plan de communication de l’ins québec - skiquebec.qc.ca · relative energy deficiency in sport...
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Relative Energy Deficiency in Sport
(RED-S)
Erik Sesbreno MSc (c), RD, CBDT, Dip Sport Nutrition IOC
Lead Sport Dietitian at INS
Certified Bone Densitometry Technologist & ISAK level 3 Anthropometrist
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Disclosure
• I, Erik Sesbreno, have no actual or potential conflict of interest in relation to this
program/presentation.
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RED-S
History & Definition
Physiological Disruptions
Performance & Injuries
Screening
Treatment
Return to Play
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Female Athlete Triad
2005 – IOC Consensus Statement
…”combination of disordered eating and irregular
menstrual cycle eventually leading to a decrease on
hormones resulting in low bone mineral density (BMD)”
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2007 – AMERICAN COLLEGE OF SPORT MEDICINE
• …”relationship between three inter-related
components: energy availability (EA), menstrual
function and bone health”
Female Athlete Triad
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• Introduced by the IOC expert working group in 2014
• Replaces “Female Athlete Triad”
• Greater complexity
• Male athletes are affected
Relative Energy Deficiency in Sports
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Considerations: Energy Availability
Mountjoy, et al., 2014
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Considerations: Energy Availability
Mountjoy, et al., 2014
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Estimating Energy Availability
• Energy Availability (EA)
= Energy Intake (kcal) - Energy Cost of Exercise (kcal)
Fat Free Mass (kg)
• In healthy adults, 45 kcal/ kg FFM per
• Low EA causes adjustments to body systems
– Disruptions to hormonal, metabolic and functional characteristics
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RED-S
History & Definition
Physiological Disruptions
Performance & Injuries
Screening
Treatment
Return to Play
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Hormonal Disruptions
EA 45kcal/kg FFM/d vs EA 10kcal/kg FFM/d
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• Low EA reduced LH pulse frequency by 10% (p <0.01) and
• Low EA increased LH pulse amplitude by 36%(P = 0.05)
• The stress of exercise neither reduced LH pulse frequency nor increase LH pulse amplitude (all p>0.4)
Loucks et al., 1998
Hormonal Disruptions
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Endocrine Alterations
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Endocrine Alterations
Loucks et al., 1994
ANOVA (threshold) model (solid line)
- p < 000001; R^2 (threshold)
- 61%
ANOVA (threshold) model (solid line)
- p < 004; R^2 (threshold)
- 29%
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Metabolic Alterations
• Energy intake = 2770 kcal day
• Exercise energy expenditure = 840 kcal day
• Energy availability = 30 kcal kg FFM/day)
were constant
• Magnitude of “-“ E balance decreased
• Rate -90kcal/d
• May have recovered 0 E balance in 3 weeks
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Effects on Fat Free Mass
Fagerberg et al., 2017
-20
-15
-10
-5
0
5
Rossow etal., 2013
Kistler etal., 2014
Robinson etal., 2015
kg Weight (kg)
FFM (kg)
FM (kg)
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Effects on Fat Free Mass
National Level Diver
Training: Hypertrophy Block
Test Method: DXA
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Effects on Fat Free Mass
Junior Elite Middle Distance Runner
Test Method: ISAK Surface Anthropometry
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RED-S
History & Definition
Physiological Disruptions
Performance & Injuries
Screening
Treatment
Return to Play
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Reasonable Weight Change Goals
SR: 0.7%/wk FR: 1.4%/wk
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• N: 2 males
• Artic hike– 95d
– 10hr/d
– 2300km
Effects on Performance
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Stroud et al., 1997
Effects on Performance
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Effects on Performance
• N: 10 (female)
• 15-17 yo
• 12wk training block
• CYC vs OVS
• Max TT 400m swim
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Effects on Performance
VanHeest et al., 2014
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EUM (n=16)Mean (SD)
SFHA (n=14)Mean (SD)
Unadjusted for FFM(kg)P-value
Reaction Time (ms) 57 (4) 61 (5) 0.025
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Bone Metabolism Alterations
Ihle et al., 2004
1. Bone Formation
• Osteocalcin (OC)
• Pro collagen carboxyl-terminal propeptide (PICP)
2. Bone Resorption
• N-Terminal telopeptide (NTX)
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Bone Metabolism Alterations
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Risk of Bone Injuries
Odds of Bone Stress Injury
Moderate Risk High Risk
2x more likely 4x more likely
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Energy Availability and Injury Risk
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Disordered Eating (DE) may underpin a large
proportion of cases of low EA, but…
• mismanaged programs to quickly reduce body mass/fat
• inability to track energy intake with an extreme exercise
commitment
… may occur without such a psychological overlay.
Reflect and Digest
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RED-S
History & Definition
Physiological Disruptions
Performance & Injuries
Screening
Treatment
Return to Play
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Disordered Eating Continuum
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Prevalence of ED and DE in Elite Athletes
Affects Both Genders
WEIGHT SENSITIVE SPORTS MALE FEMALE
AESTHETIC - 40%
WEIGHT CATEGORY 18% 30%
GRAVITATIONAL 24% -
Sundgot-Borgen et al., 2013
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Sundgot-Borgen et al., 2010
Prevalence of ED and DE in Elite Athletes
Affects Both Genders
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Prevalence of DE over Time
Sundgot-Borgen et al.,2010
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Screening and Diagnosis
Screening should be undertaking through annual health exams and/or
1. presence of DE/ED
2. weight loss
3. lack of normal growth and maturation
Mountjoy et al.,2014
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4. menstrual dysfunction
5. recurring injuries and
illnesses
6. decrease performance
7. mood changes
Mountjoy et al.,2014
Screening and Diagnosis
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Screening and DiagnosisAssess EA (No standard guidelines to determine)
1. Energy Intake
• Food intake recall or prospective methods
2. Energy Expenditure
• Exercise log and tables of energy expenditure
• Supplemented with GPS units, HR monitors or power meters
3. Fat free mass
• DXA
• Surface anthropometry
• (population specific regression equations)
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Assess Menstrual Dysfunction• Diagnosis of exclusion
Assess Bone Health• Athletes with low EA, DE, ED or amenorrhoea of
over 6 months, BMD should be measured by DXA
Mountjoy et al.,2014
Screening and Diagnosis
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RED-S
History & Definition
Physiological Disruptions
Performance & Injuries
Screening
Treatment
Return to Play
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• Improve energy availability• Increase energy intake (~500kcal/d)
• Reduce energy expenditure
• or both
• Weight gain is strongest predictor of recovery of normal menstrual function
Treatment Strategies
Mountjoy et al.,2014
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• Optimize bone health• Increasing energy intake = +1-10% bone mass in
anorexics
• Restore energy and estrogen dependent mechanisms of bone loss
• Resistance training and high impact loading
• Calcium and vitamin D supplementation
• Psychological support
Mountjoy et al.,2014
Treatment Strategies
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RED-S
History & Definition
Physiological Disruptions
Performance & Injuries
Screening
Treatment
Return to Play
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Return to Play Framework
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Mountjoy et al.,2014
Return to Play Framework
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• Underlying problem of RED-S is inadequate energy to support a range of body functions involved in health and sport performance
• Disordered Eating (DE) may underpin a large proportion of cases of low EA, but it could occur without a psychological overly
Summary
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• It could affect male and female athletes across various ages
• The prevalence could vary across a variety of sport disciplines
• Clinical competency is important in RED-S management, but it takes a team approach and the ability to develop a trusting relationship with the athlete to be successful
Summary
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Case Study Background
• Nov 2015 referral from CSIO physiologist
• Female; 18 y.o.; 1st yr university
• No CSIO nutrition support
• No CSIO IST support
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Evaluation of Health Status
• No medical illnesses or training injuries
• Bone mineral density within normal limits
• Menstrual dysfunction in 2014 & 2015
• Started OCP in 2015
• RED-S likely ongoing
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Sport Assessment
• Provincial elite program
• International competitions
• Great emphasis on leanness for P:W ratio
• No standardized performance test data
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Decision Modifiers
• Preseason around the corner
• Performance excellence a BIG priority in 2016
• No professional relationship established
• Confident with self directed nutrition planning
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elephant pic / Blind
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2016 Pre & In-Season: Monitor – Educate - Build
• Protein availability and distribution
– Currently ~ 1.8g/kg, but bolus was <20g or > 30g
• Periodize CHO availability across week and training blocks
– Limited fuelling on the ride; restricted variety of CHO based foods
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2016 Pre & In-Season: Monitor – Educate - Build
• Monitor body composition changes
• Bone mineral content
• Aim to monitor sex hormones
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2016 Pre & In-Season: Monitor – Educate - Build
(mm·kg-0.15)MTB Pre/In
Season
MTB Off
Season MTB Pre/In
Season
MTB Off
Season
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Assess Impact: Protein Availability (g) and Distribution
0
10
20
30
40
50
60
70
1-3h PreTraining
FuellingDuring
120m Ride
Recovery(<30min
PostTraining)
Recovery(1-2hrs
PostTraining)
Fuel Up(<30min
PreTraining)
FuellingDuring SCSession
Recovery(<30min
PostTraining)
Supper BedtimeSnack
Training Training
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Assess Impact: Carbohydrate Availability (g/kg) and Distribution
0
0.5
1
1.5
2
1-3h PreTraining
FuellingDuring
120m Ride
Recovery(<30min
PostTraining)
Recovery(1-2hrs
PostTraining)
Fuel Up(<30min
PreTraining)
FuellingDuring SCSession
Recovery(<30min
PostTraining)
Supper BedtimeSnack
Training Training
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2016 Off Season: Monitor – Educate - Build
(mm·kg-0.15)MTB Pre/In
Season
MTB Off
Season MTB Pre/In
Season
MTB Off
Season
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Incorporate Physique Enhancement Tactics and Support Good Energy Availability
• Periodize macronutrients across the year
• Enhance tactical nutrition approaches for competition and training camps (altitude)
• Ongoing monitoring across the In-season
• Increase circle of support (Coach and IST members)
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Nutrition Support: New Approach to YTP
Pre/In
Season
Off
Season
Pre/InSeason Off
Season
2016 20162017 2017
(mm·kg-0.15)
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Nutrition Support: Monitoring Effects
0
2
4
6
8
0
1
2
3
4
01-S
ep-1
6
01
-Oct-
16
01
-No
v-1
6
01-D
ec-1
6
01
-Ja
n-1
7
01
-Fe
b-1
7
01-M
ar-
17
01
-Ap
r-1
7
01
-Ma
y-1
7
01-J
un-1
7
01
-Ju
l-17
01
-Au
g-1
7
LH and FSH
LH
FSH
40
60
80
100
120
01
-Sep
-16
01
-Oct-
16
01
-No
v-1
6
01
-De
c-1
6
01
-Jan
-17
01
-Fe
b-1
7
01
-Ma
r-1
7
01
-Apr-
17
01
-Ma
y-1
7
01
-Jun
-17
01
-Jul-
17
01
-Aug
-17
Estradiol - 17
2016 20172016 2017
(IU/L) (pmol/L)
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Event Placement
Event 2016 2017
UCI MTB World U23 30 16
UCI MTB World Cup U23 1 10 DNS
UCI MTB World Cup U23 2 25 38
UCI MTB World Cup U23 3 32 35
Canada Cup Series (Elite) 13 1
National Championship (U23) 4 4
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elephant pic / Blind
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Paralympian: Hockey
• Men’s national team sledge hockey
• Paralympic and world championship medalist
• Goal: S4FS <55mm in 2 months
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Anthropometry and Baseline DXA
• Use DXA to enhance observations
• Use lean mass to monitor EA
• Aim -1.0kg/wk (fat)
• Feb 16: Plan
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• Weight: -3.1kg
• Lean mass stable
• Fat mass: -3.3kg
• Rate: -1.1kg/wk
• S4SF: -5.2mm
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• Weight: -3.1kg
• Rate: -1.1kg/wk
• S4SF: -5.8mm
• S4SF: 54.4mm
• Target: <55.0mm
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Summary
• Build trust and relationship
• Careful design
• Nutrition Support
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Thank You!
Erik Sesbreno MSc (c), RD, CBDT, Dip Sport Nutrition IOCLead Sport Dietitian INS
Certified Bone Densitometry Technologist & ISAK level 3 Anthropometrist
647-457-8668