Relative Energy Deficiency in Sport REDS Elizabeth Mansfield

Relative Energy Deficiency in Sport (RED-S) Elizabeth Mansfield, Ph. D, RD • Certified Specialist in Sport Dietetics • Clinical Exercise Physiologist • Registered Dietitian • OVERVIEW of TODAY • Concepts of relative energy deficiency and low energy availability • How to recognize athletes at risk • How to optimize nutritional strategies

Objectives By the end of this presentation you will be able to: • Understand what RED-S is • Identify the key features of RED-S and be able to identify athletes who may be at higher risk • Understand the mechanisms that underpin RED-S and the health/performance risks these can contribute to • Be competent in the initial management of an athlete presenting with RED -S and knowledgeable about nutrition-specific treatment options 2

What is Relative Energy Deficiency in Sport? Female Athlete Triad Impaired physiological functioning caused by an imbalance in energy availability Margo Mountjoy et al. Br J Sports Med 2015; 49: 417 -420 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.

Pay Attention to LEA Situations • Compulsively • Tendency to supply needed energy AFTER it is needed – Exercise to eat vs. eat to exercise • prolonged exercise training in a fasted state (train LOW) – to develop greater endurance or to promote weight loss; • Intentionally • Body weight concerns (aesthetic or performance related) » Restrictive eating patterns » Restrained eating patterns » Disordered eating patterns • Inadvertently • poor biological drive to match energy intake to exercise energy expenditure • tight food budget/poor shopping or food preparation skills 2019 www. peakperformance. ca Bridging science into practice

2019 www. peakperformance. ca Bridging science into practice

Endocrine Markers – Physiological Response Loss of menstruation is a red flag

Cumulative energy deficit and energy availability. Nicola Keay, and Alan Rankin Br J Sports Med doi: 10. 1136/bjsports-2018 -100354 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.

Relative energy deficiency in sport: effects on health and performance. Early detection is critical in preventing long term health and performance detriments; Include in annual health screenings; Screen if athlete presents with any symptoms. Adapted from: Margo Mountjoy et al. Br J Sports Med 2015; 49: 417 -420

Signs & Symptoms of RED-S • Disordered eating patterns – overly restricting intake or food groups, skipping meals or using unsafe weight loss methods; • Poor bone health – stress fractures can often be a sign of this /<normal Bone Mineral Density • Lower sex hormone levels – Issues with fertility, recovery, muscle mass • • Depressed mood or irritability Susceptibility to ongoing illness – poor immune function • 2019 Reduced performance, recovery and adaptations to training. www. peakperformance. ca Bridging science into practice

KEY: Optimizing Energy Availability EA = Energy intake (EI) – Exercise Energy Expenditure (EEE) Fat Free Mass (FFM) EI: Assessed with food diary or food recalls EEE: Assessed with training log and heart rate monitor FFM: Assessed with DEXA and/or other anthropometric tools

KEY: Optimizing Energy Availability EA = Energy intake (EI) – Exercise Energy Expenditure (EEE) Fat Free Mass (FFM) Optimal EA: 40 -45 kcal/kg of FFM This is the energy left over after covering off energy needs for exercise; This is the amount of dietary energy left for all other metabolic processes in the body

Case Study of LEA ASSESSMENT: • 46 kg female University skater with 13. 5% BF Ø Very low skeletal mass (< 80% of normal for height) Ø BMI 15. 6 UNDERWEIGHT Ø 40 kg FFM • Estimated EI is restricted to approximately 1800 kcal/day Ø Restrictive eater “stomach in a knot” Ø Trains “LOW” • Cost of daily PA + exercise training 650 kcal/day Ø 300 -1200 kcal/day range • • Many GIT symptoms, bloating, gas, No menstrual function for last 6 months (since stopping pill) ISSUES: • LOW energy available for physiology: 1800 kcal (EI) – 650 (EE) = 1150 kcal – LOW EA = 1150 kcal/40 kg FFM = 28. 75 kcal/kg FFM

Case study cont’d… • Minimal EA needs: 40 -45 kcal/kg FFM; – 1600 -1800 kcal/day to support FFM but only has 1150 kcal/day – (+) 450 - 650 kcal needs to be added to daily energy budget • Healthy physiological adaptation to EA – 1 st GOAL : ADD 450 -650 kcal/day for next 3 months • Maintenance of FFM • Kick start menstrual function – 2 nd GOAL: Structured meal plan • Timing of nutrient intakes to minimize daily AND within day energy deficits • Optimize calcium and Vitamin D for bone formation • Track GI symptoms with consistent food/fluid intakes

Manage Within Day Energy Availability Energy Deficits Large deficits lead to risks of RED-S January 2019 www. peakperformance. ca Bridging science into practice

Energy Availability GOAL: regular eating schedule that optimizes energy levels throughout the day AND during workouts: – 3 -4 hours before training = MEAL; – ≤ 2 hours of training = large snack/beverage – ≤ 30 -60 minutes of training = small snack/beverage

Managing Energy Availability Timing is KEY Optimize the availability of energy (specifically carbohydrate) and fluids: ü Build an energy budget including pre-workout snacks to top up hydration and energy availability • Energy Phase • Carbohydrate rich foods 3 -4 hours prior to exercise increases liver and muscle glycogen stores Enhances performance ü Include carbohydrate rich foods for DURING workouts, when needed, to minimize energy deficits throughout training sessions • January 2019 www. peakperformance. ca Minimizes potential negative effects of carbohydrate depletion Bridging science into practice

Timing of Energy Availability Optimizing RECOVERY sets the stage for next training session Energy Phase Recovery Phase January 2019 § Enhance tissue refueling: Ø Choose carbohydrate rich foods for snacks and meals post workout § Stimulate protein synthesis: Ø Leucine is the amino acid that triggers muscle protein synthesis post workout; www. peakperformance. ca Bridging science into practice

Optimal Recovery • Re-fuel with a milk based snack and include small servings of carbohydrate rich foods ü Include starches (breads, cereals, legumes, potatoes) and sugars (fruits, milk, yogurt) and combinations of starchy/non-starchy carbohydrates (vegetables) • within 15 -30 minutes if 2 or more training sessions that day; • within 2 hours if training once a day • within 4 -14 hours if not training the next day January 2019 www. peakperformance. ca Bridging science into practice

Optimal Recovery • Re-build bones and muscles with essential nutrients found in protein rich foods ü Leucine is the amino acid that triggers muscle protein synthesis post workout; • • January 2019 Growing athletes, injured athletes Weight conscious athletes; Training for power; Multiple training sessions in a day. www. peakperformance. ca Bridging science into practice

Manage Weekly Energy Availability Day 1 Day 2 Day 3 Day 4 Sufficient energy availability in daily dietary pattern 1 2 3 4 Day 1 Training Session 2019 Day 2 Training Session www. peakperformance. ca Day 3 Training Session Day 4 Training Session Relative energy deficiency Poor recovery Consistently inconsistent performance Health issues Bridging science into practice

Optimize all 3 Phases of Energy Availability ü ENERGY PHASE Build an energy budget including pre-workout snacks to top up hydration and energy availability for DURING workouts Energy Phase Recovery Phase Build Phase January 2019 ü RECOVERY PHASE Promote recovery post workout with fluids and a snack/meal to promote energy availability for optimal recovery ü BUILD PHASE Integrate frequent, small servings of protein rich foods at most eating occasions: 8 -12 grams of protein at snacks 12 -24 grams protein at meals www. peakperformance. ca Bridging science into practice

Protein Crib Sheet 22

Simple Recovery Strategies Protein Sources Eggs Chicken Large Snack Ideas Small/Large Meal Ideas Muffin vegetable frittata French toast with maple syrup Boiled egg + crackers Vegetable frittata Egg salad sandwich Chicken sausage rice cakes Honey ginger chicken wraps (cut in 2” pieces) Fish Smoked salmon and crackers/bagel pieces Meat Roast beef slices on rye bread with pickles Chick peas, lentils, kidney Beet hummus dip with baby carrots beans Soybeans, tofu soy protein products Dairy Foods whey protein Nuts Chicken tacos Chicken and bacon hash Ground chicken shepherd’s pie Salmon burgers with salad Pasta salad with canned salmon/tuna Spaghetti with meat sauce Beef and vegetable stew Black beans with quinoa and veggies Chick pea burger with sweet potato fries Steamed edamame, tofu peanut butter on crackers Tofu stir fry with rice and veggies Soy protein based energy bars Tofu vegetable noodle soup Grilled Swiss cheese and ham sandwich Tzatziki dip with vegetables, fruit smoothies Cheese and egg quiche Whey protein based energy bars Greek yogurt with muesli and fruit Mixed grain fruit oatmeal with walnuts and Chocolate peanut coconut rice cakes sunflower seeds, cooked in almond milk Almond and date rice cakes 23

Meal Planning Easy Training Day 1 hour Moderate Training Day 1 -2 sessions; cumulative training 3 -4 hours Hard or Long Training Day 2 -3+ training sessions/day = 4 -6 hours Athlete’s Plate from: United States Olympic Committee Sport Dietitians

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KEY Considerations Optimize energy intake – – – Ability to train without undue fatigue? Fast recovery between training sessions? Maintenance of body composition? Optimal biological functioning? Absence of health & performance issues?

A Sport Nutrition Checklist for Energy Availability Ö Energy needs for level of training Ö Periodized nutrition program to match training cycles Ö Promote recovery of fluid & fuel stores Ö Trial competition eating practices Ö Desirable body weight & body fat Ö Long-term good health, immune function Ö Food as source of pleasure 2019 www. peakperformance. ca Bridging science into practice

Role of the Sport Dietitian § Determine body composition and energy needs ü Body composition, RMR ü Energy budget for exercise & body composition § Follow the sport & nutrition science ü Fluid balance and energy availability ü Foods and food patterns for health AND performance ü Supplementation when needed § Practice makes perfect ü Structured meal planning - helps boost confidence of restrictive eaters ü Training is the time to test what works for performance issues § 2019 www. peakperformance. ca Individualization is KEY Bridging science into practice