Sports Pharmacy

There's something powerful about community, shared experiences, and passions that have an extraordinary effect on the human spirit.

I encourage any athlete, health care professional working with athletes, coaches, or parents to check out these outstanding articles from the Sports Pharmacy magazine: Sports Nutrition edition! So much valuable and practical information.

I have learned that the people you choose to surround yourself with shift the human experience from a robotic display to a tangible, authentic adventure.

I have found a common thread I write about in this issue that is sadly profoundly embedded in many of my high school or college teammates or current clients' lives: the Female Athlete Triad or parts of this spectrum.

Thanks to Sports Pharmacy Magazine and those friends/clients for the trust to speak up about this little-known, too common, and preventable condition, also known as Relative Energy Deficiency Syndrome (RED-S).

As an athlete, a health professional, and a friend, my goal is to help any athlete who feels the way I've felt but mainly spread awareness so as to prevent others from ever feeling that way at all,

Through this article, I hope to shed light on the unspoken, sometimes praised by others, and often overlooked journey many athletes, especially women, run in or from one scattered with dangerous obstacles, unrealistic expectations, and impassable barriers. Sadly, you are not alone!

I am proud to share a glimpse of my story and help others realize there's another path to take by providing insight and education into what RED-S is and how it can be easily prevented.

Sign up and enjoy the entire edition, I promise you will benefit from it!

Energy availability is the amount of dietary energy available after the calories used during exercise are subtracted from the cost of exercise. Energy status and healthy body weight are critical for athlete health.

Athletes are often unaware of their caloric needs compared to non-athletes their age and have a 20% higher prevalence of disordered eating verse non-athletes.1 Athletes commonly use dieting strategies for weight loss purposes to increase athletic performance believing "lighter is faster." A study presented showed 82% of middle school female athletes perceived "being thinner improved performance." 2

Many athletes struggle to balance the high pressure of sport with cultural and social pressures. Add pressures to conform to a perceived ideal body image; it can be like walking an impossible tightrope. I was one of those athletes. I'd love to say my story is unique, but it's not true.

In 1992, Female Athlete Triad was defined as a disorder characterized by relative dysfunction in energy availability (with or without disordered eating), menstrual function, and bone mineral density.3

In 2014, International Olympic Committee updated the term Female Athlete Triad to Relative Energy Deficiency Syndrome (RED-S), emphasizing the condition affects all athletes and redirecting the focus to energy intake. RED-S was defined as "impaired physiological function caused by relative energy deficiency, and includes, but is not limited to, impairment of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health." 4

RED-S affects the whole body manifesting physically and psychologically. Athletes affected by RED-S have shared their stories about consequences such as osteoporosis and mental disorders and devastating impact on their quality of life and performance.

Subtle symptoms, which often are overlooked, may present in different forms such as poor sleep, constant fatigue, dysfunctional relationship with food, late/absent periods, increased illnesses, anxiety, mood changes, and changes in performance. Even athletes without disordered eating are at risk, high training load and unintentionally inadequate fueling or lack of recovery can contribute to RED-S in these athletes.

The initial weight loss might seem beneficial for some athletes, it's a short-term result. Continued energy deficiency limits the body's systems to function leading to a wide range of adverse effects on all body systems and seriously compromising long term health and performance. Research demonstrated both acute and long-term impacts including:

· Female athletes can experience amenorrhea leading to decreased estrogen causing weakened bones, increasing risk for injuries such as stress fractures. Treatment with oral contraceptives to address symptoms masks menstrual disturbances without providing bone protection.5

· Bone mass peaks in mid-20s; RED-S interferes with the peaking of bone mineral density. If not reached, there is no way to recapture bone which may lead to osteoporosis later.

· RED-S may predispose athletes to cardiovascular disease, impaired vascular function, and unfavorable lipid profiles.

· Energy reduction suppresses the immune system, decreases protein synthesis, increases risks of illness, and slows healing from injuries.

· Negative athletic performance, including endurance, response to training, recovery, coordination, muscle strength, glycogen storage, and cognitive function.

· Many athletes experience mood changes, such as irritability, anxiety, and depression.

· Younger athletes are most impacted by the non-reversible and long-term consequences, including decreased growth and hindered sexual development.7

The danger of RED-S lies not in its symptoms but in our failure to recognize them as symptoms. Only 24% of coaches reported "having heard of the triad," and 14% could correctly name all components. While only 37% of healthcare professionals and 12% of athletes have heard of RED-S.9 Yet 1/3 of athletes have reported missing 3 consecutive menstrual cycles, and 1/3 reported a history of stress fractures or shin splints.8

Weight status is not a definitive evaluation of athlete health. Athletes may be in a calorie deficit despite having a stable body weight due to reduced metabolic rate. RED-S can occur in athletes of any sport, age, body size, socioeconomic status, and athletic ability.

Interventions can have pharmacological and non-pharmacological components; non-pharmacological methods should be the initial course of action. Proper nutrition is the most effective approach to reducing the health consequences of RED-S. The quantity of macronutrients an athlete must obtain will depend on factors such as gender, age, body mass, and level of training activities. Proper amounts of micronutrients must also be obtained especially calcium, phosphorus, iron, and Vitamin D.

RED-S is a sensitive topic and needs to be approached with care. When working with an athlete, you are challenging ideas ingrained in their mind and behaviors they taught themselves to be "wrong." Athletes will need a recovery plan emphasizing a team approach with physicians, dieticians, mental health practitioners, parents, and coaches all involved.

Encouraging athletes to seek help pays off BIG TIME in the long run for their health. I can say that thoughtfully from my personal experience.We need to break the taboos of societal norms that dieting/weight-loss increase athletic performance. Open conversations with athletes, parents, and coaches to educate them on the importance of proper caloric and macronutrient intake for sports is imperative for building a healthier generation of athletes.

1. Kussman, Nattiv JA "A 2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management" Br J Sports Med 2016;50:154-162.

2. 2022 ACSM annual meeting. Nutrient deficiencies in youth runners, bone health, and considerations for prevention and treatment in the field. Presentation by M Barrack.

3. Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, Warren MP; American College of Sports Medicine: American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc 2007;39(10):1867-1882.

4. Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, et al: The IOC consensus statement: Beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). Br J Sports Med 2014 Apr;48(7):491-497.

5. Gordon CM, Ackerman KE, Berga SL, et al. Functional hypothalamic amenorrhea: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2017;102:1413–39. doi:10.1210/jc.2017-00131

6. Erlandson MC, Kontulainen SA, Baxter-Jones AD. Precompetitive and recreational gymnasts have greater bone density, mass, and estimated strength at the distal radius in young childhood. Osteoporos Int. 2011 Jan;22(1):75-84. doi: 10.1007/s00198-010-1263-9. Epub 2010 May 11. PMID: 20458575.

7. Schneider JE, Wade GN. Inhibition of reproduction in service of energy balance. Reproduction in Context: Social and Environmental Influences on Reproductive Physiology and Behavior. 2000:35-82.

8. Tosi, M., et al. The Female Athlete Triad: A Comparison of Knowledge and Risk. J Ped Adol Gyn. 2018, 1-5.

9. Pantano KJ. Knowledge, Attitude, and Skill of High School Coaches with Regard to the Female Athlete Triad. J Pediatr Adolesc Gynecol. 2017 Oct;30(5):540-545. doi: 10.1016/j.jpag.2016.09.013. Epub 2016 Oct 6. PMID: 27721026.