Is RED-S in athletes just another face of malnutrition?

Differences in Knowledge of Female Athlete Triad and Relative Energy Deficiency in Sport in Female Cross-Country Athletes

BACKGROUND

The female athlete triad (Triad) and relative energy deficiency in sport (REDs) describe potential health and performance consequences of low energy availability.

OBJECTIVE

We surveyed female cross-country athletes to assess differences in educational impact scores (EIS; knowledge score × confidence score factor) of Triad and REDs. Associations between EIS and participant characteristics (eg, mileage [current and peak], years of running experience, age, bone stress injury history, division level participation, academic area of study, Triad or REDs diagnoses, and Triad or REDs education) were explored.

MAIN OUTCOME MEASURE(S)

An evidence-based online survey was developed and administered via Qualtrics to female collegiate cross-country athletes (n = 275; age = 20 ± 1 years).

RESULTS

A weak correlation existed between peak career mileage and EIS (r = 0.195; P = .010). Educational impact scores significantly differed in athletes with a related academic area of study versus those without (21.91 ± 5.16 and 16.11 ± 5.54, respectively). Educational impact scores significantly differed in athletes with Triad and REDs diagnoses (21.69 ± 5.85 and 22.58 ± 6.82, respectively) versus those without (16.80 ± 6.54 and 17.20 ± 6.34, respectively). Educational impact scores were higher in those who had received Triad education versus those who had not (21.03 ± 6.86 and 18.12 ± 6.82, respectively). A significant interaction between peak career mileage and Triad diagnosis was found (P = .005).

CONCLUSIONS

Significant education-based and diagnosis differences suggest that Triad diagnoses correlate with peak career mileage. These findings support the facilitation of education to improve not only the treatment but also the prevention of Triad and REDs.

A systematic review, meta-analysis, and meta-regression of the prevalence of self-reported disordered eating and associated factors among athletes worldwide

BACKGROUND

The purpose of this meta-analysis was to provide a pooled prevalence estimate of self-reported disordered eating (SRDE) in athletes based on the available literature, and to identify risk factors for their occurrence.

METHODS

Across ten academic databases, an electronic search was conducted from inception to 7th January 2024. The proportion of athletes scoring at or above predetermined cutoffs on validated self-reporting screening measures was used to identify disordered eating (DE). Subgroup analysis per country, per culture, and per research measure were also conducted. Age, body mass index (BMI), and sex were considered as associated/correlated factors.

RESULTS

The mean prevalence of SRDE among 70,957 athletes in 177 studies (132 publications) was 19.23% (17.04%; 21.62%), I2 = 97.4%, τ2 = 0.8990, Cochran's Q p value = 0. Australia had the highest percentage of SRDE athletes with a mean of 57.1% (36.0%-75.8%), while Iceland had the lowest, with a mean of 4.9% (1.2%-17.7%). The SRDE prevalence in Eastern countries was higher than in Western countries with 29.1% versus 18.5%. Anaerobic sports had almost double the prevalence of SRDE 37.9% (27.0%-50.2%) compared to aerobic sports 19.6% (15.2%-25%). Gymnastics sports had the highest SRDE prevalence rate, with 41.5% (30.4%-53.6%) while outdoor sports showed the lowest at 15.4% (11.6%-20.2%). Among various tools used to assess SRDE, the three-factor eating questionnaire yielded the highest SRDE rate 73.0% (60.1%-82.8%). Meta-regression analyses showed that female sex, older age, and higher BMI (all p < 0.01) are associated with higher prevalence rates of SRDE.

CONCLUSION

The outcome of this review suggests that factors specific to the sport affect eating behaviors throughout an athlete's life. As a result, one in five athletes run the risk of developing an eating disorder. Culture-specific and sport-specific diagnostic tools need to be developed and increased attention paid to nutritional deficiencies in athletes.

Practical Application and Methodological Considerations on the Basics of Sports Nutrition in Basketball: A Comprehensive Systematic Review of Observational and Interventional Studies

The current systematic review (PROSPERO registration no. CRD42022334707) of observational (OS) and interventional studies (IS) aimed at evaluating the state of scientific knowledge on the basics of sports nutrition, framing discipline-specific dietary recommendations, and indicating potential directions for future studies in various age, experience level, and able-bodied abilities groups of basketball players (BP). A systematic search of PubMed, SPORTDiscus, and Web of Science ended on 20 December 2022. Records were excluded if reporting studies on animals, sport disciplines other than basketball, or supplementation protocols other than those related to macronutrients and hydration manipulations. Risk of bias (RoB) was evaluated using Cochrane RoB_2 tools, 'JBI checklist for prevalence studies', and 'Quality assessment tool for before-after (pre-post) studies with no control group'. The relevant data was synthesized in tables and a narrative review was performed. Seventy-two records were included (2581 participants): 63 were on able-bodied BP (2433 participants) and 9 on para-athlete players (148 participants); 45 records were OS and 27 IS. The review disclosed widespread poor nutritional habits and knowledge and shortages in applying adequate nutritional and hydration practices in BP. Moreover, the systematic review revealed the lack of a sufficient number of investigations delivering reliable proof for framing discipline-specific and evidence-based recommendations on the basics of sports nutrition in basketball.

Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review

The purpose of this narrative review is to identify health and performance consequences associated with LCA in female endurance athletes. The intake of carbohydrates (CHO) before, during, and after exercise has been demonstrated to support sport performance, especially endurance activities which rely extensively on CHO as a fuel source. However, low energy availability (LEA) and low carbohydrate availability (LCA) are common in female athletes. LEA occurs when energy intake is insufficient compared to exercise energy expenditure, and LEA-related conditions (e.g., Female Athlete Triad (Triad) and Relative Energy Deficiency in Sport (RED-S)) are associated with a myriad of health and performance consequences. The RED-S model highlights 10 health consequences and 10 performance consequences related to LEA. The independent effect of LCA on health and performance has been under-researched, despite current CHO intake being commonly insufficient in athletes. It is proposed that LCA may not only contribute to LEA but also have independent health and performance consequences in athletes. Furthermore, this review highlights current recommendations for CHO intake, as well as recent data on LCA prevalence and menstrual cycle considerations. A literature review was conducted on PubMed, Science Direct, and ResearchGate using relevant search terms (i.e., "low carbohydrate/energy availability", "female distance runners"). Twenty-one articles were identified and twelve met the inclusion criteria. The total number of articles included in this review is 12, with 7 studies illustrating that LCA was associated with direct negative health and/or performance implications for endurance-based athletes. Several studies included assessed male athletes only, and no studies included a female-only study design. Overall, the cumulative data show that female athletes remain underrepresented in sports science research and that current CHO intake recommendations and strategies may fail to consider female-specific adaptations and hormone responses, such as monthly fluctuations in estrogen and progesterone throughout the menstrual cycle. Current CHO guidelines for female athletes and exercising women need to be audited and explored further in the literature to support female athlete health and performance.

New Epidemic of Malnutrition in Young Slovenian Athletes

Objective

The syndrome of relative energy deficiency in sports (RED-S) is the result of a prolonged period of low energy availability in athletes and leads to the deterioration of health and physical performance. Our study aimed to investigate the prevalence of RED-S-related health and performance problems in young Slovenian athletes, comparing middle (14-17 years) with late (18-21 years) adolescents.

Methods

We analysd data of 118 young athletes (61 females, 57 males) who had nutritional assessments. Statistical analysis was carried out to determine the prevalence of RED-S-related problems. RED-S was diagnosed using the Relative Energy Deficiency Tool and the Sports Clinical Assessment Tool. Nutrition-related risk factors for RED-S were assessed with the use of a questionnaire and analysis of a three-day food diary.

Results

The majority of athletes had at least one RED-S-related health disorder. The number of health-related disorders was significantly higher in females 3.0 (0.2) compared to males 1.6 (0.2). It was also significantly higher in middle 2.6 (0.2) compared to 1.9 (0.3) late adolescents. Potential nutritional risk factors for RED-S were low carbohydrate intake, skipping meals before and after practice, a desire to lose weight, and a history of weight loss in the past year.

Conclusion

The prevalence of health-related RED-S disorders and performance problems in young athletes is concerning, and our study indicates that middle adolescents are more vulnerable to this than late adolescents. Our findings suggest that screening for RED-S symptoms and nutrition-related risk factors for RED-S should be included in regular medical examination of young athletes.

Factors Influencing Nutritional Intake and Interests in Educational Content of Athletes and Sport Professionals Toward the Development of a Clinician-Supported Mobile App to Combat Relative Energy Deficiency in Sport: Formative Research and a Description of App Functions

BACKGROUND

Relative energy deficiency in sport (RED-S) as a consequence of athlete malnutrition remains a prominent issue. However, it remains underrecognized, in part due to the perceived outward health of athletes. The Eat2Win app was designed to combat RED-S and athlete malnutrition by providing education, behavior modification, and direct communication with expert sports dietitians to athletes and sport professionals (professionals who work with athletes, eg, sport coaches and athletic trainers).

OBJECTIVE

The purpose of this formative research was to gain critical insight on motivators and barriers to optimal nutritional intake from both the athletes' and sport professionals' perspectives. Additionally, since these 2 groups represent the primary end users of an app aimed at improving athlete nutrition and reducing the risk of RED-S, a secondary objective was to gain insight on the preferences and perceptions of app-based educational content and functionality.

METHODS

An electronic survey was developed by an interdisciplinary team of experts. Survey questions were established based upon prevailing literature, professional dietetic field experience, and app design considerations to obtain respondent knowledge on key sports nutrition topics along with motivations and barriers to meal choices. Additionally, the survey included questions about the development of an integrative, clinician-support app aimed at addressing RED-S. These questions included preferences for educational content, modes of in-app information, and communication delivery for the target population (app end users: athletes and sport professionals). The survey was distributed through Research Electronic Data Capture (REDCap) to athletes and sport professionals using targeted email, social media, and community engagement campaigns. The electronic survey was available from May 4 to August 2, 2022.

RESULTS

Survey respondents (n=1352) included athletes and professionals who work with athletes from a variety of settings, like high school, collegiate, professional, and club sports. Respondents reported high interest in 8 core sports nutrition topics. The preferred modes of information and communication delivery were visual formats (eg, videos and infographics) and in-app alerts (eg, direct messaging and meal reminders). Only athlete respondents were asked about motivators and barriers that influence meal choices. "Health" and "sports performance" were the highest scoring motivators, while the highest scoring barriers were "cost of food," "easy access to unhealthy food," and "time to cook or prepare food." Notably, survey respondents provided positive feedback and interest using a novel function of the app: real-time meal feedback through food photography.

CONCLUSIONS

The Eat2Win app is designed to combat RED-S and athlete malnutrition. Results from this study provide critical information on end-user opinions and preferences and will be used to further develop the Eat2Win app. Future research will aim to determine whether the Eat2Win app can prevent RED-S and the risk of athlete malnutrition to improve both health and performance.

Adequacy of energy and macronutrients intake in differently active slovenian adolescents

OBJECTIVE

Evaluate the adequacy of energy/macronutrient intake in adolescents according to the Slovenian national recommendations adopted from the recommendations of the German Nutrition Society and to identify differences in energy/macronutrient intake between differently active adolescents.

METHODS

Data on energy and macronutrient intake (24-hour dietary recall), physical activity (SHAPES questionnaire), and anthropometric characteristics (body mass and height) of adolescents were obtained on a representative sample of first-year secondary school students (average (SD) age: 15.3 (0.5) years; N = 341), who were included in the national survey The Analysis of Children's Development in Slovenia (ACDSi) in 2013/14.

RESULTS

75% of adolescents met the national recommendations for carbohydrates and proteins and 44% for fats, whereas only 10% of adolescents met the recommendations for energy intake. Energy/macronutrient intakes were significantly higher in vigorously physically active (VPA) boys compared to moderately (MPA) and less (LPA) physically active boys. No such differences were observed between girls of different physical activity levels.

CONCLUSION

Adolescents need to be encouraged to meet their energy needs according to gender and physical activity (especially VPA girls) and to reach for higher quality foods in adequate macronutrient proportions.

Body Composition and Its Perception among Professional Female Volleyball Players and Fitness Athletes (Silesia, Poland)

Female athletes experience both sociocultural and sport-specific pressures of an ideal body and appearance and are vulnerable to dissatisfaction with their bodies. Among sport-specific pressures, the type of sport is a predictor of body image dissatisfaction. The study included 150 females: 50 volleyball players, 50 bodybuilding and fitness athletes, and 50 female students, who were the control group. Body composition and perception and evaluation of one's own body were assessed. BMI was similar in the study group of female athletes and the control group, but the bodybuilding and fitness athletes had the lowest body fat, while the control group had the highest. Perception of one's own body in the aspect of the evaluation of specific body parts was highest among bodybuilding and fitness athletes, while in the aspect of body condition, the best results were obtained by volleyball players. Most female volleyball players were dissatisfied with their current body weight, as were women in the control group, in contrast to female bodybuilding and fitness athletes, who were most often satisfied with their current body weight.