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Stellingwerff T, Mountjoy M, McCluskey WT, Ackerman KE, Verhagen E, Heikura IA. Review of the scientific rationale, development and validation of the International Olympic Committee Relative Energy Deficiency in Sport Clinical Assessment Tool: V.2 (IOC REDs CAT2)-by a subgroup of the IOC consensus on REDs. Br J Sports Med 2023; 57:1109-1118. [PMID: 37752002 DOI: 10.1136/bjsports-2023-106914] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 09/28/2023]
Abstract
Relative Energy Deficiency in Sport (REDs) has various different risk factors, numerous signs and symptoms and is heavily influenced by one's environment. Accordingly, there is no singular validated diagnostic test. This 2023 International Olympic Committee's REDs Clinical Assessment Tool-V.2 (IOC REDs CAT2) implements a three-step process of: (1) initial screening; (2) severity/risk stratification based on any identified REDs signs/symptoms (primary and secondary indicators) and (3) a physician-led final diagnosis and treatment plan developed with the athlete, coach and their entire health and performance team. The CAT2 also introduces a more clinically nuanced four-level traffic-light (green, yellow, orange and red) severity/risk stratification with associated sport participation guidelines. Various REDs primary and secondary indicators have been identified and 'weighted' in terms of scientific support, clinical severity/risk and methodological validity and usability, allowing for objective scoring of athletes based on the presence or absence of each indicator. Early draft versions of the CAT2 were developed with associated athlete-testing, feedback and refinement, followed by REDs expert validation via voting statements (ie, online questionnaire to assess agreement on each indicator). Physician and practitioner validity and usability assessments were also implemented. The aim of the IOC REDs CAT2 is to assist qualified clinical professionals in the early and accurate diagnosis of REDs, with an appropriate clinical severity and risk assessment, in order to protect athlete health and prevent prolonged and irreversible outcomes of REDs.
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Affiliation(s)
- Trent Stellingwerff
- Canadian Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Margo Mountjoy
- Association for Summer Olympic International Federations (ASOIF), Lausanne, Switzerland
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Evert Verhagen
- Amsterdam Collaboration on Health and Safety in Sports and Department of Public and Occupational Health, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Ida A Heikura
- Canadian Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
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Mountjoy M, Ackerman KE, Bailey DM, Burke LM, Constantini N, Hackney AC, Heikura IA, Melin A, Pensgaard AM, Stellingwerff T, Sundgot-Borgen JK, Torstveit MK, Jacobsen AU, Verhagen E, Budgett R, Engebretsen L, Erdener U. 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med 2023; 57:1073-1097. [PMID: 37752011 DOI: 10.1136/bjsports-2023-106994] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2023] [Indexed: 09/28/2023]
Abstract
Relative Energy Deficiency in Sport (REDs) was first introduced in 2014 by the International Olympic Committee's expert writing panel, identifying a syndrome of deleterious health and performance outcomes experienced by female and male athletes exposed to low energy availability (LEA; inadequate energy intake in relation to exercise energy expenditure). Since the 2018 REDs consensus, there have been >170 original research publications advancing the field of REDs science, including emerging data demonstrating the growing role of low carbohydrate availability, further evidence of the interplay between mental health and REDs and more data elucidating the impact of LEA in males. Our knowledge of REDs signs and symptoms has resulted in updated Health and Performance Conceptual Models and the development of a novel Physiological Model. This Physiological Model is designed to demonstrate the complexity of either problematic or adaptable LEA exposure, coupled with individual moderating factors, leading to changes in health and performance outcomes. Guidelines for safe and effective body composition assessment to help prevent REDs are also outlined. A new REDs Clinical Assessment Tool-Version 2 is introduced to facilitate the detection and clinical diagnosis of REDs based on accumulated severity and risk stratification, with associated training and competition recommendations. Prevention and treatment principles of REDs are presented to encourage best practices for sports organisations and clinicians. Finally, methodological best practices for REDs research are outlined to stimulate future high-quality research to address important knowledge gaps.
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Affiliation(s)
- Margo Mountjoy
- Family Medicine, McMaster University Michael G DeGroote School of Medicine, Waterloo, Ontario, Canada
- Games Group, International Olympic Committee, Lausanne, Switzerland
| | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Louise M Burke
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Naama Constantini
- Sports Medicine Center, Shaare Zedek Medical Center, The Hebrew University, Jerusalem, Israel
| | - Anthony C Hackney
- Exercise and Sport Science, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ida Aliisa Heikura
- Canada Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | - Anna Melin
- Department of Sport Science - Swedish Olympic Committee Research Fellow, Linnaeus University, Kalmar, Sweden
| | - Anne Marte Pensgaard
- Department of Sport and Social Sciences, Norwegian School of Sports Sciences, Oslo, Norway
| | - Trent Stellingwerff
- Canada Sport Institute Pacific, Victoria, British Columbia, Canada
- Exercise Science, Physical & Health Education, University of Victoria, Victoria, British Columbia, Canada
| | | | | | | | - Evert Verhagen
- Amsterdam Collaboration on Health & Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Richard Budgett
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
| | - Lars Engebretsen
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
| | - Uğur Erdener
- Department of Ophthalmology, Hacettepe University, Ankara, Turkey
- World Archery, Lausanne, Switzerland
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Pensgaard AM, Sundgot-Borgen J, Edwards C, Jacobsen AU, Mountjoy M. Intersection of mental health issues and Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the IOC consensus on REDs. Br J Sports Med 2023; 57:1127-1135. [PMID: 37752005 DOI: 10.1136/bjsports-2023-106867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 09/28/2023]
Abstract
Overall athlete health is a stated priority by the International Olympic Committee (IOC), yet it can be difficult for athletes to safely balance nutritional needs, training load, recovery, social interactions, expectations and other demands. The effect of energy intake and, especially, low energy availability (LEA) on athlete mental health, is understudied. In this narrative review, we examine research that has included psychological factors and mental health variables when investigating the effect of LEA, dieting/restrictive eating and Relative Energy Deficiency in Sport (REDs), since the 2018 IOC consensus statement on REDs. Based on currently available data, early psychological indicators associated with problematic LEA are mood changes, fatigue and psychological conflict. More severe mental health outcomes associated with REDs are reduced well-being, elevated anxiety, depressive symptoms and eating disorders. We propose a psychological model that helps structure how possible risk factors (eg, body dissatisfaction, environmental demands or increased training load) and moderating (eg, gender, sport) and/or potential mediating (eg, social climate, self-esteem) factors are associated with LEA and ultimately REDs. The current scientific literature underscores the importance of including mental health factors when screening for REDs and for developing a clinical approach to address the psychological sequelae of REDs once diagnosed. An interdisciplinary perspective is recommended. Lastly, and importantly, the athlete perspective urges clinicians to not underestimate the drive for success and denial of health consequences that athletes demonstrate when pursuing their sport goals.
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Affiliation(s)
| | | | - Carla Edwards
- McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | | | - Margo Mountjoy
- Association for Summer Olympic International Federations (ASOIF), Lausanne, Switzerland
- Department of Family Medicine, Hamilton, Hamilton, Ontario, Canada
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Gerber M, Jakowski S, Kellmann M, Cody R, Gygax B, Ludyga S, Müller C, Ramseyer S, Beckmann J. Macronutrient intake as a prospective predictor of depressive symptom severity: An exploratory study with adolescent elite athletes. PSYCHOLOGY OF SPORT AND EXERCISE 2023; 66:102387. [PMID: 37665852 DOI: 10.1016/j.psychsport.2023.102387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 11/22/2022] [Accepted: 01/08/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Appropriate availability of macro- and micronutrients has an important impact on cognitive performance, mood and mental health. Although the critical role of nutrition for elite athletes' performance was recognized early on, little is known about whether consumption of specific macronutrients (carbohydrates, proteins, fat) predict the development of future depressive symptoms in adolescent elite athletes. METHODS Participants were recruited from three Swiss Olympic Partner Schools (SOPS) in the Northwestern German speaking part of Switzerland. A total of 97 adolescent elite athletes (38% girls, Mage = 16.35 ± 1.19) participated in the study. Depressive symptoms (PHQ9) were assessed at baseline and after 10 months follow-up. A 3-day food recall was completed three months after the baseline assessment. Linear regression analyses were used to examine whether macronutrients predict depression symptom severity after controlling for covariates and baseline depressive symptoms. RESULTS Higher protein consumption in athletes was a prospective predictor of lower depressive symptom severity at follow-up (β = -35, p < .05). Several deviations from recommended nutritional standards were observed in elite athletes. CONCLUSIONS The findings of this exploratory study support the notion that dietary behaviour may be prospectively associated with athletes' mental health. However, more research is required with larger samples and more in-depth assessment techniques. Future research should also examine whether nutrition education and dietary modification can be used to prevent depressive symptoms among adolescent elite athletes.
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Affiliation(s)
- Markus Gerber
- Department of Sport, Exercise and Health, University of Basel, Switzerland.
| | - Sarah Jakowski
- Faculty of Sport Science, Ruhr-University Bochum, Germany
| | - Michael Kellmann
- Faculty of Sport Science, Ruhr-University Bochum, Germany; School of Human Movement and Nutrition Sciences, University of Queensland, Australia
| | - Robyn Cody
- Department of Sport, Exercise and Health, University of Basel, Switzerland
| | - Basil Gygax
- Department of Sport, Exercise and Health, University of Basel, Switzerland
| | - Sebastian Ludyga
- Department of Sport, Exercise and Health, University of Basel, Switzerland
| | - Caspar Müller
- Department of Sport, Exercise and Health, University of Basel, Switzerland
| | - Sven Ramseyer
- Department of Sport, Exercise and Health, University of Basel, Switzerland
| | - Johanna Beckmann
- Department of Sport, Exercise and Health, University of Basel, Switzerland
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Langbein RK, Martin D, Allen-Collinson J, Crust L, Jackman PC. "I'd got self-destruction down to a fine art": a qualitative exploration of relative energy deficiency in sport (RED-S) in endurance athletes. J Sports Sci 2021; 39:1555-1564. [PMID: 33573478 DOI: 10.1080/02640414.2021.1883312] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Relative Energy Deficiency in Sport (RED-S) is a syndrome of impaired health and performance that occurs as a result of low energy availability (LEA). Whilst many health effects associated with RED-S have been widely studied from a physiological perspective, further research exploring the psychological antecedents and consequences of the syndrome is required. Therefore, the aim of this study was to qualitatively explore athlete experiences of RED-S. Twelve endurance athletes (female n= 10, male n= 2; M age = 28.33 years) reporting past or current experiences of RED-S, associated with periods of LEA, took part in semi-structured interviews designed to explore: contexts and mechanisms underpinning the onset of RED-S; the subjective experience of RED-S; and contexts and mechanisms influencing "recovery" from RED-S. Regardless of how RED-S was initiated, all athletes experienced a multitude of physiological impairments, accompanied by significant psychological distress. This paper contributes novel understanding of the complex interplay between physiological and psychological components of RED-S from the perspective of information-rich cases. The findings suggest that system-wide educational prevention and awareness interventions are vital for athletes and support personnel, such as coaches, parents, dieticians, psychologists, and sports medicine staff.
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Affiliation(s)
- Rachel K Langbein
- School of Sport and Exercise Science, University of Lincoln, Lincoln, UK
| | - Daniel Martin
- School of Sport and Exercise Science, University of Lincoln, Lincoln, UK
| | | | - Lee Crust
- School of Sport and Exercise Science, University of Lincoln, Lincoln, UK
| | - Patricia C Jackman
- School of Sport and Exercise Science, University of Lincoln, Lincoln, UK
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Athletes with eating disorder symptomatology, a specific population with specific needs. Curr Opin Psychol 2017; 16:148-153. [DOI: 10.1016/j.copsyc.2017.05.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 05/18/2017] [Accepted: 05/24/2017] [Indexed: 11/22/2022]
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Joy E, Kussman A, Nattiv A. 2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management. Br J Sports Med 2016; 50:154-62. [PMID: 26782763 DOI: 10.1136/bjsports-2015-095735] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Eating disorders, such as anorexia nervosa and bulimia nervosa, can have devastating effects on both the health and performance of athletes. Compared to non-athletes, both female and male athletes are at higher risk of developing an eating disorder. This is especially true for athletes participating in sports where low body weight or leanness confers a competitive advantage. Screening for disordered eating behaviours, eating disorders and for related health consequences should be a standard component of preparticipation examinations, and team physicians should be knowledgeable of the updated diagnostic criteria for eating disorders in the Diagnostic and Statistical Manual-V. Athletes with eating disorders should undergo thorough evaluation and treatment by an experienced multidisciplinary team. Team physicians play a critical role in decision-making on clearance for participation and return to play. Using evidence-based guidelines for clearance and return to play encourages transparency and accountability between the sports medicine care team and the athlete. Efforts to prevent eating disorders should be aimed at athletes, coaches, parents and athletic administrators, and focused on expanding knowledge of healthy nutrition in support of sport performance and health.
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Affiliation(s)
| | - Andrea Kussman
- Department of Family Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Aurelia Nattiv
- Departments of Family Medicine and Orthopaedic Surgery, University of California Los Angeles, Los Angeles, California, USA
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