Characterization of Risk Quantification Differences Using Female Athlete Triad Cumulative Risk Assessment and Relative Energy Deficiency in Sport Clinical Assessment Tool

Abstract

This study’s objective was to identify differences in risk for low energy availability and athletic clearance level by comparing scores on Female Athlete Triad Cumulative Risk Assessment (Triad CRA) and Relative Energy Deficiency in Sport Clinical Assessment Tool (RED-S CAT). A total of 1,000 female athletes aged 15–30 years participating in ≥4 hr of physical activity/week for the previous ≥6 months completed an extensive survey assessing health, athletic history, family disease history, and specific Triad/RED-S risk factors. Retrospective chart review ascertained laboratory and bone mineral density measures. Triad CRA and RED-S CAT were used to assign each athlete’s risk level (low, moderate, and high), and case-by-case comparison measured the level of agreement between the tools. We hypothesized that the tools would generally agree on low-risk athletes and that the tools would be less aligned in the specific elevated risk level (moderate or high). Most of the sample was assigned moderate or high risk for Triad CRA and RED-S CAT (Triad: 54.7% moderate and 7.9% high; RED-S: 63.2% moderate and 33.0% high). The tools agreed on risk for 55.5% of athletes. Agreement increased to 64.3% when only athletes with bone mineral density measurements were considered. In conclusion, Triad CRA and RED-S CAT provide consensus on the majority of athletes at elevated (moderate or high) risk for low energy availability, but have less agreement on the specific risk level assigned.

Low Energy Availability in Athletes 2020: An Updated Narrative Review of Prevalence, Risk, Within-Day Energy Balance, Knowledge, and Impact on Sports Performance

“…The risk of low EA has been investigated using surrogate markers or self-reported symptoms of low EA in various athlete populations including elite para-athletes [34], adolescent/young adult [35,36] and Olympic athletes [40], female sprinters [41], male jockeys [39] and recreationally active individuals [33,37], and ranges from 14% to 63% ( Table 3). The largest cross-sectional study investigating self-reported health and performance outcomes linked to low EA and RED-S [5] placed emphasis on including body systems beyond reproductive function and bone health such as metabolic, haematological, psychological and cardiovascular health and gastrointestinal function.…”

Review: questionnaires as measures for low energy availability (LEA) and relative energy deficiency in sport (RED-S) in athletes

“…The RED-S Clinical Assessment Tool (RED-S CAT) [ 8 ] is the preferred clinical tool and employs a ‘Red Light - Yellow Light - Green Light’ risk assessment. However, better validation is needed for this as there appears to be some consensus with existing tools on who is at risk, but less agreement on the extent of the risk and case decisions [ 9 , 10 ]. Part of this is because there is no comprehensive agreement or gold standard list of risk factors and symptoms for RED-S, probably because it affects so many body systems.…”

Are Coaches of Female Athletes Informed of Relative Energy Deficiency in Sport? A Scoping Review

“…In the last decade, there has been greater appreciation for the harmful consequences of Relative Energy Deficiency in Sport (RED-S), particularly in adolescent female endurance athletes (Holtzman, Tenforde, Parziale, & Ackerman, 2019;Logue et al, 2020). RED-S is characterized by an athlete's energy intake not matching their total exercise expenditure, resulting in a state of low energy availability (LEA) (Logue et al, 2020).…”