IOC Consensus Statement: Beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S)
Introduction
Protecting the health of the athlete is one of the goals of the International Olympic Committee (IOC). The Olympic Movement Medical Code emphasizes the importance of protecting the athlete’s health. In 2005, the IOC published the Consensus Statement and the IOC Position Stand on the Female Athlete Triad. Based on scientific evidence, the IOC convened an expert panel to update the 2005 IOC Consensus Statement.
Definition of RED-S
The term ‘Relative Energy Deficiency in Sport’ (RED-S) points to the complexity involved and the fact that male athletes are also affected. The syndrome of RED-S refers to impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular health caused by relative energy deficiency. The cause of this syndrome is energy deficiency relative to the balance between dietary energy intake and energy expenditure required for health and activities of daily living, growth, and sporting activities. Psychological consequences can either precede RED-S or be the result of RED-S.
Causes
- Energy Deficiency: The primary cause of RED-S is an imbalance between dietary energy intake and energy expenditure required for health, daily activities, growth, and sporting activities.
- Psychological Factors: Psychological consequences can precede or result from RED-S, influencing dietary habits and training behaviors.
Warning Signs
- Metabolic Rate: Decreased metabolic rate leading to fatigue and poor recovery.
- Menstrual Function: Irregular or absent menstrual cycles in females.
- Bone Health: Decreased bone density and increased risk of fractures.
- Immunity: Increased susceptibility to illness and infections.
- Protein Synthesis: Reduced muscle protein synthesis leading to muscle loss.
- Cardiovascular Health: Potential cardiovascular issues due to prolonged energy deficiency.
Impacts
- Physiological Function: Impaired metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health.
- Health: Increased risk of illness, injury, and long-term health issues.
- Athletic Performance: Decreased performance due to fatigue, poor recovery, and injury.
Prevention
- Balanced Diet: Ensuring adequate dietary energy intake to meet the demands of daily living, growth, and training.
- Regular Monitoring: Regular health assessments to detect early signs of RED-S.
- Psychological Support: Addressing psychological factors that may contribute to RED-S.
- Education: Educating athletes, coaches, and healthcare providers about the risks and prevention of RED-S.
Conclusion
The IOC expert working group recommends practical clinical models for the management of affected athletes. The ‘Sport Risk Assessment and Return to Play Model’ categorizes the syndrome into three groups and translates these classifications into clinical recommendations.
Causes of RED-S
The underlying problem of RED-S is an inadequacy of energy to support the range of body functions involved in optimal health and performance. EA is calculated as EI minus the energy cost of exercise relative to fat-free mass (FFM) and in healthy adults, a value of 45 kcal/kg FFM/day equates energy balance. Low EA, which occurs with a reduction in EI and/or increased exercise load, causes adjustments to body systems to reduce energy expenditure, leading to disruption of an array of hormonal, metabolic, and functional characteristics. Disordered eating (DE) underpins a large proportion of cases of low EA, but other situations, such as a mismanaged programme to quickly reduce body mass/fat or an inability to track EI with an extreme exercise commitment, may occur without such a psychological overlay.
Prevalence and Risk Factors
Although the literature on low EA has focused on female athletes, it has also been reported to occur in male athletes. Prevalence studies of low EA in male athletes have been few, however, low EA appears to occur among the same at-risk sports as for female athletes: the weight-sensitive sports in which leanness and/or weight are important due to their role in performance, appearance, or requirement to meet a competition weight category.
Warning Signs and Impacts
Although simple messages about optimal, tolerable, and unsafe levels of EA have been provided, there are some caveats in the science. First, the complex dose–response relationship between reduction in EA and the disruption of various hormones and bone formation markers vary in nature and thresholds. Therefore, the cost of any energy mismatch should be carefully considered before it is implemented. A second caveat is that it is now known that the resting metabolic rate in athletes of small body size is underestimated in the linear scaling of EA relative to LBM/FFM. Finally, findings from laboratory settings may not apply as cleanly to free-living athletes. Numerous studies in female athletes have failed to find clear thresholds or associations between field determinations of low EA and objective measures of energy conservation such as metabolic hormones and menstrual disturbances. It is possible that other factors seen in free-living populations such as psychological stress, greater variability in between-day and within-day energy deficiency or dietary characteristics interact with each other to alter the effects of low EA.
Prevention
Disordered eating (DE) is a critical factor in the development of RED-S. The DE continuum starts with appropriate eating and exercise behaviors, including healthy dieting and the occasional use of more extreme weight loss methods such as short-term restrictive diets (<30 kcal/kg FFM/day). The continuum ends with clinical eating disorders (EDs), abnormal eating behaviors, distorted body image, weight fluctuations, medical complications, and variable athletic performance. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic classifications for EDs include anorexia nervosa, bulimia nervosa, and binge eating disorder.
Causes of RED-S
- Low Energy Availability (EA): This is a primary cause of RED-S, leading to hormonal imbalances and decreased bone mineral density (BMD).
- Hormonal Imbalances: Low testosterone levels in men and hypoestrogenism in women contribute to poor bone health and increased risk of stress fractures.
- Increased Stress Hormones: Elevated levels of catecholamines and cortisol due to chronic stress and low EA have negative effects on bone health.
- Dietary Insufficiencies: Inadequate nutrition further increases the risk of stress fractures in both sexes.
Warning Signs of RED-S
- Menstrual Dysfunction: Amenorrhea or irregular menstrual cycles in women.
- Low Body Mass Index (BMI): Below normal BMI levels.
- Prior Fractures: History of stress fractures.
- Eating Psychopathology: Indicators of disordered eating or eating disorders.
- Compulsive Exercise: Excessive exercise beyond normal training requirements.
- Functional Impairments: Increased prevalence of viral illnesses and injuries, reduced responsiveness to training, and subsequent performance decline.
Impacts of RED-S
- Bone Health: Decreased bone mineral density and increased risk of stress fractures, including high-risk fractures like femoral neck fractures.
- Athletic Performance: Reduced responsiveness to training and subsequent performance decline.
- Health Risks: Potential health consequences such as dehydration, electrolyte imbalances, and gastrointestinal problems from extreme weight control methods.
Prevention of RED-S
- Balanced Nutrition: Ensuring adequate dietary intake to meet energy demands.
- Appropriate Training: Avoiding excessive training and focusing on balanced training programs.
- Monitoring Health: Regular health checks to detect early signs of RED-S.
- Education: Educating athletes about the risks of RED-S and promoting healthy behaviors.
- Support Systems: Providing support for athletes dealing with disordered eating or eating disorders.
Note: The source text provided was incomplete and contained some unclear references. The above summary is based on the available information and aims to provide a structured overview of RED-S causes, warning signs, impacts, and prevention strategies.
RED-S: Causes, Warning Signs, Impacts, and Prevention
Causes
Relative Energy Deficiency in Sport (RED-S) is primarily caused by a mismatch between energy intake (EI) and energy expenditure (EEE) relative to fat-free mass (FFM) or lean body mass. The formula for calculating Energy Availability (EA) is:
[ \text{EA (kcal/kg FFM/day)} = \frac{\text{EI (kcal/day) - EEE (kcal/day)}}{\text{FFM (kg)}} ]
Low EA plays a pivotal role in the development of RED-S. Various factors can contribute to low EA, including dietary restrictions, excessive exercise, and hormonal and metabolic imbalances.
Warning Signs
Screening for RED-S should be conducted as part of an annual Periodic Health Examination (PHE) and when an athlete presents with the following symptoms:
- Disordered Eating (DE/ED)
- Weight loss
- Lack of normal growth and development
- Menstrual dysfunction
- Recurrent injuries and illnesses
- Decreased performance
- Mood changes
Impacts
The impacts of RED-S can be severe and multifaceted:
- Bone Health: RED-S can lead to decreased bone mineral density (BMD) and an increased risk of stress fractures.
- Metabolic and Hormonal Imbalances: It can cause menstrual dysfunction in females and hormonal imbalances in males, affecting reproductive health.
- Performance Decline: Athletes may experience a decline in performance due to fatigue, decreased muscle strength, and reduced endurance.
- Comorbidities: Athletes with disabilities are at risk of additional health issues due to the lack of skeletal loading and the energetic challenges of movement inefficiencies.
Prevention
Prevention of RED-S involves:
- Screening: Regular screening for RED-S should be conducted to identify athletes at risk early.
- Education: Educating athletes, coaches, and healthcare providers about the importance of balanced nutrition and the risks of low EA.
- Monitoring: Monitoring energy intake and expenditure accurately to ensure adequate EA.
- Support: Providing support for athletes with disordered eating behaviors and addressing underlying psychological issues.
Conclusion
Early detection and intervention are crucial to prevent the long-term health consequences of RED-S. A multidisciplinary approach involving healthcare providers, coaches, and athletes is essential for managing and preventing RED-S.
RED-S: Causes, Warning Signs, Impacts, and Prevention
Causes
RED-S (Relative Energy Deficiency in Sport) is often caused by an imbalance between energy intake and energy expenditure. This imbalance can result from inadequate caloric intake, excessive exercise, or a combination of both. Other contributing factors include psychological issues such as eating disorders, depression, and anxiety.
Warning Signs
Warning signs of RED-S include:
- Amenorrhea or oligomenorrhea in females
- Decreased bone density or stress fractures
- Fatigue and decreased performance
- Mood changes and irritability
- Loss of menstrual cycle in females
Impacts
The impacts of RED-S can be severe and include:
- Increased risk of osteoporosis and fractures
- Impaired immune function
- Cardiovascular issues
- Psychological disorders such as depression and anxiety
- Delayed recovery from injuries
Prevention
Prevention strategies for RED-S include:
- Ensuring adequate caloric intake to meet energy demands
- Regular monitoring of menstrual function in females
- Early identification and treatment of psychological issues
- Regular bone density screenings
- Balanced training and recovery programs
- Education on the importance of proper nutrition and energy balance
Treatment and Return-to-Play
Risk Assessment for Sport Participation
A new model of criteria to assess risk for sport participation has been developed based on guidelines from the Norwegian Olympic Training Center and the IOC Consensus group. This model categorizes athletes into three risk categories:
- High Risk — Red Light: Athletes should not be cleared to participate in sport due to the severity of their clinical presentation. They should receive treatment using a written treatment contract.
- Moderate Risk — Yellow Light: Athletes should be cleared for sport participation only with supervised participation and a medical treatment plan. Re-evaluation should occur at regular intervals of 1–3 months.
Return-to-Play
Decision-making regarding return-to-play (RTP) following time away from sport for recovery from injury and/or illness is based on the assessment of the athlete’s health and the requirements of his/her sport. The RED-S Risk Assessment Model is adapted to aid clinicians’ decision-making for determining an athlete’s readiness to return to sport. Following clinical reassessment, athletes can be reclassified into the appropriate risk category.
Educational Programmes on RED-S
Educational programmes should focus on:
- RED-S, healthy eating, nutrition, and the risks of dieting.
- Emphasizing nutrition and health to enhance performance.
- Developing realistic and health-promoting goals related to weight and body composition.
- Avoiding critical comments about an athlete’s body shape/weight.
- Using reputable sources of information.
- Promoting awareness that good performance does not always mean the athlete is healthy.
- Encouraging and supporting appropriate, timely, and effective treatment.
Healthcare Professional Recommendations
Healthcare professionals can mitigate the health implications of RED-S through:
- Identifying a multidisciplinary athlete health support team including a sports physician, nutritionist, psychologist, physiotherapist, and physiologist.
- Educating the medical team in the detection and treatment of RED-S.
- Implementing the RED-S Risk Assessment Model and the RED-S RTP Model.
Sport Organization Recommendations
Sport organizations can prevent RED-S through:
- Implementing preventative educational programmes.
- Modifying rules to address weight-sensitive issues in sport.
- Establishing policies for coaches on managing athlete eating behavior, weight, and body composition.
Research Recommendations
Research institutions should focus on:
- Investigating the aetiology and treatment of athletes with RED-S, including males, ethnic, and disabled populations.
- Designing and validating tools to measure energy availability in clinical settings.
- Validating screening tools and treatment programs such as the RED-S Risk Assessment Model and RED-S RTP Model.
What is Already Known on This Topic?
- The International Olympic Committee (IOC) has published a Consensus Statement and Position Stand (2005) on the Female Athlete Triad, outlining the pathophysiology and prevalence of this syndrome.
- Low energy availability is the aetiological process underpinning the development of the Female Athlete Triad.
- Prevalence measures indicate that female athletes are particularly vulnerable to this syndrome in sports where leanness and/or weight are important due to their role in performance, appearance, or requirement to meet a competition weight category.
Impact of IOC Consensus Statement on Clinical Practice
- Scientific evidence and clinical experience show that several body systems, in addition to the reproductive and musculoskeletal systems, are affected by low energy availability.
- Men are also at risk, not just women.
- A broader term, including what has been called the ‘Female Athlete Triad’, is introduced: Relative Energy Deficiency.
RED-S: Causes, Warning Signs, Impacts, and Prevention
Causes
RED-S (Relative Energy Deficiency in Sport) is caused by inadequate energy availability due to insufficient caloric intake or excessive energy expenditure. This imbalance disrupts normal physiological functions, leading to a range of health issues.
Warning Signs
- Menstrual Irregularities: Amenorrhea (absence of menstruation) or oligomenorrhea (infrequent menstruation) in females.
- Bone Health Issues: Decreased bone mineral density and increased risk of stress fractures.
- Metabolic Changes: Low resting metabolic rate, low body temperature, and low thyroid hormone levels.
- Hormonal Imbalances: Decreased levels of leptin, insulin, and other metabolic hormones.
- Psychological Symptoms: Anxiety, depression, and disordered eating behaviors.
Impacts
- Bone Health: Reduced bone mineral density and increased risk of osteoporosis and fractures.
- Reproductive Health: Amenorrhea, infertility, and long-term reproductive health issues.
- Metabolic Health: Decreased metabolic rate, impaired glucose tolerance, and increased risk of cardiovascular disease.
- Performance: Decreased endurance, strength, and overall athletic performance.
- Mental Health: Increased risk of anxiety, depression, and eating disorders.
Prevention
- Balanced Diet: Ensure adequate caloric intake to meet energy demands of training and recovery.
- Regular Monitoring: Regularly assess energy availability and metabolic hormones to detect early signs of RED-S.
- Education: Educate athletes, coaches, and parents about the risks of RED-S and the importance of proper nutrition.
- Support Systems: Provide access to healthcare professionals who can offer guidance on nutrition and health management.
- Training Adjustments: Adjust training loads to match energy availability and avoid excessive training that leads to energy deficits.
References
- IOC Consensus Statement on the Female Athlete Triad, 2005
- Drinkwater BL, Nilson K, Ott S, et al., 1986
- Nattiv A, Loucks AB, Manore MM, et al., 2007
- Loucks AB, 2004
- Sundgot-Borgen J, Meyer NL, Lohman TG, et al., 2013
- IOC Nutrition Working Group, 2012
- Loucks AB, Heath EM, 1994
- Ihle R, Loucks AB, 2004
- Loucks AB, Kiens B, Wright HH, 2011
- Koehler K, Achtzehn S, Braun H, et al., 2013
- Reed JL, De Souza MJ, Williams NI, 2013
- Sundgot-Borgen J, Torstveit MK, 2010
- American Psychiatric Association, 2013
- Stice E, South K, Shaw H, 2012
- Martinsen M, Sundgot-Borgen J, 2013
- ACOG Committee on Adolescent Health Care, 2006
- American Society of Reproductive Medicine Practice Committee, 2008
- Redman LM, Loucks AB, 2005
- Abraham SF, Beumont PJ, Fraser IS, et al.,
RED-S: Causes, Warning Signs, Impacts, and Prevention
Causes
RED-S (Relative Energy Deficiency in Sport) is caused by inadequate energy availability, often due to excessive exercise and/or disordered eating. This imbalance disrupts the body’s normal hormonal functions, leading to a range of health issues.
Warning Signs
- Menstrual Irregularities: Amenorrhea (absence of menstruation) or oligomenorrhea (infrequent menstruation) in females.
- Bone Health Issues: Decreased bone density and increased risk of fractures.
- Hormonal Imbalances: Low levels of reproductive hormones such as estrogen and testosterone.
- Metabolic Changes: Decreased metabolic rate and thyroid function.
- Psychological Symptoms: Mood changes, irritability, and depression.
Impacts
- Bone Health: RED-S can lead to osteoporosis and increased risk of fractures.
- Reproductive Health: Amenorrhea and infertility.
- Metabolic Health: Decreased metabolic rate, thyroid dysfunction, and impaired immune function.
- Performance: Reduced physical performance and increased risk of injury.
- Psychological Health: Mood disorders, anxiety, and depression.
Prevention
- Balanced Nutrition: Ensure adequate caloric intake to meet energy demands.
- Regular Monitoring: Regularly assess bone density and hormonal levels.
- Education: Educate athletes, coaches, and healthcare providers about the risks of RED-S.
- Support Systems: Provide psychological support for athletes dealing with eating disorders and body image issues.
- Return-to-Play Protocols: Implement structured return-to-play protocols to ensure safe and gradual resumption of training and competition.
Note: The provided references are research articles and guidelines related to bone health and eating disorders, but they are not directly referenced in the summary of RED-S causes, warning signs, impacts, and prevention. They are listed for additional reading and research context.
RED-S: Relative Energy Deficiency in Sport
Overview
RED-S, or Relative Energy Deficiency in Sport, is a condition that affects athletes, particularly females, due to an imbalance between energy intake and energy expenditure. This imbalance can lead to various health and performance issues.
Causes
- Energy Deficiency: Insufficient energy intake relative to the energy expenditure required for health and activities, including sport.
- Disordered Eating: Behaviors such as restrictive dieting, binge eating, and purging.
- High Training Loads: Excessive training without adequate recovery and nutrition.
Warning Signs
- Menstrual Irregularities: Amenorrhea (absence of menstruation) or oligomenorrhea (infrequent menstruation).
- Bone Health Issues: Low bone mineral density, stress fractures.
- Performance Decline: Decreased endurance, strength, and overall athletic performance.
- Psychological Changes: Mood changes, irritability, and depression.
Impacts
- Reproductive Health: Disruption of the menstrual cycle, reduced fertility.
- Bone Health: Increased risk of osteoporosis and fractures.
- Cardiovascular Health: Potential for cardiovascular issues due to hormonal imbalances.
- Immune Function: Weakened immune system, leading to increased susceptibility to illness.
- Performance: Decreased endurance, strength, and overall athletic performance.
Prevention
- Balanced Diet: Ensure adequate intake of calories, macronutrients, and micronutrients.
- Proper Training: Balance training loads with recovery periods.
- Education and Awareness: Educate athletes, coaches, and parents about the risks and signs of RED-S.
- Regular Monitoring: Regular check-ups for bone density, menstrual function, and psychological well-being.
- Support Systems: Provide access to nutritionists, sports medicine professionals, and mental health support.
For more detailed information and updates, refer to the IOC consensus statement and related articles published in the British Journal of Sports Medicine.
