By Riley Nickols, PhD, CEDS
What is Relative Energy Deficiency in Sport (REDs)?
In 2014, the International Olympic Committee (IOC) published the consensus statement Beyond the Female Athlete Triad: Relative Energy Deficiency in Sport whereby REDs expanded upon the Female Athlete Triad’s three conditions: low bone mineral density, functional hypothalamic amenorrhea, and low energy availability (LEA).1,2 The IOC has since updated the REDs consensus statement in 2018 and again in 2023.3,4 A primary tenet of REDs is that any athlete, regardless of gender, sport, or competitive level can experience this syndrome.
It is important for athletes and sport personnel to understand how REDs can have damaging effects on all systems in the body including psychological functioning. The REDs framework includes more considerations due to low energy availability (LEA). LEA is a state in which the body does not have enough energy to support all of its functions. This leads to issues with reproductive health (menstrual dysfunction and low estrogen for females, low testosterone for males, decreased sex drive for those with LEA), cardiovascular function (unstable vital signs, bradycardia or tachycardia due to LEA), immune function, growth and development, hematological, gastrointestinal, and metabolic functioning. Psychological consequences can either precede REDs or may worsen by REDs.5,6
Despite the maintenance, or even improved, sport performance for a period of time, a continued state of REDs will eventually negatively impact an athlete’s sport performance due to:1
- Concentration and focus difficulties
- Decreased training response
- Increased injury risk
- Decreased coordination and impaired judgment
- Depression and irritability
- Decreased
- glycogen stores
- Decreased muscle strength and endurance performance
Although there is overlap between symptoms of REDs and an eating disorder, there are differences between these two conditions. For this reason, qualified providers need to determine whether an eating disorder is also present in the context of a REDs diagnosis.
What Causes of REDs?
Low energy availability is the primary component of REDs whereby there is a mismatch between an athlete’s nutritional/energy intake and the energy expended during exercise, so there is not enough energy to support the body’s functions to stay healthy and perform well.4
How to Detect REDs
A specialist should evaluate if an athlete’s symptoms support a REDs diagnosis. A comprehensive evaluation by a sports medicine physician should occur that entails obtaining an athlete’s medical history in addition to heart rate and blood pressure data to determine if an athlete meets criteria for REDs and/or medical instability.7
Additionally, the multidisciplinary treatment team (i.e., sports medicine physician, sports dietitian, and mental health provider) should assess an athlete’s sport history, an athlete’s current training volume and intensity, eating behaviors, and be aware if any changes have recently occurred specific to an athlete’s mood, energy levels, fatigue, injury, hormonal functioning, and/or sport performance.6
The IOC’s Relative Energy Deficiency in Sport (REDs) Clinical Assessment Tool Version 2 (IOC REDs CAT-2) was developed to help providers with accurate detection, diagnosis, and risk stratification. The IOC REDs CAT-2 has training and competition recommendations for athletes.8
Click here to access the IOC’s Relative Energy Deficiency in Sport (REDs) Clinical Assessment Tool Version 2 (IOC REDs CAT2) (NOTE: This assessment tool is intended for use by medical professionals only)
How is REDs Treated?
A Multi-Disciplinary Approach:
Treatment of disordered eating/eating disorders warrants a multidisciplinary team approach consisting of a physician, dietitian, and mental health provider who frequently collaborate on the care of an athlete.4
Physician:
A physician should assess and monitor the physical health of an athlete with REDs given the aforementioned systems of the body that can, and eventually will, be harmed as a result of prolonged LEA. A physician closely monitors the medical stability of an athlete with a REDs diagnosis given the heart stress that LEA can cause. It is important for the physician to determine if specialists from other fields (e.g., endocrinology, gynecology, cardiology) are needed to best support an athlete with REDs and to ensure such additional care by sub-specialists is coordinated and comprehensive.7
Dietitian:
If an athlete’s LEA is the result of unintentional under-fueling, then nutrition education and additional professional support to restore energy is recommended for treatment.5 Nutrition and exercise changes should be made by a qualified provider (i.e., a board certified specialist in sports dietetics) to restore energy. If an athlete’s LEA is the result of intentional under-fueling, finding the reason behind the under-fueling is needed so that evidence-based sports nutrition education can be provided to the athlete. Additionally, if the athlete is intentionally under-fueling, further evaluation for an eating disorder is important.4
Mental Health Provider:
A mental health provider is necessary to help an athlete address the underlying reasons in the development and sustainment of REDs. Support is often needed to address increased mood changes (i.e., depression, anxiety) that frequently occur, or intensify, as the result of REDs and malnourishment. Athletes and mental health providers can work together on ways to best handle challenges that can arise from making necessary dietary and exercise changes to restore energy.4
Increased Nutrition:
Increased caloric intake via bigger portion sizes, eating more frequently, and/or incorporating more calorically dense foods into an athlete’s diet often comprise nutritional interventions to restore an athlete’s energy availability.4
Rest and Return to Sport Considerations:
In addition to dietary modifications, stopping or decreasing the amount of training volume, training intensity, and/or sport participation are needed for energy restoration in a timely manner. In addition to using clinical judgment and collaboration from multidisciplinary treatment team members, The Safe Exercise at Every Stage Athlete (SEES-Athlete) Guidelines and the IOC’s REDs Clinical Assessment Tool Version 2 (CAT-2) can also be used by providers to guide return to play decisions.8,9 Should an athlete be unable or unwilling to restore energy with appropriate nutrition and exercise interventions, then further evaluation is warranted by a qualified expert to determine if an eating disorder is present in conjunction with LEA.4
REDs Preventative Measures
Increased education and awareness for athletes and sport personnel as to the negative effects of LEA are important protective factors to decrease the onset and sustainment of REDs. Coaches, athletic trainers, and sport personnel should consult with qualified sports dietitians and physicians to assess an athlete’s individualized energy needs, determine the current state of energy availability of an athlete, and develop corresponding interventions to support positive energy availability.4
Importantly, safe and appropriate methods for monitoring an athlete’s body weight and shape should be developed within athletic organizations. The IOC’s 2023 REDs consensus statement includes guidelines for safe and effective body composition assessment, aiming to prevent REDs and promote athlete well-being.4 Sport participation should be limited or withheld when certain weight and/or body composition are met that put the athlete’s health at risk. An additional protective measure for REDs is the removal of toxic environments in sport where athletes are shamed for eating behaviors in addition to the shape and size of their bodies.4
Sport personnel can prioritize an athlete’s health by having enough water, sports drinks, and food available to athletes before, during, and after practices and competitions. Finally, it is important for coaches and trainers to consider having required team rest days and to address if/when an athlete is exceeding recommended training parameters. In addition to inadequate fueling to meet energy needs, training that is above an athlete’s training plan increases energy demands, making an athlete more likely to be in a state of energy deficiency.4
Glossary
- Low bone mineral density: A condition that causes the amount of minerals contained in bones to decline, increasing risk of fractures
- Functional hypothalamic amenorrhea: A condition that causes the amount of minerals contained in bones to decline, increasing risk of fractures
- Low energy availability (LEA): A state in which the body does not have enough energy to support all of its functions
- Bradycardia: Slow heart rate
- Tachycardia: Fast heart rate
- Hematological: Relating to the blood
- Gastrointestinal: Relating to the stomach and the intestines
- Metabolic functioning: Relating to the chemical reactions in the body’s cells to produce energy.
- Glycogen stores: Glycogen stores serve as a form of energy storage for muscles.
- Unintentional under-fueling: Not consuming enough food for their activity level
- Energy demands: Use of energy by human activity
- Energy deficiency: The state in which there is not enough energy for body’s needs and for exercise
Resources
Project RED-S is a network of athlete ambassadors and trusted REDs specialists who provide information, resources, and support to athletes who may be impacted by Relative Energy Deficiency in Sport.
Sources
[1] Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., Meyer, N., Sherman, R., Steffen, K., Budgett, R., & Ljungqvist, A. (2014). The IOC consensus statement: beyond the Female Athlete Triad–Relative Energy Deficiency in Sport (RED-S). British journal of sports medicine, 48(7), 491–497. https://doi.org/10.1136/bjsports-2014-093502
[2] Otis, C. L., Drinkwater, B., Johnson, M., Loucks, A., & Wilmore, J. (1997). American College of Sports Medicine position stand. The Female Athlete Triad. Medicine and science in sports and exercise, 29(5), i–ix. https://doi.org/10.1097/00005768-199705000-00037
[3] Carson, T. L., West, B. T., Sonneville, K., Zernicke, R. F., Clarke, P., Harlow, S., & Karvonen-Gutierrez, C. (2023). Identifying latent classes of Relative Energy Deficiency in Sport (RED-S) consequences in a sample of collegiate female cross country runners. British journal of sports medicine, 57(3), 153–159. https://doi.org/10.1136/bjsports-2021-104083
[4] Mountjoy, M. et al. (2023). 2023 International Olympic Committee’s (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). British journal of sports medicine, 57(17), 1073–1097. https://doi.org/10.1136/bjsports-2023-106994
[5] Carson, T. L., West, B. T., Sonneville, K., Zernicke, R. F., Clarke, P., Harlow, S., & Karvonen-Gutierrez, C. (2023). Identifying latent classes of Relative Energy Deficiency in Sport (REDs) consequences in a sample of collegiate female cross country runners. British journal of sports medicine, 57(3), 153–159. https://doi.org/10.1136/bjsports-2021-104083
[6] Loucks, A. B., Kiens, B., & Wright, H. H. (2011). Energy availability in athletes. Journal of sports sciences, 29 Suppl 1, S7–S15. https://doi.org/10.1080/02640414.2011.588958
[7] Shanley, D., Hassan, A., Lunan, E., & Carmody, S. (2023). Relative energy deficiency in sport: Diagnosis and management in Primary Care. InnovAiT: Education and Inspiration for General Practice, 16(5), 229–235. https://doi.org/10.1177/17557380231155943
[8] Mountjoy, M., Sundgot-Borgen, J., Burke, L. M., Ackerman, K. E., De Souza, M. J., Pedersen, B. K., & others. (2023). REDs Clinical Assessment Tool (REDs CAT-2). International Olympic Committee. https://doi.org/10.1136/bjsports-2023-106255
[9] Quesnel, D., Cooper, M., & Dobinson, A., (2019). Safe exercise at every stage: Athlete (SEES-A). A guideline for managing exercise and return to sport in athletes with eating disorders. Available at: https://www.safeexerciseateverystage.com/sees-guideline
