Cumulative low energy availability over days and months results in suboptimal growth and development in young athletes, impaired health and ultimately below expected athletic/dance performance for given training loads.
- Low energy availability can arise unintentionally, for example an increased training load, race or performance schedule not matched by an increased energy intake. Or a situation of underestimating energy requirements for exercise outside of formal training: for example cycling to/from a training session. Small daily energy deficits accumulate.
- Low energy availability can also result from an intentional strategy to achieve and maintain a low body weight for a performance or aesthetic advantage. You will not necessarily lose weight in the face of sustained low energy availability, due to biological compensatory mechanisms to slow metabolism. Although initially you may feel that nothing is wrong and your athletic/dance performance is maintained, or even improved; in the long term energy deficit is not sustainable for either health or athletic performance.
The longer a low energy availability situation continues, the harder it can become to restore health and performance from a physical and psychological point of view.
In females, menstrual dysfunction this is a warning sign that hormones are not at healthy levels. All women of reproductive age, whether an exerciser or not, should have regular menstrual cycles. Regular periods are a barometer of health.
- Regardless of the amount of exercise being undertaken, if periods have not started (menarche) by age 16 years, this is known as primary amenorrhoea.
- Once menstrual cycles have started, if periods stop for >6 months, this is called secondary amenorrhoea
- Oligomenorrhoea is where <9 periods occur during a calendar year. In all cases, in the absence of pregnancy. These are definitions from Royal College of Obstetrics and Gynaecology.
Note that hormonal contraception does NOT produce periods, rather withdrawal bleeds due to external medication (rather than your own internally produced hormones). Hormonal contraception masks underlying menstrual issues and does NOT protect against the adverse effects of RED-S
Download the Clinical Assessment Tool for Risk Stratification of RED-S
As RED-S is a diagnosis of exclusion: treatable medical conditions need to be ruled out. Standard blood tests can rule out a hormone conditions per se (unrelated to effects of training), specific nutrient deficiencies (eg iron, Vitamin D, B12, folate), inflammatory, infective and digestive conditions per se.
Once treatable medical conditions have been excluded, a diagnosis of RED-S can be made. The results from the blood tests can be used to gauge severity of RED-S, together with an indication of bone health from a DXA (dual X-ray absorptiometry) scan, if indicated. This information can be used as a means of quantifying whether you are in green, yellow or red risk categories of RED-S, where green is good to go, yellow is proceed with caution and red means stop as serious risk to immediate health.
The priority in overcoming RED-S is restoring the optimal balance between training, nutrition and recovery. This will need an integrated team effort with your sport/dance doctor, coach/teacher and most likely input from sport nutritionist, or clinical dietician if an eating disorder is present (disordered eating with a psychological overlay). In the yellow category of RED-S once baseline nutrition has been reviewed and restored, the recovery plan to return to normal training may included temporary reduction of training intensity, review of fuelling around training and increased recovery/rest days. Monitoring of responses to these modifications can be used to guide gradual increase in training load and “return to play”
Treatment with medication is reserved for severe issues of bone health in female athletes where short-term oestradiol and progesterone may be indicated, until normal menstruation is restored with modification of nutrition and training. Oral contraceptive pill or other forms of hormonal contraception are NOT indicated in RED-S, as this has no bone protective effect and masks amenorrhoea. In men with low testosterone due to imbalances in training load and nutrition, Therapeutic Use Exemption (TUE) for banned external testosterone treatment is not justified. As in females, RED-S results in a functional hormone condition. In other words low sex steroids are not due to a proven medical condition, rather arising from mismatch of training and nutrition inputs.
“I have always been a slim build and told I have an ideal physique for Ballet. However, on starting full time training there were other students who were thinner and eating less. I did the same. However, I did not become a better dancer. My periods stopped and I couldn’t dance due to bone stress response. Logically I knew this was not a good situation, but I found it really difficult to accept that I had to eat more again and regain my lost weight. However with support from my…
“The holy grail of competitive road cycling is to achieve maximal power to weight ratio in terms of Watts/KG. What started out as “healthy eating” to achieve this goal became an unhealthy obsession to restrict nutrition and lose weight. Sleep and mood changes became problematic and my on bike performance suffered.”
Workshop to discuss Relative Energy Deficiency in Sport (RED-S) with clinically qualified professionals. All welcome athletes, dancers, coaches, students. Sunday…
Sports Injury Bulletin, Dr N Keay, Sport and Dance Endocrinologist writes: RED-S can occur in athletes of all ages and…