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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic (Synchronized) Swimming

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Abstract

The syndrome Relative Energy Deficiency in Sport (RED-S) is a clinical entity characterized by low energy availability (LEA), which can negatively affect the health and performance of both male and female athletes. The underlying mechanism of RED-S is an inadequacy of dietary energy to support optimal health and performance. This syndrome refers to impaired physiological function including metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health, with psychological consequences which can either precede (through restrictive dietary habits) or result from RED-S. The term RED-S extends beyond the condition termed the "Female Athlete Triad". Formerly known as synchronized swimming, artistic swimming is an Olympic sport requiring a high level of fitness as well as technical skill and artistry. The risk of RED-S is high in artistic swimming as it is an aesthetic, judged sport with an emphasis on a lean physique. RED-S is of significant concern in the sport of artistic swimming because of the potential negative effects on physical and mental health as well as consequences on athletic performance. This paper reviews health and performance consequences associated with LEA resulting in RED-S in artistic swimming. Medical and nutritional considerations specific to artistic swimming are reviewed and methods to help detect and manage RED-S are discussed. Prevention and management of RED-S in this athlete population should be a priority for coaches and the sport medicine professionals working with artistic swimming athletes should utilize the RED-S CAT, a Clinical Assessment Tool for screening and managing RED-S.
A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Note: This article will be published in a forthcoming issue of
the International Journal of Sport Nutrition and Exercise
Metabolism. This article appears here in its accepted, peer-
reviewed form; it has not been copyedited, proofed, or
formatted by the publisher.
Section: Scholarly Review
Article Title: A Review of Prevention, Diagnosis and Treatment of Relative Energy
Deficiency in Sport (RED-S) in Artistic (Synchronized) Swimming
Authors: Sherry Robertson1 and Margo Mountjoy2, 3
Affiliations: 1Alberta Health Services, Alberta, Canada. 2McMaster University, Hamilton,
Canada. 3FINA Sports Medicine Committee, Lausanne, Switzerland.
Running Head: RED-S in artistic swimming
Journal: International Journal of Sport Nutrition and Exercise
Acceptance Date: March 12, 2018
©2018 Human Kinetics, Inc.
DOI: https://doi.org/10.1123/ijsnem.2017-0329
A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Title:
A review of prevention, diagnosis and treatment of
Relative Energy Deficiency in Sport (RED-S) in artistic (synchronized)
swimming
Authors:
Sherry Robertson1 & Margo Mountjoy 2, 3
Affiliations:
1Alberta Health Services, Alberta, Canada
2McMaster University, Hamilton, Canada
3FINA Sports Medicine Committee, Lausanne, Switzerland
Running Head: RED-S in artistic swimming
Correspondence:
Sherry Robertson
Address/ phone #
780-935-9748
Sherry.Robertson@albertahealthservices.ca
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
ABSTRACT (247 words)
The syndrome Relative Energy Deficiency in Sport (RED-S) is a clinical entity characterized
by low energy availability (LEA), which can negatively affect the health and performance of
both male and female athletes. The underlying mechanism of RED-S is an inadequacy of
dietary energy to support optimal health and performance. This syndrome refers to impaired
physiological function including metabolic rate, menstrual function, bone health, immunity,
protein synthesis, and cardiovascular health, with psychological consequences which can
either precede (through restrictive dietary habits) or result from RED-S. The term RED-S
extends beyond the condition termed the “Female Athlete Triad”. Formerly known as
synchronized swimming, artistic swimming is an Olympic sport requiring a high level of fitness
as well as technical skill and artistry. The risk of RED-S is high in artistic swimming as it is an
aesthetic, judged sport with an emphasis on a lean physique. RED-S is of significant concern
in the sport of artistic swimming because of the potential negative effects on physical and
mental health as well as consequences on athletic performance. This paper reviews health
and performance consequences associated with LEA resulting in RED-S in artistic swimming.
Medical and nutritional considerations specific to artistic swimming are reviewed and methods
to help detect and manage RED-S are discussed. Prevention and management of RED-S in
this athlete population should be a priority for coaches and the sport medicine professionals
working with artistic swimming athletes should utilize the RED-S CAT, a Clinical Assessment
Tool for screening and managing RED-S.
Keywords: synchronized swimming, energy availability, REDS
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Introduction
Relative Energy Deficiency in Sport (RED-S) is a syndrome resulting from an energy
deficiency relative to the balance between dietary energy intake and the energy expenditure
required to support homeostasis, health, activities of daily living, growth, and sport. RED-S
affects physiological function including metabolic rate, menstrual function, bone health,
immunity, protein synthesis, cardiovascular and psychological health (Mountjoy et al., 2014).
The “Female Athlete Triad” is defined as a medical condition observed in athletic girls and
women, comprising three components: low energy availability (LEA), menstrual dysfunction
(MD), and low bone mineral density (BMD) (Nattiv et al., 2007). The International Olympic
Committee (IOC) Consensus group coined the more comprehensive term, RED-S, to more
accurately describe the pathophysiology and multisystem involvement which can affect both
male and female athletes (Mountjoy et al., 2014). Recent evidence of an increased risk for
LEA and resulting health consequences of RED-S in male athletes includes weight-class
combat sports, jockeys, rowers, cyclists, and runners (Berkovich et al., 2016; Viner et al.,
2015; Barrack et al., 2017; Wilson et al., 2014, & Loucks, 2007). Although there are no
published prevalence studies of RED-S specifically in artistic swimming, there is one study of
female Scandinavian artistic swimmers which indicated significant LEA with subsequent
endocrine signs of energy conservation and fatigue following an intense training block (Schaal
et al., 2017).
Artistic swimming requires a variety of athletic abilities, including endurance, power,
agility, acrobatics, and flexibility. Athletes must precisely synchronize choreography with both
their teammates and music (Robertson et al., 2014). Desired performance outcomes require
that artistic swimmers train for long hours in a variety of exercise modalities (Mountjoy, 2009).
The complex judging system evaluates components of technical skill, synchronization, and
artistic impression. Body shape is not a judged component, however, there is considerable
emphasis on body composition to achieve the desired aesthetic appearance. Due to the
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
sport’s aesthetic nature, which prioritizes leanness, the risk of RED-S is of concern for this
athletic population which now includes both males and females.
The sport of artistic swimming
Artistic swimming is part of the summer Olympic program and is restricted to female
athletes at the Olympic level. In addition, artistic swimmers compete at Continental and World
Championships. The rules are governed by Fédération Internationale de Natation (FINA), the
International governing body for aquatic sports. The “mixed” duet, introducing male athletes,
is the newest event on the FINA calendar and was first presented at the 2015 World
Championships. Given the recent addition of male athletes to the FINA sport program, and
the small athlete pool (n=11 in 2017), there are no scientific data on RED-S in male artistic
swimmers. However, as artistic sports are at high risk for RED-S, and RED-S can also occur
in male athletes (Mountjoy et al., 2014), it can be postulated that male artistic swimmers may
be at risk for the development of RED-S.
Physiological demands
Artistic swimming demands a high level of overall fitness, incorporating many athletic
abilities. A high sport-specific degree of complex technical skill is critical. Routines vary in
length from 2-5 minutes, requiring aerobic endurance with many intermittent bursts of
anaerobic power (Robertson et al., 2014). Complex, high intensity movements requiring
precise synchronization in a zero-gravity environment must be performed with perfection
(Mountjoy, 2009). Chatard et al. (1999) found that the physiological profile (i.e., peak oxygen
update, blood lactate concentration, and heart rate measured during a 400-m swim) of
individual swimmers is positively linked to synchronized swimming skill. Other studies found
that 45-50% of the time is spent underwater, thereby requiring exceptional breath control
(Homma,1994; Chatard et al.,1999). Modern routines incorporate more acrobatic
manoeuvres, which involve less total time underwater. However, long training sessions and
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
technical movements performed within the high resistance of water require a broad range of
cardiovascular and musculoskeletal strength.
Energy
Energy requirements
There is a dearth of literature focused on estimating the energy requirements for elite
artistic swimmers. Due to the nature of the sport, it is impossible to continuously measure VO2
during training, making it difficult to assess energy requirements and relative contributions of
aerobic and anaerobic metabolism (Bante et al., 2007). A doubly labelled water method for
measuring total energy expenditure (TEE) of elite Japanese artistic swimmers during
moderately intense training determined that the mean (SD) TEE was 11.5 (2.8) MJ/day [2738
(672) kcal/day] (Ebine et al., 2000). A study by Schaal et al. (2017) quantified energy
expenditure (EE), EI, and EA in artistic swimming, demonstrating how these variables
changed during intense training prior to major international competitions.
Energy availability
The fundamental cause of RED-S is an inadequacy of dietary energy to support
optimal health and performance (Mountjoy et al., 2014). With a reduction in energy intake (EI)
and/or increased exercise volume, LEA will occur, causing disruptions of hormonal, metabolic,
and functional characteristics (Loucks, 2004, 2011). Energy availability (EA) is calculated as
EI minus the energy cost of exercise relative to fat free mass (FFM). In healthy adults, a value
of 45kcal/kg FFM/day equals energy balance, and the health consequences of LEA occur at
<30kcal/kg FFM/day (Loucks, 2004). Schaal et al. (2017) demonstrated that the mean EA of
these athletes at baseline was less than 30 kcal/kg FFM/day, indicating that LEA may be a
concern for many artistic swimmers.
Health consequences of RED-S
RED-S has the potential to negatively affect all body systems, resulting in adverse
health consequences. Prolonged LEA can contribute to nutrient deficiencies, chronic fatigue
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
(Cialdella-Kam et al., 2014) and suppressed immune function resulting in an increased risk of
illness (Venkatraman, 2002), all of which can be detrimental to both health and athletic
performance. Figure 1 depicts potential health consequences of RED-S.
Prevalence studies estimate up to 50% of exercising women have subtle menstrual
abnormalities and 33% suffer from amenorrhea (De Souza, 2010). The MD most commonly
associated with RED-S is Functional Hypothalamic Amenorrhea (FHA) which occurs when the
hypothalamic-pituitary-gonadal hormone axis is disrupted by LEA. Long-term physical
consequences of FHA can include osteopenia/osteoporosis and potentially infertility (Sonntag
& Ludwug, 2012). A study by Sambanis et al. (2003) found that elite artistic swimmers had a
delay in menarche of 0.6 years. Two studies (Ferrand et al., 2007; Ramsay, 2001) assessing
the prevalence of MD in artistic swimmers have been published, however, the conclusions of
these studies are challenged by the confounding factor of oral contraceptive use by the
subjects.
RED-S can also contribute to the development of poor bone health mediated by the
hormonal disruption and/or nutritional deficits (Ackerman et al., 2011, 2012). Maximum bone
accrual occurs during adolescence, when training is heavy. Peak bone mass in women occurs
around age 19, and around 20.5 years in males (Baxter-Jones et al., 2011). This is a critical
time-period and disruption to bone formation due to LEA may be irreversible as evidence
shows that the effect on bone formation is cumulative with multiple risk factors (Gibbs et al.,
2014). The prevalence of osteopenia in athletes is estimated between 22-50% and
osteoporosis at 13% (Khan et al., 2002). Liang et al. (2005) demonstrated lower BMD in the
wrist of artistic swimmers (0.414g/cm2 in comparison with gymnasts (0.540g/cm2 ) and
untrained controls (0.474g/cm2 ). Similar results were found in the wrist (Roby et al., 1988)
and in the lower limb and lumbar spine (Tanaka et al., 2006) in artistic swimmers. These
findings however, may be attributed to the fact that artistic swimming is a non-weight bearing
sport.
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Performance Consequences of RED-S
RED-S has the potential to affect the athlete’s performance in sport (Mountjoy et al.,
2014). Performance outcomes are more likely to be a motivating factor for athletes than
negative health consequences, which may not prove sufficient incentive for athletes to change
behaviour due to a lack of an immediate consequence (Melin et al., 2014). Functional
impairments associated with LEA, which negatively affect performance include increase in
viral illnesses (Hagmar et al., 2008), injuries (Thein-Nissenbaum et al., 2011; Rauh, et al.,
2010), and reduced responsiveness to training stimuli resulting in decreased performance
(Vanheest et al., 2014). Figure 2 shows the potential negative effects on athletic performance.
Disordered eating and eating disorders
As a judged sport with an emphasis on a lean appearance, artistic swimming athletes
may be at higher risk for Disordered Eating (DE) and/or Eating Disorders (ED) (Melin et al.,
2014; Rosendahl, 2009). Melin et al. (2015) found a high prevalence of ED, MD, and impaired
bone health in elite endurance female athletes. Ferrand et al. (2007) found more than half of
college level artistic swimmers showed distorted body image with dissatisfaction, despite
being in the healthy weight range. A Greek study showed that artistic swimmers had higher
scores on The Eating Attitudes Test for EDs in comparison with swimmers and water polo
players (Douka, 2008). Given that males now compete in this sport; they may also be at risk,
however, there are no supporting data.
Health consequences
For both males and females, negative health consequences of DE/EDs are numerous
and can be fatal, as every body system can be affected. Physical consequences of EDs can
include delayed puberty, bone growth retardation, and decreased bone deposition. There are
also psychological consequences including depression, anxiety, and suicide (Melin et al.,
2014, 2015; Mountjoy et al., 2014).
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Prevention
To prevent DE/EDs, the focus on weight as a performance marker should be
minimized, and an environment ensuring athletes are practicing eating behaviours optimizing
performance should be encouraged (Melin et al., 2014). National Sport Federations and
Olympic Committees are encouraged to develop and implement healthy body composition
policies for athletes to help protect them from the pressure to be thin.
Assessment of RED-S
RED-S is a medical diagnosis to be made following clinical and laboratory assessment
by a trained health care professional (Mountjoy et al., 2015). As symptoms of RED-S are
subtle, screening and diagnosing can be challenging and requires focused attention on the
athlete at risk. To prevent long-term health consequences and to improve sport performance,
early detection is recommended (Mountjoy et al., 2014, 2015). The assessment for RED-S
should be in the pre-season Periodic Health Exam (Ljungqvist et al., 2009) to allow for early
identification and treatment prior to the competition season. Screening should be mandatory
given that artistic swimmers may not voluntarily report symptoms for fear of reprisal from the
coach or with team selection. In contrast to non-athletes, a Norwegian study showed that
athletes are reluctant to answer ED/ DE questionnaires, but respond more truthfully to
personal interviews, demonstrating the importance of ‘in-person’ screening for this component
of RED-S (Martinsen et al., .2013). A Clinical Assessment Tool (RED-S CAT) was developed
by the IOC to assist with the medical screening and management of the RED-S athlete. Based
on the clinical assessment, the IOC RED-S CAT categorizes athletes into either the high risk
(Red light no sport participation), moderate risk (Yellow light modified and monitored sport
participation) or low risk (Green light full sport participation). While the RED-S CAT requires
scientific validation and further study, it can be a useful tool to guide decision-making among
medical and coaching staff (Mountjoy et al., 2015).
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
For artistic swimmers, the RED-S screening should include:
Complete history for signs and symptoms relevant to RED-S including:
o Energy availability (LEAF-Q) (Melin et al., 2014)
o ED and DE screen (Brief Eating Disorder Athlete Questionnaire) (Martinsen 2014a,
2014b)
o MD: delayed menarche (lack of menses >15y,) oligomennorhea (menstrual cycles
at intervals of >35d); amenorrhea (menstrual cycles at intervals > 90d) (De Souza
et al., 2014)
o Stress fractures or bone stress reaction
o Frequent viral infections
Targeted physical examination which may consist of:
o Body Mass Index < 17.5 kg/m2 (De Souza et al., 2014)
o Weight: <85% expected; or 10% weight loss / month (De Souza et al., 2014)
o Tanner staging assessment
o Physical signs for other causes of MD (FHA is a diagnosis of exclusion)
o Bone health: if history of a bone stress injury
o Systolic blood pressure (BP) < 90mm Hg and/or diastolic BP < 60mm Hg (Melin et
al., 2015)
Laboratory assessment of
o Fasting blood glucose < 4mmol/L
o Ferritin < 25μg/L (Petkus et al., 2017).
o Vitamin D
o Endocrine function (LH, FSH, estradiol) according to the phase of the cycle
o Free triiodothyronine < 3.5 pmol/L (Melin et al., 2015)
o LDL-cholesterol > 3.0mmol/ (Melin et al., 2015)
o Fasting insulin < 20pmol/L (Melin et al., 2015)
o Insulin-like growth factor-1 (IGF-1)(Melin et al., 2015)
o Resting metabolic rate ≤ 29kcal/kg FFM (Melin et al., 2015)
o Bone mineral density by dual-energy x-ray absorptiometry (DEXA): <-1.0 g/cm2
(Melin et al., 2015)
Intake assessment of food and beverage
While it would appear to be logical to measure EA as the main diagnostic indicator of
RED-S, the accurate measurement of EA outside of a rigorously controlled laboratory setting
is challenging given the lack of reliable, validated, and practical standardized protocols for
identifying LEA, EI, EE or FFM (Guebels et al., 2014). As such, clinicians must rely on
secondary signs of LEA as indicators of RED-S which are outlined in the RED-S screening
box above.
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Eating disorders/ disordered eating
To facilitate the diagnosis of ED/DE, Martinson et al., (2014a) developed a validated
screening tool designed to distinguish between female elite athletes with and without EDs/DE.
The Brief Eating Disorder in Athletes Questionnaire” (BEDA-Q), (Martinson et al., 2014b) can
easily be implemented in electronic or paper format. As well, the LEAF questionnaire is a
screening tool for the identification of female athletes at risk (Melin et al., 2014).
Body composition
Because of the pressure to be lean, both male and female artistic swimmers are at risk
of developing DE and EDs (De Sousa Fortes et al., 2013; Sundgot-Borgen & Garthe, 2011;
Benardot & Thompson,1999). In addition to the pressure to be lean, there is also the need to
match the physique of teammates (Robertson et al., 2014). Many artistic swimmers have
eating anxiety, fearing that eating appropriate foods and beverages will negatively alter body
composition and increase body mass (Vardar et al., 2007; Haase et al., 2002; Krane et al.,
2001). ‘Weight’ per se may be an inappropriate measure to determine if the desired body
composition is being achieved, as weight is composed of proportionately more muscle and
less fat, which is clearly better for both performance and appearance than a lower body mass
with proportionately less muscle and more fat (Benardot, 2007). Body composition
assessment of artistic swimmers should include informed consent with the purpose clearly
stated to monitor any potential unhealthy changes, and to determine if training and dietary
strategies are having the optimal result. Strategies for achieving safe and sensitive body
composition screening can be found in the body composition section of Table 2 (Benardot,
2002).
Treatment of RED-S
Nutritional considerations
The training program of elite artistic swimming can average 7 hours/day for 6
days/week including technical as well as additional training methods (weights, ballet, Pilates,
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
acrobatics, flexibility, and conditioning). The schedule traditionally involves minimal and
limited breaks, and as such, athletes have reported difficulty in consuming adequate energy
and fluid. The nutritional plan should consider appropriate timing of meals and snacks and
coaches should allow sufficient breaks for proper fuelling and hydration. A failure to adequately
satisfy the increased nutrient requirement through food may i) place the athlete at a higher
injury risk, ii) fail to optimally reduce muscle soreness and enhance muscle recovery, iii)
negatively impact the immune system to increase illness frequency, and iv) negatively alter
both power and endurance (Pyne et al., 2014).
A unique training characteristic of artistic swimming involves spending a large
percentage of the time upside down in the water as well as spinning maneuvers. Reflux may
contribute to LEA through voluntary intake restriction of food prior to training to avoid gastro-
intestinal symptoms while training. To help prevent gravitational esophageal reflux, athletes
should choose easily digestible foods, avoid eating large volumes and high fibre/gas-
producing foods, and use an antacid if required (Robertson et al., 2014).
Energy
Energy requirements for artistic swimmers vary depending on the phase of training,
volume load, and tapering for competition. Energy intake should be periodized to match the
demands and individually adjusted for each athlete (Loucks et al., 2011). As well, the gender,
age, and body composition of the athlete should be considered. As perceived fatigue is
associated with LEA, adequate EI should be a priority during heavy training in artistic
swimmers (Schaal et al., 2017). It is recommended that artistic swimmers consume sufficient
calories matching differential energy expenditures, with a focus on carbohydrate and protein
(Cialdella-Kam et al., 2014). Pre- and post-exercise consumption of carbohydrate and protein
influence muscle protein synthesis, muscle soreness, and recovery (Gibala, 2002; Cermak et
al., 2009), therefore, the timing of energy and nutrient intake should be considered in the
nutritional assessment with the goal of consistent energy balance to assure optimal nutrient
utilization and to optimize performance and recovery. A study by Fahrenholtz et al., 2017
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
found that within day energy deficiency (as seen in those that train long periods of time without
adequate/ appropriate nutrition breaks, as is the training culture in artistic swimming), can
result in markers of energy deficiency such as changes in reproductive hormones. To treat
LEA, an increase in EI and a decrease in exercise may be necessary. Strategies should
include an eating plan with an increase in current EI by 300-600 kcals/day and should address
suboptimal or mismanaged nutritional practices, timing of intake, and stress surrounding
eating (Mountjoy et al., 2014).
Carbohydrate
Carbohydrate plays a key role in helping maintain energy availability during training as
well as optimizing the function of the immune system (Pyne et al., 2014; Burke et al., 2006).
Athletes that restrict total calories to decrease body weight may have difficulty in achieving
carbohydrate recommendations (Burke et al., 2001). Female athletes are often deficient in
energy, especially energy in the form of carbohydrate resulting in compromised health and
performance (Loucks, 2004). The recommended reference range of carbohydrate intake for
a sport with demands like artistic swimming is 5-7 grams per kg body mass per day (Burke et
al., 2004; Robertson et al., 2014). The timing of carbohydrate ingestion should occur at
frequent intervals throughout the day including before, during, and after training.
Protein
Elite artistic swimmers should aim for a protein intake range of 1.5-1.7 grams of protein
per kg body mass per day, with an emphasis on timing, to sustain or increase muscle mass
(Paddon-Jones & Rasmussen, 2009; Tipton et al., 2007). This range provides flexibility and
should be individualized based on the athlete’s requirements. Athletes should be encouraged
to meet protein requirements by including 20 grams of high quality, protein rich foods four
times per day (Areta et al., 2013). Tipton and Phillips (2013) suggest that not all protein
sources are equal in terms of their capacity to stimulate muscle protein synthesis, suggesting
that dairy proteins (whey protein) are the superior choice. A study on Japanese rhythmic
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
gymnasts found that a low protein intake was significantly associated with iron deficiency,
highlighting the importance of protein intake (Kokubo et al., 2015).
Fat
Fat provides essential fatty acids, fat-soluble vitamins and energy. Athletes should
strive for fat intake to be 20%-25% of total energy consumption (Rodriguez et al., 2009).
Healthy fats (from nuts, olive oil, fatty fish and avocado for example), are an important
contributor to total energy intake. A diet too low in fat has the potential to compromise the
immune system (Pyne et al., 2014). The challenge is that artistic swimmers often have an
underlying fear of consuming fat-containing foods for ill-conceived body image reasons.
Nutrition for Recovery
Adequate EI is also key in optimizing recovery. Schaal et al. (2017) demonstrated that
artistic swimmers with prolonged LEA perceived the highest fatigue ratings, which may have
decreased their ability to recover from high-intensity training. Consuming foods at regular
recovery intervals can ensure adequate EI to prevent LEA. Integration of recovery eating
needs to complement the athlete’s overall nutritional goals, including energy requirements,
body composition, and nutrient requirements (Burke & Mujika, 2014). Artistic swimmers have
individual recovery requirements based on the training phase, and recovery protocol should
be fine-tuned accordingly to their need. Since there can be a tendency for these athletes to
restrict eating, attention should be given to ensuring adequate EI to achieve glycogen
recovery.
Medical treatment of RED-S
Due to the complexity of the various body systems and psychological involvement,
successful treatment may require the utilization of a multidisciplinary team. While not part of
the treatment team, given the importance of the coach in the manipulation of body composition
in the culture of artistic swimming, coach engagement in the treatment plan is essential to
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
ensure compliance with a potential decrease in physical activity that may be required to
reverse LEA (Mountjoy et al., 2014).
Psychological treatment depends on the type, severity, and duration of the problem.
Co-morbidities such as depression and anxiety may require pharmacotherapy in addition to
various forms of psychotherapy. If there is a risk of self-harm, in-patient care may be required.
If an athlete is not able to follow the treatment plan, it is usually indicative of an underlying
psychological issue (Mitchell et al., 2013).
Oral contraceptives (OC) do not address the underlying etiological factor, and thus the
reversal of LEA should be the focus of treatment of MD. OC also potentially have a negative
effect on BMD, as well as masking amenorrhea, thus making it impossible to monitor EA as
indicated by healthy menstrual function (Warren et al., 2005).
Underlying causes for low BMD should be identified and corrected. Research from
low BMD in ED patients, identifies that weight gain is effective in improving BMD (Misra &
Klibanski, 2011). Bone loading has also been shown to improve BMD. Current
recommendations for daily calcium intake are 1000 mg/day of calcium for men and women
ages 19-50 years, and 1300 mg/day for adolescents and young adults ages 9-18 years (USDA
Dietary Guidelines, 2015). Vitamin D intake of 1500-2000IU/day is also recommended (Holick
et al., 2011). While transdermal estrogen and OC (estradiol) has been shown to improve BMD
in anorexic patients, the use of OC treatment in FHA has been shown to decrease BMD. The
bisphosphonates, which inhibit bone resorption, are not recommended in pre-menopausal
women, however, can be prescribed safely in men (Papapoulos & Cremers, 2007).
The IOC writing team developed a RED-S Return to Play (RTP) model to assist the
treatment team in the decision making of RTP. Reassessments of progress at specified time
intervals (i.e. monthly) allows for re-classification of the athlete risk and subsequent changes
to athlete sport participation are then realized in a graduated progression (Mountjoy et al.,
2014). The use of an athlete contract is recommended to facilitate athlete compliance and to
ensure that all members of the treatment team are informed.
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
RED-S prevention strategies
While early detection and effective treatment are important to prevent secondary
health and performance consequences of RED-S, primary prevention strategies are essential
to decrease the prevalence of RED-S in artistic swimming. Table 2 outlines RED-S prevention
strategies for this athlete population. A survey of International Sport Federations medical
programs revealed that only 7% of summer Olympic sports had programs on RED-S indicating
a general lack of knowledge and support for elite athletes with RED-S (Mountjoy et al., 2018).
Educational initiatives should therefore target sport organizations in addition to athletes and
coaches.
Conclusion
Given the risk of RED-S in artistic swimming, FINA should focus on educating athletes,
coaches, and medical professionals on the health and performance consequences of RED-S
to stimulate prevention through raising awareness, and to improve early detection and
treatment. Future research in artistic swimming is needed i) to determine the prevalence of
RED-S in this population of both male and female athletes, ii) to validate assessment tools to
identify LEA, and iii) to critically analyse the efficacy of treatment interventions.
Acknowledgments
The authors have no conflict of interest to declare.
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
References
Ackerman, K.E., Nazem, T., Chapko, D., Russell, M., Mendes, N., Taylor, A.P., Bouxsein,
M.L., & Misra, M. (2011). Bone microarchitecture is impaired in adolescent
amenorrheic athletes compared with eumenorrheic athletes and nonathletic controls.
Journal Clinical Endocrinology and Metabolism, 96(10), 3123-33.
Ackerman, K.E., Putman, M., Guereca, G.,Taylor, A.P., Pierce, L., Herzog, D.B., Klibanski,
A., Bouzsein, M., & Misra, M. (2012). Cortical microstructure and estimated bone
strength in young amenorrheic athletes, eumenorrheic athletes and non-athletes.
Bone, 51(4),680-7.
Areta, J. L., Burke, L. M., Ross, M. L., Camera, D.M., West, D.W., Broad, E.M., Jeacocke,
N.A., Moore, D.R., Stellingwerff, T., Phillips, S.M., Hawley, J.A., & Coffey, V.G.
(2013). Timing and distribution of protein ingestion during prolonged recovery from
resistance exercise alters myofibrillar protein synthesis. Journal of Physiology,
591(9),2319-31.
Bante, S., Bogdanis, G.C., Chairopoulou, C., & Maridaki, M. (2007). Cardiorespiratory and
metabolic responses to a simulated synchronized swimming routine in senior and
comen national level athletes. Journal of Sports Medicine and Physical Fitness, 47,
291-299.
Barrack, M.T., Fredericson, M., Tenforde, A.S., & Nattiv, A. (2017). Evidence of a cumulative
effect for risk factors predicting lower bone mass among male adolescent athletes.
British Journal of Sports Medicine, 51(3),200-205.
Baxter Jones, A.D., Faulkner, R.A., Forwood, M.R., Mirwald, R.L., & Bailey, D.A. (2011).
Bone mineral accural from 8-30 years of age: an estimate of peak bone mass.
Journal of Bone and Mineral Research, 26,1729-1739.
Benardot, D. (2002). NCAA: Guideline 2e-Assessment of body composition. In NCAA sports
medicine handbook. (14th ed.). D. Klossner(Ed.).(pp. 34-38). Indianapolis, IN:
National Collegiate Athletic Association.
Benardot, D. (2007). Timing of energy and fluid intake: New concepts for weight control and
hydration. ACSM’s Health & Fitness Journal, 11(4), 13-19.
Benardot, D., & Thompson, W.R. (1999). Energy from food for physical activity: Enough and
on time. ACSM’s Health and Fitness Journal, 3(4), 14-18.
Berkovich, B.E., Eliakim, A., Nemet, D., Stark, A.H., & Sinai, T.(2016). Rapid weight loss
among adolescents participating in competitive judo. International Journal Sport
Nutrition and Exercise Metabolism, 26(3), 276-84.
Burke, L.M., Cox, G., Cummings, N., & Desbrow, B. (2001). Guidelines for daily
carbohydrate intake: do athletes achive them? Sports Medicine, 31, 267-299.
Burke, L.M., Kiens, B., & Ivy, I. (2004). Carbohydrate and fat for training and recovery.
Journal of Sports Sciences, 22, 1530.
Burke, L.M., Loucks, A., & Broad, N. (2006). Energy and carbohydrate for training and
recovery. Journal of Sport Sciences, 24, 675-685.
Downloaded by MCMASTER UNIVERSITY LIBRARY on 05/18/18, Volume ${article.issue.volume}, Article Number ${article.issue.issue}
A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Burke, L.M., & Mujika, I. (2014). Nutrition for recovery in aquatic sports. International Journal
of Sport Nutrition and Exercise Metabolism, 24, 425-436.
Cermak, N.M., Solheim, A.S., Gardner, M.S., Tarnopolsky, M.A., & Gibala, M.J. (2009).
Muscle metabolism during exercise with carbohydrate ingestion. Medicine & Science
in Sports & Exercise, 41, 2158-2164.
Cialdella-Kam, L., Guebels, C.P., Maddalozzo, G.F., & Manore, M.M. (2014). Dietary
intervention restored menses in female athletes with exercise-associated menstrual
dysfunction with limited impact on bone and muscle health. Nutrients, 6(8), 3018-39.
doi: 10.3390/nu6083018
Chatard, J.C., Mujika, I., Chantegraille, M.C., & Kostucha, J. (1999). Performance and
physiological responses to a 5-week synchronized swimming technical training
programme in humans. European Journal of Applied Physiology 79, 479-483.
De Sousa Fortes, L., Neves, C. M., Filgueiras, J.F., Almeida, S.S., & Ferreira, M.E.C. (2013).
Body dissatisfaction, psychological commitment to exercise and eating behavior in
young athletes from aesthetic sports. Brazilian Journal of Kinanthropometry and
Human Performance 15, 695-704.
De Souza, M.J., Nattiv, A., Joy, E., Misra, M., Williams, N.I., Mallinson, R.J., Gibbs, J.C.,
Olmstead, M., Goolsby, M., Matheson, G., & expert panel. (2014). Female Athlete
Triad Coalition Consensus Statement on Treatment and Return to Play of the Female
Athlete Triad: 1st International Conference held in San Francisco, California, May
2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013.
British Journal of Sports Medicine, 48(4), 289.
De Souza, M.J., Toombs, R., Scheid, J., O’Donnell, E., West, S., & Williams, N. (2010). High
prevalence of subtle and severe menstrual disturbances in exercising women:
Confirmation using daily hormone measures. Human Reproduction, 25, 491-503.
Douka, A., Skordilis, E., Koutsouki, D., & Theodorakis, Y. (2008). Prevalence of eating
disorders among elite female athletes in aquatic sports. Inquiries in Sport and
Physical Education, 6, 87-96.
Ebine, N., Feng, J. Y., Homma, M., Saitoh, S., & Jones, P.J.H. (2000). Total energy
expenditure of elite synchronized swimmers measured by the doubly labelled water
method. European Journal of Applied Physiology, 83, 1-6.
Fahrenholtz, I.L., Sjodin, A.,Benardot D, Tornberg AB, Skouby S, Faber J, Sundgot-Borgen
JK, Melin AK. Within-day energy deficiency and reproductive function in female
endurance athletes. Scand J Med Sci Sports. 2017 Dec 5. doi: 10.1111/sms.13030.
[Epub ahead of print]
Ferrand, C., Magnan, C., Rouveix, M., & Filare, E. (2007). Disordered eating, perfectionism
and body-esteem of elite synchronzied swimmers. European Journal of Sport
Science, 7, 223-230.
Gibala, M.J. (2002). Dietary protein, amino acid supplements, and recovery from exercise.
GSSI Sports Science Exchange, 15, 1-4.
Downloaded by MCMASTER UNIVERSITY LIBRARY on 05/18/18, Volume ${article.issue.volume}, Article Number ${article.issue.issue}
A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Gibbs, J.C., Nattiv, A., Barrack, M.T., Williams, N.I., Rauh, M.J., Nichols, J.F., & De Souza,
M.J. (2014). Low bone density risk is higher in exercising women with multiple Triad
risk factors. Medicine and Science in Sports and Exercise, 46, 167-176.
Guebels, C.P., Kam, L.C., Maddalozzo, G.F., & Manore, M.M. (2014). Active women
before/after an intervention designed to restore menstrual function: resting metabolic
rate and comparison of four methods to quantify energy expenditure and energy
availability. Internation Journal of Sport Nutrition and Exercise Metabolism, 24(1),37-
46. doi: 10.1123/ijsnem.2012-0165
Haase, A.M., Prapavessis, H., & Owens, R.G. (2002). Perfectionism, social physique anxiety
and disordered eating: a comparison of male and female elite athletes. Psychology of
Sport and Exercise, 3, 209-222.
Hagmar, M., Hirschberg, A.L., Berglund, L., & Berglund, B. (2008). Special attention to the
weight-control strategies employed by Olympic athletes striving for leanness is
required. Clinical Journal of Sport Medicine,18, 59.
Holick, M.F., Binkley, N.C., Bischoff-Ferrari, H.A, Gordon, C.M., Hanley, D.A., Heaney, R.P.,
Murad, M.H., & Weaver, C.M. (2011). Evaluation, treatment, and prevention of
vitamin D deficiency, an Endocrine Society clinical practice guideline. Journal of
Clinical Endocrinal Metabolism, 96,1911-1930.
Homma, M. (1994). The components and the time of “face in” of the routines in synchronized
swimming. In M. Miyashi, Y. Mutoh, & A.B. Richardson (Eds.), Medicine and science
in aquatic sports (pp. 149-154). Basel, Switzerland: Karger.
Khan, K., Liu-Ambrose, T., Sran, M., Ashe, M., Donaldson, M., & Wark, J. (2002). New
criteria for female athlete triad syndrome? As osteoporosis is rare, should osteopenia
be among the criteria for defining the female athlete triad syndrome? British Journal
of Sports Medicine, 36, 1013.
Kokubo, Y., Yokoyama, Y., Kisara, K., Ohira, Y., Sunami, A., Yoshizaki, T., Tada,Y., Ishizaki,
S., Kida, A., & Kawano, Y. (2015). The relationship between dietary factors and
bodily iron stautus among Japanese collegiate female rhythmic gymnasts.
International Journal of Sport Nutrition and Exercise Metabolism, 26(2), 105-113.
Krane, V., Waldron, J., Stiles-Shipley, J.A., & Michalenok, J. (2001). Relationships among
body satisfaction, social physique anxiety, and eating behaviors in female athletes
and exercisers. Journal of Sport Behavior, 24, 247-265.
Liang, M., Arnaud, S., Steele, C., Hatch, P., & Moreno, A. (2005). Ulnar and tibial bending
stiffness as an index of bone strength in synchronized swimming and gymnasts.
European Journal of Applied Physiology, 94, 400-407.
Loucks, A.B. (2004). Energy balance and body composition in sports and exercise. Journal
of Sports Sciences, 22, 114.
Loucks, A.B.,(2007) Low energy availability in the marathon and other endurance sports.
Sports Medicine, 37(4-5), 348-52.
Loucks, A.B., Kiens, B., Wright, H.H. (2011). Energy availabiltiy in athletes. Journal of Sports
Sciences, 29(S1),S7-S15.
Downloaded by MCMASTER UNIVERSITY LIBRARY on 05/18/18, Volume ${article.issue.volume}, Article Number ${article.issue.issue}
A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Ljungqvist, A., Jenoure, P.J., Engebretsen, L., Alonso, J.M., Bahr, R., Clough, A.F., de Bondt
G., Dvorak, J., Maloley, R., Matheson, G., Meeuwisse, W., Meijboom, E.J., Mountjoy,
M., Pelliccia, A., Schwellnus, M., Sprumont, D., Schamasch, P., Gauthier,
J.B.& Dubi, C. (2009). The International Olympic Committee (IOC) Consensus
Statement on periodic health evaluation of elite athletes. Clinical Journal of Sport
Medicine. 19,34765. British Journal of Sports Medicine, 43(9), 631-44.
Martinsen, M., Bahr, R., Borresen, R., Holme, I., Pensgaard, A.M., & Sundgot-Borge, J.
(2014a). Preventing eating disorders among young elite athletes: a randomized
controlled trial. Medicine & Science in Sports & Exercise, 46, 435-447.
Martinsen, M., Holme, I., Pensgaard, A.M., Klungland Torstveit, M., & Sundgot-Borgen, J.
(2014b). The development of the Brief Eating Disorder in Athletes questionairre
(BEDA-Q). Medicine & Science in Sports & Exercise, 46(8),1666-1675.
Martinsen, M.& Sundgot-Borgen, J. (2013). Higher prevalence of eating disorders among
adolescent elite athletes than controls. Medicine Science in Sports & Exercise, 45(6),
1188-97.
Melin, A., Tornberg, A.B., Skouby, S., Moller, S.S., Sundgot-Borgen, J., Faber, J.,
Sidelmann, J.J., Aziz, M., & Sjodin, A. (2015). Energy availablitly and the female
athlete triad in elite endurance athletes. Scandinavian Journal of Medicine & Science
in Sports, 25(5), 610-622.
Melin, A., Tornberg, Å.B., Skouby, S., Faber, J., Ritz, C., Sjödin, A., & Sundgot-Borgen, J.
(2014). The LEAF questionnaire: a screening toolfor the identification of female
athletes at risk for the female athlete triad. British Journal of Sports Medicine,
48,540545.
Melin, A., Klungland Torstveit, M., Burke, L., Marks, S., & Sundgot-Borgen, J. (2014).
Disordered eating and eating disorders in aquatic sports. International Journal of
Sport Nutrition and Exercise Metabolism, 24, 450-459.
Mitchell J.E., Roerig, J., & Steffen, K. (2013). Biological therapies for eating disorders.
International Journal of Eating Disorders, 46(5), 470-477.
Misra, M., Klibanski, A. (2011). Bone health in anorexia nervosa. Current Opinion in
Endocrinology, Diabetes, and Obesity, 18(6), 376-382.
Mountjoy, M. (2009). Injuries and medical issues in the synchronized Olympic sports.
Current Sports Medicine Reports, 8, 255-261.
Mountjoy, M., Costa A., Budgett, R., Dvorak, J., Engebretsen, L., Miller, S., Moran, J.,
Foster, J., & Carr J. (2018). Health promotion through sport: International Sport
Federations’ priorities, actions and opportunities British Journal of Sports Medicine,
52(1), 54-60.
Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., Meyer,
N., Sherman, R., Steffen, K., Budgett, R., & Ljungqvist, A. (2014). The IOC
Consensus Statement. Beyond the female athlete triad Relative energy deficiency
in sport. British Journal of Sports Medicine, 48, 491-497.
Downloaded by MCMASTER UNIVERSITY LIBRARY on 05/18/18, Volume ${article.issue.volume}, Article Number ${article.issue.issue}
A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., Meyer,
N., Sherman, R., Steffen, K., Budgett, R., Ljungqvist, A., & Ackerman, K. (2015). The
IOC relative energy deficiency in sport clinical assessment tool (RED-S CAT). British
Journal of Sports Medicine, 49 (7), 421-4.
Mountjoy, M., Costa A., Budgett, R., Dvorak, J., Engebretsen, L., Miller, S., Moran, J.,
Foster, J., & Carr J. (2018). Health promotion through sport: International Sport
Federations’ priorities, actions and opportunities British Journal of Sports Medicine,
52(1), 54-60.
Nattiv, A., Loucks, A.B., Manore, M.M., Sanborn,C.F., Sundgot-Borgen, J., & Warren, M.P.
(2007). American College of Sports Medicine position stand. The female athlete triad.
Medicine and Science in Sports and Exercise, 39, 1867-1882.
Paddon-Jones, D., & Rasmussen, B.B. (2009). Dietary protein recommendations and the
prevention of sarcopenia: Protein amino acid metabolism and therapy. Current
Opinion in Clinical Nutrition and Metabolic Care, 12(1), 86-90.
Papapoulos S.E., & Cremers S.C. (2007). Prolonged bisphosphonate release after treatment
in children. New England Journal of Medicine, 356(10), 1075-1076.
Petkus, D.L., Murray-Kolb, L.E., & De Souza, M.J. (2017). The unexplored crossroads of the
female athlete triad and iron deficiency: A narrative review. Sports Med, 47(9), 1721-
1737.
Pyne, D.B., Verhagen, E.A., & Mountjoy, M. (2014). Nutrition, illness, and injury in aquatic
sports. International Journal of Sport Nutrition and Exercise Metabolism, 24, 460-469.
Ramsay, R., & Wolman, R. (2001). Are synchronized swimmers at risk of amenorrhea?
British Journal of Sports Medicine, 35, 242-244.
Rauh, M., Nichols, J., & Barrack, M. (2010). Relationships among injury and disordered
eating, menstrual dysfunction, and low bone mineral density in high school athletes: a
prospective study. Journal of Athletic Training, 45, 243-252.
Roby, F., Atwater, A., Going, S., Lohman, T., Puhl, J., & Tucker, M. (1988). Bone mineral
content in synchronzied swimmers. In Proceedings of the First IOC World Congress
on Sports Sciences, October 28 1989-November 3 1989. Colorado Springs, CO: US
Olympic Committee.
Robertson, S., Benardot, D., & Mountjoy, M. (2014). Nutritional recommendations for
synchronized swimming. International Journal of Sport Nutrition and Exercise
Metabolism, 24, 404-413.
Rodriguez, N.R., DiMarco, N.M., & Langley, S., American Dietetic Association, Dietitians of
Canada & American College of Sports Medicine. (2009). Position of the American
Dietetic Association, Dietitians of Canada and the American College of Sports
Medicine. Nutrition and athletic performance. Journal of the American Dietetic
Association, 109, 509-527.
Downloaded by MCMASTER UNIVERSITY LIBRARY on 05/18/18, Volume ${article.issue.volume}, Article Number ${article.issue.issue}
A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Rosendahl, J., Bormann, B., Aschenbrenner, K., Aschenbrenner, F., & Strauss, B. (2009).
Dieting and disordered eating in German high school athletes and non-athletes.
Scandinavian Journal of Medicine & Science in Sports, 19(5), 731-739.
Sambanis, M., Kofotolis, N., Kalogeropoulou, E., Noussios, G., Sambanis, P, &
Kalogeropoulos, J. (2003). A study on the effects on the ovarian cycle of athletic
training in different sports. Journal of Sports Medicine and Physical Fitness, 43, 398-
403.
Schaal, K., Tiollier, E., Le Meur, Y., Casazza, G., & Hausswirth, C. (2017). Elite
synchronized swimmers display decreased energy availability during intensified
training. Scandinavian Journal of Medicine and Science in Sports, 27(9), 925-934.
Sonntag, B., & Ludwig, M. (2012). An integrated view on the luteal phase: diagnosis and 60
treatment in subfertility. Clinical Endocrinology (Oxf); 77, 5007.
Sundgot-Borgen, J., & Garthe, I. (2011). Elite athletes in aesthetic and Olympic weight-class
sports and the challenge of body weight and body compositions. Journal of Sports
Sciences, 29(Supp 1), S101-S114.
Tanaka, C., Lida, T., Tawara, Y., Murata, M., Takamatsu, J., Honma, M., & Kawahara, T.
(2006). Characteristics of bone density in adolescent synchronized swimmers
Relationships between bone density, daily physical activity and dietary intake.
Japanese Journal of Physical Fitness and Sports Medicine, 55, 165-174.
Thein-Nissenbaum, J.M., Rauh, M.J., Carr, K.E., Lourd, K.J., & McGuine, T.A. (2011).
Associations between disordered eating, menstrual dysfunction, and musculoskeletal
injury among high school athletes. Journal of Orthopaedic & Sports Physical
Therapy, 41, 609.
Tipton, K.D., Elliott, T.A., Cree, M.G., Aarsland, A.A., Sanford, A.P., & Wolfe, R.R. (2007).
Stimulation of net muscle protein synthesis by whey protein ingestion before and after
exercise. American Journal of Physiology and Endocrinology Metabolism, 292, E71-
E76.
Tipton, K.D., & Phillips, S.M. (2013). Dietary protein for muscle hypertrophy. Nestle Nutrition
Institute Workshop Service, 76, 73-84.
U.S. Department of Health and Human Services and U.S. Department of Agriculture (2015).
2015-2020 Dietary Guidelines for Americans. (8th Ed.). December 2015. Available
at http://health.gov/dietaryguidelines/2015/guidelines/.
Vanheest, J.L, Rodgers, C.D., Mahoney, C.E. & De Souza M.J. (2014). Ovarian suppression
impairs sport performance in junior elite female swimmers. Medicine & Science in
Sports & Exercise, 46,15666.
Vardar, E., Vardar, S.A., & Kurt, C. (2007). Anxiety of young female athletes with disordered
eating behaviors. Eating Behaviors, 8(2), 143-147.
Venkatraman, J.T., & Pendergast, D.R. (2002). Effect of dietary intake on immune function
in athletes. Sports Med. 32(5):323-37.
Downloaded by MCMASTER UNIVERSITY LIBRARY on 05/18/18, Volume ${article.issue.volume}, Article Number ${article.issue.issue}
A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Viner, R.T., Harris, M., Berning, J.R., & Meyer, N.L. (2015). Energy availability and dietary
patterns of adult male and female competitive cyclists with lower than expected bone
mineral density. International Journal of Sport Nutrition and Exercise Metabolism,
25(6), 594-602.
Warren, M,P., Miller, K.K., Olson, W.H., Grinspoon, S.K., & Friedman, A.J. (2005).
Effects of an oral contraceptive (norgestimate/ethinyl estradiol) on bone mineral
density in women with hypothalamic amenorrhea and osteopenia: an open-label
extension of a double-blind, placebo-controlled study. Contraception; 72(3), 206-211.
Wilson, G., Hawken, M.B., Poole, I., Sparks, A., Bennett, S., Drust, B., Morton, J., & Close,
G.L. (2014). Rapid weight-loss impairs simulated riding performance and strength in
jockeys: implications for making-weight. Journal of Sports Sciences, 32(4): 383-91
Downloaded by MCMASTER UNIVERSITY LIBRARY on 05/18/18, Volume ${article.issue.volume}, Article Number ${article.issue.issue}
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International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Figure 1: Health consequences of Relative Energy Deficiency in Sport (RED-S)
(*Psychological consequences can either precede RED-S or be the result of REDS).
Mountjoy, M.,et al.. (2014). The IOC Consensus Statement. Beyond the female athlete triad Relative energy deficiency in
sport. Br J Sports Med, 48, 491-497.
Constantini NW. Medical concerns of the dancer. Book of Abstracts, XXVII FIMS World Congress of
Sports Medicine, Budapest, Hungary, 2002:151.
Downloaded by MCMASTER UNIVERSITY LIBRARY on 05/18/18, Volume ${article.issue.volume}, Article Number ${article.issue.issue}
A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Figure 2: Potential performance effects of Relative Energy Deficiency in Sport
(**Aerobic and anaerobic performance).
Mountjoy, M.,et al.. (2014). The IOC Consensus Statement. Beyond the female athlete triad Relative energy deficiency in
sport. Br J Sports Med, 48, 491-497.
Constantini NW. Medical concerns of the dancer. Book of Abstracts, XXVII FIMS World Congress of
Sports Medicine, Budapest, Hungary, 2002:151.
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International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Table 1. Details of Artistic Swimming
FINA
207
1984
9*
72
F + MX
I+D+T
*solo technical, solo free, duet technical, duet free, team technical, team free, combination event (solo,
duet + team in one routine) and mixed (gender) duet technical and mixed duet free.
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International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Table 2. Practical recommendations for preventing RED-S in Artistic Swimming
Nutritional recommendations
To optimize training performance, athletes should
Choose a well-balanced diet with nutrient dense food choices sufficient in energy,
carbohydrate, and protein
Consider appropriate timing of meals and snacks (before, during and after training)
Consume sufficient calories, matching differential energy expenditures
Ensure proper recovery protocol (protein and CHO choice after training)
Discourage athlete weight loss close to major competitions
Energy
Aim to have athletes in adequate/optimal EA
Periodized to match the demands of training
Individually adjusted for each athlete
Carbohydrate (CHO)
Recommended range of 5-7 grams CHO per kg body mass/day
Timing of CHO ingestion should occur at frequent intervals throughout the day (before,
during and after training)
Protein
Recommended range of 1.5-1.7 grams protein/per kg body mass/day
Emphasis on timing
Include a 20 gram, high-quality protein choice 4 times per day (examples: meat, fish,
poultry, eggs, peanut butter, nuts)
Fat
Consume healthy fats as part of the overall diet (examples: nuts, fatty fish, olive oil,
avocado)
Recommended range of 20-25% of total daily energy intake
Micronutrients
Ensure adequate intake of
Iron (red meat, beans, iron fortified cereals)
Calcium (dairy products, calcium-fortified juices, fish with bones)
Vitamin D (fortified food products)
Use a combination of dietary sources (preferable) and supplements (if required).
To help prevent gastro-intestinal upset:
Choose easily digestible food choices
Avoid eating large volumes of food
Avoid eating high fibre and gas-producing foods
Use an antacid (if required) to prevent gastro-intestinal symptoms
Strategies to treat low energy availability (LEA):
An increase in energy intake and decrease in exercise is necessary
An eating plan with an increase in current energy intake by 300-600kcals/day
Address suboptimal or mismanaged nutritional practices, timing of intake, and stress
surrounding eating
Annual periodic health examination (PHE)
Recognize that menstrual dysfunction is a sign of underlying pathology, and not
regarded as a natural result of intense training.
Include a blood and urine test to assess iron, vitamin D status, and hydration state
Include BMD (measured by DEXA) in athletes with LEA, DE/ED, or amenorrhea
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A Review of Prevention, Diagnosis and Treatment of Relative Energy Deficiency in Sport (RED-S) in Artistic
(Synchronized) Swimming” by Robertson S, Mountjoy M
International Journal of Sport Nutrition and Exercise Metabolism
© 2018 Human Kinetics, Inc.
Include RED-S screening as part of the annual PHE
Utilize the RED-S CAT (Clinical Assessment Tool) intended for sports medicine
professionals to assist with screening and management of athletes with RED-S
Body composition assessment
Body composition assessment should occur at the beginning of the season, and
in consultation with a sport dietitian, body composition manipulation should occur
in a safe manner over a long period of time.
DEXA would be the preferred method for assessing body composition
Athletes should be informed that the purpose is to monitor any potential
unhealthy changes, and to determine if training and dietary strategies are having
the desired result.
Strategies for achieving this include:
Obtaining body composition values with only one athlete at a time
Appropriate phrasing of results
Providing athletes with information on how they have changed between
assessments
Increasing the focus on muscle mass, and decreasing the focus on body fat
Using body composition values to explain changes in performance
Focusing on the changes in body composition to recommend dietary changes
Avoiding any punitive action as a result of the assessed values
Education strategies
Nutritional education strategies to help athletes and coaches understand the range
of health and performance issues related to suboptimal eating practices in order to
help reduce potential triggers
Utilize the RED-S conceptual models to show the health and performance
consequences
Educate coaches to allow sufficient breaks in training to allow athletes to properly
fuel and hydrate
Implement prevention programs and the RED-S CAT tool within athlete-monitoring
programs by FINA, as well as National Sport Governing Bodies
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... Behaviours regarding feeding and diet, exercise and physical activity, and self criticism are especially common (Table 2) 6,25,38,42,64,98,208,209 . The behaviours exhibited by those with RED-S may be similar to those exhibited by those with disordered eating 63,81,210,211 . Other signs include social withdrawal and depression 6,64,212 . ...
... Even within the moderate category, training and competitions restrictions may be imposed, with return to sport requiring clearance by a physician. The management of an athlete at risk of RED-S should include a multidisciplinary healthcare approach 6,37,38,57,211 . The coach may work with the overseeing physician or allied health professionals to develop an appropriate return-to-sport plan. ...
Article
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The Female Athlete Triad (Triad) and the more encompassing Relative Energy Deficiency in Sport (RED-S) are disorders caused by low energy availability (LEA). LEA is a state of insufficient energy intake by an athlete relative to their energy expenditure. Persistent LEA results in the deleterious consequences to health and performance that comprise RED-S. With respect to both the Triad and RED-S, researchers have called for more education of those involved with sport, particularly coaches, to help reduce the incidence of these disorders. Recent studies have shown that as few as 15% of coaches are aware of the Triad, with up to 89% unable to identify even one of its symptoms. RED-S is a more recently established concept such that coach knowledge regarding it has only begun to be assessed, but the results of these initial studies indicate similar trends as for the Triad. In this review, we synthesize research findings from 1986 to 2021 that pertains to LEA and RED-S, which coaches should know so they can better guide their athletes.
... A review by Robertson and Mountjoy [38] reported a high prevalence of specific energy deficiency syndrome in sports (RED-S) in AS athletes. This syndrome refers to impaired physiological function, including metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health. ...
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To develop a methodology for predicting success in artistic swimming based on a set of morphofunctional indicators and indices, 30 schoolgirls, average age (12.00 ± 0.22), were divided into two groups. Group 1: 15 athletes, training experience 4–5 years. Group 2: 15 schoolgirls without training experience. For each participant, we determined the length and weight of the body, the circumference of the chest, vital lung capacity, and the circumference of the biceps in a tense and at rest. The Erisman index, biceps index, and the ratio of proper and actual vital lung capacity was calculated. Them, we conducted the Stange and Genchi hypoxic tests, and flexibility tests for “Split”, “Crab position”, and “Forward bend”. Prediction was conducted using the Wald test with the calculation of predictive coefficients and their informativeness. A predictive table containing results of functional tests and indices of artistic swimming athletes is developed. It includes nine criteria, which informativeness varied in the range of 395.70–31.98. The content of the prediction consists of evaluating the results, determining the appropriate predictive coefficient, and summing these coefficients before reaching one of the predictive thresholds. The conducted research allowed us to substantiate and develop a method for predicting the success of female athletes with the use of morphofunctional indicators and indices.
... In 2018, Robertson and Mountjoy published a review of RED-S as it applies to artistic swimming. 69 ...
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Since the first modern Olympic Games in 1896, the aquatic sports have expanded both in participation and innovation over the last century. Beginning with swimming, diving, water polo, and later additions of artistic swimming, open water swimming and high diving, the aquatics sports represent a core pillar of Olympic disciplines. The rapid expansion of aquatic disciplines necessitated the foundation of the Fédération Internationale de Natation (FINA) in 1908, to govern the development of aquatic sports. The amateur spectacle has been slowly replaced with an increased focus on health and performance by dedicated professional athletes and support teams, resulting in the development of new innovations. In the early years, innovations largely centred on technical equipment such as bathing suit and springboard design. In more recent years, research and innovation have shifted focus to health and its impact on performance, including but not limited to changes in training methods, nutrition, injury and illness reduction through surveillance and access to education for athletes, coaches, and support personnel. An increased awareness on factors that affect athlete health have also driven safety innovations including the development of Nutrition and Relative Energy Deficiency in Sport Clinical Assessment Tool, the Sport Mental Health Assessment and Recognition Tools and safeguarding from harassment and abuse through embedding athletes' right to safe sport in underpinning statutory documents. While the future of aquatic health innovations remains undefined, there are many potential opportunities for research and knowledge translation as the aquatic sports continue to evolve and adapt over time.
... Early detection of eating disorders or disordered eating among athletes is highly recommended to facilitate prompt treatment and prevention of health and performance-related consequences [4,36] such as menstrual dysfunction, impaired bone health and metabolism, cardiac arrhythmias/abnormalities, endocrine/ metabolic dysfunction, increased injury risk, decreased endurance, performance, and coordination [12,[22][23][24]37]. The findings in this study may help bridge the gap in recognizing athletes at risk for developing eating disorders. ...
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Background To determine if following specific diets was associated with reporting behaviors that are consistent with disordered eating compared to non-diet-adherent athletes. We hypothesized that athletes adhering to specific diets were more likely to report disordered eating than those not following a diet. Methods One thousand female athletes (15–30 years) completed a comprehensive survey about athletic health and wellness. Athletes were asked to specify their diet and completed 3 eating disorder screening tools: the Brief Eating Disorder in Athletes Questionnaire, the Eating Disorder Screen for Primary Care, and self-reported current or past history of eating disorder or disordered eating. Descriptive statistics were calculated for all study measures and chi-squared tests assessed relationships between athletes’ dietary practices and their responses to eating disorder screening tools. Statistical significance was defined as p < 0.05. Results Two hundred thirty-four of 1000 female athletes reported adherence to specific diets. 69 of the 234 diet-adhering athletes (29.5%) were excluded due to medically-indicated dietary practices or vague dietary descriptions. Of the 165 diet-adherent athletes, 113 (68.5%) screened positively to ≥1 of the 3 eating disorder screening tools. Specifically, athletes practicing a low-carbohydrate diet were more likely to report disordered eating vs. athletes without dietary restrictions (80% vs. 41.8%; p < 0.0001). Conclusion Specific diet adherence in female athletes may be associated with reporting behaviors that are consistent with disordered eating. Health practitioners should consider further questioning of athletes reporting specific diet adherence in order to enhance nutritional knowledge and help treat and prevent eating disorders or disordered eating.
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Sport scholars have argued that to protect athlete health, competitive sport cultures must begin to de-emphasize the importance of leanness for athletic performance. However, there is a notable lack of analyses of the pressures towards leanness experienced by athletes in sports that are not considered most ‘at-risk’ for the development of disordered bodily practices, such as Olympic Weightlifting. Based on interviews with sixteen competitive American Olympic Weightlifters, this study uses Foucauldian insights about the inseparability of culture, language, and the body to examine how weightlifters come to understand—and rationalize—their weight classes, body compositions, and avoidance of body fat. We find that while weightlifters characterized a wide range of body compositions as being functional for the sport, their own weight class choices were informed by a sport-specific narrative that condemned body fat. We critically interrogate this preference for leanness-focused bodily practices in a ‘non-lean’ sport, looking to the ‘Sport Ethic’ and other dominant bodily discourses as possible sources of influence.
Relative Energy Deficiency in Sport (RED-S) refers to a condition in which energy imbalance leads to impaired physiological function of multiple organ systems and expands on the diagnosis previously known as the Female Athlete Triad. Researchers attribute the medical complications of RED-S to low energy availability, in which energy availability is defined as dietary energy intake minus exercise energy expenditure divided by fat-free mass. This article reviews the history of this diagnosis, the changing terminology, and the reasons for the expansion. Accepted definitions of each part of the energy availability equation are considered and the difficulties that exist using these equations in practice or comparatively in the literature are assessed. The review analyzes the broad spectrum of health consequences of RED-S, especially as it relates to hypoestrogenemia and menstrual function, gives guidance to those caring for athletes on the identification and management of RED-S, and sheds lights on the important role of coaches, athletic trainers, and families in recognizing this diagnosis and in helping getting patients to care.
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Objective To identify areas of priority and activity for international sportsfederations (IFs) with respect to athlete health and safety, and global health. Results serve to direct the work of the Association of Summer Olympic IF Medical and Scientific Consultative Group, the International Olympic Committee and to influence IFs’ planning and priorities. Methods The 28 IFs participating in the Summer Olympic Games (2016) were asked to rank the relative importance of 11 health-related topics and to report their activities or research initiatives on 27 identified topics using an electronic survey. A comparison with a similar survey (2012) was made. Results The response rate was 100%. In general, the ‘fight against doping’ had the highest priority followed by ‘image as a safe sport’. The topics with the lowest importance ratings were ‘increasing the number of elite athletes’, and ‘health of the general population’. Despite ranking ‘health of your athletes,’ as a top priority, IFs are not addressing all aspects of athlete health. In comparison with 2012, there was a significant decrease in priority for IFs is ‘health of the general population’. Conclusion Despite the widespread knowledge of the importance of the promotion of physical activity (sport) on global health, the decreasing priority and programming of the IFs on physical activity promotion is concerning. Although IFs have prioritised the protection of the health of elite athletes, there are gaps in programming demonstrating that IFs are missing important areas of athlete health. Improving recreational athlete health programming could also benefit population health as well as improve IF fan base and sport participation.
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Athletes competing in individual sports such as judo are categorized by weight. Before competitions, weight cutting is common. This cross-sectional study was designed to characterize and determine the prevalence of rapid weight loss (RWL) among adolescent judo competitors. Male athletes aged 12-17 years old (n=108) were recruited from local judo teams. Each participant completed a validated questionnaire regarding RWL practices. Anthropometric measurements were also performed. Average age was 14.6±1.6 years and all participants were of normal body mass index (BMI). RWL was practiced by 80% of the athletes prior to competition, beginning at an average age of 12.5±2.2 years with the highest prevalence (~94%) in the oldest group of judoka (16-17.9 years). Pre-competition weight loss duration was 8±5.4 days, with an average weight reduction of 1.5±1.1 kg. The number of weight loss efforts per athlete in the past season was 2.8±2.2. RWL was achieved by increased physical activity (82.6%), skipped meals (56.3%), or fasting at least once (47%). Two-thirds of the athletes indicated that their coaches were the most influential figure in their decision to lose weight prior to competition. RWL is highly prevalent in adolescent judo competitors. The methods used by these athletes can potentially lead to significant health risks including compromised nutritional status, diminished physical performance and impaired growth and development. It is of great importance to insure that those who guide young adults in weight loss for competitive sports have the knowledge and understanding to make safe recommendations and appropriate decisions regarding achieving specific weight goals.