Revista de Medicina Desportiva (English) September 2018 | Page 18
Figura 3 – Ferramenta clínica para estratificação do risco de RED-S (adaptado de 4 )
and recovery. On the other hand,
athletes included in the moderate
risk group (yellow light) should be
cleared for sport participation only
under medical supervision with a
personalized medical treatment
plan. Within this line, a frequent
monitoring of athlete health status
is strongly recommended (at least at
regular intervals of 1–3 months). 9
Athletes with eating disorders
should be accompanied by an
experienced multidisciplinary team
to assess the need to restrict sports
practice, especially in those with BMI
under 16,5 kg/m 2 , anorexia nervosa,
bulimia with more than 4 episodes
of self-induced vomiting per week.
In these cases of disordered eating
and severe eating disorders, sports
participation should be categorically
restricted. 28
The athlete’s periodic revaluation
is essential for risk re-categorization
and to release for normal competi-
tion practice if included in the low
risk-category (green light). 9
RED-S treatment is based mainly
on the restoration of the athlete’s
EA. In many cases, simple nutri-
tional education increasing daily
energy intake and/or reducing exer-
cise energy expenditure, with limita-
tion of the intensity and the pro-
grammed exercise load, is sufficed. 2
A practical strategy that can be
adopted is an increment of energy
daily intake in 300 to 600 Kcal,
divided throughout the day, close to
the periods of exercise practice. 7
Concerning menstrual dysfunc-
tion, the same strategy of increasing
body weight with appropriate pro-
tein and carbohydrates intake seems
to be the best treatment option.
An increase of 5 to 10 percent or
1 to 4kg on body weight has been
associated with the normalization of
menstrual cycles. 35-37 In this regard,
combined hormonal therapy (oral or
non-oral formulation) is not recom-
mended as a treatment option and
can jeopardize the athlete health
16 september 2018 www.revdesportiva.pt
status masking amenorrhea associ-
ated with RED-S, which is one of
the easily accessible symptoms to
screen in the female athlete. Moreo-
ver, the use of oral contraceptives
did not consistently show benefit on
amenorrhoeic athletes BMD and can
additionally compromise the hepatic
production of IGF-1 through drug
first-pass hepatic metabolism. 7,38,39
The athlete should receive an
optimized daily calcium intake (up
to 1500 mg/day) and vitamin D (up
to 800 IU/day). Other anti-resorptive
drugs (as bisphosphonates) or any
other bone anabolic agents (as
teriparatide or denosumab) do not
have demonstrated proven benefit in
the context of RED-S on BMD or on
fracture risk. Besides that, the pre-
scription of bisphosphonates must
be avoided, especially on young
female athletes, due to the potential
teratogenic effects in a future preg-
nancy related to the drug extended
half-life. 2,6
Multimodal treatment of the ath-
lete with mental disorders (including
disorders of eating, depression or
anxiety) is essential to RED-S reso-
lution. The strategy includes psy-
chological and medical support by
specialized health care profession-
als until it full resolution, through
psychotherapy and/or psychotropic
drugs, depending on the severity
of the condition presented by the
athelete. 9
It is also strongly recommended
the inclusion on nutritional edu-
cational programs about disorders
of eating, particularly about short
and long-term deleterious effect of
caloric restriction, as well as purga-
tive behaviors, on athlete health
status and performance. 28
sports physiologist, physiotherapist,
athletic trainer and differentiated
medical team, as well as the athlete
himself, in order to raise awareness
about the impact of EA on health
status and sports performance.
Prevention strategies of RED-S
should include an adequate daily
energy intake and a balanced ener-
getic expenditure during training
and competition. An early identifica-
tion of the athlete at risk of RED-S
will prevent adverse consequences
on the athlete’s health status, as
well as a deleterious effect on sports
performance according to its athletic
potential.
A multidisciplinary approach,
including an endocrinologist, is
essential in order to optimize ath-
letic performance, to reduce the
injury risk and to potentiate the
athlete’s competitor sports skills
throughout his career.
Conflicts of Interest
The authors declare absence of any con-
flict of interest.
Corresponding author
Adriana de Sousa Lages
[email protected]
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