Role of the Athletic Trainer in Protecting Athletes at Risk of Low

Role of the Athletic Trainer in Protecting Athletes at Risk of Low Energy Availability Know the signs and don’t be afraid to ask the tough questions By Christina Scribner, MS, RD, CSSD, CEDRD, NBC-HWC

e yearn to see our athletes ascend (EEE), calculated as the additional energy to variety of reasons, with or without an eat- to the top of the podium. How do support activities of daily living and bouts of ing disorder. While the three disorders may we encourage, motive and nudge exercise. EA is expressed relative to fat-free occur as inter-related, they may also exist W 4 our athlete while simultaneously express- mass (FFM), reflecting the most metaboli- alone or as independent entities. ing that we care enough to hold the line and cally active body tissues (EA equals caloric There is potential for misunderstanding not yield to the lure of temporary success at intake minus caloric expenditure per kilo- regarding the terms EA and energy balance the expense of health? gram of fat-free mass).1 (EB). The concepts are similar and related. The culture of the athlete is broad in In 1992, the American College of Sports EA is often used as it relates to exercise the sense that it includes both males and Medicine (ACSM) recognized health risks to training and performance. EB is discussed females, all sports, all levels of competi- females and defined the Triad as three sep- as the state of balance between energy tion and spreads across nations, races and arate, yet interrelated entities: disordered intake and energy output; imbalance affects ethnicities. The fitness and sports industry eating and low energy availability (LEA); body composition and weight. It is expected is fueled by a culture that places strong menstrual disturbance and amenorrhea; and that one can assess adequacy or inadequacy emphasis and value in extremes of perfor- bone loss and osteoporosis along a contin- of habitual energy intake by monitoring mance and appearance that may lead to uum ranging from health to disease.2 The body weight. 5 However, EB is not as simple unhealthy nutritional practices. Triad was updated in 2007 and again in 2013. as it initially appears as there are a pleth- It is imperative that professionals in exer- Figure 1 conceptualizes spectrum of interre- ora of factors that regulate and influence cise science recognize nutritional threats lationships between EA, menstrual function both the “intake” and “expenditure” sides among athletes and take steps to protect the and bone health in females.3 of the energy balance equation. Our under- athlete. The athlete who is not well-nourished Energy intake was evaluated based upon standing of EB has progressed from a static is at risk of both short-term and long-term the amount of energy available for physi- (linear process) to a “dynamic” (non-linear health complications,1 and the professional is cal activity and that LEA may result for a process) explained by evidence that altering held accountable for protecting the athlete regarding what could or should be known Health Energy Status about the athlete’s health status to partici- Disordered Eating and Low pate in exercise and competitive sport. Energy Availability

Low Energy Availability – The Triad Healthy LOW and RED-S menstrual RISK The potential health consequences of insuf- Cycles ficient energy intake among athletes is the HIGH Healthy Bones subject of both the Female Athlete Triad (the RISK Triad) and Relative Energy Deficiency in Sport (RED-S). Energy availability (EA) is an Amenorrhea and Osteoporosis and operational term that describes the amount Menstrual Disturbances Bone Loss of energy available for healthy physiological function above exercise energy expenditure FIGURE 1. FEMALE ATHLETE TRIAD

24 | NATAnews | JULY 2018 either energy intake or energy expenditure influences both biological and behavioral factors that alter the EB equation “in unpre- dictable and unintended ways.”6 Immunological The Institute of Medicine explains that Gastro- Menstrual the body is capable of diverting energy use intestinal Function based on “adaptation” and “accommodation.” Adaptation describes a change in the body that supports maintenance of function even when steady-state conditions have been altered. An example of adapta- Cardio- Triad Bone vascular Health tion is increased hemoglobin to carry oxy- gen at high altitudes. Accommodation is an adaptive process that supports survival RED-S “in more or less serious consequences on health or physiological function.”5 When energy intake is insufficient, available Psychological Endocrine energy will be diverted toward functions essential to immediate survival (body tem- perature regulation, metabolism and activity of daily movement) at the cost of reducing energy available for “nonessential” func- Growth + tions (functions that are not essential for Development Metabolic survival in the short term, such as growth and development, reproduction and resting Hemotological metabolic rate).1, 10 There is no simple method for accurately identifying an individual’s healthful body weight range. A BMI of less than 17.5 kg/ FIGURE 2. HEALTH CONSEQUENCES OF RED-S EXPANDING THE CONCEPT OF THE TRIAD1 m2, less than 85 percent expected body weight for adolescents or more than 10 per- in 2014. RED-S updated the Triad’s recog- The athlete may be in a state of LEA cent weight loss in one month have been nition of risks described in female athletes for a variety of reasons, including inten- proposed as markers for LEA.8 While these to include males, various ethnicities and tional dietary restriction or unintentional benchmarks may signal LEA, they will likely expands upon the psychological and phys- under-eating. Athletes may lack information miss identifying many people suffering ical health consequences of LEA. More about their nutritional needs, lack access from LEA. Among those who suffer from recently, the RED-S 2018 update1 reflects to food, have limited financial resources anorexia nervosa, a “significantly low body the current state of science, includes con- or engage in cultural practices that place weight” is hallmark to the diagnosis, yet the siderations for para-athletes and identi- restriction on eating or types of foods. In American Psychiatric Association allows fies limitations in the clinical assessment addition, inordinate amounts of energy for clinical judgement as to what consti- of LEA, discusses non-pharmacological used for exercise may result in LEA.1,11 tutes “too low” for an individual, rather than and pharmacological treatment strategies specifying a BMI threshold.9 While most for RED-S with and without disordered Screening and Prevention people will recognize an adult with a BMI eating/eating disorders and raises greater Early identification of LEA is essential of 17 or below as low body weight, a BMI awareness for RED-S. to prevention of long-term health conse- between 17 and 18.5 or even great may also Lack of an accurate and practical tool for quences described by RED-S. It has been be considered low weight depending on the measurement of LEA complicates iden- suggested that the determination of LEA the individual and physical complications tification of risk, yet there is clear poten- be determined by coaches and athletic related to malnutrition such as bradycar- tial for physiological complications (met- trainers via assessing a 24-hour dietary dia, hypothermia and hormonal abnormal- abolic, cardiovascular, endocrine, gastro- intake, EEE and FFM in the field setting,7 ities.10 Similarly, leaving the criteria loosely intestinal, bone and others) among both yet there is much potential for error in this defined allows the clinician working with males and females as depicted by RED-S, seemingly simple equation that limit its a child or adolescent the wiggle room to with psychological consequences that may accuracy and application. consider previous growth trajectory from either precede RED-S or be the result of Each component in the EA equation is growth charts in addition to behavior and RED-S.1 (See Figure 2.) an estimate. The gold standard method for physical complications – it also adds to the Figure 3 conceptualizes potential per- measuring energy expenditure from activ- complexity of decision-making. formance consequences to RED-S, which ity is by measurement of heat output with The International Olympic Committee are likely to engage the attention of the a metabolic chamber rather than based on 4 1 Image by neyro2008/iStock; marigold_88/iStock neyro2008/iStock; by Image (IOC) introduced the syndrome RED-S athlete and coach. calculations. The 2018 IOC RED-S update

nata.org | 25 Role of the Athletic Trainer in Protecting Athletes at Risk for Low Energy Availability underscores difficulties in accurately assess- coaches need to identify individuals who may not be forthcoming about their health, ing EA.1 There are numerous potential may be inadequately fueled, suffering from but when the athletic trainer, who holds errors in estimating EEE, including omission LEA and at risk for RED-S. As a multi- a position of trust and authority, asks the of forms of physical activity such as recre- disciplinary member of your athlete’s per- tough questions in a compassionate and ational or lifestyle activity, methods of col- formance team, you play an important role matter-of-fact way, it may reduce fear and lecting and assessing data on dietary intake, in the prevention, early recognition and raise the odds for truthfulness and protection EEE and body composition, the time frame risk management of unhealthy eating and of the athlete. difference between inadequate intake that activity-related behaviors. Strategies for reducing risk for LEA, results in LEA and assessment of EA, and There is a lack of scientifically validated RED-S and addressing disordered eating other dietary factors including dietary fiber prevention interventions.1 Yet, there is a or eating disorders include: and the distribution of energy intake over need to recognize both physical and psy- • Adopt a stance similar to the U.S. Figure the day.1 Furthermore, non-exercise activ- chological markers of LEA and address Skating Policy on Health and Well-Being17 ity thermogenesis (NEAT) may contribute to them through modification of exercise and which promotes competitive success and inaccuracy. Wearable devices used to assess nutritional intake. achievement of personal athletic poten- the energy cost of physical activity are The NATA statements15 define the athletic tial, without compromising the long-term fraught with variability in their accuracy.12 trainer’s responsibilities to their athletes. health and well-being of athletes. The actual energy expended by an individual Recommendations of national organiza- • Utilize screening tools such as the Periodic is complicated by factors such as sleep pat- tions, such as the 2015 IOC RED-S Clinical Health Examination and Preparticipation terns and circadian rhythm13 and stress can Assessment Tool (CAT)16 and Female Ath- Physical Exam.1 affect endocrine homeostasis and energy lete Triad, guide athletic trainers in clear- • Develop mandatory educational pro- availability through both metabolic and psy- ance to participate or return to play. Legal grams to improve awareness of LEA chogenic components.14 duties flow from the athletic trainer-athlete and RED-S.1 While optimal EA is typically identified relationship, including: • Understand and convey the perform- at about 45 kcal/kg FFM/d plus the amount • The duty to assess the athlete’s condition ance consequences of RED-S to coaches of energy needed for physical activity, an • The duty to monitor the athlete and athletes.1 EA of less than 30 kcal/kg FFM has histor- • The duty to evaluate and refer the athlete • Provide education about the health con- ically been identified as a target threshold for medical treatment sequences of the female athlete triad and for LEA. Yet, there is not a specific thresh- RED-S to male and female athletes for old at which energy availability is clearly Signs or symptoms of dysfunction (energy recognition of the nutrition and health “too low.”1 Among females, the pathways deficiency relative to energy intake or exer- requirements necessary for safe participa- that signal reproductive and menstrual cise dependence) or an eating disorder war- tion in sport.18 function are complex. There is a range of rant a thorough medical examination for • Include nutrition in the training program, energy intakes that are associated with safe participation. Athletic training program specifically utilizing a sports dietitian.18 menstrual disturbances1 and while severe protocols may vary regarding return to play. • Promote open communication and avoid energy deficiency is frequently associ- The RED-S CAT utilizes a red-yellow- secrecy surrounding disordered eating or ated with amenorrhea, the Diagnostic and green stoplight metaphor to categorize vary- eating disorders. Statistical Manual of Mental Disorders, 5th ing levels of risk and guide participation in • Express empathy and understanding. edition (DSM-5 )9 removed amenorrhea as activity/return to play: red light means high Maintain a compassionate and nonjudg- a diagnostic criteria for anorexia nervosa risk; yellow light means moderate risk; and mental tone. Don’t judge or criticize. The since many girls and women who severely green light means low risk. The RED-S CAT sense of trust will determine if the cli- restrict their food intake continue to have may assist clinicians in identifying athletes at ent is honest with you; dishonesty often their menstrual periods. risk and managing the play decisions related results from shame and guilt. to LEA and RED-S risk. As the body of sci- • If you suspect an eating disorder, make a Intervention ence related to the health and performance referral. Explain that an evaluation with As health care professional, you are in a risks of LEA in both female and male ath- a medical specialist is necessary. Include position to help bridge the gap between letes evolve, it is expected that the RED-S your client in the process, look for provid- the world of your athlete/client and health CAT will be further developed to protect ath- ers together, and review a list of referrals care, especially if you have an understand- letes’ health and improve performance. in your area (be prepared). A referral to a ing relationship with your athletic clients. While it may feel awkward to pose ques- specific person you have recommend is What can and should you do to improve tions related to reproductive function and more apt to be accepted. the health and performance of your cli- mental health, remember that appearances • Emphasize that health is of paramount ents, as well as protect yourself and your can be deceiving, and it is risky to presume importance and you aren’t taking any facility? Instructors, athletic trainers and health based on good performance. Athletes chances with a valuable life.

26 | NATAnews | JULY 2018 Athletes often want to push the limit and raise the bar for performance. At the Decreased same time, they recognize that there are Endurance limits and conditions for optimal perfor- Performance Decreased mance, and there are consequences to Muscle Increased going too far. Athletic trainers play an Strength Injury Risk important role in protection of the athlete’s health. Know the risks related to relative energy deficiency and the basic criteria for diagnosis of eating disorders. Decreased Decreased Glycogen Training Don’t be scared to intervene and be pre- Stores Response pared with resources for further education, support and treatment. RED-S About the Author: Christina Scribner, MS, RD, CSSD, CEDRD, NBC-HWC, is the owner of Impaired Encompass Nutrition in Littleton, Colorado. Depression Judgement She is registered dietitian nutritionist and board certified specialist in both sports dietetics and eating disorders. She specializes in nutrition therapy for weight related concerns, particu- larly disordered eating and eating disorders. Decreased Irritability Coordination Decreased References Concentration 1. Mountjoy M, Sundgot-Borgen JK, Burke LM, et al. IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. Br J Sports Med 2018;52:687-697. FIGURE 3. POTENTIAL PERFORMANCE CONSEQUENCES OF RED-S1 2. Otis CL, Drinkwater B, Johnson M, et al. American College of Sports Medicine position exercise is not linked to an energy availability 13. Westerterp-Plantenga, M. (2016). Sleep, stand. The female athlete triad. Med Sci Sports threshold. Med Sci Sports Exerc. 2018 circadian rhythm and body weight: Parallel Exerc. 1997;29:1669–1671. Mar;50(3):551-561. developments. Proceedings of the Nutrition 3. Female Athlete Triad Coalition. Title: The Society, 75(4), 431-439. doi:10.1017/ 8. De Souza MJ, Nattiv A, Joy EA, et al. 2014 American College of Sports Medicine (ACSM) Female Athlete Triad Coalition Consensus S0029665116000227 position stand. The female athlete triad. www. Statement on Treatment and Return to Play 14. femaleathletetriad.org/professionals/position- Pauli SA, Berga SL. Athletic amenorrhea: of the Female Athlete Triad : 1st International stands/. Accessed May 10, 2018. energy deficit or psychogenic challenge? Conference held in San Francisco, California, Annals of the New York Academy of 4. Mountjoy M, Sundgot-Borgen J, Burke L, et May 2012 and 2nd International Conference Sciences. 2010;1205:33-38 al The IOC consensus statement: beyond held in Indianapolis, Indiana, May 2013. Br J the Female Athlete Triad—Relative Energy Sports Med. 2014;48(4):289. 15. National Athletic Trainers Association Deficiency in Sport (RED-S) Br J Sports Med Statements. www.nata.org/news- 9. American Psychiatric Association, ed. 2014;48:491-497. publications/pressroom/statements. Diagnostic and Statistical Manual of Mental Accessed May 20, 2018. 5. Institute of Medicine. 2006. Dietary Disorders, Fifth Edition (DSM-5). Arlington Reference Intakes: The Essential Guide to VA: American Psychiatric Association; 2013. 16. Mountjoy M, Sundgot-Borgen J, Burke Nutrient Requirements. Washington, DC: L, et al. RED-S CAT. Relative Energy 10. Gray EK, Murray HB, Eddy KT. Diagnosing The National Academies Press. www.nap. Deficiency in Sport (RED-S) Clinical anorexia nervosa. In: Smolak L, Levine edu/read/11537/chapter/8#83). Accessed Assessment Tool (CAT). Br J Sports Med. MP, eds. The Wiley Handbook of Eating May 18, 2018. 2015;49(7):421-423. Disorders. Chichester, UK: John Wiley & 17. 6. Manore MM, Larson-Meyer DE, Lindsay Sons, Ltd; 2015:chap 8. US Figure Skating. U.S. Figure Skating AR, Hongu N, Houtkooper L. Dynamic Policy On Athlete Health and Well- 11. Wade GN,SchneiderJE, Li HY. Control of Energy Balance: An Integrated Framework being: Appearance, Weight Management, fertility by metabolic cues. Am J Physiol. for Discussing Diet and Physical Activity Disordered Eating and Eating Disorders. 1996;270(1 Pt 1):E1-19. in Obesity Prevention—Is it More than www.usfsa.org/content/Nutrition%20 Eating Less and Exercising More? Nutrients. 12. Xie J, Wen D, Liang L, Jia Y, Gao L, Lei J. position%20paper%20Aug%202011.pdf 2017;9(8):905. Evaluating the validity of current mainstream 18. Scribner C, Beals K. Disordered eating in wearable devices in fitness tracking under 7. Lieberman JL, DE Souza MJ, Wagstaff DA, athletes In: Karpinski C, Rosenbloom C, various physical activities: comparative Williams NI. Menstrual disruption with eds. Sports Nutrition Manual, 6th ed. study. JMIR Mhealth Uhealth 2018;6(4):e94 2017:chap 18.

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