Authors:

Samantha Sharp, Roni Mashiach-Fransis, Nicola Keay and Adrian Slee. Division of Medicine, University College London, UK

REDs is a condition characterised by low energy availability, which affects both male and female athletes of all levels and ages. It has wide-ranging negative effects on all bodily systems and can compromise health, especially in the long term.(1)

Low energy availability (LEA) underpins REDs – a multisystemic syndrome impacting athletic performance and overall health. (1) Despite its prevalence, research examining clinical REDs indicators in female runners is limited. This study investigated the relationship between REDs screening, bioelectrical impedance assessment (BIA) of malnutrition and ovulatory status in female endurance runners using an energy availability questionnaire (EAQ), (BIA) and female reproductive sex hormone levels.

Seventy female runners from London running clubs participated in this study, with a median age of 32 years old. 64% of young adults (YA) and 29% of mature adults (MA) were identified as being at significant risk of REDs. BIA measurements indicated that 19% of YA and 50% of MA had fat-free mass index (FFMI) below the ESPEN clinical malnutrition cut-off point of 15kg/m. (2) Overall, 82% of the participants had FFMI below the suggested 20th percentile for female athletes in weight-sensitive sports. In YA, REDs risk was significantly increased in FFMI 5th percentile and associated with lower fat mass index (FMI).

REDs is prevalent in female runners, regardless of age. BIA indicators of malnutrition, including FFMI, FMI and phase angle (PA) may function as useful and novel clinical indicators of REDs in female runners. Low FFMI was highly prevalent in MA runners. REDs risk in female runners is closely related to ovulation status and may be quantified using the Dance Energy Availability Questionnaire (DEAQ) framework, modified for use in female runners.(3) The study has not only contributed to the growing recognition of subclinical malnutrition and hormonal disruption in female athletes but also reinforced the need for more sex-specific research and intervention strategies.

This research on Relative Energy Deficiency in Sport has highlighted a significant gap in the way female endurance athletes are assessed and supported. This study not only contributed to the growing recognition of subclinical malnutrition and hormonal disruption in female athletes but also reinforced the need for more sex-specific research and intervention strategies.

The research supported and extended the pioneering work being done at UCL by Dr Adrian Slee and Dr Nicky Keay, whose research has been instrumental in positioning REDs as a critical issue in sports medicine and nutrition. Their work has emphasised the clinical relevance of early screening tools and the need for multidisciplinary approaches, which this project echoed and built upon in a practical setting.

Roni Mashiach-Fransis: "This research highlighted how underrepresented female-specific health issues still are, even in elite athletic contexts. This realisation reinforced my passion for women’s health and motivated me to pursue a career as a nutritionist dedicated to this field. As a result, I founded Nutrition for Women London, a nutrition consultancy focused on supporting women across all life stages. I believe this area of research must continue to evolve, and I remain committed to being part of that movement, both in practice and in advocacy."

Sam Sharp: "As an avid runner and rower at university, this project was close to my heart. Its findings confirmed a lot of what I have observed over the years among fellow athletes - many faced health consequences characteristic of REDs, and yet, this was left undiscussed. Engaging in this research equipped me with the skills and experience necessary to undertake a Master's program in Nutrition and Exercise Physiology at Columbia University. Going forward, I am excited to continue research in REDs and hope to empower female athletes with stronger, evidence-based guidance in my future clinical practice."

1. Loucks AB, Kiens B, Wright HH. Energy availability in athletes. J Sports Sci 2011 Jan;29(sup1):S7e15. https://doi.org/10. 1080/02640414.2011.588958.

2. Cederholm T, Bosaeus I, Barazzoni R, Bauer J, Van Gossum A, Klek S, et al. Diagnostic criteria for malnutrition e An ESPEN consensus statement. Clin Nutr 2015 Jun;34(3):335e40. https://doi.org/10.1016/j.clnu.2015.03.001.

3. Keay N, Overseas A, Francis G. Indicators and correlates of low energy availability in male and female dancers. BMJ Open Sport Exerc Med 2020 Nov;6(1):e000906. https://doi.org/10.1136/bmjsem-2020-000906.