performance – Dr Nicky Keay

Personal Energy Availability Questionnaire (PEAQ)

12 April 2025

If you are striving to reach your peak performance, then the PEAQ can help you reach your personal full potential. Click here to get started on the PEAQ

Matching your energy intake to your energy demands helps you reach your personal peak health and exercise performance. On the other hand, failing to meet your energy demands results in low energy availability. This increases your risk of developing relative energy deficiency (REDs) and its adverse health and performance consequences.

People of any age, whatever their level and type of exercise, can be at risk of developing REDs; from elite dancers and athletes to recreational exercisers.

The PEAQ is a mobile Application that will guide you through a series of questions about exercise, physical characteristics, nutrition, hormone function and well-being. It just takes a few minutes.

Your PEAQ report instantly generates a REDs Risk Score and provides valuable insights into your energy status and potential risks, along with guidance. The PEAQ is intended for those 16 years of age and over.

The PEAQ has been developed based on in several published research studies where the questionnaire responses and scores have been correlated with measurements of hormones and bone health in athletes in various sports [1-7] and dancers [8-12]. These questionnaires were cited in the updated International Olympic Committee (IOC) consensus statement on REDs 2013.

However the PEAQ it is not a substitute for seeking medical advice. Dr Nicky Keay offers personalised health advisory appointments

Get started on your journey to reach peak performance by completing the PEAQ.

References

Keay, Francis, Hind Low energy availability assessed by a sport-specific questionnaire and clinical interview indicative of bone health, endocrine profile and cycling performance in competitive male cyclists BMJ Open Sports and Exercise Medicine 2018
Keay, Francis, Hind Clinical evaluation of education relating to nutrition and skeletal loading in competitive male road cyclists at risk of relative energy deficiency in sports (RED-S): 6-month randomised controlled trial BMJ Open Sports and Exercise Medicine 2019
Keay, Francis, Hind Bone health risk assessment in a clinical setting: an evaluation of a new screening tool for active populations MOJSports Medicine 2022;5(3):84-88. doi: 10.15406/mojsm.2022.05.00125
Assessment of Relative Energy Deficiency in Sport, Malnutrition Prevalence in Female Endurance Runners by Energy Availability Questionnaire, Bioelectrical Impedance Analysis and Relationship with Ovulation status. Clinical Nutrition Open Science 2025S.
Body composition, malnutrition, and ovulation status as RED-S risk assessors in female endurance athletes, Clinical Nutrition ESPEN 2023, 58 :720-721
Keay N, Craghill E, Francis G Female Football Specific Energy Availability Questionnaire and Menstrual Cycle Hormone Monitoring. Sports Injr Med 2022; 6: 177
Keay N. Current views on relative energy deficiency in sport (REDs). Focus Issue 6: Eating disorders. Cutting Edge Psychiatry in Practice CEPiP. 2024.1.98-102
Keay N, Francis G, AusDancersOverseas Indicators and correlates of low energy availability in male and female dancers. BMJ Open in Sports and Exercise Medicine 2020
Nicolas J, Grafenuer S. Investigating pre-professional dancer health status and preventative health knowledge Front. Nutr. Sec. Sport and Exercise Nutrition. 2023 (10)
Keay N, Francis G. Longitudinal investigation of the range of adaptive responses of the female hormone network in pre- professional dancers in training March 2025 ResearchGate DOI: 10.13140/RG.2.2.30046.34880
Nicola Keay, Martin Lanfear, Gavin Francis. Clinical application of monitoring indicators of female dancer health, including application of artificial intelligence in female hormone networks. Internal Journal of Sports Medicine and Rehabilitation, 2022; 5:24.
Nicola Keay, Martin Lanfear, Gavin Francis. Clinical application of interactive monitoring of indicators of health in professional dancers J Forensic Biomech, 2022, 12 (5) No:1000380
Mountjoy M, Ackerman KE, Bailey DM et al 2023 International Olympic Committee’s (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs) British Journal of Sports Medicine 2023;57:1073-1098
Keay N “Hormones, Health and Human Potential: A guide to understanding your hormones to optimise your health and performance” Sequoia books 2022

The state of play on relative energy deficiency in sport (REDs)

2 October 2023

Long-term low energy availability leads to adaptive changes throughout the body resulting in the clinical outcomes of REDs

Earlier this week the updated consensus statement from the International Olympic Committee (IOC) on relative energy deficiency in sport (REDs) 2023 was published in the British Journal of Sport Medicine (BJSM)[1]. What are the key points from the range of papers presented in this issue dedicated to REDs?

What’s in a name change?

Making “s” lower case is helpful as relative energy deficiency is not limited to those involved in sport. You can still be at risk of REDs even if you would not consider yourself an athlete; rather “just” someone that does regular exercise. Furthermore, most genres of dance are not sport, yet dancers are another group who can be at risk.

Time scale of low energy availability

The type of adaptive responses to low energy availability is dependent on the temporal component of this energy deficient. Energy availability is the amount of energy “available” once demand from exercise has been accounted for. If this available energy is not sufficient to maintain all the “housekeeping” physiological processes, then the body will respond by going into “eco” mode and down regulating body systems[2]. A small, short-term energy deficit may not be problematic. We have all been in situations where eating patterns don’t go according to plan. For example, a particularly busy time at work, disruption to travel plans, or lack of food availability.

However, sustained, cumulative energy deficit can lead to progressive adaptation shown in the figure.

These adaptive changes across many body systems have adverse outcomes on both health and performance. This is REDs. The clinical syndrome of health and performance consequences of long-term low energy availability. This is what happened in our study of male cyclists referenced in the BJSM publication. We quantified the negative effects of low energy availability on hormone networks, bone health and performance in male cyclists[3]. Those cyclists in low energy availability lost bone mass commensurate with an astronaut in space for 6 months and underperformed in races[4]. This negative impact of low energy availability on performance was underlined in our other studies of male athletes, referenced in the IOC papers [5,6]. Ultimately these are particularly important findings for athletes and their coaches, where performance is the priority.

Menstrual cycles

This concept of a gradated adaptive response to the combined effects of training load, nutrition and recovery can be applied when considering the spectrum of reproductive axis responses in female athletes and dancers, ranging from eumenorrhoea, subclinical ovulatory disturbances to functional hypothalamic amenorrhoea[7] shown in figure of Subclinical Ovulatory Disturbance. Functional hypothalamic amenorrhoea (FHA) is potentially just the tip of the iceberg when it comes to adaptive change to low energy availability. Report of menstruation and even signs of ovulation, may belie suboptimal production of progesterone. As progesterone increases metabolic rate, low production could be considered an early response to low energy availability. This hypothesis is currently being tested in a study of dancers, funded by the British Association of Sport and exercise Medicine.

Carbohydrate availability

Although we talk about low energy availability, the updated IOC consensus statement highlights that carbohydrate availability is the key. This is based on evidence that carbohydrate is the main substrate for exercise above a certain intensity. Furthermore, the hormones of the reproductive axis are particularly sensitive to carbohydrate availability. The IOC statement highlights studies, where despite isocaloric diets, those low in carbohydrate resulted in hormone disruption and poorer athletic performance outlined in the statement.

Health is essential for performance

Another important theme is that optimal health is a prerequisite for performance. This includes both physical and mental aspects of health. Many of the psychological characteristics of athletes and dancers can predispose individuals to developing REDs. For example, although dedication, perfectionism and motivation are laudable qualities, these can spill over into behaviours around training and nutrition. This can be associated with exercise dependence and disordered eating patterns.

If an individual is anxious about body shape, weight and food, this can have a negative health outcome. For example, in our study of dancers[8], quoted as a reference in the updated IOC statement, we found that there were significant relationships between anxiety about controlling weight and eating and missing training, and physical outcomes of low BMI and physiological health in terms of lack of regular menstrual cycles. Regular menstrual cycles in women are a barometer of internal healthy hormones. Similarly in another referenced study, we found that cognitive restraint in male athletes had an adverse effect on hormone profiles[9]. How you think impacts hormone health. This interaction is shown by the reversible arrow between psychological factors as both a driver and result of REDs shown in the updated REDs health conceptual model.

Weighty matter

Weight is a measurement of gravity, not athletic potential. Being a certain weight or body composition does not guarantee athletic success. This fact was emphasised by the lead author of the special edition on REDs on the BJSM podcast. Realistically most types of exercise will involve overcoming gravity, nevertheless, there comes a tipping point where being too light weight and/or having too low body fat means being unhealthy and compromising both physical and mental performance. Furthermore, we are all individuals so our personal optimal weight and body composition will be personal to each of us. Not the generic “lighter is faster”.

Identification

Ultimately low energy availability is a concept and not measured outside of research settings. Rather, making a diagnosis of REDs is a diagnosis of exclusion. In other words, other potential medical conditions must be excluded. This can be achieved through a process of identifying those at risk with energy availability questionnaires, followed by assessing clinical symptoms and signs: such as growth trajectories in young athletes and menstrual status in female athletes and dancers. Readily available and reliable investigations such as blood tests and DXA scans are outlined. These clinical findings have been presented as primary, severe indicators (hypothalamic reproductive disruption in men and women), primary indicators, secondary indicators and other supportive factors.

When considering hormone tests is really important to emphasise that even if a result is not out of range, where the result lies in the range is crucial. Together with considering hormones as networks providing a pattern that is informative. For example, in correctly identifying subclinical down regulation of the thyroid or reproductive axis[2].

Risk stratification

Each of indicators described in the consensus statement carries a score, so that an individual can be risk stratified. The REDsCAT2 has a finer grained zone compromising of green, yellow, orange and red, replacing the 3 zoned traffic light system.

Clinical management

Ultimately as the underlying aetiology of REDs is low energy availability, then the aim of supporting an individual experiencing REDs is to restore sufficient energy availability through a combination of nutrition and possibility reducing demand from intense training. As this will involve behaviour change, this can be challenging and a multidisciplinary team approach is advised. Highlighted for female athletes experiencing functional hypothalamic amenorrhoea (FHA) and associated poor bone health, that the combined oral contraceptive pill is not advised. Rather for bone protection in the short-term HRT (transdermal oestradiol and cyclic micronised progesterone) is recommended in line with updated NICE guidelines in UK[10].

The risk of low energy availability and REDs in dancers will be dicsuused at the forthcoming British Association of Sports and Exercise Medicine annual conference 6/10/23. https://health4performance.basem.co.uk/

References

1 An update on REDs IOC consensus statement 2023 British Journal of Sports Medicine September 2023 https://bjsm.bmj.com/content/57/17?current-issue=y

2 Keay N. Hormones, Health and Human Potential Sequoia books 2023

3 Keay N, Francis G, Hind K Low energy availability assessed by a sport-specific questionnaire and clinical interview indicative of bone health, endocrine profile and cycling performance in competitive male cyclists. BMJ Open Sport Exerc Med 2018;4:e000424. doi:10.1136/bmjsem-2018-000424

4 Keay N, Francis G, Entwistle I et al Clinical evaluation of education relating to nutrition and skeletal loading in competitive male road cyclists at risk of relative energy deficiency in sports (RED-S): 6-month randomised controlled trial BMJ Open Sport & Exercise Medicine 2019;5:e000523. doi: 10.1136/bmjsem-2019-000523

5 Jurov I, Keay N, Spudić D et al Inducing low energy availability in trained endurance male athletes results in poorer explosive power. Eur J Appl Physiol 2022;122:503–13. doi:10.1007/s00421-021-04857-4

6 Jurov I, Keay N, Rauter S Reducing energy availability in male endurance athletes: a randomized trial with a three-step energy reduction. Journal of the International Society of Sports Nutrition 2022;19:179–95. doi:10.1080/15502783.2022.2065111

7 Keay N. Interactions of the female hormone network, exercise training and nature of adaptation. ResearchGate. June 2023 DOI: 10.13140/RG.2.2.28787.71204

8 Keay N, Overseas A, Francis G Indicators and correlates of low energy availability in male and female dancers. BMJ Open Sport ExercMed 2020;6:e000906. doi:10.1136/bmjsem-2020-000906

9 Jurov I, Keay N, Hadžić V et al Relationship between energy availability, energy conservation and cognitive restraint with performance measures in male endurance athletes. J Int Soc Sports Nutr 2021;18:24. doi:10.1186/s12970-021-00419-3

10 British Association of Sports and Exercise Medicine 2023 ‘Concerning’ lack of awareness of how best to reduce risk of stress fractures in female athletes and dancers, a year after change in NICE guidelines” https://basem.co.uk/concerning-lack-of-awareness-of-how-best-to-reduce-risk-of-stress-fractures-in-female-athletes-and-dancers-a-year-after-change-in-nice-guidelines/

Different Facets of the same Underlying Imbalances in Athlete Behaviours

11 April 2023

The Masques of Unbalanced Athlete Behaviours

Although relative energy deficiency in sport (RED-S) and overtraining syndrome (OTS) are often described as distinct entities, these can be considered as different facets of the same unbalanced behaviours. For an exerciser these behaviours consist of exercise training load, nutritional intake and recovery.

What is RED-S?

RED-S is a clinical syndrome describing adverse consequences in terms of health and performance due to sustained low energy availability (LEA). LEA is where there is a mismatch between energy intake and the combined energy demand from exercise and resting metabolic rate.

What is OTS?

OTS is a clinical syndrome describing adverse consequences in terms of health and performance when there is sustained non-functional overreaching (NFOR). NFOR is where there is an imbalance between training load relative to recovery.

It’s all about time scales

Thinking about RED-S and OTS in more detail, neither suddenly occur overnight. Rather it is the cumulative effect of energy deficit, or lack of recovery, that causes these syndromes over longer time scales of months.

Short time scales

Facets of LEA and NFOR

For example, the occasional day of suboptimal fuelling/high energy demand, with accompanying relative low energy availability, although not ideal, is nevertheless recoverable. This is shown by the warning masque of LEA of the rotating cube. On the opposite side is the warning masque of NFOR, where there have been some occasions of insufficient recovery over a short time scale of days. As with LEA, this is potentially a recoverable situation.

Longer time scales

Facets of RED-S and OTS

In practical terms, imagine you have been on a training camp or a dance intensive over a week or two. You may have unintentionally incurred a degree of LEA and NFOR, but if you take some time to rest and refuel afterwards, then you will be able to resume usual training fitter and stronger. On the other hand, if you continue to try and train at high intensity, in relative energy deficit you will progress after more weeks and months into the alert red masques of OTS and RED-S. In each case these outcomes are different facets of the same underlying imbalances in athlete/dancer behaviours around training load, nutrition and recovery.

Practical implications

When an athlete or dancer presents with symptoms that could include fatigue, poor sleep, menstrual disruption, recurrent injury (soft tissue or bone), digestive issues and other issues; it is very important to exclude medical conditions. Once this has been done and a diagnosis of exclusion made to confirm a functional issue, then deciding whether to use the terminology RED-S or OTS has a subtle nuance because in practice these syndromes are facets of the same underlying imbalance in athlete behaviours. In all cases the most important aspect is to outline a course of action for the athlete that includes training load, nutrition and recovery, in combination.

Athlete and dancer support

For example, athletes experiencing RED-S often ask if they can restore healthy hormone network function by simply eating more while maintaining a high training load. The simple answer is that this makes recovery less certain as a high training load, specifically high intensity, will most likely mean there is also a degree of NFOR. Therefore, adjustment in all athlete behaviours in synchrony is more effective for health and performance restoration. Similarly in an athlete experiencing OTS, in addition to reduction in training load, optimising nutritional intake will help.

Prevention is always better than cure

The prevention of adverse outcomes for the athlete or dancer is the other important practical implication of considering these clinical syndromes as facets of the same underlying issue. From the rotating cube of unbalanced athlete behaviours, LEA is the precursor to RED-S. Similarly, NFOR is the precursor to OTS. The progression in each case being determined by a longer time scale. Early identification of those at risk is essential to prevent this negative progression. Reversing the situation is a far easier task physiologically and psychological at an early stage of LEA and NFOR, rather than once in a “deeper hole” of RED-S or OTS.

Conclusions

RED-S and OTS being different facets of the same underlying issues of unbalanced athlete behaviours is a concept with practical implications.

References

Keay N. Hormones, Health and Human Potential. 2022 Sequoia books Act 1 Scene 9 “A Balancing Act” and Act 1 Scene 10 “In the Red”.

“Sleep is the chief nourisher in life’s great feast”

17 January 2023

Macbeth, Shakespeare

At the start of every year there is always a lot of talk about refraining from certain activities like drinking alcohol, advice about eating a particular way, or recommendations to do certain types/amount of exercise. Trends in these lifestyle choices may come and go, but there is one behaviour that remains constant to achieve optimal health. Sleep.

In my book “Hormones, Health and Human Potential: A guide to understanding your hormones to optimise your health and performance” I discuss how our lifestyle choices and behaviours around sleep, exercise and nutrition influence hormone networks and consequently our health.

Illustration from “Hormones, Health and Human Potential”

Sleep for hormone health

Why is sleep such an essential component for health? Although being asleep is a physical state of inactivity, it is when many hormone networks are at their most active. For example, one of the main stimuli for growth hormone (GH) release is sleep. Despite its name, GH is not just about growth in children. All adults continue to produce GH and this is an important anabolic (tissue building) hormone. GH maintains a healthy body composition: favouring muscle over fat deposition. GH also plays a role in bone health.

Sleep for fitness

Another stimulus for GH release is exercise. However, you don’t get fitter in real time while you exercise. You get fitter when you are asleep. After stopping exercise and during sleep these two combined stimuli for GH release drive the positive adaptations to exercise. Sleep enables you to become citius, altius, fortius.

Sleep for sex steroid hormone networks

Sleep is also essential for other hormone networks, such as those of the reproductive axis, in both men and women. Studies show that men who have reduced sleep tend to have lower levels of testosterone and poorer bone health. Essentially if you do not have sufficient quality and quantity of sleep this has a negative effect on many aspects of both physical and mental health.

Sleep for metabolic health

Hormones that control appetite and satiety are linked with the sleep/wake cycle. People who have disrupted sleep patterns are more likely to struggle with blood glucose and weight control.

Timing of sleep

The timing of sleep is also important. Hormone networks run on a variety of internal biological clocks, known as biochronometers. The trick is to try and synchronise the timing of your behaviours with these internal biochronometers. If you have an “scheduling conflict” between external and internal clocks, this leads to a situation of circadian misalignment. Circadian misalignment can lead to many adverse consequences on mental and physical health, including metabolic and cardiovascular health. This negative combination can lead to metabolic syndrome which increases the risk of type 2 diabetes mellitus, cardiovascular disease and high blood pressure.

Consequences of disrupted sleep patterns

Shift workers, for example junior doctors, are at risk of developing circadian misalignment. Disrupted sleep patterns, clashing with internal hormone timing becomes a vicious circle. Poor sleep interferes with the diurnal variation of cortisol, which peaks as an awakening response. Disruption of this cortisol awakening response can disrupt subsequent night sleeping.

A degree of circadian entrainment is possible. In other words, our hormone clocks can adapt to slight changes in sleeping patterns. For example, getting up early for exercise training. It is also possible to reset internal biological clocks, as we do after a long-haul flight. This is because in our brain we have a biological light sensor which has direct communication with the manager of the hormone orchestra, conveniently situated in very close proximity in the brain. The timing of daily hormone release can be reset to correspond with local night and day timing. This contrasts to the situation of doing shift work, where you are continuously in conflict with night/day timing and internal hormone clocks.

Top tips for sleep to optimise hormone health

So, if there is one behaviour that you are going to improve this year, it should be sleep.

Sleep hygiene is the term used to cover strategies to ensure a good night’s sleep. One of the tops tips is to try and go to bed at a regular time, before midnight. A recent study shows that is these hours before midnight that are particularly valuable for hormone health. In fact, it is useful to set an alarm for going to bed.

Another strategy to help sleep is finding a bedtime “wind down” routine that suits you. For example, reading or listening to music. Looking at mobile electronic devices is not one of these. The reason being that the light emitted from these devices prevents the production of the sleep hormone melatonin.

When it comes to hormone health, sleep is indeed the chief nourisher. Sleep and other lifestyle choices to harness hormones for optimal health, through life, are explored in detail in “Hormones, Health and Human Potential: A guide to understanding your hormones to optimise your health and performance”.

Next steps

“Hormones, Health and Human Potential: A guide to understanding your hormones to optimise your health and performance” is available in paperback and Kindle (illustrations in colour) from Amazon and direct from Sequoia books (ship overseas)

Hormone Health advisory appointments are available

Presentations and workshops

Hormones, Health and Human Potential

25 November 2022

“Hormones, Health and Human Potential” explains how hormones play a crucial role in determining health. Hormone networks provide the feedback mechanism by which our lifestyle and behaviours enable us to reach our personal potential.

Introduction

Over 2,000 years ago Hippocrates advocated that the “safest way to health” was through “the right amount of nourishment and exercise” for “every individual”. As it turns out Hippocrates was way ahead of his time in articulating the principles of personalised and preventative medicine.

Hormones as the missing link to health

Although Hippocrates understood that lifestyle and behaviours are key to health, he did not know why. We now know that hormones are the key players in this vital role. Hormones are instigators in bringing our DNA to life by determining gene expression. Hormones direct the production of proteins, in the optimal amounts and at the right time. Hormones work as networks to maintain mental and physical health.

Lifestyle factors influencing health through hormones networks

Complex internal negative feedback loops between hormones and the biological variables that they regulate, enable homeostasis for good physiological function. Challenges to homeostasis, due to our interactions with the environment are detected by the hypothalamus, which manages hormone network response. In this way there is another layer of feedback loops between lifestyle behaviours and hormones.

Well-balance lifestyle behaviours, in terms of quantity and timing, support healthy hormone network function, leading us to the “safest way to health”. Conversely, circadian misalignment, where lifestyle choices conflict between internal biochronometers, can lead to hormone dysregulation found in conditions such as metabolic syndrome.

Harnessing hormones as preventative and supportive medicine

A good balance of lifestyle factors can harness hormones as a form of supportive and preventative medicine. This is particularly relevant for type 2 diabetes mellitus and metabolic syndrome. For women, where there are physiological changes in hormones, such as occurs at menopause, attendant symptoms and impacts on long term health can be mitigated by lifestyle as part of the management of menopause. For example, exercise has been shown to have a beneficial effect on temperature regulation, metabolism, body composition, bone health and reducing the risk of breast cancer.

Athlete performance mediated by hormones

Hormones mediate the positive adaptive changes due to exercise training. Understanding these mechanisms can benefit both athletes and patients .

Imbalances in behaviours causing hormone dysregulation

Too little exercise and excess nutrition can lead to hormone dysregulation, seen in metabolic syndrome and type 2 diabetes mellitus. On the other hand, too much of a “good thing” can also cause health and performance issues in exercisers. Relative energy deficiency in sport (RED-S) can occur in exercisers of all ages and levels, where there is either an unintentional or intentional mismatch between energy intake and energy demand. Consequent low energy availability causes hormone network disruption, which in the long-term results in adverse effects on both health and performance .

Conclusions

• Hormone network function plays an important role in mental and physical health
• Hormones are influenced by our lifestyle behaviours of exercise, nutrition and sleep
• The benefits of lifestyle behaviours are derived from the positive adaptive changes driven by hormones
• Imbalances in lifestyle behaviours can cause hormone disruption leading to adverse effects on health and exercise performance

References

Keay N. Health Hormones and Human Potential. Sequoia books. 2022

McCarthy O, Pitt J, Keay N et al Passing on the exercise baton: What can endocrine patients learn from elite athletes? Clinical Endocrinology 2022 96;(6):781-792

Keay N, Francis G Infographic. Energy availability: concept, control and consequences in relative energy deficiency in sport (RED-S) British Journal of Sports Medicine 2019;53:1310-1311.

Energy Availability: Concept, Control and Consequences in relative energy deficiency in sport (RED-S)

24 May 2019

Relative energy deficiency in sport (RED-S) is an issue of increasing concern in sports and exercise medicine. RED-S impact exercisers of all levels and ages, particularly where low body weight confers a performance or aesthetic advantage. Key to mitigating adverse health and performance consequences of RED-S is supporting athletes and dancers to change behaviours. These infographics aim to assist clinicians in communicating the concepts to exercisers and in implementing effective management of athletes in their care[1].

Figure 1 illustrates the concept of energy availability (EA) in RED-S. Preferentially energy derived from dietary intake covers the demands of training and the remaining energy, EA, is, quantified in Kcal/Kg of fat free mass[2]. In Figure 1, the central bar illustrates adequate EA in an athlete where energy intake is sufficient to cover the demands of training and fundamental life processes to maintain health. Conversely, low energy availability (LEA) is a situation of insufficient EA to cover basic physiological demands. LEA leads to the adverse consequences of RED-S[3]. LEA can arise unintentionally or intentionally, due to a mismatch between energy intake and energy requirement. In Figure 1 the bar on the left shows LEA resulting from reduced energy intake with maintained training load. On the right, LEA is a consequence of increased training load with maintained energy intake.

Figure 2 illustrates that EA is under the control of an athlete[4]. The three behaviours relating to training, nutrition and recovery determine EA. Integrated periodisation of these behaviours results in optimal health and performance. Conversely, an imbalance in these behaviours results in suboptimal functionally. LEA in the case of high training loads relative to nutritional intake. Thus, this figure reinforces the important point in the IOC statements on RED-S that psychological factors which determine these behaviours are key in both the development, continuation and management of RED-S[2,3].

Figure 2 also shows the temporal, synergistic effect of these behaviours to ensure a fully functioning endocrine system. Hormones are key for health and to drive positive adaptations to exercise, to improve athletic performance. Thus hormones can be informative in tracking the response of an individual to these three input variables. Furthermore, endocrine markers relate to the RED-S clinical outcome of stress fracture in athletes, being more reliable as objective, quantifiable indicators of EA than numerical calculation of EA from direct assessment[5].

Authors

Nicola Keay¹, Gavin Francis²

¹ Department of Sport and Exercise Sciences, Durham University

²Science4Perforamnce, London

Br J Sports Med 2019;0:1–2. doi:10.1136/bjsports-2019-100611

References

1 http://health4performance.co.uk (accessed 21/01/2019) Health4Performance Educational BASEM website raising awareness of RED-S Working group on RED-S British Association of Sport and Exercise Medicine 2018

2 Mountjoy M, Sundgot-Borgen J, Burke L et al. IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update Br J Sports Med2018;52(11):687-697

3 Mountjoy M, Sundgot-Borgen J, Burke L et al. The IOC consensus statement: beyond the Female Athlete Triad–Relative Energy Deficiency in Sport (RED-S). Br J Sports Med2014;48(7):491-7

4 Burke L, Lundy B, Fahrenholtz L et al, & Melin. Pitfalls of conducting and interpreting estimates of energy availability in free-living athletes. International Journal of Sport Nutrition and Exercise Metabolism2018; 28(4):350–363. https://doi.org/10.1123/ijsnem.2018-0142

5 2Heikura I, Uusitalo A, Stellingwerff T et al. Low energy availability is difficult to assess but outcomes have large impact on bone injury rates in elite distance athletes. International Journal of Sport Nutrition and Exercise Metabolism2018; 28(4):403–411. https://doi.org/10.1123/ijsnem.2017-0313

Returning to Sport/Dance restoring Energy Availability in RED-S?

1 March 2019

Although improvements are being made in raising awareness and in effective medical management of relative energy deficiency in sport (RED-S)[1, 2] what about once an athlete/dancer is “medically cleared” to return to sport/dance? What advice/support is there for athletes/dancers and their coaches/teachers? After discussions with coaches, here are some suggestions on how to achieve return to sport/dance after RED-S.

LifeSeasonDay To recap, RED-S is a situation of low energy availability (LEA), which can lead to adverse health and performance consequences[3,4]. LEA can be a result of intentional energy restriction, which covers a spectrum of issues with eating from disordered eating to full blown clinical eating disorder. Ironically the original intention of these eating issues may have been to improve athletic performance, yet sustained LEA will ultimately lead to stagnation and deterioration in performance as found in male athletes[5].

The desire to return to full fitness can be a powerful incentive to address LEA. Nevertheless return to sport/dance needs to be carefully structured in collaboration with coaches to prevent injury and avoiding regression to the LEA state.

Structured return to training and nutrition

Initially focus should be on body weight strength and conditioning (S&C). Inevitably in RED-S adaptive responses to training stimuli will be dampened due to shut down of hormones networks into an energy saving mode. Once adequate EA has been established, hormone networks will be able to respond. Restoring muscle tone and working on proprioception forms a good basis to build from to mitigate injury risk. Impaired neuromuscular skills have been reported in female athletes in LEA[6], together with adverse effects of LEA on bone health increases injury risk.
The other reason for gradual return to training is that a routine of fuelling around training (before, during, after) needs to be established. In particular recovery nutrition within 30 minutes window to enable hormonal responses to training. Note that having this recovery nutrition does not mean reducing intake at the next meal!
Long endurance should be eased into after restoring muscle strength and control, in order to prevent injury. Additionally this type of training will necessitate a higher energy requirement. If adequate energy availability has only recently been restored, the balance is fragile and so too much training too soon can have negative effects. Especially if a fuelling strategy around training has not been established as described above.
High intensity/interval training should be the last type of training to be resumed as this places the highest stress and requires the highest energy demand on the athlete/dancer.
Injury, soft tissue and bone stress responses are more frequent in hormonal dysfunction of RED-S in both male and female athletes[7]. If an injury has been sustained during this period of LEA then particular emphasis needs to be on initial S&C. In the case of previous bone stress responses, multi-direction loading is key to build bone strength before resuming formal run training in athletes who are runners. Even if a bone injury has not occurred, bone turnover is one of the first systems to be adversely impacted by RED-S, so including this type of multidirectional bone loading in the initial structured return for all athletes/dancers would be beneficial.
Discuss with your coach a realistic, attainable goal if this will help. Maybe a low key race/event several months down the track

What to look out for

Don’t ignore injury niggles, illness or fatigue. Discuss with your coach and back off if necessary. This is a process, not a sprint.
Female athletes. You may well have experienced menstrual disruption during your time in LEA. This is a crucial training metric. Please use it! If your menstruation becomes irregular/stops this is your warning sign that your body is not ready to step up training[7]. Male coaches please reinforce this and be aware of this point. Remember Gwen Jorgensen posting her periods on Training Peaks as a training metric?
Flexibility in approach. Try not to put pressure on yourself to return to your previous PBs. It is important to have a plan, but you can be flexible. Everyone is different so this process of returning to sport/dance does not have a set, rigid timetable.
Enjoyment! Don’t forget the original reason that you started your sport/dance was for enjoyment! This is an opportunity to rediscover that joy, whether you return to competition or not.
“Recovery?” Does anyone fully “recover” from disordered eating/eating disorder? I don’t think so. To be a successful athlete, or indeed successful in life you need self-motivation, drive, determination. All admirable qualities, but sometimes these can get diverted to cause unhealthy eating/training patterns. So be aware that in times of stress it may be tempting to revert to old habits of under eating/over exercise to reassure yourself that you are in control.
Be prepared for questions: why have you been off training? Why are you not doing fully training schedule? Maybe you want to tell your team mates/friends. Maybe you don’t. That is your call.

So good luck with your return to sport/dance after RED-S, if that is what you want to do. Always discuss with you coach how to approach this.

References

1 BASEM Educational website www.health4perforamnce.co.uk

2 BJSM blog: Update on RED-S N Keay 2018

3, 4 IOC consensus statements on RED-S BJSM 2014 and update 2018

5 Low energy availability assessed by a sport-specific questionnaire and clinical interview indicative of bone health, endocrine profile and cycling performance in competitive male cyclists. N Keay, G Francis, K Hind. BMJ Open in Sport and Exercise Medicine 2018

5 Reduced Neuromuscular Performance in Amenorrheic Elite Endurance Athletes.
Tornberg Å Melin A Koivula F Johansson A Skouby S et. al.Medicine and science in sports and exercise 2017 vol: 49 (12) pp: 2478-2485

6 Low Energy Availability Is Difficult to Assess but Outcomes Have Large Impact on Bone Injury Rates in Elite Distance Athletes Heikura, Ida A. Uusitalo, Arja L.T. Stellingwerff, Trent et al International Journal of Sport Nutrition and Exercise Metabolism 2018, 28, 4, 403-411

7 What’s so good about Menstrual Cycles? N Keay BJSM blog 2019

What’s so good about menstrual cycles?

3 February 2019

Menstrual periods are a barometer of healthy hormones. The evolutionary purpose of ovulation is to reproduce. Furthermore the carefully biologically choreographed variation of hormones that occurs during an ovulatory menstrual cycle is crucial to health and athletic performance.

Why? Hormones are chemical messengers that have far reaching effects throughout the body and drive the beneficial adaptations to exercise. In the case of menstrual cycles, the fluctuations of oestrogen and progesterone are key to this process. The effects of these sex steroids go far beyond reproduction. These hormones play important roles in bone strength, cardiovascular health, optimal lipid profile and production of neurotransmitters to regulate mood. The effects of low levels of oestrogen and progesterone are well documented in menopausal women who experience loss in bone mass, risk of osteoporosis and fracture, together with an increase risk of cardiovascular disease.

Some definitions

Amenorrhoea=lack of menstrual cycles

Menarche= start of menstrual cycles

According to the Royal College of Obstetrics and Gynaecology

Primary Amenorrhoea: no onset of menstrual cycles by age 16 years.

Secondary amenorrhoea: cessation of menstrual cycles in a previously regularly menstruating woman for > 6months

Oligomenorrhoea: < 9 menstrual cycles per calendar year

Any form of amenorrhoea requires medical investigation to exclude an underlying medical condition. The most common medical causes of amenorrhoea are polycystic ovary syndrome (PCOS), prolactinoma, thyroid conditions and other endocrine conditions. Functional hypothalamic amenorrhoea (FHA) is a diagnosis of exclusion. In other words before arriving at a diagnosis of FHA [1], medical conditions that could potentially cause amenorrhoea have to be ruled out.

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Relative energy deficiency in sport (RED-S) is a situation of low energy availability (LEA) that can be unintentional or intentional as a result of a mismatch between energy intake and energy requirement. The two sources of energy demand arise from exercise training load and maintenance of fundamental physiological function across multiple body systems [2]. In female athletes/dancers with RED-S the most obvious clinical sign is amenorrhoea as a result of FHA. In all cases of RED-S the management strategy is directed to address the underlying issue of LEA [3].

In female athletes/dancer with FHA due to RED-S, there is the possibility of pharmacological intervention based on the RED-S Clinical Assessment Tool [4]. In other words evidence from DXA of Z-score of lumbar spine < -1 and/or stress fracture. What are the most effect hormonal interventions in such cases?

What’s in a name? It is every woman’s right to choose the form of contraception she wishes to use. Hormonal contraception provides a convenient method. The combined oral contraceptive pill (OCP) contains oestrogen and progesterone to prevent ovulation. The OCP produces regular withdrawal bleeds in response to these external hormones. Progesterone-only contraception can be taken orally, via implant or delivered by an intrauterine coil and typically does not produce withdrawal bleeds. As with any medication there are potential side effects, which have to be weighed up against the benefits. Regarding the effect of hormonal contraception on bone in young menstruating women, there is evidence that such medication can impair bone health [5].

The OCP produces regular withdrawal bleeds. These are NOT menstrual periods; ovulation is prevented. Rather the OCP causes withdrawal bleeds driven by external non-physiological hormones, as opposed to internally physiologically produced hormones. This is a reason why the OCP is not recommended in FHA, as this medication will mask what is happening with internal hormones [6]. In other words the barometer of healthy hormones has been removed when taking the OCP.

Furthermore, studies show that the OCP can impact other hormone systems that play a role in bone health. The OCP is taken orally thereby producing first pass effects in the liver. These effects include induction of liver enzymes and increased production of binding proteins for hormones. Binding proteins reduce the freely available active form of hormones such insulin like growth factor 1 (IGF-1). This effect is particularly marked in those OCP with non-physiological ethinyl oestradiol. In the case of RED-S there is already a low level of active IFG-1, due to the general suppression of the hypothalamic-pituitary axis.

Therefore in addition to masking FHA, the OCP can also further decrease IGF-1 and thus compound the negative effect on bone. This has been shown to be the case in the clinical setting where the OCP was found to have no bone protective effect on bone mineral density (BMD) in women with FHA. Rather hormone replacement therapy (HRT) consisting of transdermal physiological oestrogen with cyclic micro-ionised progesterone was found to have a positive effect on BMD [7 , 8]

Therefore, if hormonal treatment is to be used in RED-S, HRT (transdermal oestradiol and cyclic micro-ionised progesterone) is best clinical practice. This decision requires careful discussion with the athlete/dancer clarifying that HRT should only be a short-term measure to protect bone health whilst the underlying issue of LEA is being resolved. Behavioural measures relating to training load, nutrition and recovery are essential to restore global hormonal function.

OCP V HRT

• What? Both provide oestrogen and progesterone, but in different forms: non-physiological v physiological

• Why? Purpose of the OCP is to suppress production of endogenous female hormones and prevent ovulation. Purpose of HRT is to replace the physiological amount and form of oestrogen and progesterone

• How? The OCP decreases levels of active, unbound IGF-1. Not bone protective in FHA of RED-S. HRT shown to improve BMD in FHA of RED-S

What to do? Hormonal contraception is a choice for women. In some medical conditions where there is adequate/excess oestrogen such as endometriosis or PCOS, hormonal contraception is effective in clinical management. However in the case of FHA, in particular when occurring as a consequence of LEA in RED-S there is evidence that the OCP is not bone protective and masks the clinical sign of menstruation.

The priority in managing RED-S is to address LEA. If bone protection is required, whilst addressing LEA, HRT (transdermal oestrogen and cyclic progesterone) is best clinical practice.

References

[1] Joy, E., De Souza, M. J., Nattiv, A., Misra, M., Williams, N. I., Mallinson, R. J., … Borgen, J. S. (2014). 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad. Current Sports Medicine Reports, 13(4), 219–232. https://doi.org/10.1249/JSR.0000000000000077

[2] Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., … Ljungqvist, A. (2014). The IOC consensus statement: Beyond the Female Athlete Triad-Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine, 48(7), 491–497. https://doi.org/10.1136/bjsports-2014-093502

[3] Mountjoy, M., Sundgot-Borgen, J. K., Burke, L. M., Ackerman, K. E., Blauwet, C., Constantini, N., … Budgett, R. (2018). IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. British Journal of Sports Medicine, 52(11), 687–697. https://doi.org/10.1136/bjsports-2018-099193

[4] Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., … Ackerman, K. (2015, April 1). Relative energy deficiency in sport (RED-S) clinical assessment tool (CAT). British Journal of Sports Medicine. BMJ Publishing Group. https://doi.org/10.1136/bjsports-2015-094873

[5] Beksinska M, Smit J, Hormonal contraception and bone mineral density. Expert Review of Obstetrics & Gynecology, 2011 vol: 6 (3) pp: 305-319

[6] Gordon, C. M., Ackerman, K. E., Berga, S. L., Kaplan, J. R., Mastorakos, G., Misra, M., … Warren, M. P. (2017). Functional hypothalamic amenorrhea: An endocrine society clinical practice guideline. Journal of Clinical Endocrinology and Metabolism, 102(5), 1413–1439. https://doi.org/10.1210/jc.2017-00131

[7] Ackerman, K. E., Singhal, V., Baskaran, C., Slattery, M., Campoverde Reyes, K. J., Toth, A., … Misra, M. (2018). Oestrogen replacement improves bone mineral density in oligo-amenorrhoeic athletes: A randomised clinical trial. British Journal of Sports Medicine. BMJ Publishing Group. https://doi.org/10.1136/bjsports-2018-099723

[8] Singhal, V., Ackerman, K. E., Bose, A., Torre Flores, L. P., Lee, H., & Misra, M. (2018). Impact of Route of Estrogen Administration on Bone Turnover Markers in Oligoamenorrheic Athletes and its Mediators. The Journal of Clinical Endocrinology & Metabolism. https://doi.org/10.1210/jc.2018-02143

Low Energy Availability in Climbers

17 November 2018

Listen into a great discussion I had with Dr Nigel Callender an ex competitive climber and climbing coach about the “elephant in the room” in competitive climbing.

Discussion of Low Energy Availability and RED-S

As a gravitational sport, being a light-weight climber confers a performance advantage. However, being alert to low energy availability and the clinical consequences of RED-S on health and performance is important for climbers. With climbing being included the next Olympics, then hopefully this will raise awareness of being alert to athletes at risk of low energy availability and RED-S.

Insights from Dr Nigel Callender, sports scientist turned medical doctor (anaesthetics/critical care trainee) an active researcher, largely into the exercise physiology aspects of climbing and ex-competitor, having represented Ireland at international level and been British bouldering champion before shoulder injuries ended that. Sport climbing is included in the 2020 Tokyo summer games in its three competitive disciplines; bouldering, lead climbing and speed climbing. Each sub-discipline has a slightly different athlete profile and physiological demands, but all are obviously under the heading of gravity dependent sports. Current participation figures put yearly indoor climbing participation at around the one million mark in the UK and it is said to be one of the fastest growing sports worldwide. The sport is being recognised as a great way to improve overall health and fitness, with recent papers citing it as a useful rehab activity for many physical and mental health conditions and also as a health promotion tool.

Although climbing has been a formal competitive sport in some sense since the late 80’s, it still lacks much in the way of formal training and medical guidelines. Being a gravity dependent sport, strength to weight ratio is important, however Dr Callender and his colleagues are seeing a high incidence of restrictive eating patterns at all levels of the sport and a lack of awareness around the performance impairments and health risks associated with a significant or prolonged negative energy balance in some athletes.

The Outdoor Athlete Podcast is a bit of a winter project that came about to establish a gold-standard resource, driven by credible experts in their relevant fields, as an attempt to provide high-quality and evidence-based information amongst the confusing advice that is now the internet. It’s free and always will be and it was inspired by the BJSM Podcasts though broadly aiming at ‘Outdoor Athletes’ e.g. Climbers, Fell/Trail runners, Mountain bikers and anyone happy to listen.

For more information on climbing in the UK, including competition climbing see http://www.thebmc.co.uk

Raising Awareness of RED-S in Male and Female Athletes and Dancers

11 October 2018

Health4Performance is a recently developed BASEM open access educational resource

This is a world premier: a resource developed for and by athletes/dancers, coaches/teachers, parents/friends and healthcare professionals to raise awareness of Relative Energy Deficiency in Sport (RED-S)

What?

Optimal health is required to attain full athletic potential. Low energy availability (LEA) can compromise health and therefore impair athletic performance as described in the RED-S clinical model.

Dietary energy intake needs to be sufficient to cover the energy demands of both exercise training and fundamental physiological function required to maintain health. Once the energy demands for training have been covered, the energy left for baseline “housekeeping” physiological function is referred to as energy availability (EA). EA is expressed relative to fat free mass (FFM) in KCal/Kg FFM. The exact value of EA to maintain health will vary between genders and individuals, roughly equivalent to resting metabolic rate of the individual athlete/dancer. LEA for an athlete or dancer will result in the body going into “energy saving mode” which has knock on effects for many interrelated body systems, including readjustment to lower the resting metabolic rate in the longer term. So although loss in body weight may be an initial sign, body weight can be steady in chronic LEA due to physiological energy conservation adaptations. Homeostasis through internal biological feedback loops in action.

The most obvious clinical sign of this state of LEA in women is cessation of menstruation (amenorrhea). LEA as a cause of amenorrhoea is an example of functional hypothalamic amenorrhoea (FHA). In other words, amenorrhoea arising as a result of an imbalance in training load and nutrition, rather than an underlying medical condition per se, which should be excluded before arriving at a diagnosis of FHA. All women of reproductive age, however much exercise is being undertaken, should have regular menstrual cycles, which is indicative of healthy hormones. This explains why LEA was first described as the underlying aetiology of the female athlete triad, as women in LEA display an obvious clinical sign of menstrual disruption. The female athlete triad is a clinical spectrum describing varying degrees of menstrual dysfunction, disordered nutrition and bone mineral density. However it became apparent that the clinical outcomes of LEA are not limited to females, nor female reproductive function and bone health in female exercisers. Hence the evolution of the clinical model of RED-S to describe the consequences of LEA on a broader range of body systems and including male athletes.

A situation of LEA in athletes and dancers can arise unintentionally or intentionally. In the diagram below the central column shows that an athlete where energy intake is sufficient to cover the demands from training and to cover basic physiological function. However in the column on the left, although training load has remained constant, nutritional intake has been reduced. This reduction of energy intake could be an intentional strategy to reduce body weight or change body composition in weight sensitive sports and dance. On the other hand in the column on the right, training load and hence energy demand to cover this has increased, but has not been matched by an increase in dietary intake. In both these situations, whether unintentional or intentional, the net results is LEA, insufficient to maintain health. This situation of LEA will also ultimately impact on athletic performance as optimal health is necessary to realise full athletic potential.

Although LEA is the underlying aetiology of RED-S, there are many methodological and financial issues measuring LEA accurately in “free living athletes“. In any case, the physiological response varies between individuals and depends on the magnitude, duration and timing of LEA. Therefore it is more informative to measure the functional responses of an individual to LEA, rather than the value calculated for EA. As such, Endocrine markers provide objective and quantifiable measures of physiological responses to EA. These markers also reflect the temporal dimension of LEA; whether acute or chronic. In short, as hormones exert network effects, Endocrine markers reflect the response of multiple systems in an individual to LEA. So by measuring these key markers, alongside taking a sport specific medical history, provides the information to build a detailed picture of EA for the individual, with dimensions of time and magnitude of LEA. This information empowers the athlete/dancer to modify the 3 key factors under their control of training load, nutrition and recovery to optimise their health and athletic performance.

Why?

Who is at risk of developing RED-S? Any athlete involved in sports or dance where being light weight confers a performance or aesthetic advantage. This is not restricted to elite athletes and dancers. Indeed the aspiring amateur or exerciser could be more at risk, without the benefit of a support team present at professional level. Young athletes are at particular risk during an already high energy demand state of growth and development. Therefore early identification of athletes and dancers at risk of LEA is key to prevention of development of the health and performance consequences outlined in the RED-S clinical model. Although there is a questionnaire available for screening for female athletes at risk of LEA, more research is emerging for effective and practical methods which are sport specific and include male athletes.

How?

Early medical input is important as RED-S is diagnosis of exclusion. In other words medical conditions per se need to be ruled out before arriving at a diagnosis of RED-S. Prompt medical review is often dependent on other healthcare professionals, fellow athletes/dancers, coaches/teachers and parents/friends all being aware and therefore alert to RED-S. With this in mind, the Health4Performance website has areas for all of those potentially involved, with tailored comments on What to look out for? What to do? Ultimately a team approach and collaboration between all these groups is important. Not only in identification of those at risk of LEA, but in an integrated support network for the athlete/dancer to return to optimal health and performance.