Understanding Relative Energy Deficiency in Sport (REDs) in Athletes

Relative Energy Deficiency in Sport (REDs) is a condition that affects athletes when their energy intake is insufficient to meet the energy demands of their training and exercise.

REDs is a proposed extension of the Female Athlete Triad and encompasses both male and female athletes.

REDs is a result of problematic, long-term low energy availability. This imbalance can lead to a range of physiological and psychological issues, impacting health, performance, and overall well-being.

In this blog post, we will explore the various aspects of REDs, contributors, signs and symptoms, and preventive measures.

Understanding REDs:

Experiencing long-term problematic low energy availability can lead to adverse health outcomes in both male and female athletes. Specifically, REDs can lead to detrimental outcomes impacting various systems in the body, including decreases in energy metabolism, impaired cardiovascular and reproductive function, glycogen synthesis, musculoskeletal health, and immunity. 

REDs also negatively impacts performance by decreasing endurance performance, muscular strength, power, athlete availability due to injury or illness, training response, recovery, cognition, and motivation.

REDs contributors:

1. Inadequate Caloric Intake: Athletes may not consume enough calories to compensate for the energy expended during training and competition. Long-term deficits may lead to further REDs signs and symptoms

2. Disordered Eating: Restrictive eating patterns, extreme dieting, or engaging in disordered eating behaviors contribute to REDs

3. Excessive Exercise: High-volume and high-intensity training without proper fueling can exacerbate energy deficiency

Signs and Symptoms of REDs (Primary, Secondary, and Emerging Evidence Indicators)

From the IOC REDs CAT2 Severity/Risk Assessment Tool (Stellingwerff et al. 2023)

These indicators are scored to assess an athlete's severity and/or risk for REDs from none or very low to very high or extreme. The guidelines are NOT to be used for diagnosis (a physician must diagnose).

Primary Indicators:

1. Menstrual Dysfunction: Female athletes may experience irregular or absent menstrual cycles; specifically secondary amenorrhea (absence of 3-11 consecutive menstrual cycles) OR primary amenorrhea

2. Decreased Bone Density: Insufficient energy intake can lead to decreased bone mineral density, increasing the risk of stress fractures (specific criteria includes a history of ≥ 1 high-risk or ≥ 2 low-risk bone stress injuries within the previous 2 years or absence of ≥ 6 months from training)

3. Clinically Low Testosterone in Males 

4. An Eating Disorder Examination Questionnaire (EDE-Q) global score of ≥ 2.30 in females and ≥ 1.68 in males)

Secondary Indicators 

1. Oligomenorrhea (irregular or inconsistent menstrual cycles > 35 days between cycles for a maximum of 8 per year)

2. History of 1 low-risk bone stress injury within the previous 2 years or absence of ≥ 6 months from training 

3. Elevated total LDL cholesterol 

4. Clinically diagnosed depression and/or anxiety 

Emerging Indicators (need more scientific evidence) 

1. Subclinically or clinically low Insulin-like growth factor (IGF-1)

2. Clinically low blood glucose

3. Clinically low blood insulin 

4. Clinically poor or sudden decline in Iron 

5. Lack of ovulation

6. GI or liver dysfunction 

7. Low libido in males 

8. Bradycardia (slow heart rate in athletes; ≤ 40 in adult athletes and ≤ 50 in adolescent athletes)

9. Low systolic/diastolic blood pressure (<90/60 mm Hg)

10. Sleep disturbances 

11. Psychological symptoms (i.e. increased stress, anxiety, mood changes, body dissatisfaction/dysmorphia)

Preventing and Managing REDs:

1. Nutrition Education: Athletes should receive proper education on nutrition from a Sports Dietitian to understand their energy needs and fueling strategies

2. Individualized Nutrition Plans: Tailoring nutrition plans to athletes' specific needs can help ensure they meet their energy requirements 

3. Monitoring Training Load: Coaches and athletes should carefully manage training loads to avoid excessive exercise-induced energy deficits, and encourage rest and recovery

4. Cultivating a Healthy Performance Culture: Teammates, coaches, and other individuals should avoid commenting on an athlete's appearance, weight, or body

5. Open Communication: Encourage athletes to communicate openly about their physical and mental well-being, fostering a supportive environment within teams and sports organizations

Seeking Professional Help:

Athletes experiencing signs and symptoms of REDs should consult with healthcare professionals, including sports dietitians, physicians, and psychologists. Early intervention is critical to prevent long-term health and performance consequences.

Collaboration with Healthcare Professionals: 

Those working closely with athletes who have a REDs diagnosis or exhibit signs and symptoms should collaborate in monitoring and addressing potential issues related to REDs, while prioritizing the athlete's health and well-being.

Relative Energy Deficiency in Sport is a multifactorial issue that requires a comprehensive approach involving nutrition, training management, and mental health support.

By raising awareness and implementing preventive measures, athletes can maintain optimal performance, health, and well-being throughout their careers.

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The information cited in this post was used from Mountjoy et al. 2023 (PMID: 37752011) and Stellingwerff et al. 2023 (PMID: 37752002)