International Olympic Committee issues a consensus statement to help athletes at risk of REDs

Prevalence rates vary between sports

Estimates of the prevalence of REDs varies from sport to, ranging from 15 to 80 per cent. Athletes often fail to recognise when they are personally affected – as do their coaches and team clinicians. It may, albeit unwittingly, be exacerbated by an underlying ‘sports culture,’ in which short-term performance boosts are achieved by limiting calorie intake, either intentionally or unintentionally, the statement warns.

The IOC first recognised REDs as a distinct entity in a consensus statement in 2014. This update draws on key advances in REDs science over the past five years, with the aim of raising awareness and optimising athletes’ health, psychological wellbeing, and performance. 

The statement highlights new evidence on the

• emerging role of inadequate carbohydrate intake
• overlap between REDs and ‘overtraining syndrome’
• time course of REDs development
• interplay between mental health and REDs
• advances in the understanding of the syndrome in male athletes and para athletes

The panel has included a summary of practical clinical guidelines both for assessing persistent calorie deficit and for safe body composition measurement that deliberately excludes those aged under-18 years. There is also an updated clinical assessment tool (IOC REDs CAT2) incorporating a four-colour ‘traffic light system’ to promote accurate diagnoses and assessments of risk/severity.

This ranges from full participation in training and competition (green) to continued monitoring (yellow) through to intensive medical interventions and monitoring (orange) all the way to full medical support, coupled with possible removal from competition and training (red). 

A deficit in the amount of available energy needed to maintain optimal health and athletic performance is referred to as low energy availability (LEA), the statement notes.

We very much hope that this consensus statement will enhance awareness and understanding of REDs and stimulate action by sports organisations and scientists and athlete health and performance teams to protect the health and wellbeing of the many athletes [Margo Mountjoy]

In the short term, the body is able to adapt to this, a process known as ‘adaptable LEA’, but it isn’t able to cope with large, prolonged, and frequent deficits in available energy, known as ‘problematic LEA’, which leads to REDs, the statement notes.

While age, gender, genes, external factors and behaviours may worsen or mitigate the effects, these can be many and varied as the body is forced to divert energy from processes involved in growth, reproduction, and maintenance, the statement continues. 

The effects of REDs on the body can include 

• hormonal disturbances, loss of periods, erectile dysfunction, low libido; weakened bones, susceptibility to stress fractures 
• abdominal pain, cramps, bloating; impaired energy metabolism; low iron, insufficient red blood cell oxygen carrying capacity (haemoglobin) 
• urinary incontinence; impaired glucose and blood fat (lipid) metabolism; depression, exercise dependence/addiction, eating disorders
• impaired cognitive skills (such as memory, decision-making and spatial awareness); sleep disturbances
• heart rhythm and blood flow abnormalities; reduced muscle function; reduced growth and development; impaired immunity

REDS also affects performance, manifesting as

• reduced availability for training and competition as a result of injury/illness; reduced response to training
• taking longer to recover from training and competition; slowed reaction times; reduced motivation, low mood
• lower muscle strength; reduced endurance capacity; reduced performance power

Professor Margo Mountjoy said: ‘REDs is common in both male and female athletes in many sports, and although we understand a lot more about its causes, awareness of the syndrome and its consequences for health and performance is still low among athletes, their medical and performance support teams, and the general public.

‘We very much hope that this consensus statement will enhance awareness and understanding of REDs and stimulate action by sports organisations and scientists and athlete health and performance teams to protect the health and wellbeing of the many athletes at risk of this syndrome.’

To access the article – titled 2023 International Olympic Committee’s (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs) doi:10.1136/bjsports-2023-106994 – click