Education reviews

Br J Sports Med: first published as 10.1136/bjsports-2017-097700 on 6 July 2017. Downloaded from http://bjsm.bmj.com/ on October 11, 2023 at UFSC - Universidade Federal de Santa
Relative energy deficiency in ►► Tanner staging
►► Musculoskeletal injury assessment.

sport (RED-S) Additional testing

►► Basic laboratory testing may include a
complete blood count and comprehen-
1 2 3
Siobhan M Statuta, Irfan M Asif, Jonathan A Drezner sive metabolic panel with particular
attention to potassium (K+)
►► ECG: assess for arrhythmias or
prolonged QT interval in athletes with
Background ►► Body image eating disorders
Relative energy deficiency in sport ►► Recent weight changes ►► Dual-energy X-ray absorptiometry
(RED-S) is the result of insufficient caloric ►► Recent training increases to measure bone mineral density for
intake and/or excessive energy expendi- ►► Disordered eating (restricting or athletes with prior or current bony
ture. Consequences of this low-energy self-induced vomiting)
stress injury or eating disorders
condition can alter many physiological ►► Prior stress fractures
►► Additional laboratory evaluation
systems, including metabolism, menstrual ►► Medications
may be indicated depending on the
function, bone health, immunity, protein ►► Supplements (energy, weight loss or
unique athlete clinical presentation
synthesis, and cardiovascular and psycho- dietary)
(significant fatigue/poor performance,
logical health1 (figure 1). ►► Menstrual history in women
prior bone stress injury, secondary
The RED-S concept has been adapted (menarche, menstrual cycle frequency)
amenorrhoea or severe hypogonado-
from a previously identified syndrome, ►► Duration of fatigue or poor athletic
tropic hypogonadism). Possible tests
the female athlete triad, which affects performance
to consider are thyroid hormones,
active women with low-energy availability, ►► Increase in resting heart rate
►► Sleep pattern/hygiene
gonadotropins, prolactin, vitamin
menstrual dysfunction and low bone mineral
levels and a pregnancy test in women.
density.2 Emerging data suggest there may be ►► Athlete knowledge of ‘energy
a parallel syndrome in undernourished male balance’.
Physical exam Management

Catarina. Protected by copyright.

athletes with resulting hypogonadotropic
hypogonadism and impairment of bone ►► Height, weight, BMI; consider ortho- Treatment of RED-S preferably involves
health.3 RED-S is a comprehensive model statics (blood pressure and pulse), a multidisciplinary team of health profes-
depicting a low-energy status in physically per cent body fat sionals to address the complex interplay of
active women or men. ►► Physical signs of disordered eating: eating, training, body image and perfor-
lanugo, parotid gland enlargement, mance. This panel ideally includes a sports
Case hypercarotenaemia, Russell’s sign medicine physician, sports dietician and
A 29-year-old male runner presents for (scab on purging finger) sports psychologist/psychiatrist. Coaches,
evaluation with concerns of fatigue and ►► Cardiac: bradycardia, arrhythmia strength and conditioning specialists,
poor athletic performance. Over the ►► Mucus membranes: pale, dry athletic trainers, exercise physiologists and
past year, he has focused on his training, ►► Skin: acne, male pattern hirsutism appropriate subspecialists with expertise
running approximately 72 miles per week
and performing yoga 3 days per week. He
also has revised his diet to eat ‘healthy’
and avoid alcohol, and subsequently lost
21 lbs. The following were his vital signs
on presentation: blood pressure 128/57,
pulse 56, height 6’3.5’, weight 151 lbs and
body mass index (BMI) 18.6.

Clinical questions
1. What are the symptoms and clinical
features of RED-S?
2. What management interventions
should be considered?

Clinical features
Important history elements
►► Eating habits and caloric intake

1
Family Medicine, University of Virginia, Charlottesville,
Virginia, USA
2
Family Medicine, University of South Carolina,
Greenville, South Carolina, USA
3
Family Medicine, University of Washington, Seattle,
Washington, USA
Correspondence to Dr Siobhan M Statuta, Family
Medicine, University of Virginia, PO Box 800729, Figure 1 Spoke and wheel figure (from Mountjoy et al1). RED-S, relative energy deficiency in
Charlottesville, 22908, USA; s​ iobhan@​virginia.e​ du sport.

1570    Statuta SM, et al. Br J Sports Med November 2017 Vol 51 No 21


in affected organ systems may also be
involved.
The basis of RED-S is an energy defi-
ciency; thus, treatment must focus on
increasing the caloric intake and/or
decreasing the caloric expenditure (ie,
training demands) to correct the energy
balance. Education is critical, as many
athletes believe it is normal to experi-
ence fatigue, appetite variation, mood
swings, recurrent injuries and (for women)
menstrual dysfunction. However, a
prolonged state of energy deficiency often
has negative effects on many systems,
including a higher risk of bony stress
injury, fatigue and poor performance.
Serving as an educator is imperative to
gain trust from the athlete, family, team-
mates and coaches. Promoting the concept
of ‘eating to perform’ is helpful to change
the athletes’ relationship with food, so
that they may consume the calories and
nutrients needed for optimal athletic
performance.
Athletes presenting with specific
complaints such as weight loss, endocrine
dysfunction, recurrent injuries or illnesses,
or diminishing performance should
undergo a more detailed evaluation and
laboratory assessment to evaluate for more
serious medical consequences resulting
from energy deficiency. Screening for
RED-S should be considered as part of an
annual health or preparticipation exam-
ination, especially in endurance athletes
or sports emphasising aesthetics or a lean
physique.
Statuta SM, et al. Br J Sports Med November 2017 Vol 51 No 21
The IOC has developed a tool to assist
medical professionals in the evaluation
and management of at-risk athletes: the
RED-S Clinical Assessment Tool.4 This
model uses information collected from
the history and physical examination and
provides a guide to activity recommenda-
tions. Athletes are classified as being in the
‘Red’, ‘Yellow’ or ‘Green’ zone, correlating
with high, moderate and low risk states.
The Red group is held from all activity, the
Yellow group requires a more individual-
ised plan involving close supervision, and
the Green group is permitted full sport
participation.4 This model requires more
research to validate the approach.
Practical tips
►► RED-S affects both female and male
athletes, causing changes to many
physiological systems, including bone
metabolism, menstrual dysfunction,
cardiovascular performance and
mental health.
►► A low-energy state and ‘under-fue-
ling’ result in suboptimal function,
and serious health consequences may
result if not reversed.
►► Early detection is paramount, and a
high level of suspicion is warranted in
endurance and lean body sports.
►► Assessing for weight loss, recent
training increases with ‘fueling’
mismatch, lack of normal growth or
development in adolescents, recurrent
bony or soft tissue injuries, illnesses,
decreased performance, mood
Education reviews
Br J Sports Med: first published as 10.1136/bjsports-2017-097700 on 6 July 2017. Downloaded from http://bjsm.bmj.com/ on October 11, 2023 at UFSC - Universidade Federal de Santa
changes and menstrual dysfunction
are helpful signs.
►► Treatment relies on a multidiscipli-
nary approach to educate and support
the athlete with the primary aim to
correct and maintain energy balance.
Competing interests None declared.
Provenance and peer review Not commissioned;
externally peer reviewed.
© Article author(s) (or their employer(s) unless
otherwise stated in the text of the article) 2017. All
rights reserved. No commercial use is permitted unless
otherwise expressly granted.
To cite Statuta SM, Asif IM, Drezner JA.
Br J Sports Med 2017;51:1570–1571.
Accepted 30 May 2017
Published Online First 1 July 2017
Br J Sports Med 2017;51:1570–1571.
doi:10.1136/bjsports-2017-097700
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Catarina. Protected by copyright.
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-Relative Energy Deficiency in Sport (RED-S). Br J Sports
Med 2014;48:491–7.
2 Joy E, De Souza MJ, Nattiv A, et al. Female athlete triad
coalition consensus statement on treatment and return
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3 Tenforde AS, Barrack MT, Nattiv A, et al. Parallels with
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2016;46:171–82.
4 Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC
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tool (RED-S CAT). Br J Sports Med 2015;49:1354.
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