Br J Sports Med: first published as 10.1136/bjsports-2019-101926 on 10 January 2020. Downloaded from http://bjsm.bmj.

com/ on January 12, 2020 at Barts and The London - Queen Mary's
Editorial

#REDS (Relative Energy Deficiency in education including prevention/awareness

interventions and by optimising energy

Sport): time for a revolution in sports intake. One of these system opportuni-
ties to address RED-­ S was spearheaded
in Canadian elite sport when B2ten—a
culture and systems to improve athlete philanthropic group—sponsored a
3-­day meeting of 30 key stakeholders in
health and performance November 2019. At the table were inter-
nationally renowned topic experts, Cana-
dian coaches from at-­ risk sports, and
Kathryn E Ackerman ‍ ‍ ,1,2 Trent Stellingwerff,3,4 Kirsty J Elliott-­Sale,5 athlete support staff representing both
Amy Baltzell,6 Mary Cain,7 Kara Goucher,8 Lauren Fleshman,9 sport science and medicine, all of whom
Margo L Mountjoy10,11 work in Canadian, American or British
sport. This group examined the science,
sport cultures, gaps and opportunities
associated with RED-­S. Some of the key
Changing a sport system requires the can make wise choices for their own
themes developed included:
appointment of new leaders or a grass long-­term health.
Prevention
roots cultural revolution. ‘I got caught in a 2. Updating and developing best-­practice
►► We need to implement awareness
system designed by and for men, which protocols and safe standards for moni-
education adapted to female and male
destroys the bodies of young girls,’ said toring body composition/weight.
athletes of all ages and sport levels,
Mary Cain as she cast light on her toxic 3. Eliminating toxic training environ-

School of Medicine and Dentistry. Protected by copyright.

and tailored for support staff, coaches
coach/athlete relationship and exposed ments featuring abusive body shaming.
Overexercising or underfueling, occur- and parents. Educational initiatives
unhealthy coaching and nutrition prac-
tices. Her candour has inspired a social ring consciously or subconsciously, can should underscore the positive aspects
media movement calling for changes to cause Relative Energy Deficiency in Sport of energy, namely, that food is fuel;
women’s sport.1 In the following days, (RED-­ S). RED-­ S is the ‘impaired phys- and fuel is needed for performance.
major news publications followed up with iological functioning caused by relative Content should include RED-­S signs/
similar reports of athletic women being energy deficiency, and includes but is symptoms; positive communication
body shamed.2–4 not limited to impairments of metabolic around menstrual cycles and body
It is time for a drastic paradigm change rate, menstrual function (for females), image; appreciation of athletes/
in women’s sport, coupled with educa- bone health, immunity, protein synthesis sports at higher risk; and best prac-
tion at all levels to improve the long-­term and cardiovascular health.’5 Chronic LEA tices pertaining to body composi-
health and athletic achievement of female (over many weeks to years) leading to tion/weight assessment protocols.
athletes. The shift needs to include: RED-­S can limit training adaptation6 and We developed a conceptual frame-
1. Raising awareness of the negative ef- substantially increase injury risk.5 7 8 It work outlining when, and when not,
fects of chronic low energy availability cripples performance in both female6 and to implement these methods (see
(LEA) (calorie restriction) so athletes male athletes.5 It can occur unknowingly figure 1).
without a diagnosed eating disorder.7 Diagnosis
There is good news: there are oppor- ►► Multicentred research is required to
1
Divisions of Sports Medicine and Endocrinology, tunities to mitigate the occurrence and develop and validate a diagnostic tool
Boston Children’s Hospital, Boston, Massachusetts, USA effects of RED-­ S through system-­ wide for RED-­S.
2
Neuroendocrine Unit, Massachusetts General Hospital
and Harvard Medical School, Boston, MA, USA
3
Canadian Sport Institute, Victoria, British Columbia,
Canada
4
Department of Exercise Science, Physical & Health
Education, University of Victoria, Victoria, British
Columbia, Canada
5
Musculoskeletal Physiology Research Group, Sport
Health and Performance Enhancement Research Centre,
School of Science and Technology, Nottingham Trent
University, Nottingham, UK
6
Author, Consultant, Olympian, Past-­President of the
Association of Applied Sport Psychology, Boston,
Massachusetts, USA
7
Professional Runner, Bronxville, New York, USA
8
Professional Runner and Olympian, Athlete Advocate,
Boulder, Colorado, USA
9
Professional Runner, Athlete Advocate, Bend, Oregon,
USA
10
Department of Family Medicine, McMaster University
Michael G DeGroote School of Medicine, Hamilton,
Ontario, Canada
11
IOC Medical Commission Games Group, Lausanne,
Switzerland Figure 1  A conceptual framework on the implementation of body composition assessments (e.g,
Correspondence to Dr Kathryn E Ackerman, Sports
height, weight, anthropometrics, skinfolds, etc.) within the context of athlete stage of development
Medicine, Boston Children’s Hospital, Boston, MA and their nutritional preparation skills. BC, body composition; LTAD, long-­term athlete development
02115, USA; ​kathryn.​ackerman@​childrens.​harvard.​edu model; TBD, to be determined.

Ackerman KE, et al. Br J Sports Med Month 2020 Vol 0 No 0    1

 Br J Sports Med: first published as 10.1136/bjsports-2019-101926 on 10 January 2020. Downloaded from http://bjsm.bmj.com/ on January 12, 2020 at Barts and The London - Queen Mary's
Editorial
►► RED-­S-­associated diagnostic factors to have RED-­S prevention, diagnosis and To cite Ackerman KE, Stellingwerff T, Elliott-­
may include: chronic dietary restric- treatment protocols, targeting athletes, Sale KJ, et al. Br J Sports Med Epub ahead of print:
[please include Day Month Year]. doi:10.1136/
tion and/or extreme diets, drive for coaches and the athlete entourage. Media
bjsports-2019-101926
thinness, large changes in body weight and sponsors can raise awareness and
Accepted 30 December 2019
or composition in short time periods, support research in the field. Empowering
training inconsistencies, prolonged athletes to identify and protect themselves Br J Sports Med 2020;0:1–2.
doi:10.1136/bjsports-2019-101926
fatigue, decreased libido, oligo-­ from toxic cultures, and to understand the
amenorrhoea (missing three or more importance of energy/food as it relates to ORCID iD
menstrual cycles in 6 months), two RED-­S, is paramount. Kathryn E Ackerman http://​orcid.​org/​0000-​0003-​2626-​
or more career bone stress injuries As signs and symptoms of RED-­S are 7785
and low bone mineral density for age present in ~2%–60% of female and male
(Z-­score <-1.0).5 athletes, depending whether athletes are References
Treatment in endurance, aesthetic, weight categories 1 Cain M. I was the fastest girl in America, until I joined
Nike, 2019. Available: https://www.​nytimes.​com/​2019/​
►► We must ensure athlete access to a and power/sprint sports,5 7 we believe that
11/​07/​opinion/​nike-​running-m ​ ary-​cain.​html
referral network of RED-­S and eating a revolution in sport culture and aware- 2 Fleshman L. I changed my body for sport. No girl should,
disorder experts, including sport ness regarding energy availability can 2019. Available: https://www.​nytimes.​com/​2019/​11/​16/​
and exercise medicine physicians, transform the physical and mental health opinion/​girls-​sports.​html
registered sport dieticians and sport and performance of athletes globally. 3 Futterman M. Another of Alberto Salazar’s Runners
Says He Ridiculed Her Body for Years, 2019. Available:
psychologists, within each country.
https://www.​nytimes.​com/​2019/​11/1​ 4/​sports/​olympics/​
The working group also identified Twitter Kathryn E Ackerman @drkateackerman alberto-​salazar-​nike.h​ tml
that certain sports have physiological Contributors  KEA, TS, KJE-­S, AB and MLM attended 4 Chavez C. Inside the Toxic Culture of the Nike Oregon
and energetic requirements that dictate the B2ten summit and wrote and revised the Project ’Cult’, 2019. Available: https://www.​si.​com/​

School of Medicine and Dentistry. Protected by copyright.

that certain athlete phenotypes may be manuscript. MC, KG and LF wrote and revised the track-​and-​field/​2019/​11/1​ 3/​mary-​cain-​nike-​oregon-​
successful. There was much discussion manuscript and provided guidance on the athlete’s
project-​toxic-​culture-​alberto-​salazar-a​ buse-​investigation
perspective. 5 Mountjoy M, Sundgot-­Borgen JK, Burke LM, et al. IOC
about methods to safely improve perfor- consensus statement on relative energy deficiency
mance while ensuring athlete physical and Funding  The authors have not declared a specific in sport (RED-­S): 2018 update. Br J Sports Med
grant for this research from any funding agency in the
mental health. Elite athletes may need to public, commercial or not-­for-­profit sectors. 2018;52:687–97.
manipulate energy availability for short 6 Vanheest JL, Rodgers CD, Mahoney CE, et al.
Competing interests  None declared. Ovarian suppression impairs sport performance in
periods to change body composition and junior elite female swimmers. Med Sci Sports Exerc
Patient consent for publication  Not required.
improve their power/force profiles for 2014;46:156–66.
critical performance windows. On the Provenance and peer review  Not commissioned; 7 Gibbs JC, Williams NI, De Souza MJ. Prevalence of
other hand, the working group empha- externally peer reviewed. individual and combined components of the female
sised that prolonged LEA impairs health © Author(s) (or their employer(s)) 2020. No commercial athlete triad. Med Sci Sports Exerc 2013;45:985–96.
re-­use. See rights and permissions. Published by BMJ. 8 Heikura IA, Uusitalo ALT, Stellingwerff T, et al. Low
and performance. energy availability is difficult to assess but outcomes
Modeling the work in sport concussion, have large impact on bone injury rates in elite distance
we call for national policies requiring sports athletes. Int J Sport Nutr Exerc Metab 2018;28:403–11.

2 Ackerman KE, et al. Br J Sports Med Month 2020 Vol 0 No 0