with a disability, their occurrence should not be overlooked. RED-S in athletes with a disability should be taken seriously due to possible comorbidities. Athletes with an amputation and who ambulate may have additional energetic challenges due to the inefficiency of movement,80 creasing their risk for inadvertent energy deficiency.81 thus inScreening and diagnosis Relative energy deficiency and EDs in sport The screening and diagnosis of RED-S is challenging, as symptomatology can be subtle. A high index of suspicion of the athlete at risk is needed. Early detection is crucial to improve performance and prevent long-term health consequences. Screening for RED-S should be undertaken as part of an annual Periodic Health Examination (PHE) and when an athlete presents with DE/ED, weight loss, lack of normal growth and development, menstrual dysfunction, recurrent injuries and illnesses, decreased performance or mood changes. Although various screening instruments exist,16,82,83 they have not been validated and there is no consensus on which screening tool has the best efficacy.84,85 Furthermore, these tools exclude men, disabled athletes and are not ethnically diverse. Since low EA plays a pivotal role in the development of the RED-S, diagnosis should focus on identification of the presence and causes of the low EA. Unfortunately, there are no standardised guidelines to determine EA. EA is equivalent to EI minus the cost of exercise energy expenditure (EEE) relative to FFM or lean body mass: EA (kcal/kg FFM/day) = (EI (kcal/day)−EEE (kcal/day )) The measurement of each of these components requires expertise and is generally imprecise. EI can be assessed by retrospective (recall) or prospective (written or electronic food diary) methods.86 EEE is usually assessed by an exercise log and tables of energy expenditure associated with sports/exercise activities, but may be supplemented where available by data collected via modern sports technology (eg, Global Positioning System Units, Heart Rate Monitors or Power Meters). Ideally, EI and EEE are measured over a similar time period that is representative of habitual practices. FFM can be quantified by methods such as dual-energy X-ray absorptiometry (DXA) and anthropometry.87 A measurement of resting metabolic rate via indirect calorimetry may provide confirmation of suppressed metabolism secondary to low EA. Underpinning factors related to an unintentional mismatch between EI and large training/ competition volume, intensity or misguided weight loss practices may be relatively easy to diagnose. The Brief Eating Disorder in Athletes Questionnaire (BEDAQ) is a validated screening tool that shows promising results in terms of distinguishing between female elite athletes with and without ED/DE.88 diagnosis of EDs is the Eating Disorder Examination interview (EDE-16).89 For diagnostic criteria for ED see APA.16 Menstrual dysfunction FHA is a diagnosis of exclusion. Assessment of irregular menses should include a menstrual history assessing age of menarche, regularity of menses, use of medications, the presence of other health issues and a family menstrual history. Physical examination includes assessment of anthropometry, pubertal stage, signs of ED and secondary causes of amenorrhoea.83 Pelvic examination may reveal pregnancy or hypoestrogen-related vaginal atrophy. Laboratory assessment of haemoglobin, luteinising hormone, follicle stimulating hormone, prolactin, oestradiol, T4, thyroid stimulating hormone, pregnancy and androgen profile may be indicated. More extensive testing might include a pelvic ultrasound and endometrial sampling to rule out other gynaecological pathologies. Bone health In athletes with low EA, DE, ED or amenorrhoea of over 6 months, BMD should be measured by DXA.90,91 In the adolescent, DXA should include the whole body (head excluded) in addition to the lumbar spine.6,92 As athletes in weight-bearing sports should have 5–15% higher BMD than non-athletes93,94 a BMD Z-score <−1.0 SD warrants further attention. In the athlete population, low BMD is defined as a Z-score between −1.0 and −2.0 SD, together with a history of nutritional deficiencies, hypoestrogenism, stress fracture or other secondary clinical risk factors for fracture. A value below −2.0 SD is considered as osteoporosis with the presence of secondary clinical risk factors.6 The recommended interval to reassess BMD via DXA scan for athletes at risk, or who are being treated for low BMD is 12 months in adults and a minimum of 6 months in adolescents.95 Treatment strategies of RED-S Treatment strategies for low EA The treatment of low EA should involve an increase in EI, reduction in exercise or a combination of both. The only strategy to have received scientific scrutiny is the addition of an energy-rich supplement (eg, liquid meal product) to habitual intake and a small reduction in, or introduction of a rest day to the weekly training programme.96–98 the small sample size, this intervention was successful,96,97 Despite nummer 4 | september 2014 | Sport & Geneeskunde 19 The Gold Standard for the Pagina 18
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Sport & Geneeskunde nummer 4 | november 2014 Lees publicatie 43Home