1. Relative Energy Deficiency in Sport (RED-S)
Elizabeth Mansfield, PhD, RD
Certified Specialist in Sport Dietetics
Clinical Exercise Physiologist
Registered Dietitian
OVERVIEW of TODAY
Concepts of relative energy deficiency and low energy availability
How to recognize athletes at risk
How to optimize nutritional strategies

2. Objectives By the end of this presentation you will be able to:
Understand what RED-S is
Identify the key features of RED-S and be able to identify athletes who may be at higher risk
Understand the mechanisms that underpin RED-S and the health/performance risks these can contribute to
Be competent in the initial management of an athlete presenting with RED-S and knowledgeable about nutrition-specific treatment options

3. What is Relative Energy Deficiency in Sport?
Female Athlete Triad
Impaired physiological functioning caused by an imbalance in energy availability
Originally termed the female athlete triad and more recently updated to include additional psychological and physical components, Relative Energy Deficiency in Sport (RED-S) is a condition that can affect athletes of any age and sex. RED-S occurs when an imbalance in energy intake and energy output has detrimental effects on bone health, menstrual function (in women), metabolic rate, immune function, cardiovascular health, and psychological health.
The underlying cause of RED-S is the inadequacy of energy intake to support body functions involved in both health and performance (an imbalance in Energy Availability)
Margo Mountjoy et al. Br J Sports Med 2015;49:
Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.

4. Pay Attention to LEA Situations
Compulsively
Tendency to supply needed energy AFTER it is needed
Exercise to eat vs. eat to exercise
prolonged exercise training in a fasted state (train LOW)
to develop greater endurance or to promote weight loss;
Intentionally
Body weight concerns (aesthetic or performance related)
Restrictive eating patterns
Restrained eating patterns
Disordered eating patterns
Inadvertently
poor biological drive to match energy intake to exercise energy expenditure
tight food budget/poor shopping or food preparation skills
Compulsively and/or Intentionally:
The female athlete triad (disordered eating, osteoporosis, amenorrhea) has been reported to occur in 12-15% of elite athletes and 5-27% of normally active females (Torstveit MK et al., Med Sci Sports Exerc. 2005;37:
Body weight and shape preoccupy many active females and female athletes. Although, by medical standards, the body weight of active women is well within normal limits (and sometimes below), these women still want to maintain their below normal weight or lose that “extra” 5-10 lbs. The following scenario may sound familiar:
Julie is a skater who trains daily. She is in great shape. Julie is unhappy with her weight and body shape. She meticulously watches what she eats AND has hundreds of dieting tricks to take off that extra 5 – 7 lbs. Julie is successful at maintaining weight (but not losing). She skips meals, buys fat free snacks and diet sodas; she substitutes energy bars for meals; she avoids “bad” foods (any foods high in fat, calories, or sugar). She has little variety in her diet. She frequently eats the same foods (types and amounts) daily. A special dinner out or an occasional dessert will bring on a bout of guilt – she will resume dieting or add an extra exercise session in.
Inadvertently:
Some athletes can have a similar low energy intake but for a different reason. Grant is a skater who spends lots of time on the ice trying to improve his performance. His coach recently increased his training time to twelve 2-3 hour sessions a week. At first he had coped with the extra training load, but by the end of the second month he was feeling fatigued. Not only was his performance beginning to drop off, but his schoolwork had started to get on top of him as well. To cap it all off, his weight seemed to be going down and he could not really afford to lose any more body fat. Grant’s mother encourages him to eat a larger serving of meat at the evening meal, but by this time of the night he is often too tired to do more than pick at it. Grant’s typical daily meal plan consists of three meals per day – breakfast, hastily eaten in the car on the way from the rink to school, lunch, juggled between school activities, and a late evening meal at home after his one ice and off ice training sessions.
2019
Bridging science into practice

5. Bridging science into practice
A situation of LEA in athletes can arise unintentionally or intentionally. In the diagram the central column shows that an athlete where energy intake is sufficient to cover the demands from training and to cover basic physiological function. However in the column on the left, although training load has remained constant, nutritional intake has been reduced. This reduction of energy intake could be an intentional strategy to reduce body weight or change body composition in weight sensitive sports and dance.  On the other hand in the column on the right, training load and hence energy demand to cover this has increased, but has not been matched by an increase in dietary intake. In both these situations, whether unintentional or intentional, the net result is LEA, insufficient to maintain health. This situation of LEA will also ultimately impact on athletic performance, as optimal health is necessary to realise full athletic potential.
2019
Bridging science into practice

6. Endocrine Markers – Physiological Response
Loss of menstruation is a red flag

7. Cumulative energy deficit and energy availability.
Nicola Keay, and Alan Rankin Br J Sports Med doi: /bjsports
Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.

8. Include in annual health screenings;
Relative energy deficiency in sport: effects on health and performance.
Early detection is critical in preventing long term health and performance detriments;
Include in annual health screenings;
Screen if athlete presents with any symptoms.
Relative energy deficiency in sport: effects on health and performance.
Adapted from: Margo Mountjoy et al. Br J Sports Med 2015;49:

9. Signs & Symptoms of RED-S
Disordered eating patterns
overly restricting intake or food groups, skipping meals or using unsafe weight loss methods;
Poor bone health
stress fractures can often be a sign of this /<normal Bone Mineral Density
Lower sex hormone levels
Issues with fertility, recovery, muscle mass
Depressed mood or irritability
Susceptibility to ongoing illness
poor immune function
Reduced performance, recovery and adaptations to training.
2019
Bridging science into practice

10. KEY: Optimizing Energy Availability
EA = Energy intake (EI) – Exercise Energy Expenditure (EEE)
Fat Free Mass (FFM)
EI: Assessed with food diary or food recalls EEE: Assessed with training log and heart rate monitor FFM: Assessed with DEXA and/or other anthropometric tools
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. Energy availability is the amount of dietary energy remaining after exercise training for all other metabolic processes.
To determine energy availability (in units of kilocalories or kilojoules per kilogram of fat-free mass), athletes can record their diets and use diet analysis software to calculate energy intake, measure energy expenditure during exercise using a heart monitor and measure fat-free mass using a bioelectrical impedance body composition scale.
Loucks, Anne B. Low Energy Availability in the Marathon and Other Endurance Sports. Sports Medicine, 2007, Vol. 37 Issue 4/5, p , 5p;

11. KEY: Optimizing Energy Availability
EA = Energy intake (EI) – Exercise Energy Expenditure (EEE)
Fat Free Mass (FFM)
Optimal EA: kcal/kg of FFM This is the energy left over after covering off energy needs for exercise; This is the amount of dietary energy left for all other metabolic processes in the body
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. Energy availability is the amount of dietary energy remaining after exercise training for all other metabolic processes.
To determine energy availability (in units of kilocalories or kilojoules per kilogram of fat-free mass), athletes can record their diets and use diet analysis software to calculate energy intake, measure energy expenditure during exercise using a heart monitor and measure fat-free mass using a bioelectrical impedance body composition scale.
Loucks, Anne B. Low Energy Availability in the Marathon and Other Endurance Sports. Sports Medicine, 2007, Vol. 37 Issue 4/5, p , 5p;

12. Case Study of LEA ISSUES:
ASSESSMENT:
46 kg female University skater with 13.5% BF
Very low skeletal mass (< 80% of normal for her height)
BMI 15.6 UNDERWEIGHT
40 kg FFM
Estimated EI is restricted to approximately 1800 kcal/day
Restrictive eater “stomach in a knot”
Trains “LOW”
Cost of daily PA + exercise training 650 kcal/day
kcal/day range
Many GIT symptoms, bloating, gas,
No menstrual function for last 6 months (since stopping pill)
ISSUES:
LOW energy available for physiology: 1800 kcal (EI) – 650 (EE) = 1150 kcal
LOW EA = 1150 kcal/40 kg FFM = kcal/kg FFM

13. Case study cont’d… Minimal EA needs: 40-45 kcal/kg FFM;
kcal/day to support FFM but only has 1150 kcal/day
(+) kcal needs to be added to daily energy budget
Healthy physiological adaptation to EA
1st GOAL : ADD kcal/day for next 3 months
Maintenance of FFM
Kick start menstrual function
2nd GOAL: Structured meal plan
Timing of nutrient intakes to minimize daily AND within day energy deficits
Optimize calcium and Vitamin D for bone formation
Track GI symptoms with consistent food/fluid intakes

14. Manage Within Day Energy Availability
Energy Deficits
Large deficits lead to risks of RED-S
January 2019
Bridging science into practice

15. Energy Availability
GOAL: regular eating schedule that optimizes energy levels throughout the day AND during workouts:
3-4 hours before training = MEAL;
≤ 2 hours of training = large snack/beverage
≤ minutes of training = small snack/beverage

16. Managing Energy Availability
Optimize the availability of energy (specifically carbohydrate) and fluids:
Build an energy budget including pre-workout snacks to top up hydration and energy availability
Carbohydrate rich foods 3-4 hours prior to exercise increases liver and muscle glycogen stores
Enhances performance
Include carbohydrate rich foods for DURING workouts, when needed, to minimize energy deficits throughout training sessions
Minimizes potential negative effects of carbohydrate depletion
Energy Phase
Timing is KEY
ENERGY Phase (Pre and during exercise):
January 2019
Bridging science into practice

17. Timing of Energy Availability
Energy Phase
Recovery
Phase
Optimizing RECOVERY sets the stage for next training session
Enhance tissue refueling:
Choose carbohydrate rich foods for snacks and meals post workout
Stimulate protein synthesis:
Leucine is the amino acid that triggers muscle protein synthesis post workout;
January 2019
Bridging science into practice

18. Bridging science into practice
Optimal Recovery
Re-fuel with a milk based snack and include small servings of carbohydrate rich foods
Include starches (breads, cereals, legumes, potatoes) and sugars (fruits, milk, yogurt) and combinations of starchy/non-starchy carbohydrates (vegetables)
within minutes if 2 or more training sessions that day;
within 2 hours if training once a day
within 4-14 hours if not training the next day
January 2019
Bridging science into practice

19. Bridging science into practice
Optimal Recovery
Re-build bones and muscles with essential nutrients found in protein rich foods
Leucine is the amino acid that triggers muscle protein synthesis post workout;
Growing athletes, injured athletes
Weight conscious athletes;
Training for power;
Multiple training sessions in a day.
January 2019
Bridging science into practice

20. Manage Weekly Energy Availability
Day 1
Day 2
Day 3
Day 4 1
Sufficient energy availability in daily dietary pattern 2
Relative energy deficiency
Poor recovery
Consistently inconsistent performance
Health issues 3 4
Day 1 Training Session
Day 2 Training Session
Day 3 Training Session
Day 4 Training Session
2019
Bridging science into practice

21. Optimize all 3 Phases of Energy Availability
ENERGY PHASE Build an energy budget including pre-workout snacks to top up hydration and energy availability for DURING workouts
RECOVERY PHASE Promote recovery post workout with fluids and a snack/meal to promote energy availability for optimal recovery
BUILD PHASE Integrate frequent, small servings of protein rich foods at most eating occasions: 8-12 grams of protein at snacks grams protein at meals
Energy Phase
Recovery
Phase
Build Phase
January 2019
Bridging science into practice

22. Protein Crib Sheet

23. Simple Recovery Strategies
Protein Sources
Large Snack Ideas
Small/Large Meal Ideas
Eggs
Muffin vegetable frittata
French toast with maple syrup
Boiled egg + crackers
Vegetable frittata
Egg salad sandwich
Chicken
Chicken sausage rice cakes
Honey ginger chicken wraps (cut in 2” pieces)
Chicken tacos
Chicken and bacon hash
Ground chicken shepherd’s pie
Fish
Smoked salmon and crackers/bagel pieces
Salmon burgers with salad
Pasta salad with canned salmon/tuna
Meat
Roast beef slices on rye bread with pickles
Spaghetti with meat sauce
Beef and vegetable stew
Chick peas, lentils, kidney beans
Beet hummus dip with baby carrots
Black beans with quinoa and veggies
Chick pea burger with sweet potato fries
Soybeans, tofu soy protein products
Steamed edamame, tofu peanut butter on crackers
Soy protein based energy bars
Tofu stir fry with rice and veggies
Tofu vegetable noodle soup
Dairy Foods
whey protein
Tzatziki dip with vegetables, fruit smoothies
Whey protein based energy bars
Grilled Swiss cheese and ham sandwich
Cheese and egg quiche
Greek yogurt with muesli and fruit
Nuts
Chocolate peanut coconut rice cakes
Almond and date rice cakes
 Mixed grain fruit oatmeal with walnuts and sunflower seeds, cooked in almond milk

24. Meal Planning Easy Training Day 1 hour Moderate Training Day  
Moderate Training Day
1 -2 sessions; cumulative training 3-4 hours
 Hard or Long Training Day
2-3+ training sessions/day = 4-6 hours 
Potato vs potato chips
Grapes vs raisins
Oatmeal/rice/quinoa/pasta vs bagels/toast/crackers
Milk/yogurt vs cheese
Legumes/hummus vs nuts/seeds
Omelets/fish vs grilled meats
Athlete’s Plate from: United States Olympic Committee Sport Dietitians

27. Optimize energy intake
KEY Considerations
Optimize energy intake
Ability to train without undue fatigue?
Fast recovery between training sessions?
Maintenance of body composition?
Optimal biological functioning?
Absence of health & performance issues?
The Female Athlete Triad Umbrella

28. A Sport Nutrition Checklist for Energy Availability
Energy needs for level of training
Periodized nutrition program to match training cycles
Promote recovery of fluid & fuel stores
Trial competition eating practices
Desirable body weight & body fat
Long-term good health, immune function
Food as source of pleasure
2019
Bridging science into practice

29. Role of the Sport Dietitian
Determine body composition and energy needs
Body composition, RMR
Energy budget for exercise & body composition
Follow the sport & nutrition science
Fluid balance and energy availability
Foods and food patterns for health AND performance
Supplementation when needed
Practice makes perfect
Structured meal planning - helps boost confidence of restrictive eaters
Training is the time to test what works for performance issues
Individualization is KEY
2019
Bridging science into practice