Relative Energy Deficiency in Sport (RED-S)
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1 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
2 Disclosure I, Erik Sesbreno, have no actual or potential conflict of interest in relation to this program/presentation.
3 History & Definition Return to Play Physiological Disruptions RED-S Treatment Performance & Injuries Screening
4 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)
5 Female Athlete Triad 2007 AMERICAN COLLEGE OF SPORT MEDICINE relationship between three inter-related components: energy availability (EA), menstrual function and bone health
6 Relative Energy Deficiency in Sports Introduced by the IOC expert working group in 2014 Replaces Female Athlete Triad Greater complexity Male athletes are affected
7 Considerations: Energy Availability Mountjoy, et al., 2014
8 Considerations: Energy Availability Mountjoy, et al., 2014
9 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
10 History & Definition Return to Play Physiological Disruptions RED-S Treatment Performance & Injuries Screening
11 Hormonal Disruptions EA 45kcal/kg FFM/d vs EA 10kcal/kg FFM/d
12 Hormonal Disruptions 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
13 Endocrine Alterations
14 Endocrine Alterations ANOVA (threshold) model (solid line) - p < ; R^2 (threshold) - 61% ANOVA (threshold) model (solid line) - p < 004; R^2 (threshold) - 29% Loucks et al., 1994
15 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
16 kg Effects on Fat Free Mass Rossow et al., 2013 Kistler et al., 2014 Robinson et al., 2015 Weight (kg) FFM (kg) FM (kg) Fagerberg et al., 2017
17 Effects on Fat Free Mass National Level Diver Training: Hypertrophy Block Test Method: DXA
18 Effects on Fat Free Mass Junior Elite Middle Distance Runner Test Method: ISAK Surface Anthropometry
19
20 History & Definition Return to Play Physiological Disruptions RED-S Treatment Performance & Injuries Screening
21 Reasonable Weight Change Goals SR: 0.7%/wk FR: 1.4%/wk
22 Effects on Performance N: 2 males Artic hike 95d 10hr/d 2300km
23 Effects on Performance Stroud et al., 1997
24 Effects on Performance N: 10 (female) yo 12wk training block CYC vs OVS Max TT 400m swim
25 Effects on Performance VanHeest et al., 2014
26 EUM (n=16) Mean (SD) SFHA (n=14) Mean (SD) Reaction Time (ms) 57 (4) 61 (5) Unadjusted for FFM(kg) P-value
27 Bone Metabolism Alterations 1. Bone Formation Osteocalcin (OC) Pro collagen carboxyl-terminal propeptide (PICP) 2. Bone Resorption N-Terminal telopeptide (NTX) Ihle et al., 2004
28 Bone Metabolism Alterations
29 Risk of Bone Injuries Odds of Bone Stress Injury Moderate Risk High Risk 2x more likely 4x more likely
30 Energy Availability and Injury Risk
31 Reflect and Digest 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.
32 History & Definition Return to Play Physiological Disruptions RED-S Treatment Performance & Injuries Screening
33 Disordered Eating Continuum
34 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
35 Prevalence of ED and DE in Elite Athletes Affects Both Genders Sundgot-Borgen et al., 2010
36 Prevalence of DE over Time Sundgot-Borgen et al.,2010
37 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
38 Screening and Diagnosis 4. menstrual dysfunction 5. recurring injuries and illnesses 6. decrease performance 7. mood changes Mountjoy et al.,2014
39 Screening and Diagnosis Assess 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)
40 Screening and Diagnosis 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
41 History & Definition Return to Play Physiological Disruptions RED-S Treatment Performance & Injuries Screening
42 Treatment Strategies Improve energy availability Increase energy intake (~500kcal/d) Reduce energy expenditure or both Weight gain is strongest predictor of recovery of normal menstrual function Mountjoy et al.,2014
43 Treatment Strategies 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
44 History & Definition Return to Play Physiological Disruptions RED-S Treatment Performance & Injuries Screening
45 Return to Play Framework
46 Return to Play Framework Mountjoy et al.,2014
47 Summary 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
48 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
49 Case Study Background Nov 2015 referral from CSIO physiologist Female; 18 y.o.; 1 st yr university No CSIO nutrition support No CSIO IST support
50 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
51 Sport Assessment Provincial elite program International competitions Great emphasis on leanness for P:W ratio No standardized performance test data
52 Decision Modifiers Preseason around the corner Performance excellence a BIG priority in 2016 No professional relationship established Confident with self directed nutrition planning
53 elephant pic / Blind
54
55 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
56 2016 Pre & In-Season: Monitor Educate - Build Monitor body composition changes Bone mineral content Aim to monitor sex hormones
57 2016 Pre & In-Season: Monitor Educate - Build MTB Pre/In Season MTB Off Season (mm kg ) MTB Pre/In Season MTB Off Season
58 Assess Impact: Protein Availability (g) and Distribution Training Training 0 1-3h Pre Training Fuelling During 120m Ride Recovery (<30min Post Training) Recovery (1-2hrs Post Training) Fuel Up (<30min Pre Training) Fuelling During SC Session Recovery (<30min Post Training) Supper Bedtime Snack
59 Assess Impact: Carbohydrate Availability (g/kg) and Distribution Training Training 0 1-3h Pre Training Fuelling During 120m Ride Recovery (<30min Post Training) Recovery (1-2hrs Post Training) Fuel Up (<30min Pre Training) Fuelling During SC Session Recovery (<30min Post Training) Supper Bedtime Snack
60 2016 Off Season: Monitor Educate - Build MTB Pre/In Season MTB Off Season (mm kg ) MTB Pre/In Season MTB Off Season
61
62 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)
63 Nutrition Support: New Approach to YTP Pre/In Season Off Season Pre/InSeason (mm kg ) Off Season
64 01-Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug-17 Nutrition Support: Monitoring Effects 4 LH and FSH (IU/L) Estradiol - 17 (pmol/l) LH FSH
65 Event Placement Event UCI MTB World U UCI MTB World Cup U DNS UCI MTB World Cup U UCI MTB World Cup U Canada Cup Series (Elite) 13 1 National Championship (U23) 4 4
66 elephant pic / Blind
67 Paralympian: Hockey Men s national team sledge hockey Paralympic and world championship medalist Goal: S4FS <55mm in 2 months
68 Anthropometry and Baseline DXA Use DXA to enhance observations Use lean mass to monitor EA Aim -1.0kg/wk (fat) Feb 16: Plan
69 Weight: -3.1kg Lean mass stable Fat mass: -3.3kg Rate: -1.1kg/wk S4SF: -5.2mm
70 Weight: -3.1kg Rate: -1.1kg/wk S4SF: -5.8mm S4SF: 54.4mm Target: <55.0mm
71
72 Summary Build trust and relationship Careful design Nutrition Support
73 Thank You! Erik Sesbreno MSc (c), RD, CBDT, Dip Sport Nutrition IOC Lead Sport Dietitian INS Certified Bone Densitometry Technologist & ISAK level 3 Anthropometrist esesbreno@insquebec.org
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