How to Identify and Treat Relative Energy Deficiency in Sport (RED-S) [transcript]

Written by Christopher Kelly

Sept. 12, 2018


Tommy:    Hello and welcome to the Nourish Balance Thrive Podcast. My name is Tommy Wood. Today, I'm joined by Dr. Nicky Keay. Hi, Nicky.

Nicky:    Hi, Tommy.

Tommy:    We met earlier this year when you organized the British Association of Sport and Exercise Medicine Conference in Doncaster, which is all about hormonal responses and metabolism and health in athletes, which is something that obviously, we’re very interested and you and I have a shared interest in. I was very interested to talk to you about your experiences and all the research that you've been doing particularly to do with Relative Energy Deficiency in Sports or REDS or RED-S. Which do you prefer? Do you use one or the other?

Nicky:    Personally, I say REDS. But I mean it’s one of those things. It means the same thing.

Tommy:    Before we get into that, maybe you can tell us a bit about yourself, your background and training. Then we can get into some of the details of how energy deficiencies affect athletes.

Nicky:    Well, first of all, thank you, dear, for coming to that conference. It was really great to bring together everyone with like minds and objective. Thank you for that.

    About me, I originally did my medical training. It seems a long time ago now. Anyway, at Cambridge University, I did my medical degree and also medical qualifications there. Then afterwards, I moved to London where I did my postgraduate medical qualification called MRCP, Membership of the Royal Colleges of Physicians.

    Since achieving that, I've been really focusing on endocrinology, specifically sport endocrinology. How the hormones interact in athletes, when it can go wrong and seeing how they can become healthier and therefore optimize their performance.

Tommy:    Before we get into the exact research you’ve been doing, then some of the ways that we can think about this, maybe you could just give us an overview of REDS? Maybe include some of the history because it just underwent a name change, which is the athlete’s formerly known as Female Athlete Triad.

Nicky:    That’s right, yes. Now, we're more inclusive. Anyway, the main thing, the underlying issue is that of low energy availability. What that means? If you take, consider the amount of nutritional intake, if you add up all the calories in that, and then from that, you've got to bonds of the exercise training. Then also, you need some left-over, just to do your basic biological processes in the body, just to keep taking over.

    The problem is if you're training hard, then obviously those demands are going to be massive. Sometimes there isn't enough energy left over, if you will, for just carrying out the basic housekeeping duties, as I call it, of the body. It's said that you need at least 45 kilocalories per kilogram of Fat-Free Mass. I mean, don't worry about the figures but just to make the point that you need energy to cover just staying alive, if you will. If you sail a little bit too closely to the wind, then that's when you run into troubles.

    This was first appreciated, as you say, in female athletes, the beginnings of the so-called Female Athlete Triad. Originally, it was actually back in the ‘80s by a woman called Barbara Drinkwater, who’s a big name in this field. Anyway, she was looking at some collegiate runners. Although in a group of collegiate runners, they were all eating the same, more or less. Those ones with a higher training load were more likely to have menstrual disruption and also low bone mineral density, in other words weaker bones. That's where it was first started with the female athletes.

    Since that, even the Female Athlete Triad has now evolved into this clinical spectrum. It's not an all or nothing. It's not you either have it or you don't. Through variations in between depending on how restrictive you are with your nutrition, depending on how disrupted your menstrual cycle is and depending on how severely your bones are affected from just a little bit of a niggle to a full-blown stress fracture.

    That brings us up to 2014. But then in 2014, the IOC produced a consensus statement, published in the BJSM describing this model of REDS, Relative Energy Deficiency in Sport. The major points from that consensus statement: number one, it's not just female athletes. It was recognized that there are male athletes out there who could be experiencing the same issues.

    The other important thing apart from just talking about periods and bones, now we are talking about all of the body systems, so yes, of course, the bones but also cardiovascular system, metabolic systems, everything.

    Even further than that, that there are performance consequences, athletic performance consequences. Because, let's be frank, if you're an athlete or you’re training seriously, the whole point of putting yourself through this training is because you want to improve as an athlete, do the best you can. If you find that what you're doing actually is hindering your performance or even detrimental to your performance, then, athletes, of course, will pay more attention or sit up and take note of what the issue is.

    That's why we've evolved. Now it's called REDS, which incorporates still the Female Athlete Triad. On the nice little diagram, you'll see there's still a little triangle specific for females. But REDS is a really important model because it includes male athletes and not just limited to bones, many, many body systems and the effects on performance.


Tommy:    Yeah, I think that's certainly important in terms of the work that we do because a lot of the people we work with, roughly 50% are male. Many of them experience all of these issues that you’re talking about.

Nicky:    Well, that’s true. They're half the population. Actually, I have to say that it is in lots of research -- I’m not just talking about REDS now, research in general -- lots of guidelines about nutrition and things is for male athletes whereas we only had the Female Athlete Triad.

    It's just basically redressing the balance to recognize whoever you are, whatever your age, male, female. This could potentially be an issue, which will affect not only your health but actually your athletic performance. That's really the common strand. That's what, whether you're male or female, if you’re training, that's what you're trying to achieve. You optimize your performance. If there's something you're doing which isn't helping that, then that's really important to address that.

Tommy:    Yeah, absolutely. Maybe before we go through all the different potential downstream effects of REDS, we could talk a bit about the research that you've done. You started out in ballet dancers. Now, you're working with cyclists. Maybe we can go through some of the stuff you've previously done and some of the things that you found.

Nicky:    Well, when you have to declare your interests, I'm declaring my interest that I'm very biased towards ballet. Because me, personally, I've done ballet ever since I was either four or five or whatever it is. I've always done shows, dancing. I still dance four times a week.

    Why I started off with dancers is because I'm familiar with what it takes to be a dancer. I mean I was never a professional but I took it seriously enough and rubbed shoulders with people who were. That's why I focused on the ballet dancers because they are certainly at risk.

    Well, back then when I started my sports research, we didn't have REDS, we just had the Female Athlete Triad. Certainly, they were a group of athletes that’s all certainly at risk of low energy availability.

    My first question with the dancers was “Okay, there is a problem but what happens…” I mean, maybe the sort of being devil's advocate. Maybe we're making too much of a thing about this. Maybe it's a training effect. If you train hard, endurance training, you expect your cardiac output to go up. You expect your pulse rate to drop.

    Maybe if you're a female athlete, you could argue that's part of that training effect is it might dampen your reproductive system and your bones maybe become lighter. Maybe if you stopped doing that intense training, then everything will return to normal. When I say a normal, return to the rested state, if you will, okay, because we know that if you stop training, then you lose your fitness. Maybe there isn't a long-term effect.

    My first question was what happens to these dancers once they've retired? I collected -- it’s a cross-sectional study -- collected a group of retired professional dancers. I put them all on a DEXA machine, which measures body composition, but more specifically for this study, hormonal density at the various sites in the body, the spine, the hip.

    It was slightly concerning because what I found was that even though these dancers had retired, so they're not doing intense training. All of the dancers, if they had had a menstrual issue when they were in training, all their periods return and they haven't reached the menopause yet. But nevertheless, their bone density at the lumbar spine was less than you would expect for their age. Particularly, if they had a delayed onset of periods -- age of menarche -- if they had duration of amenorrhea -- period stopping -- and also if their weight had dropped substantially during their training, their professional career.

    The conclusion of that study is that we are dealing with something, a low energy availability. Not only affects the immediate health of an athlete but also, potentially has long-term consequences. That was with the older group.


    Then I also did a contrast study, a three-year longitudinal study with a group of younger dancers, musical theater students and control girls. In other words, the gradation of exercise: the control girls at school which is doing some PE classes; the musical theatre were doing a bit more exercise; and then the ballet dancers  were doing a lot of training many hours per day.

    In that case, the ones that were really doing heavy-duty exercise training; they were the ones that had problems with regular menstruation. In other words, they weren't menstruating regularly. Also, they had low bone mineral density. To highlight point from that study is that if you disrupt your normal development and particularly your bone health when you're young, it's probably going to be difficult to recoup that and get up to adult levels.

    But I want to be positive, on the positive note in that group of youngsters. Some of them did have very good bone density. They were the ones -- not surprisingly -- that were doing the optimal amount of exercise. In other words, they weren't just sitting around. But equally, they weren't really training intensively. I think that's an important message.

    There have been several articles, papers saying that really, we have to be careful, young athletes specializing too early and doing too much intensity or just one specific type of sport. Because that, not only an injury issue, but in this situation, if it's a sport where you need to be lightweight, that also could have long-term consequences. That's the summary of my ballet dancers.

Tommy:    There’s so many points I want to discuss there. But that loss, one that you mentioned, I think is really important particularly because the majority -- not all -- but the majority of the listeners of this podcast are based in the US. The push for kids to do competitive sports and train every day for months, for hours, it's insane.

    Having worked in Sportsfest in here and the US, I’d seen some of the things that parents are willing to do to their kids so that kid can perform or be the star in a certain sport; just the number of kids to get thrown on the scrapheap, just so you can have professional sports.

Nicky:    Well, exactly. It's not just the physical aspect. It’s also the mental burnout. I mean, by the way, it’s the same over here in the UK. I mean some sports don't change much, for example, swimming.

    When my boys were youngsters, they were doing the same type of training that I used to do back in the Dark Ages, which was basically just thrash up and down twice a day. Yes, for listeners, for sure, the short-term gains, of course, they're great. But universally, the youngsters got fed up with that. It's just doing one thing intensively. It’s the mental burnout. Also, it can be quite difficult to accept that the ones that the [0:12:52] [Indiscernible] show early promise are often the ones that's just the chronological age or the ones that have gone into puberty earlier than the others because they're now taller than their peers, because they've got a certain birth date.

    I think there's evidence to show that if you have a birth date at the beginning of January, for example, and it's your age. That element to it, that the child might get the impression, “Oh, they are fantastic.” But then if others start to catch up with them, that's very difficult to accept psychologically. They're more likely to frankly give up.

    But anyway, ultimately, it's got to be for the enjoyment of the sports. Health warning comes with pushing children too much when they're young. It’s difficult because obviously you don't want to dampen their enthusiasm. But equally, you've got a temper it with knowing what the potential long-term outcomes might be in a discussion with a coach.

    There are some very good coaches I know here in the UK, who say that they won't let the children train more than 14 hours until they are 14, per week I'm talking about. Emphasizes that it’s important the enjoyment aspect, getting the technique right. Then it's relatively easy to add in the hours as to when the young athlete is physically and mentally able to cope with that.

Tommy:    I'm interested in – to go back to the ballet dancers -- whether that training and lifestyle and performance, whether it's possible to do that yet put yourself not at risk. In my biased view of ballet dancing, I'm imagining disordered eating, overtraining. But also, I know you need to be at certain weight so you can go on points, so that you can do a lot of stuff that you have to do. Is there a possibility of doing it correctly without risking all this stuff and still performing at the highest level?


Nicky:    Sure. Well, in fact, you could argue that it's essential that you are healthy and able to perform. I'm not just talking about ballet, by the way. But for sure listen, there are challenges. I'm sure everyone knows, probably have a friend or another athlete or dancer, who they are just naturally have a physique and a metabolism, whatever you will, that find it easy to be as they want. This is difficult to say, exactly, what is the difference here.

    That's also the difficulty for the coach to distinguish between the dancer, who is naturally slender and the one who is, as you say, has disordered eating problems and all that thing. But absolutely, it is possible to be a top-class athlete and ballet dancer as well and be healthy. In fact, as I say, it’s pretty much essential. But it is a fine balance. Ballet and some, especially the ones sports with specific neuromuscular skills, you do need to start that early. I mean I mentioned I started ballet when I was four or five. There's no doubt it's very difficult.

    I know Nureyev is a slight exception to the rule. He came into ballet, I think, when he was 18 or very, very late, relatively speaking. You do have to build up your technique, your skills when you're younger. There's no denying that in something like ballet. But it's a tricky one.

    Also, there's also the peer pressure. A dancer, that I saw recently, who is absolutely fine, naturally slim, eating properly, doing well, then goes into the environment of the peer pressure and maybe the coaches, teachers giving indirect signals. Of course, nowadays, we know coaches shouldn't say or overtly say, “This athlete is better because they're thinner.” Obviously, that's a no-no nowadays.

    Nevertheless, you can give subtle hints that an athlete that is thinner than the others is given more corrections or whatever it might be. There's also a big responsibility on the coaches and the teachers to get it right. Listen, I agree with you. It is difficult but it's certainly possible. That's what we need to improve upon.

    Dance medicine, I just wrote something recently. Traditionally, has been this poor relation of sports medicine. But now, actually, they are forging ahead. I mean it’s tricky though as a ballet dancer. You don't like talking about workload and things like this. That sounds a bit too mechanical. But nevertheless, you have to. I think things are moving forward but there will still be some old prejudices there.

Tommy:    Moving on to cyclists, which is what your more recent work has been. I know you're in the process of publishing your data so you probably can’t tell us everything that you've done. But can you give us a bit of an idea of the demographic you've been working in and some of the issues that you've been seeing?

Nicky:    Sure. I mean to try and redress the balance. Let’s say, I am biased towards ballet and my first two studies were in female. People, I've heard it said that, “Oh, well, male athletes, this doesn't affect them so much -- REDS.” I was thinking, well, I don't think that's right. Is it just that we're not looking forward or we’re not picking it up that we think that it's not there? That was part of my motivation. Just see what the situation is.

    Also, my family are a family of Mad Keen Cyclists. That was the other reason. To delve down and see if male athletes or certain groups of male athletes, should I say, are equally at risk of REDS. So cycling is an example. I mean we've just had various tours on the TV. I'm sure that lots of your listeners will have been alarmed like me. Some of those cyclists look pretty thin. Yeah, exactly.

    The problem is that aspiring amateur cyclists see these pictures of their heroes winning the tours and whatever, really skinny and think, “Oh, that's what we have to be look like in order to be successful.” But they forget that those guys in the WorldTour teams we see, they are surrounded by a multidisciplinary team. They’ve got a nutritionist. They've got a physiotherapist. They've got a sports scientist. Everything is very much controlled and carefully regulated.

    My question was what's the situation in amateur but good level, competitive male cyclists? I recruited 50 male cyclists. I don't know if you have the same categories for cycling over there. But category two and above on race points, BC, British Cycling race points. Anyway, serious, to get that number of points and to be at that level or above, you definitely got to be serious about your cycling, put it that way. It's not just an easy commute to work. It's serious training. That was why I chose that study group.


    My other question is in female athlete, there's an obvious clinical sign. I mean quite crude, I suppose you could say, but if a female -- not just athlete but a female in general -- her periods are not regular of reproductive age, then there's a problem. I mean there's a hormone problem. That's the classical other sign in REDS of eight menstrual disruption in female athletes.

    But of course, you don't really have this obvious thing in men. Also, they don't like to admit that they might have disordered eating or anxiety around food. It's not really the male thing to do. I was wondering how am I going to detect those at risk of REDS. I use the faithful DEXA scan because that's the gold standard when it comes to body composition and bone health, bone mineral density.

    Also, the other tool I had up my sleeve was my experience as a clinician. That's what doctors do every day. We interview patients. We gather a clinical history. We get an impression; make a provisional diagnosis in our mind. Then we do tests often to back that up. Could I, from my clinical experience, identify male athletes I thought could be at risk of REDS? Then, does that match up with what their bone scan is? That was the question.

    The other thing about it, you have to be sports specific about it. I have to talk the language of a cyclist, if I'm dealing with the cyclists. I have to talk the language of a ballet dancer. Otherwise, they're not going to give you the trust and the information that you want.

    Is there a way of identifying male athletes that are risk of REDS? Also, how big is the problem? Suffice to say, there is a problem, which actually isn't new in that sense. There have been other papers saying that male cyclists have low bone mineral density. Because they're trying to be slim, thin, lightweight so they can produce more watts per kilo.

    Also, because the other risk factor about cycling through the bone health is that it's the non-weight bearing sport. It's like swimming in that sense. You’re not putting forth through your bones. Your bones are very good at responding to external load. But if you're not subjecting the bones to that, then they're not going to be very strong. Plus, on top of that, if you're not supplying sufficient nutrition then therefore, the hormonal environment, they're not going to be very good. That's a sneaky preview of what I found.

    Then I'm going to follow these guys up and see what differences I can make by giving practical and effective advice about nutrition and about off bike exercises. We're going to rescan them at the end of the season. We have two groups. Those that I just let them do their own thing and those ones that I've given advice to. We’ll see. Because there's no point in identifying a problem if you can't do anything about it.

    How can you identify a potential problem? Then, what is effective? It's the principles of the screening test, isn't it? How sensitive is your screening test? Also, what can you do about it? Hopefully, I'll have some practical advice for these cyclists wanting to be lightweight and doing then on weight bearing exercise all the time.

Tommy:    Fantastic, that sounds like stuff that we’re very much interested in. When those data are published, then maybe we can you have back.

Nicky:    For sure, yeah. Hopefully, soon.

Tommy:    I wanted to ask you about when you were assessing these guys, the cyclists, what things are you looking for, even just in general terms? We go back to the crude measure of amenorrhea or issues with the cycle and ballet dancers or female athletes. I often want to talk about erectile function whether you're regularly waking up with an erection in the morning that certainly correlates with testosterone level –

Nicky:    Yes, exactly. That can correlate. That's the equivalent in females, for sure, however awkward that question is. By the way, I used to work at one of my jobs in the NHS, was in a male infertility clinic. Everyone, all the medics, were all females. But anyway, listen, we certainly have something that has to be discussed but there are other clues from taking a history that are going to give you the information.

    This is a doctor. You get a feel for their attitudes, the way they tell it to you and also the way that they present you with the information. If I ask a question about, “Oh, tell me what would you eat on average?” if they produce an absolutely detailed thing, every single little thing, then I can surmise from that that actually this is something that they've got strong beliefs about.

Tommy:    That watching the process of how they're thinking about food is going to give--


Nicky:    Yes, exactly. I have to say that the thought of going through loads of diet fills me with horror, that's not me. For my dancer’s study, I was lucky. I recruited some friend, who is electorate, SURI University, and nutritionist. It’s great. She had some PhD student. Otherwise, I mean listen, that's definitely important to do that in certain people.

    But anyway, there's lots of argument as about how accurate that is -- people saying what they've eaten -- and also how do you measure accurately how much energy someone is expending? Even if you end up with a figure, I mentioned that 45 kcal/kg FFM. Even if you end up with whatever you think the figure is, there’s also, as you’re probably aware, lots of literature just saying actually that it isn't this magic all or nothing threshold. Above this, you’re fine and below this, your hormones switch off. Nothing obviously is that easy.

    But still you have to ask about their nutritional, more about the habits, I would say. If they're on purpose admitting, taking fueling post exercise or if they're doing excessive amounts of fasted rides in cycling terms I’m talking about, then you have to wonder, “Is this actually a good idea?” I think it's anything taken to extreme.

    There's a very good nutritionist who's advised Team Sky. They've obviously got it right. He talks about taking the amount of carbohydrate required according to the Taika training sessions. Maybe there is a place for low-carb riding and all this thing. But again, it has to be in a really good schedule and all that thing.

    When I'm trying to work out, if someone might be at risk of REDS, I'll just be asking them to give me a feel for, if their periodizing their training and nutrition in a good way. Other little clues, yes, the menstrual, the erectile dysfunction. These things also give you clues. Whatever it is, whatever sport it is, I think that's also what I've found. You have to make it relate to what the sport they're practicing.

    When I'm talking to cyclists, I'm happy talking about FTP. I'm happy talking about faster drives. I have to keep it in that language. If I’m talking to a dancer, I'll be talking about classes, their rehearsals schedule, the roles they're practicing, for all this thing. You have to tailor it. I mean I think you come from a rowing background, don't you?

Tommy:    Yeah.

Nicky:    You know what I mean?

Tommy:    Yeah.

Nicky:    I don't know what the equivalent is in rowing terms but some feel. Because then you're going to get more information from the person. You're going to be on the same wavelength. That is my other thing that I found very useful in trying to find out all the details about somebody, trying to relate it to what they're doing, what they're interested in, what their passion is.

Tommy:    I think that’s a very good advice. That sums too that trust is going to be the key, to slightly talk about some of these difficult things.

    In terms of some of the other downstream consequences of REDS, you talked about bone health, low bone mineral density or decreased strength of certain bones within the skeleton. We talked about performance. That's got to be a big one especially if you can tie some of these issues to a decrease in performance or show that or suggest that performance might increase if you start to address these problems.

    Obviously, that's tied a lot to the hormones, testosterone, issue of gastronome, females, the sex hormones. The one thing you mentioned earlier was cardiovascular. I was very interested in the long-term cardiovascular effects of REDS. I was wondering if you could about that a little bit.

Nicky:    Sure. Yeah, it's counterintuitive because you would think that someone, say there’s someone with REDS, who is avoiding carbohydrates, avoiding fats -- well, basically avoiding foods. But particularly, those ones are the like as seen as quite “bad” or “unclean” or “unhealthy” or whatever words you want to use.

    You would have thought instinctively, someone that is not eating carb, not much, not many carbs, not many fats that you would have thought that surely there would be cardiovascular. They’re lipid profile, for example, you would expect would be amazing. But actually, it’s the opposite.

    I'm often surprised, you see a very slim athlete sitting in front of you. Yet the blood tests say that actually their lipid profile isn't great. But it's not just the lipids. It's actually the endothelial function.

    The research is more in women in this case because we know a lot from menopausal women. I mean one of the reasons why the incidence of heart attacks and myocardial infarction increases in postmenopausal women. It comes to the same level as men is because of the lack of estrogen.

    We now know there's lots of research saying that estrogen is good for your endothelial function. That is fascinating. Someone that's sitting there looking really slim and not eating any of the “foods” that are meant to be bad for your cardiovascular health. Yet, actually, there’s an increased risk. That’s quite, that’s a worry.


Tommy:    It’s hotly debated, I guess in the cardiology field. But there certainly seems to be a point where the diminishing returns of more exercise end up becoming harmful as the volume increases. Then certainly, at that point you may end the gap in terms of a calorie deficit is probably getting high too. It’s coming from both sides.

    In terms of, then you've assessed somebody, you're fairly sure they've got REDS and then starting to put together some plan to help them obviously. Your own research has shown that unless you target it you may end up with long-term consequences that are never fixed without being actively worked on.

    I was wondering about the way you approach, treating or coaching somebody who has these issues and maybe starting with some of the cognitive aspects. Particularly the groups you've worked with and in many others, there's going to be a large prevalence of exercise addiction and then also disordered eating. There's a huge psychological aspect to both of those. Do you have any tips on how you start these conversations? Or how you maybe start to change things for these athletes?

Nicky:    Yup. One thing I should just say before we get onto treatment, if you will, management, is that -- just to emphasize to everyone listening -- that REDS is a diagnosis with big exclusion. You should take your clinical history as you would do but particularly with detail about relating specifically to the type of sport and what they're doing, that thing.

    Even if at that point your instinct is this person 99% has got REDS, nevertheless, you should run some tests. Especially if it's a woman with amenorrhea because you can be caught out. Fortunately, I haven't been caught out because I did the test. But put it that way. In some cases, I'd run the tests to see if there's any other cause of amenorrhea. Certainly, in one case I was surprised. It was actually of the high Prolactin, something different.

    First of all, bear that in mind. Well, there's two reasons for doing some baseline blood tests. First of all, it will exclude anything else. Also, it will give you an indication of the severity of the condition depending on how disrupted the hormones are. Say, you have done all that and now you're convinced. You've got evidence that there isn't anything medical that needs treating, this is an energy deficiency issue. Then what are you going to do then. It's quite helpful just to mention.

    There's this thing called REDS CAT, which basically puts you in the athlete, into a category. You've heard about this one, haven’t you, Tommy? Green is good to go so basically there's no issues in terms of blood tests or what they're doing. That's all fine.

    Amber, that’s caution, you're worried about some of their eating, what they describe their relationship with food and how they're managing their nutrition. There's probably some evidence on blood tests and maybe within the decks of the bone since they're not so good, so that's amber.

    Then red is the person is seriously ill and actually, health is at risk. Maybe the ECG is abnormal or even the electrolytes are abnormal in that person. Obviously, that might even need hospitalization. First of all, establish diagnosis as you would do with anything. Then secondly, get a feel for what you're dealing with here.

    I'm going to talk more about the amber. I think they call it yellow. The ones where they don't need immediate admission to hospital but you definitely cannot just send them on their way. In that case, I agree with you. The first thing to do is to establish this trust. Get a feel for the psychology behind. What are their beliefs about their nutrition?

    I have to be honest and say lots of athletes with REDS will say, “There's nothing wrong with me.” By the way, I used to be one of these people so I know exactly how it feels. Everyone is saying to you, “You're too thin. You're not eating enough.” But you're sitting there thinking, “What are they talking about? I can still do my 32 fouetté or whatever it is. I can still run my marathon fine. I haven't got an injury yet. What are they talking about? Really. I'm an athlete. I'm different. I don't have to. I'm not the normal population.” I know that is what the athlete often is thinking, right?

    If they've got into energy deficit intentionally, just to mention, there are the unintentional ones that just when I say, “It isn’t a training error. They've just increased their training load but they’ve forgotten or not accounted for their need to increase their nutrition.” Those are the easy guys. It's a simple mistake, if you will.

    First of all, that's another thing to say if we’re dealing with that person with RED-S. That's pretty straightforward. You just point out that actually they need to get refueled rapidly after their training or whatever it is. That's easy. Going back to the athletes in this yellow or amber group, they do have-- it’s an intentional situation they've gotten too. They’re restricting their nutrition. You mentioned exercise addiction and that's very interesting.


    There was a recent article last year in this in the BMJ, which I recommend people looking at. It’s a very interesting reading. Basically, it’s a person that has a very rigid schedule to the exercise and their nutrition. They have to do these three sessions every day, training sessions. They have to eat exactly these things at exactly these times. It's very rigid.

    Now, the tricky thing is in order to be a successful athlete, you have to have a certain type of personality trait that is very driven, very regimented. I mean it's easy to say, “Oh, I feel a bit tired. I won't bother with that.” But athletes, to be successful, you need that drive, the ambition. A little bit of both obsession, I suppose you could say.

    How to distinguish those that tip over, where that obsession to stick rigidly to a schedule, becomes problematic? There's not an absolute difference has within, everything it's not black and white in all that business. But the key thing is ask, “Why I have to got to do this schedule?” That's quite a confronting question.

    The answer I get if it's an exercise addiction is, “Well, because this is the schedule I've set for myself. I have to do it.” You see? Whereas, the athlete that has maybe gone a little bit off the rails will say, “It is performance driven. I have to do this so I get better.” You see?

    Then if the person says that, that is your way in. Because they're saying, they believe by sticking to this specific schedule that will make them improve. If therefore, I can show them that actually they're holding themselves back by sticking to this schedule, they're not going to make the improvements they want, they're not reaching their full potential; that is an easy way of persuading them that things need to change.

    The people that are doing it because it's just a rigid schedule and they just have to, that is also problematic. But then you have to find out their incentives. Why this schedule isn't so good for them apart from the health issues, obviously? Because now you're losing all your friends, your relationships, it's not working out. You have to look at other incentives for why continuing like this isn't going to work.

    When you're talking about the psychology of it, that's tricky. But you have to find out what's making this person tick. Why are they sticking to this restrictive eating pattern?

    Also, you mentioned food avoidance. I mean, of course, there are many valid medical reason why you might. Think of celiac disease, then you should not eat gluten, of course. But it's where it becomes, again, almost an obsession. “I cannot eat. I have to eat cleanly. I cannot eat carbs, whatever the food group is.” That's orthorexia. Although it's not defined yet exactly on DSM criteria.

    I have a friend, a sports performance dietician, who's working very hard to make it an official psychological eating disorder. But that's tricky again. If someone is absolutely firm in their belief that that's what the key is to their performance, but then you just have to show them in the evidence and try and persuade them that actually it's counterproductive. Listen, it's not easy but once you have got a chink that they’re willing to try it or listen and then the results will speak for themselves.

    I had a dancer recently who was convinced -- as I used to be -- that she had to be thin-thin that she couldn't eat carbohydrates and that was the only way she was going to be a good dancer and be successful on the audition. Eventually, eventually, eventually, persuading habit to change, now, she says “Oh my goodness. I didn't realize. I feel so much better. I'm not stressed physically. I'm stronger. I can pick up the steps. I can pick up the corrections. I'm just better.”

    Once you can persuade them to change, then the results speak for themselves. But you're right. There's no easy solution. There’s not a standard way you do this. You just have to -- like we were discussing -- get the trust, understand what is making the person tick. Then you can try and tailor it around that. Give them an objective, some motivation.

Tommy:    Once you've found the chink, we found the way in the dancers trying to change some patterns of behavior. Do you target a certain amount of food? You mentioned 45 kcal/kg FFM.


Nicky:    I just mentioned that. I'm not a dietitian. As I said, it fills me with horror, all the exact measure of this and that. Also, part of me thinks, surely, if you encourage them once to get out the scales and all that, isn't that just feeding into their obsession?

    Well, first of all, I just try and speak, talk to them in general terms and try and focus on their training and say, “Look you really do need to be properly fueled for your training session. Also, please at least focus on fueling in that 30-minute window after the training.” I try and go for small things like that. “So focus on that and also please focus that every meal you have. You have got some amount of carbs and protein in it.” Just personally, I just give them guideline like that as a starting point. Because it's a lot to take in and accept and all that business.

    Beyond that, if they still are struggling, then actually I would refer them to a dietitian who can give them the more specific nitty-gritty of it. But just trying to change their mentality in the first place and just give some rough guidelines, that's my starting point.

    Personally, I wouldn't recommend weighing it and all that business. Because number one, I don't feel comfortable. That's not my area of expertise. Secondly, in my opinion, I feel it could be counterproductive to get them to feeding into that obsession thing again. I just give some general guidelines and see how they go with that. Sometimes that works. Sometimes that's good enough.

    The ones where actually I'm not getting through, then I need to ask. I refer to my colleague. But again, that's what they’re saying about REDS. It's got to be a multidisciplinary approach. Ideally, also depending on who, athlete or dancer, depending on their age of course, get the parents involved. Get the coach involved. We're all on the same wavelength. Otherwise, people are going to be giving different bits of advice. Then it becomes really, really confusing.

    Actually, working with coach I found really helpful in the case of cycling, for example. Speaking to the coach and saying, “Actually, can you give them some sessions which aren't such high intensity just for a while until we get the T3 recovered and this sort of thing.” You can't focus on just one thing. It's got to be the exercise, the nutrition and also recovery. I mean some of these people aren't taking a rest day. They're not having periodized training. There's plenty of things that you need to modify not just focusing on one particular thing. It's all got to be connected.

Tommy:    Absolutely, that makes perfect sense, so to say. The way you need to approach these things. As you mentioned, the levels of activities, whether reducing volume, reducing intensity obviously, because one of your main interests has been in bone density, are you talking about specific ways of doing some actual loading or weight training or some things trying to improve bone density in ballet dancers or cyclists? I guess that runs the risk of adding more training sessions again.

Nicky:    Yeah, exactly. I mean depending on the exact circumstance of the person. I mean any amount of training in that by the way also includes or just escalate loading stuff. It's not going to have its beneficial effect unless you've got the proper nutrition on board. It may be that we have to put that slightly on the back burner if we're trying to get someone to get out of energy deficits basically.

    The other point to mention, just a slight aside is, the person doesn't have necessarily be losing weight to be an energy deficit. Because they've already lost the weight and then their metabolism has, the dirt just didn't slow down. They can still be in energy deficit and not losing weight.  Anyway, just a point.

    Again, saying, “Stop all activity.” Because number one, it's very unlikely they're going to do that. Unless we're talking about the RED or the REDS CAT where we're talking about hospital mission and then you’re right, of course, they can. But generally, I'm very reluctant to do that because that's the incentive.

    “You can increase during training intensity and you can go to that summer dance school and all you can do, whatever, provided you just lower the intensity now and get the nutrition patterns in place. Then we're going to gradually increase the intensity.” That's what I did recently with the cycling coach, for example, about the specific bone loading stuff.

    I mean if the person is reasonable with their nutrition as they are, then I think actually all cyclists should be doing strengthening anyway off the bike. Strengthening and not just endless leg presses by the way.

    There's a nice study on some older guys in their 80s and just getting them to do I think it was about two lots of 10 hops per day improved the bone density. We're not talking dead lifts and things like that, by the way. Just even a little bit of hopping and things like that. But again, it will depend on the situation.


    If the person isn't at risk, then some low key strengthening like that would be appropriate. But obviously, you're right. You don't want to go charging in there with too much strength and conditioning. Otherwise, as you say, then you're just adding in another training session. You would just have to play that a little bit by ear.

    But ideally, rather than doing an extra whatever it is, like session run, session whatever, then actually replace that with a strength and conditioning, one, you see? Because that's actually going to be more helpful than the multidirectional loading of the bone like you mentioned, extra loading, and all that, to a bone density. That's really useful. It's just a case of playing it by ear according to the individual. But you're right. Don't get too enthusiastic. Oh, yes, you need to strength and conditioning because you're right. Then of course, these are driven people. They're going to start doing that every day.

    What I do is when I say, “I draw up a schedule.” I do it with the athlete. It’s like, “Okay, fine let’s decide. How many of these sessions you’re doing what are you doing?” One of them said, “Should I do it?” I said, “That's fine. You draw up the schedule you show it to me.” Then we come to an agreement. You see what I mean?

Tommy:    Yeah.

Nicky:    Playing it by ear like that, I think, is the good way round that.

Tommy:    Is there anything else that you would address in terms of early treatment or management that we haven't talked about?

Nicky:    Depending on what your blood tests have shown. I mean do you want to start talking about HRT? Is that where you're coming onto or not?

Tommy:    I was just wondering before we move on. Yes, can I ask about the timeline for recovery and HRT particularly in female athletes but it’s just where there was anything else that we had –

Nicky:    With the nutrition, well, listen. I think you’re very expert on that, Tommy, yourself about if there is specific nutritional elements that need addressing. Although I find in general, even though the person might not be eating enough in terms of calories, actually they're probably taking loads of supplements. Actually, yes, quite. Actually, normally, their vitamin D is fine, their Ferritin is fine because they're taking load and loads of multi-vits. Normally, generalization I know.

    But, of course, make sure all the basics are right and that their vitamin D is up to scratch and the Ferritin -- especially in the female athletes or the other hematinics and everything -- is in order. The other thing, the type of nutrition, of course, high-density nutrition. There's plenty of things. You can make it yourself with plenty of things on the market, sport and nutrition with high protein and all things. There's plenty of resources out there.

Tommy:    Yeah. Let's get on to the timelines. The first thing I want to know is in your experience. How long does it take to recover? I mean, obviously, the answer will be it depends. But in general terms, if you make good progress, adjusting activity patterns and eating patterns, what timeline might we expect to get a reasonable recovery?

Nicky:    Well, obviously it depends on the starting point. How much in energy deficit you are? But the early signs of recovering at is at least the T3 is starting to be the short-term energy availability is improving. Then gradually all the other hormones will start to reboot and hopefully the reproductive axis as well. We're talking several months for all of this.

    In terms of bone health process, a much longer process, I mean at least a year. I wouldn't recommend repeating a DEXA. Say you've had a DEXA scan and say that your score is less than minus one, as per the amber category of REDS, then there's no point repeating that DEXA for at least another year. Because it might not change and then actually it might be a bit of a disappointment to the athlete if they've been trying hard and whatever. We're talking several months, maybe years. Also -- I don't like to be depressing but -- maybe never.

    Tommy, if you remember my retired dancer study, some of them still had significant negative Z-score of the lumbar spine. All you can do is do your best.

    But I think everyone likes fast results, let's be frank. If this was a magic thing, “Okay, you do this for a day. Then everything is back to normal.” Then of course, everyone would do that. But the body isn't like that. It takes a much longer for things to reboot especially the endocrine system.

    But there are positive stories out there that actually some other studies have shown that bone density can recover fully. But it’s just really giving the athlete, the incentive. It's like, “This will improve.” But also, when you start feeling better, you won't realize that there was a problem until you start feeling better. That's always the tricky thing, to convince them.


Tommy:    Okay, well, that's emphasizes it’s going to take some time. You might see thyroid function improve first. Then the second, it’s going to take longer than bone health. It can take even longer.

Nicky:    Exactly, it’s a stepwise thing.

Tommy:    I wanted to ask about HRT or bioidentical hormone replacement therapy, particularly in female athletes who are still of reproductive age, who maybe want to continue to perform in their sport particularly. Others may want to give it up but still need some help. Maybe recovering hormone function or they never seem to recover a normal cycle or normal part of hormone production.

    I’m just wondering about your experience with that. We have certainly seen people do that. Often the experience hasn't been entirely positive. I know some people have seen positive benefits. I'm wondering how you might approach that? I also worry that if somebody maintains an energy deficit and then you just medicate the hormones on top, you're not really doing them any favors. Could you give us your thoughts on that process?

Nicky:    Yeah, sure. Well, I'm glad you're saying HRT. Just to emphasize to everyone, there is no place for oral contraceptive pill for female athletes with hypothalamic functional amenorrhea, which we're all talking about in REDS. No, basically. It doesn't have any bone protective effect.

    Actually, there's even evidence to show that it actually might even make it worse by suppressing IGF-1, which is important for bone health. Also, the other thing is that you should’ve alluded to it, a masking agent, the oral contraceptive pill. Because there's also people who use to say, “Oh, yes. I'm having a period now.” That's not a period on the oral contraceptive pill. It’s a withdrawal bleed. That’s not a period. That’s not your own hormone. Anyway, that bee in my bonnet--

Tommy:    That’s important.  

Nicky:    It is important because until relatively recently that was still being given a slight, “Oh, here you are. You can have your periods.” It's like, “Those aren’t periods.” Anyway, if there is any hormone therapy to be given, the only appropriate one would be HRT for a female athlete and that would have to be both estrogen and progesterone, obviously, not estrogen alone because of the increased risk of uterine cancer. But you're quite right. You had to be a little bit careful there because it's not a long-term solution, taking HRT.

    What's the rationale for giving HRT? Well, in my experience there are two reasons. Number one, it may be in a young athlete who hasn't yet reached menarche. Athletes in their 20s who haven't yet reached menarche. If actually it's because their puberty is delayed and they got very small ovaries. Then actually giving unusually some unopposed estrogen for a few months and then adding in the progesterone. You would be giving HRT in that situation to complete puberty. That would be one scenario where it will be justified.

    The other scenario would be where there's a serious health issue i.e. bone density really, really bad and lots of stress fractures and things like this. Maybe even like we’d mentioned, the adverse lipid profile, something like that. Basically, someone where you're really worried that if they carry on having no estrogen, it's going to be a serious health risk to them.

    But, by the way, even in those two scenarios, that's not a replacement for correcting the low energy availability. That has to be done in conjunction with sorting out the nutrition, which is what I've just recently done with, for example, in the dancer who hadn't yet finished and had arrested puberty. The deal was “Yes, you have this HRT but you got to work on nutrition.” Indeed, she is.  Those would be the situations where you would consider giving HRT.

    But the main thing is, like you say, it's not the underlying cause. It would only be in conjunction with addressing the nutrition. Then it's not the long-term solution. With a view to stopping the HRT after whatever the duration is you decide on. Whether it's just a couple of months or a bit longer, until the person has maybe put on some weight and got the nutrition going so that you hope that when you stop the HRT they're going to be in a good situation to start their periods again.

Tommy:    The last topic that I wanted to cover was gut health in athletes. We know that people who have REDS certainly have a high frequency of gut issues. Even some of the questionnaires, which are trying to assess energy availability like the Leaf Q in female athletes, as a whole section of question on gut function. We maybe talk about your experience of GI symptoms in athletes with REDS and what you think some of the mechanisms might be?  


Nicky:    Sure, you're probably more the expert than me on the gut but we definitely should mention it nevertheless. Because it is one of those systems that is potentially affected in the REDS model. That's important. As you quite rightly say, the questionnaire, the Leaf questionnaire for example, puts a lot of emphasis on the gut issues. Like I mentioned, it's counterintuitive sometimes that you would have thought someone eating loads of fruit and vegetables and not much else, would have very regular motions. But actually, they're more prone to constipation, these athletes.

    Now, why these GI symptoms? Well, I was thinking about that. I was thinking that there's probably the physical aspects and then the more endocrine aspect. The physical aspects, for example, if you're an endurance athlete, you're more likely to get the leaky gut, the reperfusion injury; therefore, the tight junctions are less, the integrity is lost. You get some leakage -- as the name suggests -- of stuff in the gut that isn't meant to go through into the blood. That increases inflammation, problems like that. That's the physical aspect.

    But of course, that's not limited to athletes with REDS. It could be any athletes. But still we've got to put that, throw that in there.

    But also, the endocrine mechanisms, I mean, there's a whole of host of hormones involved in the gut, particularly, interestingly, the one which is responsible for feeling hungry, Ghrelin, the hungry hormone. Because when you got intentional REDS, you restrict your nutritional intake. Actually, your Ghrelin levels will be really high. But you try and ignore that. It's very difficult for the athlete then to reprogram that.

    I've had lots of athletes say to me “It's so difficult. I don't know when I'm hungry. I don't know if I need to eat this food.” Which is why when I said that talking about how to help someone get back on track, getting them into a routine again with their nutrition. You almost do have to do it, set the routine again because they can't rely on their own mechanisms for detecting when they're hungry.

    The other thing we should mention of course when we're talking about gut nowadays is the microbiome, the gut microbiota. But I think your super glued up on that. But what I'm trying to say is that all these factors: the physical factors, the endocrine issues, the microbiome disruption, all of these things cause GI problems in REDS. Maybe I can pass the question back to you, Tommy, what do you reckon?

Tommy:    Yeah, I've actually thought about this a lot recently. I think most of my thoughts are definitely lined up with what you've been saying. If you're doing a high intense exercise that can certainly directly damage the gut. It might affect your ability to digest certain things. You then become more intolerant of things like fiber. Low FODMAP diets has certainly helped some athletes with GI symptoms. That could be just because of the direct negative effects of lots of exercise on the gut.

Nicky:    Yeah, physical things.

Tommy:    Yeah, the physical things. There's certainly the potential that if you're then intolerant to a certain food and eating becomes very uncomfortable because you get bloating or gastric constipation, then actually you avoid food because of the symptoms. You end up with a deficit that way. The hormones are also super important. Even estrogen in the gut is very important for the integrity of the lining of the gut. It could be other hormones; the sex hormones that we talked about.

    Then if you're in an energy deficit, I imagine that the high turnover cells in the body like those on the gut are going to be the ones that’s going to suffer first.

Nicky:    That’s a very good point. Exactly. Also, you need a lot of energy to digest and assimilate and all that stuff. You need energy to actually get all that food onboard and do stuff with it. If you haven't got the energy available, like you’re saying, not only the cell turnover of the gut lining, but actually processing that food that you just haven't got the spare energy to do that. It's one of those processes that is affected.

    You're right, it's a vicious circle now. The person isn't eating. Therefore, the normal digestive processes, and all the microbiome et cetera, et cetera, that's all affected. Now, they can't even absorb that, the food that they are eating. So it's a vicious circle.

    Also, that FODMAPs thing is true. I've had several athletes who have been put on that. You're right. At first that does help. But in the long term, actually, then it just feeds into their anxiety about eating. Now, they're restricting it down to these foods. Actually, you need to start reintroducing some of this more high-energy density foods and things, which aren't on FODMAPs. But the person is now anxious that they can't deal with it. Actually, they may not be able to. It's true. Yeah, it’s a tricky one. It's a vicious circle really.

Tommy:    That's a great point you just made there, which is these dietary changes. Things like a low form of diet or something else that will initially help with symptoms.


Nicky:    Yeah, they do.

Tommy:    It's not a long-term solution. You always should be trying and say reintroduce foods, as diverse as possible, get as many calories back as possible. Yes, there are lots of different things we can manipulate. But just like with the hormones, just like with everything else, none of it is a long-term solution. That's a great point that you finished on. I think that's the perfect place to wrap up.

    I'm certain that people will be very interested to read more of your work. You have a lot of blogs on the British Journal of Sports Medicine blog and also your published articles. You have a website. Maybe you can just tell people where they can find more of your work and maybe find or whether can anticipate the results of your upcoming studies.

Nicky:    Sure. Well, my website -- maybe you can post it for me, Tommy, to people -- it’s On there, it's got who I am, what I'm doing. I mean it goes through some of the stuff we discussed and also links to the blogs I've written.

    Or if you want to go direct onto BJSM, British Journal Sports and Exercise Medicine or onto the website of BASEM, British Association of Sports and Exercise Medicine, they also published some of my blogs there as well. You can look at things like that.

    Well, I'll keep you posted on hopefully getting -- fingers crossed and all that -- the cycling study published. But on my website, there's links to the previous things that I’ve published on the dancers. There's also some stuff on growth hormone and things like that. If you want to look at that in more detail, that's there.

    Oh, the only other thing to highlight is that I'm working with BASEM to produce an online educational resource for REDS. Open access to everybody, whether you’re an athlete, a doctor, a teacher, a coach, whatever, parent. That's coming soon.

Tommy:    Fantastic.

Nicky:    I'm just putting that together now. I hope that that will be available in the next few months. It will be some of the stuff we've discussed and also, of course, always looking with a new website for feedback on it. People making comments, criticisms, that's all welcome. That will be coming soon, I hope.

Tommy:    We'll link everything that is currently available. Then once your studies are out, your data has published, we'll have you back. Then, hopefully, that resource will be available too.

Nicky:    That will be fab. Yeah, really great.

Tommy:    A whole new set of things that people can look at. This has been really great. I really, really enjoyed this, Nicky. Thank you so much for your time.

Nicky:    No, listen. Absolutely, my pleasure, Tommy. Thanks to all the listeners for listening. I look forward to discussing more in the future.

[1:02:42]    End of Audio

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