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Abstract

In April 2014, the International Olympic Committee (IOC) published a Consensus Statement in the British Journal of Sports Medicine (BJSM) entitled “Beyond the Female Athlete Triad - Relative Energy Deficiency in Sport (RED-S)”. To assist sports medicine professionals working in clinical sports medicine with the practical screening and management of the RED-S athlete, the IOC authors have developed a Clinical Assessment Tool - the .
The IOC relative energy deciency
in sport clinical assessment tool
(RED-S CAT)
Margo Mountjoy,
1
Jorunn Sundgot-Borgen,
2
Louise Burke,
3
Susan Carter,
4
Naama Constantini,
5
Constance Lebrun,
6
Nanna Meyer,
7
Roberta Sherman,
8
Kathrin Steffen,
2,9
Richard Budgett,
9
Arne Ljungqvist,
9
Kathryn Ackerman
10
It is well known that the utility of scien-
tic knowledge is limited at a practical
level and that implementing effective
interventions in the real life sport setting
are challenging. As in all areas of medi-
cine, there is now attention in sports
medicine to the growing eld of knowl-
edge translation. Effective translation of
the science into practical usable formats
are necessary to ensure that athlete care is
both evidence based and effective.
Sports medicine clinicians utilise guiding
principles and various models to assist with
the medical management and harm mini-
misation in their course of their care of ath-
letes. The RED-S Red Light Yellow Light
Green LightRisk Assessment and Return
to Play (RTP) models are designed to take a
complex clinical assessment and RTP deci-
sion making process and integrate them
into a functional model that is both simple
to understand by the athlete and the clin-
ician, and is relatively easy to implement in
the real world. Effective sports medicine
models are designed with latitude to accom-
modate the interpretation of an athletes
unique situation by the treating clinician,
acknowledgement of mitigating factors,
ongoing monitoring of the individual, and
continual re-evaluation of the model. The
RED-S Red Light Yellow Light Green
LightRisk Assessment and Return to Play
models were developed with this exibility
to allow clinicians in the eld the ability to
adapt the model to their particular athlete
situation. These models enable the treating
clinicians to apply their knowledge of the
sport-specic demands and case-specic
parameters, combined with their clinical
experience, within the exible parameters
of the model. The models were developed
to be adaptable for both males and females.
The endpoints identied as red light high
riskcriteria and the yellow light caution
criteria all apply to both male and female
athletes except for the two endpoints
related to the menstrual cycle. These
models have been implemented successfully
since 2012 at the competitive level, for all
ages and sport disciplines of athletes at the
Norwegian Olympic Training Center. The
IOC authors recommend that the RED-S
conceptual models should be integrated
into performance nutrition educational
approaches, as they offer an opportunity
for athletes and coaches to understand the
broad scope of issues related to suboptimal
eating practices.
To facilitate this recommendation, the
IOC authors have developed a RED-S
Clinical Assessment Tool
1
(RED-S CAT)
modelled after the Sport Concussion
Assessment Tool (SCAT-3), which is
widely used in clinical practice. Utilisation
of the RED-S CAT will assist clinicians in
the eld with the screening of athlete
populations at risk and the management
of return to play decisions of RED-S ath-
letes. Like the original SCAT, the RED-S
CAT is designed to facilitate clinical prac-
tice and to encourage further research and
validation. It is expected that the RED-S
CAT will evolve over time as the body of
science in the eld grows.
The RED-S CAT should be implemen-
ted globally to facilitate and improve the
medical management of both male and
female athletes with RED-S.
To cite Mountjoy M, Sundgot-Borgen J, Burke L,
et al.Br J Sports Med Published Online First: [please
include Day Month Year] doi:10.1136/bjsports-2015-
094873
Br J Sports Med 2015;0:1.
doi:10.1136/bjsports-2015-094873
REFERENCE
1 Relative Energy Deciency in Sport (RED-S). Br J
Sports Med 2015;49:4213.
In April 2014, the International Olympic
Committee (IOC) published a Consensus
Statement in the British Journal of Sports
Medicine (BJSM) entitled Beyond the
Female Athlete Triad Relative Energy
Deciency in Sport (RED-S).Toassist
sports medicine professionals working in
clinical sports medicine with the practical
screening and management of the RED-S
athlete, the IOC authors have developed a
Clinical Assessment Tool the RED-S CAT.
1
Department of Family Medicine, Michael G. DeGroote
School of Medicine, McMaster University, Hamilton,
Ontario, Canada;
2
Department of Sports Medicine, The
Norwegian School of Sport Sciences, Oslo, Norway;
3
Department of Sports Nutrition, Australian Institute of
Sport, Belconnen, Australia;
4
University of Northern
Colorado, University of Colorado Medical School,
Colorado, USA;
5
Orthopedic Department, Hadassah-
Hebrew University Medical Center, Jerusalem, Israel;
6
Department of Family Medicine, Faculty of Medicine &
Dentistry, and Glen Sather Sports Medicine Clinic,
University of Alberta, Edmonton, Alberta, Canada;
7
Health Sciences Department, University of Colorado,
Colorado Springs, Colorado, USA;
8
The Victory Program
at McCallum Place, St. Louis, Missouri, USA;
9
IOC
Medical and Scientic Department, Lausanne,
Switzerland;
10
Divisions of Sports Medicine and
Endocrinology, Boston Childrens Hospital,
Neuroendocrine Unit. Massachusetts General Hospital,
Harvard Medical School, USA
Correspondence to Margo Mountjoy, Department of
Family Medicine, Michael G. DeGroote School of
Medicine, McMaster University, Hamilton, Ontario,
Canada; mmsportdoc@mcmaster.ca4444
Mountjoy M, et al.Br J Sports Med Month 2015 Vol 0 No 0 1
Editorial
What is the RED-S CAT?
The RED-S CAT is a clinical assessment tool for the evaluation of athletes / active
individuals suspec ted of having relative energ y de ciency and for guiding return to
play decisions. The RED -S CAT is designed for use by a medical professional in the
clinical evaluation and management of athletes with this sy ndrome. The RED-S CAT
is based on the IOC Consensus Statement on RED -S, 2014.1
This tool may be freely copied in its current form for use by sport organizations
and the athlete medical team entourage. Alterations to the tool or reproduction for
publication purposes require permission from the International Olympic Committee.
NOTE: The diagnosis of RED-S is a medical diagnosis to be made by a trained health
care professional. Clinical management and return to play decisions for athletes with
RED-S should occur under the guidance of an experienced sports medicine team.
What is Relative Energy De ciency in Sport?
The syndrome of RED-S refers to impaired physiologic al functioning caused
by relative energy de ciency, and includes but is not limited to impairments
of metabolic rate, menstrual function, bone health, immunity, protein syn -
thesis , and cardiovascular health.
The cause of RED-S is the scenario termed “low energy availability”, where an in-
dividual’s dietary energy intake is insuf cient to support the energy expenditure
required for health, function, and daily living, once the cost of exercise and sporting
activities is taken into account.
The potential health consequences of RED -S are depic ted in the RED -S conceptual
model (See Figure 1). Psychological problems can be both the result of and the cause
of RED-S.
RED-S CAT
Relative Energy Defi ciency in Sport (RED-S)
Clinical Assessment Tool (CAT)
For use by medical professionals only
Name Date : Examiner :
Screening for RED-S
The screening and diagnosis of RED-S is challenging, as symptomatology can be sub-
tle. A special focus on the athlete at risk is needed. Although any athlete can suffer
from RED-S, those at particular risk are those in judged sport s with an emphasis on
the aesthetic or appearance, weight category sports, and endurance sports. Early
detection is of impor tance to maintain and improve performance and prevent long-
term health consequences.
Screening for RED-S can be undertaken as part of an annual Periodic Health Exam-
ination and when an athlete presents with Disordered Eating (DE) / Eating Disorders
(ED), weight loss, lack of normal growth and development, endocrine dysfunction,
recurrent injuries and illnesses, decreased performance / performance variability or
mood changes.
RED-S may also affect athlete sport performance. The potential effect s of RED-S on
sport performance are illustrated in Figure 2:
Immuno-
logical
Gastro-
intestinal
Cardio-
vascular
Psycho-
logical
Growth +
develo-
pement
Hermato-
logical
Metabolic
Bone
health
Menstrual
Function
Endocrine
TRIAD
Decreased
endurance
performance
Decreased
muscle
strength
Decreased
glycogen
stores
Depression
Irritability
Decreased
concentration
Decreased
coordination
Decreased
training
response
Increased
injury
risk
Impaired
judgement
Triad
Figure 1
Figure 2
Br J Sports Med 2015;0:1–33 . doi:10.1136/bjsports-2014-094559
3
Treatment of Relative Energy Deciency in Sport (RED-S)
Athletes categorized in the red light and yellow light zones should receive medi-
cal evaluation and treatment. The treatment of RED-S should be undertaken by a
team of health professionals including a spor ts medicine physician, sports dietician,
exercise physiologist, athletic therapist or trainer, sports psychologist / spor ts psy-
chiatrist as needed. Patient condentiality must be maintained. Treatment should
focus on correcting the relative energy decit through increasing energy intake
and / or decreasing energy output. Intake of nutrients and other vitamins should fol-
low established guidelines. Repeat assessment of BMD should occur at inter vals of
6 – 12months, depending on clinical present ation and initial values.
The use of an athlete contract is also recommended. (See Appendix)
Relative Energy Deciency in Sport (RED-S) risk
assessment decision making steps for determining
readiness for returning to play
Prior to returning an athlete to sport / physical activity following time away for RED-S
treatment, an assessment of the athlete’s health and the requirements of his / her
sport should be under taken following the step -wise approach:
STEPS RISK
MODIFIERS
CRITERIA RED-S SPECIFIC
CRITERIA
STEP 1
Evaluation of
Healt h Status
MEDICA L
FACTOR S
- Patient Demo-
graphics
- Symptoms
- Medical History
- Signs
- Diagnostic Tests
- Psychological
Health
- Potential
Seriousness
- Age, sex
- See Yellow Light column
in RED-S Risk assessment
model
- Recurrent dieting,
menstrual health, bone
health
- Weight loss / uctuations,
weakness
- Hormones, electrolytes,
electrocardiogram, DXA
- Depression, anxiety,
disordered eating /
eating disorder
- Abnormal hormonal and
metabolic function
- Cardiac arrhythmia
- Stress fracture
STEP 2
Evaluation of
Participation
Risk
SPORT RI SK
MODIFIERS
- Type of Sport
- Position Played
- Competitive Level
- Weight sensitive,
leanness sport
- Individual vs. team sport
- Elite vs. recreational
STEP 3
Decision
Modication
DECISI ON
MODIFIERS
- Timing and
Season
- Pressure from
Athlete
- External Pressure
- Conict of Interest
- Fear of Litigation
- In / out of season, travel,
environmental factors
- Mental readiness to
compete
- Coach, team owner,
athlete family, sponsors
support
- If restricted from
competition
Return to Play Model
Following clinical reassessment utilizing the 3 step evaluation outlined above, ath-
letes can be re- classied into the “High Risk – Red Light”, “Moderate Risk – Yellow
Light” or “Low Risk – Green Light” categories. The RED -S Risk Ass essment Model is
adapted to aid clinicians’ decision making for determining an athlete’s readiness to
return to spor t / physical activity.
The RED-S Return to Pla y Mo del outlines the sport activit y recommended for each
risk category.
HIGH RISK
RED LIG HT
MODERATE RISK
YELLOW L IGHT
LOW RISK
GREEN LIGHT
- No competition
- No training
- Use of written contract
- May train as long as
he / she is following the
treatment plan
- May compete once
medically cleared under
supervision
- Full sport participation
RED-S Risk Assessment Model for sport participation
This model c an be incorporated into the Periodic Health Examination. Depending on
the ndings on history and physical examination, the athlete is classied into one of
the 3 following c ategories: “Red Li ght”: High risk, “Yellow Light”: Moderate risk,
“Green Light”: Low Risk.
HIGH RISK:
NO START
RED LIG HT
MODERATE RISK:
CAUTION
YELLOW LIGHT
LOW RISK :
GREEN LIGHT
- Anorexia nervosa and other
serious eating disorders
- Other serious medical
(psychological and physio-
logical) conditions related
to low energy availability
- Use of extreme weight
loss techniques leading to
dehydration induced hemo-
dynamic instability and other
life threatening conditions.
- Prolonged abnormally low
% body fat measured by
DXA* or anthropometry
- Substantial weight loss
(5 – 10 % body mass in
one month)
- Attenuation of expected
growth and development
in adolescent athlete
- Appropriate
physique that
is managed
without undue
stress or un-
healthy diet /
exercise strategies
- Low **EA of prolonged
and / or severe nature
- Healthy eating
habits with
appropriate EA
- Abnormal menstrual cycle:
functional hypothalamic
amenorrhea > 3 months
- No menarche by age 15 y
in females
- Healthy function-
ing endocrine
system
- Reduced bone mineral
density (either in compari-
son to prior DXA or
Z-score < -1 SD).
- History of 1 or more stress
fractures associated with
hormonal / menstrual
dysfunction and / or low EA
- Healthy bone
mineral density
as expected for
sport, age and
ethnicity
- Healthy
musculoskeletal
system
- Severe ECG abnormalities
(i.e. bradycardia)
- Athletes with physical /
psychological compli-
cations related to low
EA+ / -disordered eating;
- Diagnostic testing abnor-
malities related to low EA
+ / -disordered eating
- Prolonged relative energy
deciency
- Disordered eating behavior
negatively affecting other
team members
- Lack of progress in
treatment and / or
non-compliance
* dual energy X-ray absorptiometry
**EA: Energy availability = Energy intake – Energy cos t of exercise
(additional energy expended in undertaking exercise).
NOTES on diagnostic tools for Low EA:
Although low EA is a key factor in RED-S, at the present time there is no standardised
protocol for undertaking an assessment of EA in free -living athletes. Some sports
nutrition expert s may have developed tools to monitor EA in which they have con-
dence, and may use these to screen for problems or guide dietary counselling.
However, a univers al recommendation to measure EA is unwise in the absence of a
protocol that is sensitive, reliable, time- efcient and cost-effective.
Sport Participation based on Risk Category
“High Risk - Red Light”: no clearance for sport participation.
Due to the severity of his / her clinical presentation, sport par ticipation may pose
serious jeopardy to his / her health and may also distract the athlete from devoting
the attention needed for treatment and recovery.
“Moderate Risk -Yellow Light”: cleared for sport participation only with super-
vised par ticipation and a medical treatment plan.
Re-evaluation of the athlete’s risk assessment should occur at regular intervals of
1 3 months depending on the clinical scenario to assess compliance and to detect
changes in clinical status.
“Low Risk – Green Light”: full sport participation.
Br J Sports Med 2015;0:1–33 . doi:10.1136/bjsports-2014-094559
3
References
Mountjoy M, Sundgot-Borgen J, Burke L, et al. IOC Consensus Statement. Beyond the Triad – RED-S in sport. Br J Sports Med. 2014; 48: 491-7.
Contributing Authors
Margo Mountjoy (CAN) IOC Medical Commission Games Group
McMaster University Medical School
Jorunn Sundgot-Borgen (NOR) Department of Sports Medicine
The Nor wegian School of Sport Sciences
Louise Burke (AUS) Sports Nutrition, Australian Institute of Sport
Susan Carter (US A) University of Northern Colorado
Universit y of Colorado Medical School
Naama Con stantini (ISR) Orthopedic Department, Hadassah- Hebrew University Medical Center
Constance Lebrun (CAN) Department of Family Medicine,
Faculty of Medicine & Dentis try, and Glen Sather Spor ts Medicine Clinic, University of Alberta
Nanna Meyer (USA) University of Colorado, Health Sciences Department
Roberta Sherman (USA) The Victory Program at McCallum Place
Kathrin Steffen (NOR) Department of Sports Medicine,
The Nor wegian School of Sport Sciences
Richard Budget t (SUI) IOC Medical and Scientic Depar tment
Arne Ljun gqvist (SWE) IOC Medical Commission
Kathryn Ackerman (USA) Divisions of Sports Medicine and Endocrinology,
Boston Children’s Hospital, Neuroendocrine Unit
Massachus etts General Hospital, Harvard Medical S chool
APPENDIX
Relative Energy Deciency in Sport (RED-S) Treatment Contract
RED-S Treatment Contrac t for
Multidisciplinary Team:
(Physician)
(Psychotherapist / Ps ychiatrist)
(Exercise physiologist)
(Dietitian)
(Other)
Requirements
Meet w ith:
The psychotherapist at intervals recommended by the health profes sional treatment team
The dietitian at intervals recommende d by the health professional treatment team
The physician at intervals recommended by the health professional treatment team
Follow daily meal plan developed by the health professional treatment team
Follow the adapted training plan developed by the health professional treatment team
If underweight, weight gain expected to be kg per week / weight st able within week
If underweight, must achieve minimal acceptable body weight / fat of kg / percent by
Regular weigh-in at the following time intervals of we ek (s)
After this date, (dd / mm / y yyy), must maintain weight and % fat at or above minimal acceptable body weight/ fat mass of (kg / %)
Other
If ALL requirement s are met and the eating behavior (and other severe conditions) are normalized the Team Physician will decide if cleared for competition.
I, have read this contract and all of my questions were answered.
Athlete Name Athlete Signature Date
Team Physician Name Team Physician Signature Date
Br J Sports Med 2015;0:1–33 . doi:10.1136/bjsports-2014-094559
3
... Einerseits fehlen allgemeingültige Therapieempfehlungen für Athletinnen mit RED-S und auf der anderen Seite wird die Athletin auf eine zeitintensive Geduldsprobe gestellt. Es lohnt sich gemeinsam mit der Athletin einen multimodalen Behandlungsplan mitsamt Zielvereinbarungen und Zeithorizont zu formulieren [31]. Die Athletin soll darüber informiert werden, dass trotz wiederhergestellter Energieverfügbarkeit eine Latenz von 12 Monaten bis zum Wiedereinsetzen der Menstruation zu erwarten ist [32]. ...
Article
Zusammenfassung Die „female athlete triad“ (FAT) beinhaltet die Kombination aus einer verminderten Knochendichte und einer Amenorrhö, welche durch eine verminderte Energieverfügbarkeit bei Athletinnen getriggert werden. Die Begrifflichkeit der FAT wurde in den vergangenen Jahren durch das „relative energy deficiency in sports“ (RED-S) erweitert und schliesst auch männliche Athleten ein. Ein erhöhtes Energiedefizit verursacht durch inadäquate Energiezufuhr oder übermässige Energieausgaben löst eine Kaskade an pathophysiologischen Anpassungsreaktionen aus. Neben der Suppression der Hypothalamus-Hypophysen-Gonaden-Achse (HHG-Achse) mit konsekutiver Amenorrhö und verminderter Knochendichte setzt ein persistierendes Energiedefizit den Körper in den „Sparflammen-“ oder besser gesagt „Kampfmodus“. Dies beinhaltet eine herabgesetzte Funktion des Immunsystems und der Regeneration, metabolische Anpassungen, kognitive, psychologische, gastrointestinale und kardiovaskuläre Störungen wie auch eine eingeschränkte Leistungsfähigkeit des Sportlers. Das Beschwerdebild eines RED‑S bei Athletinnen ist initial subtil und kommt meist erstmals durch das Ausbleiben der Menstruation merklich zum Vorschein. Damit sind Gynäkologen/-innen oft die erste Anlaufstelle bei Athletinnen mit RED‑S und übernehmen eine wichtige Funktion im Management des RED‑S. Das Management des RED‑S bei Athletinnen ist komplex: Es besteht aus einer gynäkologisch-endokrinologischen Amenorrhöabklärung und dem Aufstellen eines interdisziplinären, längerfristigen Behandlungsplans zusammen mit der Athletin. Résumé La triade de l’athlète féminine (TAF) implique la combinaison d’une densité de masse osseuse réduite et d’une aménorrhée déclenché par une insuffisance énergétique chez les athlètes féminines. La notion de TAF a été étendu ces dernières années par la notion de déficit énergétique relatif dans le sport (ou en anglais RED‑S, relative energy deficiency in sport), incluant aussi les athlètes masculins. Un déficit énergétique accru dû à un apport énergétique inadéquat ou à des dépenses excessives d’énergie déclenche une cascade de réactions d’adaptation physiopathologiques. En plus d’une suppression de l’axe hypothalamo-hypophyso-gonadique (axe HHG) avec aménorrhée consécutive et diminution de la densité minérale osseuse, un déficit énergétique persistant a pour effet de mettre le corps en «mode économie», ou plus précisément en «mode combat». Cela comprend une fonction réduite du système immunitaire et de la régénération, des adaptations métaboliques, des troubles cognitifs, psychologiques, gastro-intestinaux et cardio-vasculaires ainsi qu’une capacité réduite de performance du sportif. Les symptômes du RED‑S chez les athlètes féminines sont discrets au début et se manifestent pour la première fois généralement avec l’absence des règles. Les gynécologues sont souvent le premier point de contact des athlètes féminines atteintes d’un RED‑S et c’est à eux que revient alors la fonction importante de la prise en charge du RED‑S. La prise en charge du RED‑S chez les athlètes est complexe: elle consiste en une évaluation gynécologique et endocrinologique de l’aménorrhée et l’établissement d’un plan de traitement interdisciplinaire à long terme en accord avec l’athlète. „Female athlete triad“ vs. RED-S Reden wir nun von der „female athlete triad“ (FAT) oder dem „relative energy deficiency in sports“ (RED-S)? Da scheiden sich die Geister weiterhin. Vorab ein kurzer historischer Abriss: Noch nicht allzu lange her im Jahr 1976 ging die US-Amerikanerin Katherine Switzer als erste dazumal noch als Mann verkleidete Marathonläuferin am Boston-Marathon in die Sportgeschichte ein. Sie gilt als Paradebeispiel für das Erwachen des kompetitiven Frauensports in den 70er- und 80er-Jahren. Gleichzeitig wurden erstmals Insuffizienzfrakturen bei Sportlerinnen, insbesondere bei Läuferinnen mit Essstörungen, beschrieben [1]. Die FAT wurde erstmals 1997 durch das American College of Sports Medicine (ACSM) definiert [2]. Zu dieser Triade gehören: gestörtes Essverhalten und unregelmässige Menstruationszyklen gepaart mit einer verminderten Knochendichte durch den Abfall der Östrogenlevel. Folgestudien brachten mehr Licht in die Pathophysiologie dieses Geschehens und zeigten, dass nicht nur ein gestörtes Essverhalten, sondern eine gestörte Energieverfügbarkeit als Hauptverursacher dieser Triade anzusehen ist [3]. Auch bei männlichen Athleten wurde die Assoziation zwischen verminderter Knochendichte und hypogonadalem Hypogonadismus hergestellt [4]. Im Jahr 2014 wurde der Terminus wie auch das Konzept des FAT durch ein Expertengremium des International Olympic Committee (IOC) überarbeitet und die FAT in das Konzept des „RED-S“ integriert. Das Konzept der FAT wurde bisher noch nicht von allen Fachkreisen verlassen und so bestehen zurzeit beide Konzepte fort. Der gemeinsame Nenner beider Konzepte besteht darin, dass eine verminderte Energieverfügbarkeit und nicht zwingend eine zugrunde liegende Essstörung als Hauptauslöser der FAT wie des RED‑S angesehen wird. Gemäss einer aktuellen Umfrage an einer Sportmedizinkonferenz an der Harvard Medical School fehlt das Bewusstsein für die Begrifflichkeit und für das Therapiekonzept des RED‑S bei 71 % der Konferenzteilnehmenden [5]. Dieses Resultat ist nebenbei aber auch ein Abbild des existierenden „Grabenkampfs“ zwischen Europa und den USA, wobei dort weiterhin am Konzept der FAT festgehalten wird. Der folgende Artikel widmet sich dem Management des RED‑S.
... A clinical screening tool, such as the RED-S-CAT, may provide a useful proforma to assess for RED-S within clinical practice. 68 sleeping patterns, RED-S, or psychological well-being. However, physical therapists serving postpartum women should also be aware of potential thyroid autoimmunity in this population. ...
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Background: Postpartum women frequently engage in running. In the absence of official guidance on returning-to-running postpartum, physical therapists rely on clinical experience alongside the available literature. Subsequently , the traditional evaluation of postpartum readiness for running tends to focus on musculoskeletal factors. This clinical commentary addresses how to evaluate and manage postpartum return-to-running in a systematic order by discussing relevant whole-systems considerations beyond the musculoskeletal system, while also highlighting possible interactions between relevant considerations. Discussion: Using a whole-systems biopsychosocial approach, physical therapists should consider the following when managing and evaluating readiness to return-to-running: physical deconditioning, changes to body mass, sleeping patterns, breastfeeding, relative energy deficiency in sport, postpartum fatigue and thyroid autoimmunity, fear of movement, psychological well-being, and socioeconomic considerations. Undertaking a risk-benefit analysis on a case-by-case basis using clinical reasoning to determine readiness to return-to-running postpartum should incorporate these considerations and their possible interactions, alongside considerations of a musculoskeletal evaluation and graded exercise progression. Conclusions: Return-to-running postpartum requires an individualized, whole-systems biopsychosocial approach with graded exercise progression, similar to the management of return to sport following musculoskeletal injuries. A video abstract for this article is available at: http://links. lww.com/JWHPT/A51 Key Words: biopsychosocial, breastfeeding, fear of movement, relative energy deficiency in sport, whole-systems
Chapter
At the most primitive level, humans were made to run. The ability to run long distances may have given humans a competitive advantage in persistence hunting that provided essential food for survival (Lieberman et al., 2007). In modern times, most distance running is performed for athletic competition, physical fitness or play. Participation in the sport of running has seen a steady upward trend over the last few decades, including in adolescents. This trend creates a specific opportunity for pediatric clinicians. Running can be beneficial for health and wellness, however a significant proportion of habitual runners sustain an overuse injury annually. Running can improve mental health by decreasing symptoms of anxiety and depression, but it can play a role in exercise addiction and eating disorders (Paluska and Schwenk, 2000; Yates et al., 1983). For clinicians to effectively care for the adolescent runner, knowledge of the unique developmental physical, physiologic, and psychological aspects of their patients must be applied to optimize their health and wellness.
Full-text available
Article
PurposeEnergy availability (EA) is considered an important measure for athletes, particularly due to the possible health and performance outcomes defined under the RED-S. Low EA is reported to have far-reaching health consequences among female athletes, especially in weight-sensitive sport. However, it is less explored among male athletes, particularly in the traditional Indian tag sport called Kho-Kho. This cross-sectional observational study aimed to determine the prevalence of LEA and associated RED-S health and performance outcomes among Kho-Kho players.Methods Fifty-two male national-level Kho-Kho players aged 16–31 years were assessed for energy availability, bone mineral density (BMD), sleep quality, disordered eating, selected metabolic (hemoglobin, blood glucose, etc.) and performance outcomes (agility, speed, and power) as per RED-S risk assessment tool. Differences across the low EA (≤ 25 kcal/ kg fat-free mass) and Optimal EA (> 25 kcal/ kg fat-free mass) groups were evaluated using the Independent Samples t test and the chi-square test.ResultsLow EA among athletes was associated with lower z-scores for BMD, sleep quality and agility, compared to athletes with optimal EA. At least one moderate-to-high RED-S risk outcome was prevalent among 98% of the Kho-Kho players, irrespective of EA. Most athletes exhibited a lower EAT score and disordered eating outcomes, with no significant differences across groups.Conclusion The male Kho-Kho players showed a prevalence of low EA that can be due to higher training loads and unintentional under-eating, not related to an eating disorder. The players also exhibited higher RED-S risk outcomes; however, it was irrespective of low EA.
Article
PURPOSE The purpose of this review was to summarize the current knowledge on the trends in athletes’ health problems (and their preventive strategies) caused by low energy availability (LEA) and relative energy deficiency in sports (RED-S).METHODS In this narrative review, we summarized previous studies by searching the literature in the PubMed, Google Scholar, and Science Direct databases.RESULTS Energy availability (EA) refers to the amount of energy from caloric intake used for exercise, and a LEA is considered as a surrogate marker of RED-S. In several previous studies, chronic low energy availability in female athletes has been reported to cause health problems such as endocrine dysfunctions, immunosuppression, and psychological disorders, and to also affect the hypothalamic-pituitary-gonadal (HPC) axis and bone health. Moreover, it has been suggested that an increase in injury risk and a decrease in exercise performance may occur.CONCLUSIONS Since it can be difficult to recover from the health deteriorations caused by RED-S, early detection (of related signs and symptoms) and prevention are very important. Therefore, athletes, coaches, and parents need to develop educational programs that ease the recognition of the problems caused by various symptoms related to RED-S and promote educational interventions.
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Climbing belongs to the sport disciplines in which low body weight represents an advantage. Many athletes therefore use at least one unhealthy way of controlling their weight. The consequence is relative energy deficiency in sport or RED-S with possible long-term complications like dental caries, osteoporosis, renal insufficiency, anemia, and recognized psychiatric disorders. The most common psychiatric disorders resulting from RED-S, formerly titled anorexia athletica, are true anorexia nervosa and depression. Some of the athletes are so convinced of the dependence of their weight on their performance, and this wrong belief is so firmly ingrained that they suffer their whole life from the mental consequences. Early detection of possible warning signs and providing assistance early on is therefore a priority in order to reduce long-term damage.KeywordsAnorexia athleticaAthlete female triadRED-S
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A questionnaire-based screening tool for male athletes at risk of low energy availability (LEA) could facilitate both research and clinical practice. The present options rely on proxies for LEA such screening tools for disordered eating, exercise dependence, or those validated in female athlete populations. in which the female-specific sections are excluded. To overcome these limitations and support progress in understanding LEA in males, centres in Australia, Norway, Denmark, and Sweden collaborated to develop a screening tool (LEAM-Q) based on clinical investigations of elite and sub-elite male athletes from multiple countries and ethnicities, and a variety of endurance and weight-sensitive sports. A bank of questions was developed from previously validated questionnaires and expert opinion on various clinical markers of LEA in athletic or eating disorder populations, dizziness, thermoregulation, gastrointestinal symptoms, injury, illness, wellbeing, recovery, sleep and sex drive. The validation process covered reliability, content validity, a multivariate analysis of associations between variable responses and clinical markers, and Receiver Operating Characteristics (ROC) curve analysis of variables, with the inclusion threshold being set at 60% sensitivity. Comparison of the scores of the retained questionnaire variables between subjects classified as cases or controls based on clinical markers of LEA revealed an internal consistency and reliability of 0.71. Scores for sleep and thermoregulation were not associated with any clinical marker and were excluded from any further analysis. Of the remaining variables, dizziness, illness, fatigue, and sex drive had sufficient sensitivity to be retained in the questionnaire, but only low sex drive was able to distinguish between LEA cases and controls and was associated with perturbations in key clinical markers and questionnaire responses. In summary, in this large and international cohort, low sex drive was the most effective self-reported symptom in identifying male athletes requiring further clinical assessment for LEA.
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This article provides an overview of levels of care for eating disorders (EDs) and considerations that are specific to elite athletes. We discuss the following levels of care in terms of ED pathology and treatment aspects that may be unique to athletes: 1) inpatient and residential care, 2) intensive outpatient and partial hospitalization treatment, and 3) outpatient. Illustrative case studies also are presented to highlight distinctions between levels of care and athlete-specific nuances to treatment approaches and health care teams. Finally, we review aspects of return to play plans for elite athletes with EDs.
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Protecting the health of the athlete is a goal of the International Olympic Committee (IOC). The IOC convened an expert panel to update the 2005 IOC Consensus Statement on the Female Athlete Triad. This Consensus Statement replaces the previous and provides guidelines to guide risk assessment, treatment and return-to-play decisions. The IOC expert working group introduces a broader, more comprehensive term for the condition previously known as 'Female Athlete Triad'. 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. The clinical phenomenon is not a 'triad' of the three entities of energy availability, menstrual function and bone health, but rather a syndrome that affects many aspects of physiological function, health and athletic performance. This Consensus Statement also recommends practical clinical models for the management of affected athletes. The 'Sport Risk Assessment and Return to Play Model' categorises the syndrome into three groups and translates these classifications into clinical recommendations.
ioc consensus Statement. Beyond the triad -ReD-S in sport
  • References Mountjoy M
  • J Sundgot-Borgen
References mountjoy m, Sundgot-Borgen J, Burke l, et al. ioc consensus Statement. Beyond the triad -ReD-S in sport. Br J Sports med. 2014; 48: 491-7.
Relative Energy Deficiency in Sport (RED-S)
Relative Energy Deficiency in Sport (RED-S). Br J Sports Med 2015;49:421-3.