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What is RED-S? Assessing the Risk and Treatment through Nutrition By Rebecca Jaspan, MPH, RD, CDN, CDCES and the LCWNS Team What is Relative Energy Deficiency in Sport? Relative Energy Deficiency in Sport, also known as RED-S, refers to impaired physiological functioning caused by energy deficiency.  It includes but is not limited to impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health.  An athlete diagnosed with RED-S will have low energy availability or insufficient intake to support the level of energy expenditure required for the demands of their sport in addition to supporting the health and function of daily living.  RED-s used to be referred to as the Female Athlete Triad, whose symptoms include low energy availability, menstrual dysfunction, and poor bone health.  In 2014, the International Olympic Committee expanded the clinical model for RED-S to also include males.  This model greatly widens the scope of this condition beyond menstrual function and bone health to include other body systems and psychological health imperative to athletic performance. Any individual who participates in physical activity is at risk of developing low energy availability and therefore at risk for the consequences of RED-S.  Athletes who are at increased risk typically include runners, cyclists, and climbers.  Additionally, RED-S is commonly seen in sports that involve certain weight requirements such as wrestling or rowing, as well as sports with possible aesthetic pressures such as dance and gymnastics. Not only is adequate caloric intake a concern, it is also common for these specific individuals to follow strict meal regimens and even eliminate specific foods or food groups they believe to offer a competitive advantage.  This can also lead to an unhealthy obsession with food and body as well as over-training.  If these symptoms are not treated, athletes are at risk of developing eating disorders.  It is estimated that 6 – 45% of female athletes and 0 – 19% of male athletes demonstrate disordered eating patterns. The RED-S Risk Assessment Model is used to diagnose RED-S.  Upon assessing  the athlete’s presentation and symptoms, he or she is classified into “Green Light” or low risk, “Yellow Light” or moderate risk, and “Red Light” or high risk categories.  These categories help inform sport participation.  At the “Green Light” level, full participation is granted; “Yellow Light” risk allows for sport participation with supervision and a medical treatment plan with regular re-evaluation; at the “Red Light” risk level, sport participation is not granted, as participation would pose a serious health risk and may distract the athlete from devoting the time and attention needed on treatment and recovery from RED-S. Treatment Options Treatment for RED-S involves a team of health professionals including a sports medicine doctor, dietitian, athletic trainer, sports psychologist, and sports psychiatrist.  In our practice, the dietitian’s role serves to correct the energy deficiency by increasing energy intake and or decreasing energy output.  The focus is on replenishing glycogen, repairing muscles, ensuring adequate fat storage, improving bone health and decreasing inflammation through adequate nutrition, muscle rest, and using tools to aid in engaging the parasympathetic nervous system..  Many studies show interventions to increase energy availability are successful in reversing impaired functions seen in RED-S.  In one study, female athletes with menstrual dysfunction increased their intake to 40kcal/g of their fat free mass daily resulting in resumed menses in about of 2.6 months.  Keep in mind, bone mineral density must be assessed using a DEXA scan. For more on osteoporosis and bone health, read Osteoporosis and Eating Disorders. In collaboration with the medical team, LCWNS RD’s work toward nutrition replenishment, resumed and regular menses in females, and both hormone and electrolyte balance with improvement in bone density for males and females. If you notice signs and symptoms such as weight loss, prolonged healing from injuries, decreased endurance and concentration, and irritability, you may be at risk for RED-S and should consult a sports medicine doctor and dietitian.  When addressed early, not only can you prevent further complications, a full recovery from RED-S and return to your sport, whether recreational or competitive, is possible. Schedule with Rebecca Jaspan, MPH, RD, CDN, CDCED by clicking here Sources: Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2015;49(7):421-423. doi:10.1136/bjsports-2014-094559 Bratland-Sanda S, Sundgot-Borgen J. Eating disorders in athletes: overview of prevalence, risk factors, and recommendations for prevention and treatment. Eur J Sport Sci. 2013;13(5):499-508 Nutrition and Athletic Performance, Medicine & Science in Sports & Exercise: March 2016 – Volume 48 – Issue 3 – p 543-568 doi: 10.1249/MSS.0000000000000852 Holtzman B, Whitney KE, Parziale A, Ackerman KE. RELATIONSHIP BETWEEN AGE AND RED-S OR FEMALE ATHLETE TRIAD RISK LEVEL. Orthop J Sports Med. 2019;7(3 Suppl):2325967119S00011. Published 2019 Mar 29. doi:10.1177/2325967119S00011 “Relative Energy Deficiency in Sport (RED-S): What All Health Professionals Need to Know.” Sports Injury Bulletin, 6 Jan. 2019, www.sportsinjurybulletin.com/relative-energy-deficiency-in-sport-red-s-what-all-health-professionals-need-to-know/. Health, Refresh Mental, et al. “RED-S Syndrome an Easier Entry into Eating Disorders Treatment for Athletes.” The Body Image Center, 13 Sept. 2019, thebodyimagecenter.com/news-blogs/eating-disorder-treatment/red-s-syndrome-easier-entry-eating-disorders-treatment-athletes/. “Latest Issue.” Aspetar Sports Medicine Journal – Relative Energy Deficiency in Sport, www.aspetar.com/journal/viewarticle.aspx?id=260.

Exploring the Link Between Alzheimer’s and Insulin Resistance: Understanding Type 3 Diabetes. by Rebecca Jaspan, MPH, RD, CEDS, CDCES Are some cases of Alzheimer’s disease caused by a form of diabetes in the brain? Researchers are identifying another form of diabetes, known as type 3 diabetes. This type manifests as insulin resistance in the brain and has potential to impact neurocognition, contributing to Alzheimer’s disease. While not universally adopted, many in the medical community are beginning to label Alzheimer’s disease as type 3 diabetes. Physicians, researchers, and nutritionists for diabetes are noticing similarities between how diabetes and Alzheimer’s affects the brain and cognition and some are even classifying Alzheimer’s disease as type 3 diabetes. What is Alzheimer’s Disease? Alzheimer’s disease affects over 5 million people in the United States. It is a type of dementia that affects memory, thinking, and behavior. Alzheimer’s is a progressive disease and over time, symptoms grow severe enough to interfere with daily tasks. A risk factor for Alzheimer’s is increasing age and the majority of people with Alzheimer’s disease are 65 and older. Other risk factors include family history, genetics, head injury, excessive alcohol consumption, heart health, and poorly controlled blood sugars.1 Specifically prediabetes symptoms, insulin resistance and high blood sugars, have been linked to memory deficits, cognitive decline, and many other characteristic symptoms seen in Alzheimer’s disease.2 How Insulin Plays a Role In order to understand the relationship between diabetes and Alzheimer’s disease, it is important to examine the role of insulin in the brain. Insulin performs many essential functions in the brain related to the regulation of food intake, body weight, eating habits, and homeostasis of energy. It also appears to act as a regulator of long-term memory enhancement and suppression.3 Further, Alzheimer’s disease and type 2 diabetes are both diseases that contribute to the formation of amyloid plaques, which are abnormally configured proteins that play a critical role in the formation of Alzheimer’s disease. The accumulation of these amyloids is involved in the progression of Alzheimer’s disease. Research shows that insulin dysfunction, one of the causes of inflammation, enhances the concentration of these amyloids.4 How Is Type 3 Diabetes Diagnosed? While there is no specific test to diagnose type 3 diabetes, clinicians will look for both signs of Alzheimer’s disease and type 2 diabetes. To diagnose Alzheimer’s, a physician will take a full medical history, ask about family history, perform a neurological exam, administer neurophysiological testing, and recommend imaging studies of the brain. Type 2 diabetes patients are not routinely evaluated on their cognitive status and Alzheimer’s disease patients are not routinely evaluated for high levels of insulin and poor blood sugar control. Studies are suggesting that Alzheimer’s disease is a metabolic disease caused by insulin resistance in the brain and offers strong support for evaluation in both types of health conditions.5 Working with a diabetes dietitian, or a Certified Diabetes Care and Education Specialist (CDCES), can help you make changes to your diet and lifestyle to contribute to the prevention of both type 2 diabetes and Alzheimer’s disease.   A Armstrong R. Risk factors for Alzheimer’s disease. Folia Neuropathol. 2019;57(2):87-105. doi:10.5114/fn.2019.85929 Nguyen TT, Ta QTH, Nguyen TKO, Nguyen TTD, Giau VV. Type 3 Diabetes and Its Role Implications in Alzheimer’s Disease. Int J Mol Sci. 2020;21(9):3165. Published 2020 Apr 30. doi:10.3390/ijms21093165 Banks W.A., Owen J.B., Erickson M.A. Insulin in the brain: There and back again. Pharmacol. Ther. 2012;136:82–93. doi: 10.1016/j.pharmthera.2012.07.006 Blasko I., Stampfer-Kountchev M., Robatscher P., Veerhuis R., Eikelenboom P., Grubeck-Loebenstein B. How chronic inflammation can affect the brain and support the development of Alzheimer’s disease in old age: The role of microglia and astrocytes. Aging Cell. 2004;3:169–176. doi: 10.1111/j.1474-9728.2004.00101.x Michailidis M, Moraitou D, Tata DA, Kalinderi K, Papamitsou T, Papaliagkas V. Alzheimer’s Disease as Type 3 Diabetes: Common Pathophysiological Mechanisms between Alzheimer’s Disease and Type 2 Diabetes. Int J Mol Sci. 2022;23(5):2687. Published 2022 Feb 28. doi:10.3390/ijms23052687