RED-S in the exercising athlete is challenging and requires a range of health practitioners and support staff to be involved. The condition is becoming such a common problem, and perhaps reflects growing pressures for athletes (and non-athletes) to achieve unrealistic body fat or mass levels as well as increasing recognition of the presence of the condition.

Symptoms were traditionally researched in females leading to the development of the female athlete triad which represents the severe end of the spectrum; amenorrhoea, osteoporosis, and eating disorders. In more recent times it has been widely recognised there is far more extensive involvement of other physiological processes and that males too can be affected by a similar process causing varying degrees of hormone suppression. This has led to the development of the term Relative Energy Deficiency in Sport; RED-S.

The underpinning factor (Low Energy Availability or LEA) is difficult to screen for, with very little guiding us in definitive biochemical markers for a firm diagnosis. Mood issues, gut issues, fatigue, poor performance, recurrent illness, and recurrent injuries can all be markers for an underlying such process. Like most things in medicine, the clues are in an in-depth history; and in this case, the training log and nutritional evaluation give a lot of information. Blood tests are often useful but do not consistently demonstrate abnormal hormone profiles, given the high prevalence of subclinical LEA. The early detection of this condition is key to being able to turn things around quickly before those sitting in a subclinical group move into a harder group to manage. Although noting the BMI/weight parameters are important, a key concept is that LEA can occur in a weight stable athlete. As a result of the LEA, the resting metabolic rate can be suppressed, thus can be weight stable, or even retaining weight.

Such are the intricacies of RED-S, that an interdisciplinary approach is essential in managing it. I see the role of the sports medicine specialist key in making the diagnosis. Menstrual disturbances in female athletes cannot be just assumed to be as a result of low energy availability, with a range of medical conditions (some potentially serious) needing to be considered prior to confirming relative energy deficiency in sport. Once the diagnosis has been reached then the next step is education to the athlete, preferably with their parents, and their coaching and support staff. Risk stratification is important, and considering whether the athlete is safe health wise (i.e. do not harm) to continue exercising must be appraised and discussed. In some rare cases, the medical practitioner has the mandate to advise withdrawal from all sporting endeavours until a state of health is achieved. The sports medicine practitioner should operate as a good traffic director to refer to the right specialists and assist with the communication with the athlete’s personal support team with permission (family, physiotherapists etc).

I refer to a sports nutritionist very early on once I have a suspicion of diagnosis, as a nutritional assessment, and in some cases, nutritional ‘counselling’, is the foundation for management. The difficult overall calculation of energy intake versus expenditure, and ensuring there is a surplus is best done by an expert in this field. Often very small changes (i.e. sandwich/bar during prolonged training sessions) of even 300kcal per day can make a significant difference. We are fortunate to have Dane Baker, Performance Nutritionist, working with us at Axis Sports Medicine who is extremely experienced and leading in this area in New Zealand.

Reproductive Endocrinologists are medical specialists trained in reproductive health and hormone pathways and are a crucial part of the management team. I often refer an athlete onwards for their expert opinion to assist confirming the diagnosis and assistance with management particularly in those who have more severe risk factors; clearly prolonged and suppressed hormone levels, bone density issues for example. Another voice echoing the same message from an experienced medical practitioner is very useful, as there is frequently an element of denial and resistance about the diagnosis which makes compliance with the optimal management plan challenging.

The coach (as well as the strength and conditioning team if present) is a very important person to involve and educate. Given that excessive training, or even moderate level training (but not fueling enough to support moderate exercise) is often a contributor, the need to reduce training load is usually required to assist recovery. It’s vital there is open communication flowing.

Occasionally a sports or clinical psychologist is required. RED-S is reported to have an effect on depressive symptoms, poor concentration which in itself may require psychology input; and tackling some of the disordered eating behaviours that can be present require psychological expertise.

For the younger athlete, parents are vital to educating and supporting this process. Their assistance in gently helping support and in some cases, deliver, adequate ‘fueling’ is very important. Furthermore, parental buy-in to reducing overall exercise load until adequate recovery is instrumental.

I don’t believe the medical practitioner is very effective in dealing with this issue without the involvement of the wider interdisciplinary team, and there is a strong movement in New Zealand sporting circles recognising this. Whilst seeing male and female athletes alike with low energy availability issues in my private Axis clinics I am also privileged to be part of WHISPA – Healthy Women in Sport; A performance advantage. This panel involves endocrinologists, sports physicians, lead academic researchers, physiologists, sociologists, nutritionists, general practitioners, physiotherapists, psychologists and strength and conditioners. We frequently meet to collaborate on a range of issues that affect women in sport; with RED-S being a very popular topic. We are hopeful that with further outreach of our group and dissemination of guidelines and resources we will be able to tackle this issue at both an elite and community level.

Axis Female Athlete Health Clinic

Are you suffering from fatigue, difficulty sleeping, weight loss, irregular menstrual cycles, frequent injuries? This could be classified as Relative Energy Deficiency in Sport (RED-S) / Female Athlete Triad issues. These issues are extremely common in elite, sub-elite and recreational athletes and can affect a range of age groups.

If this does sound familiar you could greatly benefit from a consultation at our dedicated Female Athlete Health Clinic.

To make an appointment call 09 521 9811

By Dr Sarah Beable on