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 adrianamslages@gmail.com Bibliography Conclusions 1. Otis CL, Drinkwater B, Johnson M, Loucks A, Wilmore J. American College of Sports Medicine position stand. The Female Athlete Triad. Med Sci Sports Exerc. 1997; 29(5):i-ix. 2. Nattiv A, Loucks AB, Manore MM, et al. Ame- rican College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc. 2007; 39(10):1867-1882. 3. Loucks AB, Kiens B, Wright HH. Energy availability in athletes. J Sports Sci. 2011; 29 Suppl 1:S7-15. 4. Mountjoy M, Sundgot-Borgen J, Burke L, et al. Authors’ 2015 additions to the IOC consensus statement: Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2015; 49(7):417-420. 5. Abacı A, Çatlı G, Anık A, et al. Significance of serum neurokinin B and kisspeptin levels in the differential diagnosis of premature thelarche and idiopathic central precocious puberty. Peptides. 2015; 64:29-33. 6. Joy E, De Souza MJ, Nattiv A, et al. 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Curr Sports Med Rep. 2014; 13(4):219-232. The screening of the athlete at risk for RED-S should include a multi- disciplinary team including a coach, The remaining bibliography is at: www.revdesportiva.pt (A Revista Online)