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#REDS (Relative Energy Deficiency in Sport): time for a revolution in sports culture and systems to improve athlete health and performance

Authors:
1
AckermanKE, etal. Br J Sports Med Month 2020 Vol 0 No 0
#REDS (Relative Energy Deficiency in
Sport): time for a revolution in sports
culture and systems to improve athlete
health andperformance
Kathryn E Ackerman ,1,2 Trent Stellingwerff,3,4 Kirsty J Elliott- Sale,5
Amy Baltzell,6 Mary Cain,7 Kara Goucher,8 Lauren Fleshman,9
Margo L Mountjoy10,11
Changing a sport system requires the
appointment of new leaders or a grass
roots cultural revolution. ‘I got caught in a
system designed by and for men, which
destroys the bodies of young girls,’ said
Mary Cain as she cast light on her toxic
coach/athlete relationship and exposed
unhealthy coaching and nutrition prac-
tices. Her candour has inspired a social
media movement calling for changes to
women’s sport.1 In the following days,
major news publications followed up with
similar reports of athletic women being
body shamed.2–4
It is time for a drastic paradigm change
in women’s sport, coupled with educa-
tion at all levels to improve the long- term
health and athletic achievement of female
athletes. The shift needs to include:
1. Raising awareness of the negative ef-
fects of chronic low energy availability
(LEA) (calorie restriction) so athletes
can make wise choices for their own
long- term health.
2. Updating and developing best- practice
protocols and safe standards for moni-
toring body composition/weight.
3. Eliminating toxic training environ-
ments featuring abusive body shaming.
Overexercising or underfueling, occur-
ring consciously or subconsciously, can
cause Relative Energy Deficiency in Sport
(RED- S). RED- S is the ‘impaired phys-
iological functioning caused by relative
energy deficiency, and includes but is
not limited to impairments of metabolic
rate, menstrual function (for females),
bone health, immunity, protein synthesis
and cardiovascular health.’5 Chronic LEA
(over many weeks to years) leading to
RED- S can limit training adaptation6 and
substantially increase injury risk.5 7 8 It
cripples performance in both female6 and
male athletes.5 It can occur unknowingly
without a diagnosed eating disorder.7
There is good news: there are oppor-
tunities to mitigate the occurrence and
effects of RED- S through system- wide
education including prevention/awareness
interventions and by optimising energy
intake. One of these system opportuni-
ties to address RED- S was spearheaded
in Canadian elite sport when B2ten—a
philanthropic group—sponsored a
3- day meeting of 30 key stakeholders in
November 2019. At the table were inter-
nationally renowned topic experts, Cana-
dian coaches from at- risk sports, and
athlete support staff representing both
sport science and medicine, all of whom
work in Canadian, American or British
sport. This group examined the science,
sport cultures, gaps and opportunities
associated with RED- S. Some of the key
themes developed included:
Prevention
We need to implement awareness
education adapted to female and male
athletes of all ages and sport levels,
and tailored for support staff, coaches
and parents. Educational initiatives
should underscore the positive aspects
of energy, namely, that food is fuel;
and fuel is needed for performance.
Content should include RED- S signs/
symptoms; positive communication
around menstrual cycles and body
image; appreciation of athletes/
sports at higher risk; and best prac-
tices pertaining to body composi-
tion/weight assessment protocols.
We developed a conceptual frame-
work outlining when, and when not,
to implement these methods (see
figure 1).
Diagnosis
Multicentred research is required to
develop and validate a diagnostic tool
for RED- S.
1Divisions of Sports Medicine and Endocrinology,
Boston Children’s Hospital, Boston, Massachusetts, USA
2Neuroendocrine Unit, Massachusetts General Hospital
and Harvard Medical School, Boston, MA, USA
3Canadian Sport Institute, Victoria, British Columbia,
Canada
4Department of Exercise Science, Physical & Health
Education, University of Victoria, Victoria, British
Columbia, Canada
5Musculoskeletal Physiology Research Group, Sport
Health and Performance Enhancement Research Centre,
School of Science and Technology, Nottingham Trent
University, Nottingham, UK
6Author, Consultant, Olympian, Past- President of the
Association of Applied Sport Psychology, Boston,
Massachusetts, USA
7Professional Runner, Bronxville, New York, USA
8Professional Runner and Olympian, Athlete Advocate,
Boulder, Colorado, USA
9Professional Runner, Athlete Advocate, Bend, Oregon,
USA
10Department of Family Medicine, McMaster University
Michael G DeGroote School of Medicine, Hamilton,
Ontario, Canada
11IOC Medical Commission Games Group, Lausanne,
Switzerland
Correspondence to Dr Kathryn E Ackerman, Sports
Medicine, Boston Children’s Hospital, Boston, MA
02115, USA; kathryn. ackerman@ childrens. harvard. edu
Editorial
Figure 1 A conceptual framework on the implementation of body composition assessments (e.g,
height, weight, anthropometrics, skinfolds, etc.) within the context of athlete stage of development
and their nutritional preparation skills. BC, body composition; LTAD, long- term athlete development
model; TBD, to be determined.
on January 10, 2020 at CASEM. Protected by copyright.http://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2019-101926 on 10 January 2020. Downloaded from
2AckermanKE, etal. Br J Sports Med Month 2020 Vol 0 No 0
Editorial
RED- S- associated diagnostic factors
may include: chronic dietary restric-
tion and/or extreme diets, drive for
thinness, large changes in body weight
or composition in short time periods,
training inconsistencies, prolonged
fatigue, decreased libido, oligo-
amenorrhoea (missing three or more
menstrual cycles in 6 months), two
or more career bone stress injuries
and low bone mineral density for age
(Z- score <-1.0).5
Treatment
We must ensure athlete access to a
referral network of RED- S and eating
disorder experts, including sport
and exercise medicine physicians,
registered sport dieticians and sport
psychologists, within each country.
The working group also identified
that certain sports have physiological
and energetic requirements that dictate
that certain athlete phenotypes may be
successful. There was much discussion
about methods to safely improve perfor-
mance while ensuring athlete physical and
mental health. Elite athletes may need to
manipulate energy availability for short
periods to change body composition and
improve their power/force profiles for
critical performance windows. On the
other hand, the working group empha-
sised that prolonged LEA impairs health
and performance.
Modeling the work in sport concussion,
we call for national policies requiring sports
to have RED- S prevention, diagnosis and
treatment protocols, targeting athletes,
coaches and the athlete entourage. Media
and sponsors can raise awareness and
support research in the field. Empowering
athletes to identify and protect themselves
from toxic cultures, and to understand the
importance of energy/food as it relates to
RED- S, is paramount.
As signs and symptoms of RED- S are
present in ~2%–60% of female and male
athletes, depending whether athletes are
in endurance, aesthetic, weight categories
and power/sprint sports,5 7 we believe that
a revolution in sport culture and aware-
ness regarding energy availability can
transform the physical and mental health
and performance of athletes globally.
Twitter Kathryn E Ackerman @drkateackerman
Contributors KEA, TS, KJE- S, AB and MLM attended
the B2ten summit and wrote and revised the
manuscript. MC, KG and LF wrote and revised the
manuscript and provided guidance on the athlete’s
perspective.
Funding The authors have not declared a specific
grant for this research from any funding agency in the
public, commercial or not- for- profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned;
externally peer reviewed.
© Author(s) (or their employer(s)) 2020. No commercial
re- use. See rights and permissions. Published by BMJ.
To cite AckermanKE, StellingwerffT, Elliott-
SaleKJ, etal. Br J Sports Med Epub ahead of print:
[please include Day Month Year]. doi:10.1136/
bjsports-2019-101926
Accepted 30 December 2019
Br J Sports Med 2020;0:1–2.
doi:10.1136/bjsports-2019-101926
ORCID iD
Kathryn EAckerman http:// orcid. org/ 0000- 0003- 2626-
7785
REFERENCES
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alberto- salazar- nike. html
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Project ’Cult’, 2019. Available: https://www. si. com/
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project- toxic- culture- alberto- salazar- abuse- investigation
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on January 10, 2020 at CASEM. Protected by copyright.http://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2019-101926 on 10 January 2020. Downloaded from
... Since 2006, the IOC has released multiple consensus statementssuch as its 2014 consensus statement on RED-S (Mountjoy et al., 2014)-to protect athletes' health and provide guidelines for the IOC and other sports organizations (Weston, 2017). Still, scholars and other athletes have urged sports organizations to take a more proactive role in establishing protocols and eliminating abusive training environments (Ackerman et al., 2020). ...
... For Semenya and Negesa, 'protection' involved adhering to (arbitrary) medical standards to support reductive and biocentric definitions of 'eligibility.' For Cain, despite urging attention to the cultural dimensions that contribute to RED-S (see Ackerman et al., 2020), policy documents remain focused on individual diagnosis and treatment, rather than reimagining toxic sporting cultures. ...
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... In addition, the frequency of protein consumption should increase 201,203,204 . By spreading protein intake throughout the day, it is thought that a sufficient pool of protein and amino acids will be available to support protein synthesis 201,203,205,206 . ...
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... Sustained research on factors associated with LEA is important for practitioners and other health professionals for early detection and aid in the nutrition interventions to prevent potential decrements in health and performance Ackerman et al., 2020). The association between disordered eating behavior and health consequences as a result of LEA in female athletes is well-researched and suggest that particular athletes from weight-sensitive sports, including endurance sports, may be at higher risk (Gibbs et al., 2013). ...
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Competitive female athletes restrict energy intake and increase exercise energy expenditure frequently resulting in ovarian suppression. The purpose of this study was to determine the impact of ovarian suppression and energy deficit on swimming performance (400m swim velocity). Menstrual status was determined by circulating estradiol (E2) and progesterone (P4) in ten junior elite female swimmers (15-17 yrs). The athletes were categorized as cyclic (CYC) or ovarian suppressed (OVS). They were evaluated every two weeks for metabolic hormones, bioenergetic parameters and sport performance over the 12-week season. CYC and OVS athletes were similar (p > 0.05) in age (CYC = 16.2 ± 1.8 yr; OVS = 17 ± 1.7 yr), BMI (CYC = 21 ± 0.4 kg/m; OVS = 25 ± 0.8 kg/m), and gynecological age (CYC = 2.6 ± 1.1 yr; OVS = 2.8 ± 1.5 yr). OVS had suppressed P4 (p < 0.001) and E2 (p = 0.002) across the season. Total triiodothyronine (TT3) and insulin-like growth factor (IGF-1) were lower in OVS (TT3: CYC = 1.6 ± 0.2 nmol/l; OVS = 1.4 ± 0.1 nmol/l p < 0.001; IGF-1: CYC = 243 ± 1 μg/ml; OVS = 214 ± 3 μg/ml p < 0.001) than CYC at Week 12. Energy intake (p < 0.001) and energy availability (p < 0.001) were significantly lower in OVS versus CYC. OVS exhibited a 9.8% decline in [INCREMENT]400m-swim velocity compared to an 8.2% improvement in CYC at Week 12. Ovarian steroids (P4 and E2), metabolic hormones (TT3 and IGF-1) and energy status markers (EA and EI) were highly correlated with sport performance. This study illustrates that when exercise training occurs in the presence of ovarian suppression with evidence for energy conservation (ie. reduced TT3), it is associated with poor sport performance. These data from junior elite female athletes support the need for dietary periodization to help optimize energy intake for appropriate training adaptation and maximal sport performance.
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Purpose: The female athlete triad (Triad) is a syndrome linking low energy availability (EA) with or without disordered eating (DE), menstrual disturbances (MD), and low bone mineral density (BMD) in exercising women. The prevalence of Triad conditions (both clinical and subclinical) has not been clearly established.The purpose of this review is to evaluate the studies that determined the prevalence of clinical or subclinical Triad conditions (low EA, DE, MD, and low BMD) in exercising women and in women participating in lean (LS) versus nonlean sports (NLS) using self-report and/or objective measures. Methods: A review of publications using MEDLINE and PubMed was completed. Randomized controlled trials and observational studies that evaluated the prevalence of clinical and subclinical Triad conditions (MD, low BMD, low EA, and DE) in exercising women were included. Results: Sixty-five studies were identified for inclusion in this review (n = 10,498, age = 21.8 ± 3.5 yr, body mass index = 20.8 ± 2.6 kg·m; mean ± SD). A relatively small percentage of athletes (0%-15.9%) exhibited all three Triad conditions (nine studies, n = 991). The prevalence of any two or any one of the Triad conditions in these studies ranged from 2.7% to 27.0% and from 16.0% to 60.0%, respectively. The prevalence of all three Triad conditions in LS athletes versus NLS athletes ranged from 1.5% to 6.7% and from 0% to 2.0%, respectively. LS athletes demonstrated higher prevalence rates of MD and low BMD (3.3% vs 1.0%), MD and DE (6.8%-57.8% vs 5.4%-13.5%), and low BMD and DE (5.6% vs 1.0%) than the NLS athletes. Conclusions: Although the prevalence of individual/combined Triad conditions is concerning, our review demonstrates that additional research on the prevalence of the Triad using objective and/or self-report/field measures is necessary to more accurately describe the extent of the problem.
I was the fastest girl in America, until I joined Nike
  • M Cain
Cain M. I was the fastest girl in America, until I joined Nike, 2019. Available: https://www. nytimes. com/ 2019/ 11/ 07/ opinion/ nike-running-mary-cain. html
I changed my body for sport. No girl should
  • L Fleshman
Fleshman L. I changed my body for sport. No girl should, 2019. Available: https://www. nytimes. com/ 2019/ 11/ 16/ opinion/ girls-sports. html
Another of Alberto Salazar’s Runners Says He Ridiculed Her Body for Years
  • M Futterman
Futterman M. Another of Alberto Salazar's Runners Says He Ridiculed Her Body for Years, 2019. Available: https://www. nytimes. com/ 2019/ 11/ 14/ sports/ olympics/ alberto-salazar-nike. html
Inside the Toxic Culture of the Nike Oregon Project 'Cult
  • C Chavez
Chavez C. Inside the Toxic Culture of the Nike Oregon Project 'Cult', 2019. Available: https://www. si. com/ track-and-field/ 2019/ 11/ 13/ mary-cain-nike-oregonproject-toxic-culture-alberto-salazar-abuse-investigation