Spotting the Signs: How to Identify Energy Deficiency (REDs) in Athletes

The IOC has recently updated their guidelines (IOC paper) from 2014 to provide us with more detailed information on how to recognise and treat Relative Energy Deficiency in Sports (REDs) . Recognising RED-S can be challenging due to its varied manifestations. The core issue in RED-S is when energy intake (EI) falls substantially below energy expenditure (EE), however, accurately measuring both EI and EE is fraught with difficulties, largely due to errors in assessing these parameters. As a result, there are no standardised methods in place to definitively diagnose REDs, making its detection more complex.

The diagram below effectively illustrates the negative consequences of Low Energy Availability (LEA) and RED-S. According to the latest IOC guidelines, LEA is categorised into two types: 1) Adaptable LEA, characterised by its short duration and minimal impact on the body, and 2) Problematic LEA, which is more concerning due to its significant side effects and its role as a potential precursor to RED-S.

REDS model

1. Body Composition

Changes in body composition can be an initial indicator of REDs, although you might also see no weight changes, despite under fuelling. For some people, this might be one of their first indicators, especially if the weight loss is rapid or happens alongside an increase in training with severe restriction in intake. It is also important to understand that with REDs, it is not necessary for you to fall below the NHS healthy BMI range to see the side effects of LEA. It is usually the combination of changes in body composition with low carbohydrate availability (LCA) and an increase in exercise that all precipitates problematic LEA and ultimately REDs.

2. Primary or Secondary Amenorrhea

A particularly noticeable sign of LEA in women is the absence of menstruation. In adolescents, it’s concerning if menstruation hasn’t started by the age of 15. For those who have already started menstruating, a sudden stop in periods can also indicate an issue. This cessation suggests that the body is conserving energy due to insufficient intake, prioritising other functions over the reproductive system. It is also concerning if menstruation is sporadic or intermittent. Neglecting this issue can lead to detrimental effects on bone health, which is always a crucial concern. There is typically a delay of six to eight months between the resumption of menstrual cycles and the improvement of bone density. Therefore, my priority is always to focus on helping you regain your menstrual cycle as promptly as possible.

3. Injuries or Stress Fractures

Often, the journey to addressing REDs begins with the occurrence of injuries or stress fractures. This highlights the importance of sports doctors and physiotherapists being well-informed about RED-S and its symptoms. A stress fracture frequently arises from an escalation in physical activity that is not matched by a corresponding increase in nutritional intake. This kind of injury serves as a crucial indicator that changes in diet or exercise routines are needed.

4. Hypothyroidism

In REDs, hypothyroidism is a result of the body trying to conserve energy. It is due to insufficient calories being taken in compared to energy expenditure and so the body slows down its metabolic rate to conserve energy. A sign of hypothyroidism is that you could be feeling extremely tired all the time and lacking in energy.

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