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Relative Energy Deficiency in Sport (RED-S)

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Presentation on theme: "Relative Energy Deficiency in Sport (RED-S)"— Presentation transcript:

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

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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


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