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Figure 1. Physiological impacts of harmful low energy availability on athletes.
Figure 2. Performance( training and competition) impacts of harmful low energy availability on athletes.
GREEN *
Severity / risk None to very low
Clinical criteria 0 primary indicators ≤ 1 secondary indicator
Treatment, training and competition recommendations
• No treatment required
• Full training and competition clearance
YELLOW * Severity / risk Mild Clinical criteria 0 primary and ≥ 2 secondary indicators OR 1 primary and ≤ 2 secondary indicators OR 2 primary and ≤ 1 secondary indicator Treatment, training and competition recommendations
• Treatment, monitoring and regular follow-up at appropriate intervals
• Full training and competition clearance
REDs DIAGNOSIS WITH ↑ SEVERITY AND / OR RISK CATEGORISATION * ORANGE *
RED *
Severity / risk Moderate to high Clinical criteria 1 primary and ≥ 3 secondary indicators OR 2 primary and ≥ 2 secondary indicators OR 3 primary and ≤ 1 secondary indicator Treatment, training and competition recommendations
• Treatment, close monitoring and follow-up required( eg, monthly)
• Some aspects of training and / or competition may need to be modified
Severity / risk Very high / extreme
Clinical criteria 3 primary and ≥ 2 secondary indicators OR ≥ 4 primary indicators
Treatment, training and competition recommendations
• Immediate treatment(± hospitalisation) required, frequent monitoring at daily to monthly intervals depending on severity
• Significant training and competition modifications required, and in the majority of cases, removal from all training and competition is indicated
* Serious medical indicators of relative energy deficiency in sport( REDs) and / or eating disorders, that require immediate medical attention, potential hospitalisation and removal from training and competition include: ≤75 % median BMI for age and sex; electrolyte disturbances; ECG abnormalities( eg, prolonged QTc interval or severe bradycardia— adult heart rate( HR) ≤ 30bpm, adolescent HR ≤45bpm); severe hypotension: ≤90 / 45mmHg; orthostatic intolerance( adult and adolescent, a supine to standing systolic BP drop > 20mmHg and a diastolic drop > 10mmHg); failure of outpatient ED treatment program; acute medical complications of malnutrition; any condition that inhibits medical treatment and monitoring while training and / or competing.
Figure 3. Management of athletes with relative energy deficiency in sport.
Management of REDs requires a multi-
can also lead athletes to falsely believe normal ovarian function has been returned, particularly if the method used induces a withdrawal bleed. It is not possible to accurately assess ovarian dysfunction during hormonal contraceptive use, so for many athletes, coming off hormonal contraception can be preferable until they have resumed normal menstrual cycles. Menstrual cycle disturbance can be a very early sign of LEA, and identification and treatment can prevent associated complications( such as BSIs, impaired immunity, mental health disturbance). Increasing energy intake and reducing training load will usu-
supplementation in cases of deficiency, to ensure total calcium intake of 1500mg / day and vitamin D levels greater than 50ng / ml. 3 In female athletes with impaired bone metabolism, topical oestrogen( coupled with cyclical progesterone) may be considered, with this regimen demonstrated to be superior to the combined oral contraceptive pill in athletic populations. 5 In males, testosterone treatment may be required for hypogonadism. 3 Any use of supplements, infusions or medications must adhere to anti-doping codes as directed by Sport Integrity Australia for Australian athletes( see online resources).
Treatment of REDs is often protracted and difficult, as fundamentally changing training, psychological and nutrition habits is challenging at the best of times. It can be devastating for an athlete to be ruled out from sport. Psychology involvement should be considered early, particularly where disordered eating and mental health concerns are identified. 3 In these cases, it is important to review the patient at frequent intervals for monitoring and safety. A treatment contract may be considered. With regards to ongoing participation in training and competition, the REDs CAT2 provides a scoring system to guide ongoing participation / further treatment requirements( see figure 3) depending on if they are classified as green, yellow, orange or red. 6
Some athletes can make relatively quick changes to energy balance and overcome
REDs within 3-6 months. However, for many others, true recovery during their athletic career may never occur and lifelong consequences may persist, such as infertility, osteoporosis, ill health and unfulfilled athletic potential. Early identification of REDs and management, with a team that includes a sport and exercise physician, is crucial and for many will prove life-altering. References on request from kate. kelso @ adg. com. au
disciplinary team which may include parents
/ carers / a support person, coach, GP, dietitian, psychologist, psychiatrist, sport and exercise physician, gynaecologist, and an endocrinologist. 1, 3
It is important to treat the cause of REDs, reaching a state of positive energy balance, by increasing fuelling and reducing training loads. Early engagement with an accredited sports dietitian is important, with strategies to address energy intake including reviewing dietary intake, increasing frequency and optimising meal timing and addressing micro- and macronutrient deficiencies. A sport and exercise physician can assist in determining appropriate training loads for the severity of REDs. This often requires reduced training volume, scheduled days off and even time off training altogether. Successful management needs buy in from all members of the athlete’ s support team including coaches, parents, strength and conditioning trainers, as well as the athlete themselves. 3 Commonly, athletes take time to process the diagnosis and become engaged in successful management. Ultimately, the realisation that improved health status can improve athletic performance is often the driver.
With regards to menstrual disturbance, it is important not to commence hormonal contraception to treat amenorrhoea. This approach does not treat the cause of LEA. It
Online resources
Commonly, athletes take time to process the diagnosis.
ally take an athlete from‘ battery saver mode’. 3 It is also important to remember that delayed menarche and amenorrhoea are not a normal part of training.
Impaired bone metabolism( manifested as bone stress or bone stress fractures) can be directly treated by improving energy intake and reducing overall load. In addition, increasing bone loading with high-impact and resistance training improves bone mineral density. Such training can be difficult to balance during the recovery from BSI. Consider calcium and vitamin D
• Australian Sports Commission— Female performance and health initiative bit. ly / 40C1aWY
• British Journal of Sports Medicine— Edition on REDs bit. ly / 3PWe0KA
• British Journal of Sports Medicine— 2023 REDs consensus update bit. ly / 4jGrRCj
• British Journal of Sports Medicine— REDs CAT2 assessment tool bit. ly / 40CsSmj
• Sport Integrity Australia— Antidoping bit. ly / 4aFSxPC
• Project REDs— Athlete led resource page on REDs for athletes red-s. com