What is the management approach for Relative Energy Deficiency in Sport (RED-S)?

Management of Relative Energy Deficiency in Sport (RED-S)

The management of RED-S requires a multidisciplinary team approach focused on increasing energy availability through dietary changes and/or exercise modification, with treatment strategies tailored to address the specific physiological and psychological manifestations in each athlete. 1

Assessment and Risk Stratification

The first step in managing RED-S is proper assessment and risk stratification using the RED-S Risk Assessment Model:

High Risk (Red Light - No Start)

• Anorexia nervosa and other serious eating disorders
• Serious medical conditions related to low energy availability
• Extreme weight loss techniques causing hemodynamic instability
• Menarche >16 years
• Reduced BMD (Z-score < -1 SD)
• Physical/psychological complications related to low EA
• Lack of treatment progress or non-compliance 1

Moderate Risk (Yellow Light - Caution)

• Prolonged abnormally low body fat percentage
• Substantial weight loss (5-10% body mass in 1 month)
• Amenorrhea >6 months
• Abnormal hormonal profile in men
• History of stress fractures with hormonal dysfunction
• Prolonged relative energy deficiency 1

Low Risk (Green Light)

• Healthy eating habits with appropriate energy availability
• Normal hormonal and metabolic function
• Healthy bone mineral density
• Healthy musculoskeletal system 1

Treatment Strategies

1. Address Energy Availability

• Increase energy intake by 300-600 kcal/day (1.2-2.4 MJ/day)
• Optimize energy distribution throughout the day, especially around exercise sessions
• Improve dietary composition with adequate macronutrients
• Consider energy-rich supplements (e.g., liquid meal products) 1, 2
• Potentially reduce exercise load or introduce rest days 1

2. Bone Health Management

• Ensure calcium intake of 1500 mg/day through diet or supplementation
• Maintain vitamin D levels (25(OH)D) between 32-50 ng/mL
• Implement high-impact loading and resistance training 2-3 days/week for athletes in non-weight bearing sports 1
• Monitor bone mineral density via DXA scan (every 12 months for adults, 6 months minimum for adolescents) 1

3. Menstrual Function Recovery

• Weight gain is the strongest predictor of menstrual function recovery
• Ensure adequate protein and carbohydrate intake
• Pharmacological treatment may be considered but is not first-line therapy 1

4. Psychological Support

• Treatment by mental health professionals knowledgeable about eating disorders in athletes
• Consider cognitive behavioral therapy, dialectical behavior therapy, or family-based therapy
• Address comorbid conditions (depression, anxiety, other psychological problems)
• Pharmacotherapy may be recommended (antidepressants most commonly) 1

Return-to-Play Decision Making

The RED-S Return-to-Play Model guides decisions based on:

Medical Factors (Step 1)

• Patient demographics (age, sex)
• Health status (symptoms, medical history, laboratory tests)
• Psychological health
• Potential seriousness of condition 1

Sport Risk Modifiers (Step 2)

• Type of sport (weight-sensitive, leanness sport)
• Position played
• Individual vs. team sport
• Competitive level 1

Decision Modifiers (Step 3)

• Timing and season
• Pressure from athlete and external sources
• Potential conflicts of interest 1

Prevention Strategies

Primary Prevention

• Educational programs on RED-S, healthy eating, nutrition, and energy availability
• Reduce emphasis on weight, focusing instead on nutrition and health for performance
• Develop realistic health-promoting goals for weight and body composition
• Avoid critical comments about athlete's body shape/weight
• Use reputable information sources 1, 3

Secondary Prevention

• Early identification through screening instruments and health interviews
• Regular assessment of RED-S markers 3

Tertiary Prevention

• Identify and treat the source of problematic low energy availability
• Limit short-term and long-term health consequences 3

Special Considerations

Athletes with Disabilities

• Consider additional energetic challenges in athletes with amputations
• Monitor bone health in athletes with spinal cord injuries 1

High-Risk Sports

• Aesthetic and weight-sensitive sports require particular attention (e.g., artistic swimming, gymnastics) 4

Common Pitfalls to Avoid

• Focusing only on female athletes - RED-S affects both males and females 1, 5
• Treating only one aspect of the syndrome rather than addressing the underlying energy deficiency 2
• Overlooking psychological factors that may precede or result from RED-S 1
• Assuming good performance means the athlete is healthy 1
• Failing to involve a multidisciplinary team (sports physician, nutritionist, psychologist, physiotherapist, physiologist) 1
• Relying solely on self-reported measures without objective assessment 3

By implementing these comprehensive management strategies, clinicians can effectively address RED-S and help athletes return to optimal health and performance.