Relative energy deficiency in sport: consensus statement highlights health risks

By Rebecca Jenkins

Athletes who undergo prolonged periods where the energy costs of training and competition outstrip their energy intake are putting their health at significant risk, an updated international consensus statement warns.

The International Olympic Committee’s expert writing panel first introduced the syndrome, known as relative energy deficiency in sport (REDs), in a 2014 consensus statement, which was updated in 2018.

More than 170 studies have since been published advancing the field of REDs science, the expert group wrote in the 2023 consensus statement, published in the British Journal of Sports Medicine.

Consensus coauthor Professor Louise Burke, Chair in Sports Nutrition at the Mary Mackillop Institute for Health Research at the Australian Catholic University, Canberra, said the additional evidence had allowed experts to identify more body systems that might be affected by low energy availability (LEA) as well as recognise that individual athletes can have different outcomes from LEA exposure.

‘LEA is the term used to describe situations where a mismatch between an athlete’s energy intake and the energy cost of their training and competition (i.e. reduced energy intake, increased energy expenditure or both scenarios) means there is insufficient energy left to support all the processes needed by the body to stay healthy and fully functioning,’ Professor Burke told Medicine Today.

REDs was complex and required a nuanced approach, she added, noting that not every case of LEA presented a concern.

She recommended that clinicians focused on ‘problematic LEA’ in which severe and/or prolonged exposure to LEA, in conjunction with other characteristics around the athlete, could cause severe and potentially persistent impairment leading to health and performance concerns.

Physical symptoms, such as menstrual dysfunction, poor bone health and gastrointestinal problems, could point to early signs of problematic LEA, she said.

Clinicians could also assess psychological symptoms, including disordered eating/eating disorders, or behaviours, such as excessive exercise or overactive interest in body mass, if they were concerned about an athlete.

Professor Burke said some causes of LEA were deliberate – such as intentional strategies to rapidly reduce weight or body fat – but there were many inadvertent scenarios.

Many athletes did not recognise the energy costs of heavy training loads, and others might not have time, ‘stomach comfort’ or access to food to consume enough energy.

Some of the assessments for problematic LEA would require the further input of specialists, Professor Burke said, with the processes and protocols outlined in the REDs Clinical Assessment Tool 2 that accompanied the consensus statement.

The statement also included a summary of practical clinical guidelines for assessing persistent calorie deficit and for safe body composition measurement.

‘The cornerstone of treatment is to identify and reverse the source of the underlying problematic LEA, while also providing adjuvant treatments for the specific health outcomes,’ Professor Burke said.

Br J Sports Med 2023; 57: 1073-1097.