- Unintentional low energy availability can arise with an increase in training load that is not matched with an appropriately timed increased of nutritional intake. Or underestimation of energy expenditure from exercise outside of training schedule, for example active transport to/from training sessions, study or work.
- Intentional low energy availability is more prevalent in sport or dance where low body weight confers a performance or aesthetic advantage.
Low energy availability arises due to non-integrated periodisation of training load, nutrition and recovery. In cases of intentional low energy availability a possible cause is that athletes/dancers may misinterpret corrections to be directed at physical attributes, rather than technique. Where there is an element of subjective selection in athletes, if this this is favoured towards the thinnest candidates, this could also be misinterpreted as endorsement of this physique, rather than on ability. Even where body weight is steady, low energy availability may be present due to high training loads and/or endocrine and metabolic adaptations have occurred to prevent weight loss. So a steady body weight does not rule out low energy availability. There are many examples, including road cycling, long distance running, triathlon, ski-jumping, rhythmic gymnastics, aquatic sports and ballet, where there is a high incidence of RED-S, to mention just a few disciplines (see IOC consensus statements on RED-S)
The symptoms of RED-S in terms of adverse health and performance consequences are not unique to low energy availability, or indeed any issues of non-integrated periodisation of training, nutrition and recovery. Medical conditions per se, not related to training, can potentially cause these symptoms. In other words RED-S is a diagnosis of exclusion. So medical advice may be advisable, not only to rule out treatable medical conditions, but also to quantify parameters such as hormone and nutritional markers reflecting severity of energy deficit. Combined with training metrics such as training load, heart rate, heart rate variability, times/power production etc, this information can be used to track response to strategies aimed at addressing low energy availability and hence return to optimal health and fitness.
Download the Clinical Assessment Tool for Risk Stratification of RED-S
Discussion with the athlete/dancer, and the parent/welfare officer as appropriate.
Although menstrual function of female athletes may be a tricky subject to discuss for male coaches, nevertheless these conversations should not be avoided. As having healthy hormones is fundamental to optimal athletic performance, menstrual cycles could be viewed as another training metric. Discussing topics in this website could be a starting point.
If an athlete is underperforming, review of periodised training load is advisable, in conjunction with periodised nutrition and recovery. Is the athlete doing extra training, beyond that on schedule? Simple measures such as ensuring increased recovery/rest and post training nutrition of carbohydrate and protein within a 30 minute window can be valuable.
Encourage asking for GP referral to NHS Clinic RNOH London, Dr Roger Wolman, for medical review if RED-S suspected to exclude underlying medical conditions and for quantification of the degree of functional disruption if RED-S confirmed as diagnosis.
Management of athletes with RED-S will require a multidisciplinary approach involving athlete, coach, healthcare professionals. In the case of an eating disorder, clinical dieticians are trained to work with these athletes/dancers. Specifically for coaches this will include carefully monitoring /tailoring of training load as nutritional intake being modified. For example, gradual re-introduction of training intensity whilst monitoring response to this.
“Focusing on resolving nutrition issues alongside reduced training intensity and increased recovery has been key to improving health in this cyclist. From this position, training intensity has been increased, whilst carefully monitoring response to this”
Global Cycling Network in conversation with Renee Mc Gregor, clinical dietician with expertise working with athletes, including those with RED-S and…
British Journal of Sports and Exercise Medicine, Dr N Keay, Sport and Dance Endocrinologist writes: Surprisingly low levels of Vitamin…