Relative energy deficiency in sport
[1][6] As the non-menstrual components are also seen in males, the name was changed to the comprehensive term RED-S.[1] Formerly known as the female athlete triad, RED-S is a syndrome of three interrelated conditions.
The competitive sports that promote this physical leanness may result in disordered eating and be responsible for the origin of the female athlete triad.
[11] In addition, for some competitive female athletes, problems such as low self-esteem, a tendency toward perfectionism, and family stress place them at risk for disordered eating.
[11] Clinical symptoms of RED-S may include disordered eating, fatigue, hair loss, cold hands and feet, dry skin, noticeable weight loss, increased healing time from injuries (e.g., lingering bruises), increased incidence of bone fracture and cessation of menses.
Upon physical examination, a physician may also note the following symptoms: elevated carotene in the blood, anemia, orthostatic hypotension, electrolyte irregularities, hypoestrogenism, vaginal atrophy, and bradycardia.
These signs can be considered "occult," as no one symptom may be severe enough to seek medical attention, leaving the triad to go unnoticed or untreated.
More severe examples of disordered eating habits may include binge-eating; purging; and the use of diet-pills, laxatives, diuretics, and enemas.
[16] Exercising intensely and not eating enough calories can lead to decreases in estrogen, the hormone that helps to regulate the menstrual cycle.
[4] Osteoporosis is defined by the National Institutes of Health as ‘‘a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture.’’[19] Low estrogen levels and poor nutrition, especially low calcium intake, can lead to osteoporosis, the third aspect of the triad.
[21] Gymnastics, figure skating, ballet, diving, swimming, and long-distance running are examples of sports which emphasize low body weight.
[24] Persons with RED-S should get treatment from a multi-disciplinary team that includes a physician, dietitian, and mental health counselor, and seek support from family, friends, and their coach.
A menstruating person taking contraceptives to treat menstrual dysfunction without correcting this energy imbalance will continue to lose bone density.
[25] Persons with RED-S are often asked by health care providers to reduce the amount of time they spend exercising by 10–12 percent.
[5] Low energy availability with or without eating disorders, functional hypothalamic amenorrhea, and osteoporosis, alone or in combination, pose significant health risks to physically active girls and women.
Prevention, recognition, and treatment of these clinical conditions should be a priority of those who work with female athletes to ensure that they maximize the benefits of regular exercise.
To both induce menses and improve bone density, doctors may prescribe cyclic estrogen or progesterone as is used to treat post-menopausal women.
[5] Finally, if indicated by a psychiatric examination, the affected athlete may be prescribed anti-depressants and in some cases benzodiazepines to help in alleviating severe distress at mealtimes.
If there are other comorbid psychological disorders, such as depression and anxiety, a risk of self harm, medical complications and lack of progress in an outpatient level of care, the person struggling with RED-S may need more intensive care at an inpatient, residential, partial hospitalization or intensive outpatient level.
Medical complications involve the cardiovascular, endocrine, reproductive, skeletal, gastrointestinal, renal, and central nervous systems.
The prognosis for anorexia nervosa is grave with a six-fold increase in standard mortality rates compared to the general population.
Although 83% of anorexia nervosa patients partially recover, the rate of sustained recovery of weight, menstrual function and eating behavior is only 33%.
[22] Amenorrheic women can be infertile, due to the absence of ovarian follicular development, ovulation, and luteal function.
[22] Due to low bone mineral density that declines as the number of missed menstrual cycles accumulates, and the loss of BMD may not be fully reversible.
Risk of RED-S is heightened in "road cyclists, rowers (lightweight and open weight), athletes in combat sports, distance runners, and jockeys.
