How Do We Assess Energy Availability and RED-S Risk Factors in Para Athletes?

Periodic health evaluation in Para athletes: a position statement based on expert consensus

Para athletes present a broad range of sports-related injuries and illnesses, frequently encountering barriers when accessing healthcare services. The periodic health evaluation (PHE) is a valuable tool for continuously monitoring athletes' health, screening for health conditions, assisting in the surveillance of health problems by establishing baseline information and identifying barriers to athlete's performance. This position statement aims to guide sports healthcare providers in the PHE for Para athletes across key impairment categories: intellectual, musculoskeletal, neurological and vision. A panel of 15 international experts, including epidemiologists, physiotherapists, optometrists and physicians with expertise in Para athlete health, convened via videoconferences to discuss the position statement's purpose, methods and themes. They formed working groups to address clinical, cardiorespiratory, neuromusculoskeletal, nutritional status, mental and sleep health, concussion and female Para athlete health assessment considerations. The PHE's effectiveness lies in its comprehensive approach. Health history review can provide insights into factors impacting Para athlete health, inform physical assessments and help healthcare providers understand each athlete's needs. During the PHE, considerations should encompass the specific requirements of the sport modality and the impairment itself. These evaluations can help mitigate the common tendency of Para athletes to under-report health issues. They also enable early interventions tailored to the athlete's health history. Moreover, the PHE serves as an opportunity to educate Para athletes on preventive strategies that can be integrated into their training routines, enhancing their performance and overall health. This position statement can potentially enhance clinical translation into practice and improve the healthcare quality for Para athletes.

Body dissatisfaction, disordered eating and exercise behaviours: associations with symptoms of REDs in male and female athletes

Objectives

Disordered eating and compulsive exercise behaviours are common among athletes and can increase the risk of relative energy deficiency in sport (REDs). Contrarily, the prevalence of muscle dysmorphia and its relationship with REDs are unknown. This cross-sectional study aimed to evaluate associations of all three with REDs symptoms.

Methods

Elite and subelite Icelandic athletes (n=83, 67.5% females) answered the Low Energy Availability in Females/Males Questionnaires (LEAF-Q/LEAM-Q), Eating Disorder Examination-Questionnaire Short (EDE-QS), Exercise Addiction Inventory (EAI) and Muscle Dysmorphic Disorder Inventory (MDDI). Body composition was assessed via dual-energy X-ray absorptiometry; resting metabolic rate via indirect calorimetry; and blood samples were drawn for analysis of nutrition and hormonal status. Females were compared based on LEAF-Q total score (≥8 (at risk) vs <8). Simple linear regression was applied to evaluate associations of (a) testosterone with other objective measures and LEAM-Q scores in males; and (b) LEAF-Q/LEAM-Q scores with EDE-QS, EAI and MDDI scores.

Results

In total, 8.4% of participants scored above cut-off on EDE-QS, 19.3% on EAI and 13.3% on MDDI. Females with LEAF-Q total score ≥8 had higher median scores on EDE-QS, EAI and MDDI compared with those scoring <8. Testosterone was positively associated with iron and inversely with total iron-binding capacity but was not associated with scoring on any of the administered questionnaires.

Conclusion

Drive for muscularity and aesthetic physique may play a role in the complex presentation of REDs. Screening for muscle dysmorphia, in addition to disordered eating and compulsive exercise, could therefore facilitate early detection of REDs.

2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs)

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.

Mapping the complexities of Relative Energy Deficiency in Sport (REDs): development of a physiological model by a subgroup of the International Olympic Committee (IOC) Consensus on REDs

The 2023 International Olympic Committee (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs) notes that exposure to low energy availability (LEA) exists on a continuum between adaptable and problematic LEA, with a range of potential effects on both health and performance. However, there is variability in the outcomes of LEA exposure between and among individuals as well as the specific manifestations of REDs. We outline a framework for a 'systems biology' examination of the effect of LEA on individual body systems, with the eventual goal of creating an integrated map of body system interactions. We provide a template that systematically identifies characteristics of LEA exposure (eg, magnitude, duration, origin) and a variety of moderating factors (eg, medical history, diet and training characteristics) that could exacerbate or attenuate the type and severity of impairments to health and performance faced by an individual athlete. The REDs Physiological Model may assist the diagnosis of underlying causes of problems associated with LEA, with a personalised and nuanced treatment plan promoting compliance and treatment efficacy. It could also be used in the strategic prevention of REDs by drawing attention to scenarios of LEA in which impairments of health and performance are most likely, based on knowledge of the characteristics of the LEA exposure or moderating factors that may increase the risk of harmful outcomes. We challenge researchers and practitioners to create a unifying and dynamic physiological model for each body system that can be continuously updated and mapped as knowledge is gained.

The Influence of Energy Balance and Availability on Resting Metabolic Rate: Implications for Assessment and Future Research Directions

Resting metabolic rate (RMR) is a significant contributor to an individual's total energy expenditure. As such, RMR plays an important role in body weight regulation across populations ranging from inactive individuals to athletes. In addition, RMR may also be used to screen for low energy availability and energy deficiency in athletes, and thus may be useful in identifying individuals at risk for the deleterious consequences of chronic energy deficiency. Given its importance in both clinical and research settings within the fields of exercise physiology, dietetics, and sports medicine, the valid assessment of RMR is critical. However, factors including varying states of energy balance (both short- and long-term energy deficit or surplus), energy availability, and prior food intake or exercise may influence resulting RMR measures, potentially introducing error into observed values. The purpose of this review is to summarize the relationships between short- and long-term changes in energetic status and resulting RMR measures, consider these findings in the context of relevant recommendations for RMR assessment, and provide suggestions for future research.

Energy Availability and Nutritional Intake during Different Training Phases of Wheelchair Athletes

Optimizing nutritional intake and timing helps athletes to improve performance and long-term health. Different training phases can require varying nutritional needs. In this study, we conducted a descriptive assessment of dietary intake, energy availability (EA), and blood biochemical parameters in elite wheelchair athletes during distinct training phases. Data analyzed in this study were collected as part of a randomized controlled crossover trial exploring the feasibility of probiotics and prebiotic supplementation. Data were obtained from consecutive three-day diaries and blood samples, both collected at four different time points across four consecutive months. We included 14 athletes (mean (standard deviation) age 34 (9) years, eight females, and six males) active in different wheelchair sports. The mean daily nutritional intake (g/kg body mass) for females and males was 2.7 (0.9) and 4.0 (0.7) for carbohydrates, 1.1 (0.3) and 1.5 (0.3) for protein, and 0.8 (0.3) and 1.4 (0.2) for fat. EA did not change across the four time points in either female (p = 0.30) or male (p = 0.05) athletes. The mean EA was lower in female athletes compared to male athletes (p = 0.03). Low EA (≤30 kcal/ kg fat-free mass/day) was observed in female (58 (29) % of days) and male (34 (23) % of days) athletes. Iron deficiency with anemia was observed in two female athletes. Mean vitamin D levels were insufficient (<75 nmol/L). Macronutrient intake, EA, and blood biochemical parameters were suboptimal in this cohort of elite wheelchair athletes, especially in female athletes.

The Role of Diets and Dietitians for Para-Athletes: A Pilot Study Based on Interviews

Efforts to provide nutrition support to para-athletes have not been established to date, and are far behind those established for athletes without disabilities. In the present study, we attempted to clarify the actual situation regarding dietary challenges of para-athletes. The aim of this study was to obtain clues to effective intervention methods that encourage the practice of sports nutrition. Six active elite para-athletes (30–70 years, four males) and a female physical therapist without physical disability participated in semi-structured interviews. All para-athletes had lower-limb disabilities and participated in the international wheelchair sports competitions (tennis, softball, and table tennis, with 2–26 years of player history). The interview items were on the ideal diet for improving competitive performance, evaluation of their typical diets, and the role of the dietitian as support. Responses obtained from participants were analyzed using quantitative content analysis by language analysis software. There are differences in the ideal diet based on the characteristics of the sport, but most participants believed that a nutritionally well-balanced diet with abundant vegetables was ideal for improving competitive performance. Para-athletes who use a wheelchair daily pay attention to their total calorie intake, because gaining weight is a critical issue for operating their wheelchairs and transferring themselves to and from their wheelchairs. Despite their world-class competition levels, none of them received routine dietary advice from dietitians. Some para-athletes did not even feel the need to engage with dietitians. Even for these para-athletes at a high level of competition, the “ideal diet” they considered was not always the optimal diet for improving their competitive performance. In addition, there are various barriers to practicing their optimal diet due to disability characteristics. Dietitians need to understand these barriers, their concerns and conflicts, and how to help them plan the optimal diet to improve their performance and maintain overall health.