at day 2-5
depending on activity

Cahill, George F, Jr. “Fuel Metabolism in Starvation” Annual Review of Nutrition Vol. 26: 1-22 (Volume publication date August 2006)
Prolonged Starvation
 Increased
o Glucagon o Epinephrine
 Increases glucose in  Also known as adrenaline
bloodstream
 Important role in the fight-or-flight
 Opposite to insulin response by increasing blood flow
to muscles, output of the heart,
o Cortisol pupil dilation, and blood sugar
 Increased in response to
stress which increases blood o Antidiuretic hormone
sugar through  Prevents the production of dilute
gluconeogenesis urine
 Suppresses the immune  Fluid controls
system
 Aids in the metabolism of fat,
protein, and carbohydrate
 Decreases bone formation
Gropper, S and Smith J. Advanced Nutrition and Human Metabolism. 6th ed (2013): 246-248.
Prolonged Starvation
 Increased
o Aldosterone o Thyroid hormone
 Steroid hormone critical to  Thyronines act on every cell in the
blood pressure regulation human body by:
 Causes the conservation of  Increasing basal metabolic rate
sodium & secretion of
potassium  Affect protein synthesis

 Causes increase in water  Assist regulation of long bone

retention growth and neural maturation

 Causes increase in blood  Increase the body's sensitivity to

pressure and blood volume catecholamines (such as
adrenaline) by permissiveness
 Regulate protein, fat, and
carbohydrate metabolism
 Affect how cells use energy
Gropper, S and Smith J. Advanced Nutrition and
Human Metabolism. 6th ed (2013): 246-248.
 Stimulate vitamin metabolism
Prolonged Starvation
 Decreased
o Insulin Decrease glucose in blood stream
o Sex Hormones Male and Females; Non-essential

Gropper, S and Smith J. Advanced Nutrition and Human Metabolism. 6th ed (2013): 246-248.
Changes in Metabolic Rate

http://www.medscape.org/viewarticle/432384_4
Starvation & Fuel Use Summary
 If more than 4 hours passes between exogenous fueling then one can
start to cross in to the underfueled state
 From 2-24 hours, one’s body can begin to switch to glycogen and
gluconeogenesis pathways for fueling
 Carbohydrate fueling at intervals of every 2 to 4 hours maintains
glucose use in all of one’s body tissues
 “Fat burns in a carbohydrate flame” – Nancy Clark, RD

Gropper, S and Smith J. Advanced Nutrition and Human Metabolism. 6th ed; 2013.
Starvation & Fuel Use Summary
 Consuming inadequate energy through CHOs can cause protein
breakdown (catabolism) and losses of lean mass as well as impair
organ function and cell structures
 In the course of an overnight fast, nearly all reserves of liver glycogen
and most muscle glycogen have been depleted
 After 3 days of fasting, liver releases ketone bodies (from fat
oxidation) as alternative fuel for the brain; Gluconeogenesis provides
glucose to RBCs and brain

Gropper, S and Smith J. Advanced Nutrition and Human Metabolism. 6th ed; 2013.
Energy Recovery Creates A
Hypermetabolic State
 As much as 40% decrease to one’s
metabolic rate
 Refeeding is a hypermetabolic state
 The increase in metabolic rate
reflects an increase in energy
demands
 This demand persists for weeks to
months even after complicated
surgery or tissue damage
 Increased calories are required

http://www.medscape.org/viewarticle/432384_4
How Much Energy Do We Need?
 Normal Metabolic rate: 25-30 kcal/kg FFM/day

 Goal for Athletes (Gold Standard) approx. 45 kcal/kg FFM/day

 Disruptions occur < 30 kcal/kg FFM/day

 30 kcal/kg FFM/day corresponds to the energy expended in resting

metabolism in healthy adults

Burke L and Deakin V. Clinical Sports Nutrition. 4th Ed; 2010.

Rosenbloom, C and Coleman, E. Sports Nutrition: A Practice Manual for Professionals. 5 th Ed; 2012.
Prolonged Starvation RED-s Disruptions
 Cardiorespiratory  Gastrointestinal
o Heart Palpitations o Gastroparesis
o Arrhythmias (EKG) o Delayed gastric emptying &
Early satiety
o SOB
o Constipation
o Edema
o Gastroesophageal Reflux (GERD)
o Postural Orthostatic
Tachycardic Syndrome (POTS) o Decreased hunger
o Syncope  Hematological
 Endocrine o Glucoregulatory hormones do not
maintain normal plasma glucose
o Amenorrhea or Oligomenorrhea concentrations below energy
o Loss of libido availability of 30 kcal/kg FFM per
day
o Low bone mineral density
o Low RBC count
o Infertility
o Anemia
Prolonged Starvation RED-s Disruptions
 Immune  General
o Low WBC count o Fatigue, Weakness
o Increased risk for illness or injury o Hot flashes, Sweating episodes
o Poor wound healing o Not just weight loss – may be
weight maintenance or failure to
gain in children or adolescents
 Growth and Development
o Loss of height/stature progression
 Psychological*
o Lack of physical development
o Can occur prior to the energy
(Tanner stages)
restriction or as consequence to
o Cold intolerance post-restriction
o Decreased focus / brain function
o Anxiety
o Depression
Physiological Consequences Associated with
Energy Restriction:
What are Athletes Concerned About?
 Performance Issues
o Fatigue
o Inability to finish workout
o Getting “slower” “weaker”
o Focus and concentration lost
 Coaches and ATs hear “I need to train more”
not “I'm underfueled”
 These findings should launch your assessment

ASK!
Four- Step Nutrition Care Process for
Achieving Goals
 Nutrition Assessment & Reassessment
o The RDN collects and documents information such as food or nutrition-related history;
biochemical data, medical tests and procedures; anthropometric measurements, nutrition-
focused physical findings and client history
 Nutrition Diagnosis
o Data collected during the nutrition assessment guides the RDN in selection of the
appropriate nutrition diagnosis (i.e., naming the specific problem)

 Nutrition Intervention (Action Plan)

o RDN selects the nutrition intervention that will be directed to the root cause (or etiology) of
the nutrition problem and is aimed at alleviating the signs and symptoms of the diagnosis

 Nutrition Monitoring & Evaluation

o The final step where RDN determines if the patient/client has achieved, or is making
progress toward, the planned goals

http://www.eatrightpro.org/resources/practice/nutrition-care-process
Nutrition Assessment
 Dietary Intake and Red Flag screens
o Energy Availability
 Medical Assessment
o Scope of practice
 Can you calorie count?
o Lost art, now you can get the APP!
o Athletes are often better at it than professionals
 Disordered Eating Behaviors
o Food “allergies”
o Gluten restricted for no reason
o Veganism / Vegetarianism
o Eating Alone
o Leaving the table for bathroom
Eating Disorder Assessment Tools
General Population
 Eating Attitudes Test (EAT)
o See Copy
o The EAT-26 has been reproduced with permission. Garner et al. (1982).
The Eating Attitudes Test: Psychometric features and clinical correlates.
Psychology Medicine, 12, 871-878. (On 12-15-15 by Jennifer Doane)

 Eating Disorder Examination Questionnaire (EDE-Q)

o Historically considered the gold standard in ED/DE assessment
o See Copy
 Eating Disorder Inventory (EDI)
o 64 questions with 8 subscales
o 20minutes to complete, 20 minutes to “grade”
Eating Disorder Assessment Tools
Athletic Population
 Female Athlete Screening Tool (FAST)
o See copy
o 33-item questionnaire developed specifically for female athletes
o Approximately 15 min to complete and validated in collegiate populations with
subjects from both Division I and III NCAA schools
 Athletic Milieu Direct Questionnaire (AMDQ)
o 119 item, self-report questionnaire to screen for eating disorders and
disordered eating in female athletes
 Survey of Eating Disorders among Athletes (SEDA)
o 33-item self-report questionnaire mentioned in the NATA recommendations
o 30+ years old, is based on outdated diagnostic criteria, and lacks recent
validation

McNulty, K. et al. Development and validation of a screening tool to identify eating disorders in female athletes. J Acad Nutr Diet, August 2001, Vol 101(8): 886–892.
Nagel, D. et al. Evaluation of a Screening Test for Female College Athletes with Eating Disorders and Disordered Eating. J Athl Tr 2000; 35(4): 431-440.
Eating Disorder Assessment Tools
Athletic Population
 Health, Weight, Dieting, and Menstrual History Questionnaire
o 54 item, self-report questionnaire
o Test items are composed of four categories including musculoskeletal health,
menstrual history, dieting behaviors, and weight history
 College Health-Related Information Survey (CHRISY73)
o 32 item, self-report screening test for male and female collegiate athletes based on
the Juvenile Wellness and Health Survey
o Has not been validated
 BEDA-Q
o Screening tool not included in the NATA position stand due to the timing of its
publication
o Developed in elite high school female athletes (ages not reported) in three phases.
o Version 2 had 95% confidence interval

Knapp, J., DO et al. Eating Disorders in Female Athletes: Use of Screening Tools. Current Sports Medicine Reports July/August 2014; 13(4): 214-218.
Pre-Season Nutrition Assessment
 Screening for Eating Disorders esp. High Risk Sports
 BEDA-Q: Brief Eating Disorder in Athletes – Questionnaire
Always Usually Often Sometimes Rarely Never

 I feel extremely guilty after overeating.

 I am preoccupied with the desire to be thinner.
 I think that my stomach is too big.
 I feel satisfied with the shape of my body.
 My parents have expected excellence of me.
 As a child, I tried very hard to avoid disappointing my parents and teachers.
 Are you trying to lose weight now? Yes No

 Have you tried to lose weight? Yes No

 If yes, how many times have you tried to lose weight? 1-2 times 3-5 times >5 times

Martinsen, M. et al. The development of the brief eating disorder in athletes questionnaire. Med Sci Sports Exerc. 2014 Aug; 46(8): 1666-75.
BEDA-Q Rating
Version 2: Highest possible score 18 points

 Positive scores are rated as follows (reverse-scored items are

weighted in the opposite manner):
o 3 points – always
o 2 points – usually
o 1 point - often
o 0 points – sometimes
o 0 points – rarely
o 0 points – never
2014 Female Athlete Triad Coalition Consensus Statement on
Treatment and Return to Play of the Female Athlete Triad
 The Panel recommends asking these screening questions at the time of
the sport preparticipation evaluation.
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 past 12 months?
Are you presently taking any hormone replacement?
(estrogen, progesterone, oral 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. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad Br J Sports Med 2014;48:289.
Nutritional Intervention
 Progression necessary due to potential for refeeding
concerns
o Add 500 calories at a time
 Liquids better tolerated than solids
 Reassess vitals at minimum weekly
o Refeeding can have multiple concerns
o Gradual improvements in HR
o Improving body temperature
o Correcting any nutrients imbalances from lab work
 Iron, Vitamin D, Phosphorous, electrolytes, etc…

 Monitor weight (?BLIND) – must be consistent towards

recovery goals
 When weight plateaus, add an additional 500 calories
Nutrition Intervention
How Much Energy Do We Need?
 Normal Metabolic rate: 25-30 kcal/kg FFM/day

 Energy Availability Goal for Athletes (Gold Standard)

approx. 45 kcal/kg FFM/day

 Disruptions occur < 30 kcal/kg FFM/day

 30 kcal/kg FFM/day corresponds to the energy expended in resting

metabolism in healthy adults

Burke L and Deakin V. Clinical Sports Nutrition. 4th Ed; 2010.

Rosenbloom, C and Coleman, E. Sports Nutrition: A Practice Manual for Professionals. 5 th Ed; 2012.
Nutrition Intervention
Is Exercise OK?
 Medical Concerns about exercise in treatment and recovery
o Might prolong energy imbalance
o Increase risk for organ damage
o Undermine weight gain
o Increased cardiac risk
o Increase risk of injury
Medical Clearance for Adding Exercise
in Treatment
 BMI
 DEXA
 EKG
 Blood Pressure / Pulse, Postural VS (POTS)
 Comprehensive Metabolic Panel (CMP)
 Magnesium, Phosphorous
 Urinalysis
 Complete Blood Count (CBC)
 Nutritional Labs (Vit D,Serum Iron, Ferritin)

Mountjoy M, et al. “The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S)”. Br J Sports Med 2014;48:491–497.
Nutrition Intervention
Returning To Sport
 Work with a “team”: AT, RD, MD in treatment planning
o Sport psychologist very beneficial
o Clinical ED diagnosis should be mandated to work with a counselor /
therapist
 Set goals for return to sport and/or maintenance of participation
 Monitor safety
 Energy availability goal is greater than 45 kcals/kg FFM
o Test exercise load and eating to assure energy balance / weight
stabilization
 Ideal = No stress fractures, menstrual dysfunction or “disruptions”
Decision-Based Return-to-Play (RTP)
Model for the Female Athlete Triad
 RTP decision is determined by the
primary care or team physician
 Based on a complex and
comprehensive synthesis of
health status, cumulative risk
assessment, participation risk,
sport and decision modifiers.
 Abbreviations:
o 25(OH) Vit D, 25-hydroxyvitamin D
o BMI, body mass index
o BP, blood pressure
o CBC, complete blood count
o DXA, dual-energy X-ray absorptiometry
o ED, eating disorder
o OCD, obsessive compulsive disorder
o TFTs, thyroid function tests
o TSH, thyroid stimulating hormone

Creighton D W et al. Return to Play in Sport: A Decision-based Model. Clin J Sport Med 2010 September; 20(5): 379-385.
 Female Athlete Triad: Cumulative Risk
Assessment De Souza M J et al. Br J Sports Med 2014; 48: 289.

MAGNITUDE OF RISK
Risk Factors Low Risk = 0 points each Moderate Risk = 1 point each High Risk = 2 points each

Low EA with or without ED/DE No dietary Restrictions Some dietary restrictions; Meets DSM-V criteria for ED
Current/PMH ED/DE
Low BMI BMI >18.5 or >90% IBW or BMI 17.5<18.5 or BMI < 17.5 or
weight stable < 90% IBW or < 85% IBW or
5-10% wt loss/month >10% wt loss/month
Delayed Menarche Menarche < 15 y/o Menarche 15 to <16 years Menarche >16 years

Oligomenorrhea and/or >9 menses in 12 months 6-9 menses in 12 months <6 menses in 12 months
Amenorrhea
Low BMD Z-score >-1.0 Z-score -1.0 < -2.0 Z-score <-2.0

Stress Reaction / Fracture None 1 >2; >1 high risk or of

trabecular bone sites
Cumulative Risk (total each _____ points + _____ points + _____ points =
column, then add for total score)
_____Total Score
Female Athlete Triad: Clearance and Return-
to-Play (RTP) Guidelines by Medical Risk
Stratification
*Cumulative Risk Score determined by summing the score of each risk factor (low, moderate, high risk) from
the Cumulative Risk Assessment
Cumulative Low Risk Moderate Risk High Risk
Risk Score *

Full 0-1

Provisional / 2-5 Provisional

Limited
Clearance Limited

Restricted from >6 Restricted

Training / from
Competition Training /
Competition –
Provisional

Disqualified
 Steps Risk modifiers Criteria Red-S Specific Criteria
The RED-s
Decision-based Age, sex
Recurrent dieting

Return-to-Play Patient demographics

Symptoms
Menstrual health, Bone health
Weight loss/fluctuations

Model
Step 1 Medical history Weakness
Evaluation of health Medical factors Signs Hormones, electrolytes, ECG and DXA
status Laboratory tests Depression, anxiety
Table 3 Psychological health
Potential seriousness
Disordered eating/eating disorder
Abnormal hormonal and metabolic
(modified from Creighton et al143) function
Stress fracture

Step 2 Type of sport Weight sensitive, leanness sport

Evaluation of Sport risk modifiers Position played Individual vs team sport
participation risk Competitive level Elite vs Re-creational

In/out of season, travel,

Timing and season
environmental factors
Step 3 Pressure from athlete
Desire to compete
Decision Decision modifiers External pressure
Coach, team owner, athlete family and
modification Conflict of interest
sponsors
Fear of litigation
If restricted from competition

Mountjoy M, et al. “The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S)”.
•DXA, dual-energy X-ray absorptiometry.
Br J Sports Med 2014;48:491–497.
The IOC consensus statement: beyond the
Female Athlete Triad—Relative Energy Deficiency
in Sport (RED-S)
Table 3: The Relative Energy Deficiency in Sport Return-to-Play Model (modified from
Skårderudet al, 2012)

Moderate risk yellow

High risk red light Low risk: green light
light

▸ No competition ▸ May compete once

▸ Supervised training medically cleared under
allowed when medically supervision
▸ Full sport participation
cleared for adapted training ▸ May train as long as is
▸ Use of written contract following the treatment
(see sample) plan

Mountjoy M, et al. “The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S)”. Br J Sports Med 2014;48:491–497.
Nutritional Assessment
REDs: Green Light or Low Risk
 Healthy eating habits
 Normal hormonal and metabolic function
 Healthy BMD
 Healthy musculo-skeletal system
 Absence of POTS

This is where we want athletes to be!

Mountjoy M, et al. “The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport
(RED-S)”. Br J Sports Med 2014;48:491–497.
Nutrition Assessment
REDs: Moderate Risk
 Prolonged abnormally low % body fat or weight loss >5-10% in one
month
 Abnormal menstrual cycle: Functional Hypothalamic Amenorrhea
(FHA) > 6 months
 Menarche > 16 years
 Abnormal Hormone profile in men
 Reduced bone mineral density (BMD)
o History of one or more stress fractures associated with hormonal/menstrual dysfunction
and/or low energy availability (EA)
 Athletes with physical/psychological complications related to low EA /
disordered eating
o ECG abnormalities, lab abnormalities, etc…
 Prolonged relative energy deficiency
 Disordered eating behavior negatively affecting other team members
 Lack of progress in treatment and/or non-compliance

Mountjoy M, et al. “The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S)”. Br J Sports Med 2014;48:491–497.
Nutritional Assessment
REDs: High Risk
 Anorexia nervosa and other clinically diagnosed eating disorders
 Other serious medical conditions related to low energy availability
o Diagnosis
o Physiological and/or psychological
 Example: Repeat stress fractures
Syncope
Abnormal EKG,etc…
 Extreme weight loss techniques leading to dehydration induced
hemodynamic instability and other life-threatening conditions

Mountjoy M, et al. “The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S)”. Br J Sports Med 2014;48:491–497.
RED-s Implications for Sports Medicine
 Underfueled athletes
 Distance runners, Wrestlers, Ballerinas
 Nutrition Assessment and Intervention needs to be comprehensive!
o Hypothermia
 Less than 97.5 degrees, cool hands & feet
o Bradycardia (less than 50bpm women, 40 bpm men)
 Defined as less than 60 beats per minute
o POTS (postural orthostatic tachycardic syndrome)
 Lightheaded, dizzy, syncope
 Lying to standing, HR changes 30 bpm
o Urinary Ketones (Use keto strips)
o Increase in urine specific gravity – ketones increase specific gravity
o Weight change
 Weight status is one variable but not the only one
Treatment Approach Within Athletics
 Team Approach
 Experienced RD with CSSD
 Education for Athletes and Coaches (Separately)
o Female Athlete Forum
o Help connect normal physiological functions with optimal
performance
o Help individuals and teams to find their own “recipe” for
fueling success
o Dispel “Eating Disorder” label
 Regularly asses risk for subclinical ED
 Consider Treatment Contracts
Treatment Contracts
 Team physician support is critical
 Athletes in moderate and high-risk categories should receive a written
contract reviewed & presented by the team physician
 Although a verbal contract may be sufficient, it is recommended to utilize
a written contract.
 The Legal Duty of a College Athletics Department to Athletes with Eating
Disorders: A Risk Management Perspective (1999)
Available at: http://scholarship.law.marquette.edu/sportslaw/vol10/iss1/6
 The goal of the written contract is to:
 Specify the criteria necessary for ongoing or future clearance and return to
play for the athlete with the multidisciplinary team members
 To ensure a shared understanding of how the clinical status of the athlete will
be followed with each member of the multidisciplinary team.

http://bjsm.bmj.com/content/suppl/2014/03/11/48.7.491.DC1/bjsports-2014-093502supp.pdf
Barbara Bickford, The Legal Duty of a College Athletics Department to Athletes with Eating Disorders: A Risk Management Perspective, 10 Marq. Sports L. J. 87 (1999)
Treatment Contracts
 The team physician coordinates the treatment goals with each
multidisciplinary team member, and includes:
o The specific recommendations in the contract
o The requested frequency of visits
o Expectations for each team member
 The team physician then reviews the recommendations with the
athlete, and answers any questions.
o In the case of the written contract, athlete and team physician sign the
contract after it is discussed
o Written contract which can be modified based on the athlete's clearance
status.

SAMPLE
http://bjsm.bmj.com/content/suppl/2014/03/11/48.7.491.DC1/bjsports-2014-093502supp.pdf
Summary
 Relative energy
deficit in sport
encompasses the
female athlete
triad
 However, REDs
expands the
assessment areas
which are multi-
faceted
Recommendations to address RED-S
 For the Athlete
o Educational programs on RED-S, healthy eating, nutrition, EA, the
risks of dieting and how these affect health and performance
o Reduction of emphasis on weight, emphasizing nutrition and health
as a means to enhance performance
o Development of realistic and health-promoting goals related to
weight and body composition
o Avoidance of critical comments about an athlete’s body
shape/weight
o Use of reputable sources of information
o Promotion of awareness that good performance does not always
mean the athlete is healthy
o Encouragement and support of appropriate, timely and effective
treatment
Recommendations to address RED-S
 For The Healthcare Professional
o Identification of a multidisciplinary athlete health support team
including sports physician, nutritionist, psychologist,
physiotherapist and physiologist
o Education of the medical team in the detection and treatment of
all aspects of RED-S
o Implementation of the RED-S Risk Assessment Model in the PHE
and the RED-S Return-To-Play Model inclusive of the Female
Athlete Triad
Find A SCAN RD/CSSD
 Incorporate a “team” approach when assisting your athletes with their
nutrition related health and performance goals
 Many loopholes (Medically, Psychologically, Nutritionally)
 Set guidelines and adherence will be key to your program’s successful
management of RED-s for your athletes
 Use SCAN DPG for finding an RD/CSSD in your area
Sports, Cardiovascular and Wellness Nutrition Group
A Dietetic Practice Group of the Academy of Nutrition & Dietetics (AND)

www.scandpg.org
THANK YOU!

Jennifer M. Doane, MS, RD, CSSD, LDN, ATC

Registered Dietitian
Certified Specialist in Sports Dietetics
Certified Athletic Trainer

2005 City Line Road, Suite 104

Bethlehem, PA 18017
610-443-1885
[email protected]
References
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 Bickford B “The Legal Duty of a College Athletics Department to Athletes with Eating
Disorders: A Risk Management Perspective”, 10 Marq. Sports L. J. 87 (1999)
Available at: http://scholarship.law.marquette.edu/sportslaw/vol10/iss1/6

 Bjornsson A. et al. Body Dysmorphic Disorder. Dialogues Clin Neurosci. 2010 Jun;
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