Rugby to RED-s: Part I
Written by: Dane Baker
Over the past three years I have had the unique opportunity to work in a multi-disciplinary setting for patients diagnosed with Relative Energy Deficiency in Sport (RED-s) / hypothalamic amenorrhea. After a busy day of clinic, I often look back at how my working life has changed from being on the side-lines with rugby teams day to day to working in clinical practice.
Through my experiences with Super Rugby in New Zealand, I had
become fascinated in energy availability. In the 2014 season we were experiencing challenges with body image. Players were restricting their intake to achieve extremely low levels of body fat, this was impacting body mass goals needed for the style of play our coaches desired (strong, physical, and combative). At the same time, I was experiencing my first challenge with popular diets in the media. The Paleo diet was the most googled diet in 2014, coinciding with the ever-expanding claims to the benefits of a Low Carb High Fat diet on twitter (sigh….). The following pre-season we undertook observational research into what our players were consuming over a three-day period where we weighed and recorded everything the players consumed. We also used surveys to get a greater understanding of body image (1,2). Obviously, studies like these lack the control for high quality publications, however getting 7 days of dietary data in real time would have likely ended in blood for many of our young masters’ students! The results and application to our team were significant. We educated the players and coaches about energy availability and successfully encouraged our board to significantly increase the funding for our nutrition program. We could now fuel our players onsite to optimise body composition, health and adaptation to training.
Around this time with my role in the Black Ferns 7s (NZ Woman’s rugby 7s team), we began planning how we could best monitor energy availability within the resources we had available and establish it as our key theme for the Tokyo Olympic cycle. We created two regular assessment points across each season from 2016-2021. Early in the cycle we looked at a range of all the key indicators through research collaborations with the University of Otago and Waikato. These included resting metabolic rate, Dual Energy X-ray Absorptiometry (DEXA), dietary assessment, the LEAF-Q survey, blood work, saliva and a sociology interview process.
As the seasons progressed, we refined what we used, and I focused on how this information was presented back to the players to influence behaviour around their nutrition. This process also opened the conversation around menstrual health. Within two years, nearly all players were monitoring their menstrual cycle and being proactive with support staff regarding concerns or questions about contraception. We created our own indigenous theme to energy availability to create greater buy-in with players termed “Pūngao”. Its English translation from Māori is “Energy cannot be seen, but the results of using energy can. Energy is required for growth, change, movement and heat”. Dietary assessment has its limitations in screening and diagnosis, but how you educate athletes can be invaluable. This was a key process that evolved at each check point over the Olympic cycle.
In 2018 the Healthy Women in Sport: A Performance Advantage
(WHISPA) group at High Performance Sport New Zealand (HPSNZ) was initiated. I was invited to be part of a unique multi-disciplinary group of practitioners to optimise the health and performance of elite female athletes. Here I collaborated with sports medicine physicians and reproductive endocrinologists who were struggling with a growing list of patients in their clinics with a diagnosis of hypothalamic amenorrhea / RED-s needing nutritional intervention. This chance connection has progressed to now, where a significant amount of my week is dedicated to working with patients recovering from RED-s.
The multi-disciplinary approach, the RED-s Clinic.
I am in a unique position where I am consulting patients who have been diagnosed through a full clinical assessment by either a reproductive endocrinologist or a sports physician. The specialist
co-ordinates the recovery process and requests nutritional input from myself as well psychological input as appropriate. The goal of recovery is to restore regular ovulatory menstrual cycles. Patient circumstances vary significantly, from long standing amenorrhea of 5 to 10 years to more recent and shorter periods of amenorrhea of 5 to 6 months. Ages range from 15 through mid-40s. Patient demographics include elite athletes, adolescent athletes, students to corporates. Having the patient go through the diagnostic process allows me to completely focus on their nutritional planning and educate them around the concept of energy availability. The patient is followed up regularly across their recovery process by different members of the multi-disciplinary team and regular communication is kept. Reproductive hormones are assessed at regular intervals (every 4-6 weeks) until the first period occurs, upon which the focus turns to the length of the cycle. The recovery process is a journey which can often range between 12 to 24 months but sometimes as quickly at 3-4 months in some of the straight-forward cases.
Next month I’ll discuss how I approach the nutritional assessment and plan for the patient plus share the key insights I have gained along the way.
Author
Dane Baker is a New Zealand based Sports Dietitian currently working in private practice at Axis Sports Medicine and the University of Otago as a lecturer & professional practice fellow. Previously Dane worked in Professional rugby for over 12 years with the Chiefs and Blues Super Rugby teams. He was also a senior performance nutritionist at High Performance Sport New Zealand (HPSNZ) for 10 years where he was the lead provider for the NZ woman’s rugby 7s team (Black Ferns 7s) and previously worked with NZ swimming and the NZ Men’s Hockey team. In this two-part series, Dane discusses his experience working in the elite team sport setting, as well as his transition to private practice with a focus on athlete health. He provides insight into the multidisciplinary approaches used in the management of relative energy deficiency in sport.
References
- Gibson, C., Hindle, C., McLay-Cooke, R., Slater, J., Brown, R., Smith, B., Baker, D., Healey, P., Black, K. (2019) Body Image Among Elite Rugby Union Players. J Strength Cond Res 33(8):2217-2222https://doi.org/10.1519/jsc.0000000000002312
- Black, K., Hindle, C., McLay-Cooke, R., Brown, R., Gibson, C., Baker, D., B, Smith. (2019) Dietary Intakes Differ by Body Composition Goals: An Observational Study of Professional Rugby Union Players in New Zealand. Am J Men’s Health, 13(6) https://doi.org/10.1177/1557988319891350
