Nov. 13, 2020

"Relative Energy Deficiency: Research to Practice" with Dr Nicky Keay

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Episode 148 of the Institute of Performance Nutrition's "We Do Science" podcast! In this episode, I (Laurent Bannock) discuss "Relative Energy Deficiency: Research to Practice" with DrNicky KeayBA, MA (Cantab), MB BChir, MRCP (Honorary Fellow, Department of Sport and Exercise Sciences, Durham University, UK).

Discussion Topics Include:

  • Relative Energy Deficiency: an overview and background to RED-s
  • Energy availability and impact on health and performance
  • Recognising relative energy deficiency: from the research lab to "real world" practice
  • RED-s as an issue in female and male athletes, dancers etc
  • Dr Keay's recent research on cyclists and dancers

Podcast Episode Transcript: Download PDF Copy

Key Paper(s) Discussed / Referred to:

Related Podcast Episodes:

Check out our other podcasts, publications, events, and professional education programs for current and aspiring sports nutritionists at and follow our social media outputs via @TheIOPN







[00:00:00] LB: Hi, and welcome back to the We Do Science Podcast, the podcast of the Institute of Performance Nutrition. I am the host, of course. I am Dr. Laurent Bannock, for those of you that have not yet listened to this podcast.


Today, I have just had a really fascinating conversation with Dr. Nicky Keay, who is both a clinician, a medical doctor, but also a practitioner, researcher, an academic working in a number of areas. In particular, this topic that we're going to delve into today, which is relative energy deficiency, not just in sport, for reasons that you'll learn today. Although, it is abbreviated as RED-S, Relative Energy Deficiency in Sport. They had come up with a title and that was the one, but of course, it applies to active people who could be described as athletes by virtue of levels of activity.


Of course, that does not just apply to sports. It could be performing artists, recreational exercises, a wide variety of people, where this concept of an energy deficiency is of particular value. This is the conversation that we get into in great detail today. Although, we could have delved very much into the meaty science, which I’ve done in previous podcasts with Dr. Kirsty Elliot-Sale, Dr. Jose Areta, Dr. James Morton, of course, and a wide variety of other experts that I’ve talked to over the years, who I don't want to leave out. I will link those podcasts to the show notes, so you can get that wider set of resources as it relates to this theme, this body of knowledge that we're accumulating here on this podcast on this this area of relative energy deficiency. You'll find that on the website. Just go to and click on podcasts. You'll find that there.


What we did is we discussed what actually is energy deficiency? Does it affect males? Does it affect females only? What about athletes? What about dancers? This really interesting area of whether it's an intentional, or an unintentional process. How do you recognize relative energy deficiency? Is that something that can be done in the lab? Is that something only a medical doctor does, or is that something that we as performance nutritionists, dietitians, or even personal trainers, for example, might be able to play a role in. We've discussed that in detail.


What are the issues that relate to the consequences, the impact, if you like, of being in a relative energy deficiency state? Why does that even matter? What are the physiological and clinical outcomes of that situation? We talk a lot about this in general, but we also managed to spend some time on her research on dancers, specifically. Also, on road cyclists. What did the research find and what are the take-home messages from that?


I don't really want to tease you further. I’ll just let you listen to the show in a minute, the conversation that we recorded. Just before I do, please do come and check our website out at, where you can also learn about our 100% online diploma in performance nutrition, which is a practice focus training program, advanced level training in applying the science to practice; a well-recognized program internationally. It's all about enabling you, or helping you to become highly effective practitioners in the real world, so to speak.


You can also, of course, learn about our podcast and access the new We Do Science Podcast website, which has a whole range of upgraded resources to include, not just some edited versions of these podcasts, but also transcripts, so you don't have to listen. You can also read, or combine the listening and reading together. I hope you find those of great value.


Those are going to be applied to all-new upcoming episodes and a number of select past episodes. If there's any particular past episodes you'd love to have me upgrade, get edited and get transcripts created for, just do a message to me on Twitter, or Instagram, or e-mail me via the website and just let me know. I’ll do my best to add that to the list of upgrades. We have a variety of other resources on our websites. Just go check that out.


I won't blab on. I won't waffle on here any further. I’ll let you enjoy this conversation I have with Dr. Nicky Keay. Enjoy.




[00:04:49] LB: Hi, and welcome back to the Institute Performance Nutrition's We Do Science Podcast. My guest today is Dr. Nicky Keay.  Dr. Nicky Keay? Did I get it right? Dr. Keay?


[00:04:59] NK: Keay. Exactly.


[00:05:00] LB: Great. Yeah, I didn't prompt you before we started recording, so I nervously attempt people's names. I’m pleased I got that one. Thank you for giving up some of your valuable time today, Nicky. I know you're super busy. As you know, I have bumped into you at various conferences and I’ve heard you speak. Always been fascinated by your work. I know you have various areas of expertise, which we're going to delve in today as a clinician and as an academic, as a researcher, which is I think a particularly valuable combination, particularly for this conversation today.


Before we jump into what I wanted to talk about, perhaps you could just give us a quick introduction to yourself and what you're up to.


[00:05:44] NK: Sure. Well, listen. First of all, thanks for inviting me. Likewise, as we were saying earlier, we've heard each other speak at various events, so it's good to meet well, virtually face-to-face. Yeah, as you say, I’m a medical doctor by training, but I’ve always had a particular interest in how that medical knowledge applies to exercise, whether that's an athlete, or a dancer, or whatever level of exercise you're doing. That's always fascinated me, because the things why do you get fitter if you exercise, or dance, whatever you do? Why do you improve over time?


Actually, those adaptations, positive adaptations are driven by hormones. That's particularly my focus and where my interest really, really lies. What's going on internally inside, or not? I mean, the things that can happen inside, in terms of your hormones, to both drive the positive adaptations. Therefore, also on the other side, what happens when that goes wrong, when for whatever reason those hormones aren't up to speed and maybe you can't get those benefits? That's really in a nutshell, what I’m about, what I’m interested in, and as you say both clinically, I see athletes and dancers with issues and also, research along the way as well.


[00:07:08] LB: Yeah. Actually, I’m really pleased you mentioned that business of when things go wrong, because I – and I mentioned this to you just before we started speaking, an area that I find particularly interesting, because my work and my personal interests are largely about trying to get this information that comes from the scientific studies, from textbooks, from journal papers, and bringing that into the real world, where we can help our athletes, our clients get the results that they're after.


It isn't always that idealistic process of let's turn this person into an Olympian. Let's turn this person into the greatest dancer in the world and how can our respective skills and expertises influence that, because that's all very – well, it's almost a reductionist view of these things. The reality is that we live in and right now, it's really obvious how crazy, chaotic –


[00:08:05] NK: Challenging. Yeah.


[00:08:06] LB: - things can be.


[00:08:09] NK: Also, to tailor it for the individual.


[00:08:11] LB: Indeed.


[00:08:11] NK: When we say oh, to be a really good dancer, it's like, unfortunately, not all of us can be like Darcey Busell. I mean, I know she's now retired, but not all of us can. That's the way it is, to be an Olympian, win an Olympic medal. It's all about your personal best. What is it? Is it you want to win your age group, or is it you just want to take part? Also, matching up your aims and expectations to tailoring that's what you want to achieve, so how are you going to achieve that? Also, making sure you're actually not aiming, well, unless you are truly able to get an Olympic goal. Obviously, that's fine. Whatever it is you're trying to achieve and what you need personally as an individual, because we're all – Although we've all got the same blueprint and physiology, more or less, having said that, there are vast variations between individuals. It's all about the personalized approach, I think.


[00:09:12] LB: Yeah. Well, that I mean, that's a hornet's nest of areas to get into. I guess, that's almost a holy grail for some people, isn't it? Is that concept of well, are we able to identify those that can make it all the way to being an Olympian, or a top ballet dancer, or whatever? Of course, for a lot of people, it comes back to basic things, like just being lucky enough to get into the scenarios where they can meet a coach.


[00:09:40] NK: I mean, there's always luck involved in anything. Being as prepared as possible, so that when you do, hopefully, have that opportunity, you're in a good position to get in there. Otherwise, you're not prepared even if you do have all the luck in the world. All the luck in the world will not win you a gold medal. You know what I mean?


You have to control what you can control. We can't control everything, but you just have to focus on what and as you say, especially in these strange times, you can spend a lot of time worrying about uncertainty. Actually, when all said and done, the only thing, the only option is to as I say, take control of those things that you can. Make sure you are taking control of the things that are in a good way, and helpful, positive way and not maybe in an obsessive, over the top way. Anyway, that's also –


[00:10:31] LB: Well, no. That's relevant to this conversation, because that's something that I talk about a lot is my concept that I like to talk about as my – the thing I live by is the question you must ask yourself before you do something. That is you can, but should you? I can do this, but should I do it?


There are strengths and weaknesses. There are pros and cons. There's limitations to things, but that requires knowledge, skills, training. Often, when you look at research into expertise, for example, when they look at top surgeons, one thing that can differentiate a truly master of that aspect of surgery, for example, from somebody who's just competent is often when knowing not to do something, when to cut something, I guess.


[00:11:18] NK: You make a very good point. Because I remember when I was deciding I’ve snapped my [inaudible 00:11:22] a couple of years, back skiing, as one does, the surgeon that I actually decided to go with was the one that wasn't sharpening his scalpel. I mean, as it turned out, I was actually looking for surgery, but I wanted to be guided through all the stages. There is the no surgery option. What happens then? Then there is this option. Having all those options open. One of them might be actually a null thing. Actually, no. Don't change anything, or don't do it. That can also be a positive decision.


[00:11:59] LB: This is not entirely off topic, but do you find in that scenario the surgeon's like, “Oh, my God. She's a doctor. She's a specialist in sports.”


[00:12:09] NK: No. I would think, I mean, especially, that's what I always say, especially surgery, because that definitely is not my field. When I go to the GP, I want to be treated as a patient. I know that sounds weird. I want to be taken through all the steps, because it's different. In fact, I was discussing this this morning. It's easy as a doctor. I’m very good at discussing RED-S and helping people. Actually, then when you turn the mirror back on yourself, it's like, “Oh. Actually, now that's really uncomfortable. I’m not so sure.” Yeah, for sure. It's always good to have an outside objective view.


[00:12:51] LB: Absolutely. Absolutely. Well, this is relevant to this because the reason for these conversations with experts such as yourself in the areas, for example, that we're going to get into today is because what we're trying to do is to truly understand this information before we try and use our whatever, our understanding of that topic, is to influence, in this case, a client's nutritional programming, or research, or whatever that pertains to this area.


I think a lot of people misunderestimate where they lie in terms of their actual knowledge and understanding of that particular topic. I think some people jump in, because they're over enthusiastic about something. They go, “Oh, it's RED-S, or FODMAPs,” or whatever topic you're finding yourself fascinated in and you start throwing that at your clients. You just need to be careful about whether or not you truly understand this. That's why I wanted to talk to you today about one area that you're well-known for being an expert in, which of course, is in relative energy deficiency. But not just in sports.


I find sports is a word that's quite limiting. That's why I like performance nutrition, as opposed to sports nutrition. I find your work, for example, in this area with performing artists, like dancers for example, particularly interesting. I have a personal reason for that. That's because a very long time ago, I had the opportunity to do some work in a more health and fitness nutritionally, before I became properly trained and qualified, with the Rambert Dance Company.


[00:14:31] NK: Oh, yeah, yeah.


[00:14:32] LB: This is a long time ago, but I had an insider's view of what went on in those companies and what the dancers went through and the stress and the strain and the impact of the coaches, we’ll call them. I mean, it's fascinating to get inside of that scenario. You truly see a humanistic angle here, which is very different from just a participant in a research study. There's so much more to that person, in the environment that they live and enact their lifestyle, which of course, for example is for an athlete training, or competition, or for a dancer, they've got their equivalents, but they've also got life and they live with themselves, they live with people, they have relationships, they've got hang-ups, they've got all sorts of things going on. There's nothing more interesting than that to me, and how that actually influences things, like eating behaviors, which of course, affects performance and health.


[00:15:35] NK: We know that there's a lot of peer group in quite a tight environment. Of course, you're going to compare and look who's eating what. Definitely, it's a rarefied atmosphere, whether that's a dancer, or an athlete in those training groups, which is a good thing. On the one hand, that's a great thing. You can support each other and whatever, but equally, there is a downside to that that anything negatives can also start to disperse.


I think, going back also to what you say about sport, I mean, the reason it's called RED-S, Relative Energy Deficiency in Sport is because, frankly, the acronym would be way too long if we said sport, dance and any other type of activity. Because I often see a lot of people who almost apologize to me. They come to see me and they say, “Oh, I’m not an athlete and I’m not a dancer. I’m just going to the gym twice a day and all this other thing.” It's like, listen. That definitely counts as a high-level exerciser, in the terms that you're doing a lot. That's the problem with any label, but it's there just for convenience really.


[00:16:42] LB: Yeah. Well, fortunately, the bulk of our listeners are going to be pretty clued up. We've over the last couple of years, had some fantastic guest experts, like Kirsty Elliot-Sale, Jose Areta and loads of others that have gotten one way or other into this topic. I think the first chat that spoke about this actually, as it related to men was James Morton, for example.


[00:17:09] NK: Oh, yeah.


[00:17:09] LB: I mean, almost seven years ago when we started this podcast. The very first podcast I did, he had mentioned that it's not just about females and so on. Right, we've got lots of things to get into. Let's just quickly do a few definitions and so on, so that everyone's on the same page. Perhaps, you could just give us from your perspective, an overview of what actually is RED-S.


[00:17:34] NK: RED-S stands for Relative Energy Deficiency in Sport. Although, as we said, other things as well. There are a few important words there; relative and energy and deficiency. Obviously, you get all the energy you need from your diet. What you put in your mouth, that's partitioned and it's prioritized the energy to cover training demand. Whatever type of exercise you're doing, you're dancing, you're running, whatever, that part of your energy intake, that gets hyped up over there.


Then the residual energy, what's left over, that's what's called energy availability. As the name suggests, it's available to cover other energy demands in the body, of which there are many. Because even if you just lie in bed all day, if only, then that takes a lot of energy, because after all, we're warm blooded, for a start. Also, we're digesting, we're respiring, all those life processes, excreting, etc., etc. That takes a lot of energy.


Then on top of that, there are other things that people wouldn't necessarily classify as exercise, but walking around at work, or just day-to-day activities, or just making a cup of coffee or something, that's going to take a little bit of every day, of what they call it, activities of daily living. I think people underestimate the energy availability, you need a sizeable chunk. If you haven't got enough of that, if – There are two ways you could end up in low-energy availability. Either you've got such a high training demand, like the cyclists who were training hours and hours per day, there's such a big drain on your food intake, from your output through your exercise, then that obviously could lead you up in low-energy availability.


Those are more what I call the unintentional ones, where it is, because they've got a very high training load, or they've gone away on a training camp, or you know what I mean. Whatever it is, something like that that got a really big demand. On the other hand, you could have more the intentional low-energy availability person, who is in a weight dependent sport, or a gravitational sport. Climbing is one. Road cycling is gravitational and also, athletic sports, diving, and also we bring in here dancers, that's obviously athletic.


Those groups of people might be more inclined to intentionally restrict what they're taking in in the first place, but they're still doing all their training. That all gets burnt off. Then the residual energy now is low. That's low energy availability. That's what energy availability is; energy you have available for physiological processes. Low-energy availability when that is below what you need personally, and you could either be the unintentional sort, or the intentional one. There we go. That's that.


[00:20:28] LB: Yeah. I mean, that's an important distinction, isn't it? Is that it is going to be intentional, which takes you down one path potentially of how you would manage that and the unintentional lot. The reason why I’m differentiating here, of course, is if I look at this from the perspective as being a practitioner, so I’m not a lay person in this area, but then again, I’m not a clinician. I might have doctor in front of my name, but that's not because I’m a medical doctor.


We live in a gray area as practitioners, as nutritionists. Of course, this is an area where I feel that having quite a lot of knowledge on it is useful, because we need to understand all scope of practice in this area and when and where not we can play a role in how we recognize and deal with the next steps, if you like, of how we’re supposed to deal with this, or our recommendations to our assets.


[00:21:20] NK: Yeah. I think you’re right there that if it’s the unintentional person, those are very straightforward. When I say straightforward, relatively so, because you haven’t got psychological aspect of it. I’ve had several of those cyclists, for example, where they certainly did not realize that they being out on the bike for four hours. They had put maybe a banana in their back pocket, but they hadn't put enough bananas, or enough cereal bowls or whatever it was. They just literally did not register and didn't realize, or hadn't had taken on enough fuel beforehand, or hadn't taken on enough fuel afterwards. Those are the unintentional ones.


As I say, there isn't a psychological overlay to those sometimes. It's just literally, the mechanics of it, there's a mis-timing. That's okay. The ones that the intentional one, you're right. That's where it gets a little bit more complex. Because it's like, why are you doing this in the first place? It's easy enough to give someone some mechanical advice, like eat this at this time, like that. Actually, if they're going to then have this massive psychological barrier to do that, even if they managed to do that for a bit, then if you haven't found out why that was happening in the first place, it's just they're going to keep recurring. Those ones are more tricky and complex.


[00:22:39] LB: Yeah. That's what I find interesting, when you're looking at these different types of athletes, whether it's their intention to manipulate their diet to arrive at a given outcome, which might be getting that gold medal. Those are very strong drivers. You can become very blinkered. That's perhaps, a skill set that is advantageous maybe to an Olympic athlete is that ability to – is to not want the sweets and the chocolates and the treats, because the goal at the end is worth missing out on those things.


Whereas for others, it might be they've become obsessed with their body composition. I remember a few years ago, we published a case study on reducing infection incidents in a premier league football player. On the analysis of that player's diet, it turned out the reason why they kept getting these URTIs was because they were in a state of energy deficiency, because they were missing, cutting out carbs, missing out breakfast, because they were obsessed by their body composition. The impact on their performance and their health became the consequence of that. I guess, there's an indirect victim there. Then of course, what I saw in those dancers, which was a whole – there's almost a fear factor. What about those sorts of areas?


[00:24:01] NK: Yeah. Well, you see, it's the more intentional RED-S person, by their nature there's a reversible arrow of the psychology in RED-S. The reason that you might become one of these restrictive eaters, or exercise-dependent types is because guess what, that's your personality. That's why actually, you're good at sport or dancing, or good in life. It's laudable to be driven, focus, all those things. When that becomes misdirected, so now rather than thinking about doing these things, so they can improve performance, what they believe they are improving their performance, but they've gone about it in a wrong way, if you see what I mean. They've gone off track and trying to take control of something, but they feel really, they can take control of.


I can take control of reducing my carbs. I can take control by increasing my training load, which they perceive as being positive things. Actually, like you say, then we get into the vicious circle. They start going off-kilter like this, but now they're in this situation of low-energy availability, so they haven't got enough energy in the system to have a good immunity, etc., to drive the positive adaptations to their exercise.


Also, if you're in low-energy availability, actually, your cognitive function becomes a little bit impaired. There are studies to show that. Actually now, you don't make a good call. Now you're convinced you're right, generally, that you're pursuing the right way. If you don't see the improvements in performance, then you misinterpret that as you haven't tried hard enough. I should restrict more. I should exercise more. Now you get more and more in a vicious circle.


You're right. Then it potentially can become a vicious circle, spiral out to control, whatever word you want to use in trying to get someone to steer them back to the more balanced approach. That's really tricky.


[00:25:56] LB: Yeah. It's a fascinating area, the behavioral compensatory mechanisms that are based on perception, or belief. That's why I think we have a potentially positive, or a destructive role if we don't understand how we're feeding those perceptions. For example, any of the listeners that have been performance nutritionists, or registered dietitians, or personal trainers or whatever who've had a client, feel that they're doing relatively well on their nutrition and training program, until they stand on the scales.


Despite the fact that their clothes are looser and they appear better in the mirror from an aesthetic perspective, the number on that scale just shoves a massive spanner in the works again.


[00:26:46] NK: I call it the weighty problem. After all, it's just a number on a scale. What is that number on the score? It just tells you what earth's gravity happens to be that day. I mean, we could go up to the moon and obviously, it would be a different number. Does that suddenly change who you are? Well, I mean, I know you'd have had to go on a rocket, so probably it would have actually – Anyway. Individually, or you went into an anti-gravity room or something and now you've got a different number.


[00:27:16] LB: Different set of scales, different time of day, before and after eating.


[00:27:18] NK: All that sort of thing. Yeah, a different set of scale.


[00:27:21] LB: During menstruation, away from menstruation.


[00:27:23] NK: Yeah, all those sorts of things. It's funny. It's easy enough to get upset by one thing, isn't it?


[00:27:29] LB: Nicky, where I’m going with that then is from a recognition perspective, I know the scientists in our audience here are going to be going well, rather than just recognizing this through symptoms and discussion and so on, is there some diagnostic process, number one? I guess, there's a way of, well, how do you determine energy deficiency from a research perspective? How do you determine it from a clinical perspective? People like me who don't have necessarily either of those opportunities, how am I supposed to recognize and not diagnose, but get close to that thing?


[00:28:09] NK: Yeah. Recognize it through the warning signs. Well, yes. I mean, if you want to measure it in the lab, fine. That's tricky. I mean, in the sense that it's possible, but it's just complicated. Realistically, we can't get everyone going around, weighing their food and all this thing.


Louise Burke herself, who is one of the great researchers in this field, she talks about measuring in the free-living athlete, as she puts it, because how are you going to take account for, “Oh, that time that they walk to the kettle to make a cup of coffee or something.” If you want to do it really precisely, it's difficult.


You can measure it. It's true. Then even if you didn't measure it, so you did do all this weighing and metabolic rate, what's your lean body mass from a deck says. Pretend you did all that. Now, you come get a figure. It's a bit like the number on the scales. It's like, well, what the heck does that mean? What does it mean for a male, or female? What does it mean for you personally as an individual? I mean, we know that there have been studies in women showing that when the energy availability reaches a certain level threshold, even we don't not so keen about saying exactly threshold, because it sounds like this absolute line in the sand.


We know, of course, recognize then hormone problems do occur. Again, it's exactly like the weight on the scale. What's the relevance of that number that you get for that person? It's fine in a research setting, very interesting and all that. We'll leave that there. Probably, the more practical way is something like a screening questionnaire. There's the leaf cue, which is for female athletes. We're just developing something specifically for dancers, a questionnaire for dancers.


Then also, we did with male cyclists. I’m thinking that probably, it's better to make it sports-specific, because it would be a turn off, you as a male cyclist, sat down and looked at a questionnaire that's talking about periods and stuff. It's like, well, or talking about dancing. It's like, “Mm.” The same for a dancer. They don't want to be asked about their cycle training, or something.


It's important to take that into account in the assessment about the training and things. I think that realistically in the practical way, a questionnaire to filter out the people, but also you're saying, other people recognizing that, like the coaches, even teammates, things like that, noticing that a teammate is not necessary – I mean, thin probably isn't always the big discriminating thing. Even in their mood and their personality and avoiding eating and avoiding interactions.


There are plenty of warning signs and then there's the questionnaire. Then ultimately, it does have to come down to a medical diagnosis, because it's a diagnosis of exclusion, because there are some days when we do feel bad, right? Yeah, I’m feeling a bit tired this morning, but I’m not immediately going to assume it's – and I had a bad night's sleep, but I’m not going to assume it's because RED-S, because actually, I’m still recovering from COVID, by the way, or what other stuff.


The medical diagnosis bit and as doctors, the thing we always do, we take a clinical history, which is like a screening questionnaire, but only in more detail and it's easier to put in a little bit more of the psychological overlay. You gather all the information. How much exercise are they doing? Are they avoiding certain food groups? What's going on for them? Then ultimately, it comes down also to doing some blood tests. Because for females, a big red flag is no period. There can be many reasons for no periods; some medical ones that you need to just cross off the list and say, “Okay, fine. It's not that.” Then we move on. You always have to do a blood test.


For the men, it's also useful, well, for anybody; men and women, that you suspect clinically have this, then getting a blood test just to see what's going on with the hormones, what's going on inside. Does that correlate to your clinical impression? Also, sometimes for those that have a bone stress injury, or a previous history of bone stress injury, then obviously, and a long time of amenorrhea, for example, then also, you might be thinking about getting a dexa, just to see what's going on with the bone health.


There is, the IC has published, it's called the RED-S CAT. It's a clinical assessment tool and there are little columns. It's like a traffic light thing; green, amber, red. Really, we want to be picking up the people in the amber section. I mean, if they're in red, they should frankly be in hospital. If they're green, they're good to go. Maybe they're just not feeling that great, because maybe they are over-trained and maybe they have got a glandular fever. There's actually something else.


The ones that actually, there are some warning signs from the clinical history from your screening questionnaire, from blood that actually, and the dexa, those are the ones we're trying to pick up in terms of who's at risk of RED-S.


[00:32:58] LB: Yeah. No, thank you for that. That was great. Yeah, I guess from a nutritionist, dietitian's perspective, we should be pretty well-trained to recognize if they're clearly in a state of energy sufficiency, as long as we're monitoring their diets appropriately. Like you say, where's the line in the sand? Of course, with elite performers, elite athletes and we're not living with them and it does get tricky and difficult, doesn't it? That's why I think those markers of recognition that you've pointed out are really helpful.


I like the way that you mentioned that there are people around these people. We're not just trying to educate and inform the athlete. It's people that are with them; their coaches and their families, I guess. I mean, what are the sorts of people you think that need to be in their community of awareness, if you like, on this topic?


[00:33:50] NK: Yeah. Well, I mean, teammates for a start. If you notice that actually, this person is really fatigued. I think actually, a lot on the coach. Recently, I’ve done a course for coaches to look out the warning signs of RED-S and athletes, because the coaches, they will know the athlete, or we're talking about the dance teacher will know – get to know that person.


Actually, if they are turning up all the time really fatigued, just not looking great, then that's a warning sign from the coach. Of course, for the parents, for the youngsters, the parents obviously will notice if there's something going on with the younger athlete. I think we all have a role to play. The sooner these things are picked up on, the better.


I think the coaches shouldn't – it is cringe to them if they spot it and are alert to it. I work and I’ve got a good relationship with many coaches who are absolutely on the ball, by the way, with this. They say actually, “I’m a bit worried about this athlete. Her periods have stopped, or she's got a little bit –” Or actually, they're complaining of sore shins, you're thinking bone stress injury. I’m not sure what's going on about their nutrition, or something like this. I think coaches are the majority are on the ball, but obviously, more is to be done.


I think, we all have a role to play in this. Ultimately, I can do all the medical thing, but I can only see the people who are sent to me as it were. I’m not going out there into the general population, looking around. I mean, it is a fun game as a doctor. You go out and you spot some – you make a different diagnosis. Anyway, joking aside, everyone has the opportunity to play their part. Actually, I think the hardest thing is recognize against yourself.


[00:35:36] LB: Yes, of course.


[00:35:38] NK: That's actually, you are relying on others. I mean, also sometimes people do just take a moment, just sit down. It's like actually, and being honest with yourself is actually probably the hardest.


[00:35:50] LB: Yeah, well that's the tricky one, isn't it, Nicky? Because athletes, or highly active people that we would still describe as an athlete aren't just in communities, like a team. A lot of athletes are on their own. Ultra-endurance athletes are a good example of people who –


[00:36:07] NK: Yup. That’s a very good point.


[00:36:07] LB: - who I worked a lot with, who spend huge amounts of times on their own. I’m also thinking like, iron man triathletes, or whatever, absolutely are athletes. They're just not necessarily professional athletes, but there are –


[00:36:21] NK: Yeah. That's a very good point you make. That is probably the hardest of all, if you're a solo trainer as it were. Even solo trainers will have some hopefully, some contact with people. Maybe they've got a partner. Maybe they've got some friends. Even friends can say, “Oh, actually, we haven't seen you for a while. Or what's going on?” Yeah, ultimately –


[00:36:50] LB: Well, it’s in their best interest, isn't it? I think with these people, where the obsession ultimately is about winning the races, or doing as well as they can. I think what helps and this is the next step of this conversation is okay, look, relative energy deficiency is real. It happens. There are quite a lot of people, more than people imagine dealing with a situation, but why does it even matter? I mean, what are the actual consequences of this?


[00:37:17] NK: Well, first of all, the sad thing about it is that ultimately, the person, why is the person doing this anyway? In most cases, it's because they think they perceive it as a performance advantage. It's true. At first, they actually might pull off a few good performances, races. As time goes on, it's just not sustainable. That's the main significant consequence for the person. They're just going to underperform. They're never going to reach their personal full potential. That's probably the most relevant thing for the person themselves to realize that.


In terms of health-wise, I mean, we mentioned psychological effects, because hormones are super important for neurotransmitters. Mood, low mood, or just mood changes, anxiety, all this sort of thing. In terms of physical, I mean, for the women, we've already mentioned the red flag, or no periods, so amenorrhea. Primary, or secondary amenorrhea appear switching off for more than six months. That's an obvious big red flag that that could be due to RED-S, so that you need to get that checked out.


The equivalent in men is a little bit tricky. I mean, I suppose we have to talk about morning erections. How many per week? If it's not many, then that could be a sign that the testosterone is low. Sleep for both, for men and women, by the way, well everything from now on is for men and women, okay. Disrupted sleep, poor sleep, because if you haven't got enough energy onboard, particularly carbohydrate, then literally, you're going to wake up, because your body's saying, “Hey, I’m hungry. Where’s some food?”


Also, gastrointestinal problems, which is very interesting one, especially in the women I’m finding. Lots of athletes, dancers come and say, “Oh, I think I’ve got IBS, or I’ve told I’ve got IBS, irritable bowel syndrome.” Therefore, they have been put on a FODMAP start, or they think they should restrict something, or whatever. The problem is they're not eating very much in the first place, which is actually why they have gastric problems, because there isn't enough energy for the process of digestion, you see?


Actually, they need to be doing the exact opposite. They do need to be eating a bit more to get the digestive system going, because literally, gastric motility slows down. It takes energy to absorb your food. That's actually a very interesting one; gastrointestinal issues. Bone health, we mentioned, of course, the sex steroids, those being low, along with the thyroid hormones, then poor bone mineral density. Means bone stress injuries, ranging from just painful to a stress fracture, anywhere on that spectrum.


What else have we not done? Oh, cardiovascular health even. In women especially, there are good studies to show that low estrogen levels associated with amenorrhea, this causes cardiovascular problems in terms of autonomic control of blood pressure and things like this and lipid profile. In fact, I tend to slightly avoid doing a lipid profile in someone I suspect with RED-S. because I know what it's going to show. It's not going to be great. Then the person misinterprets that. But, “Oh, I’m eating too much fat.” It's like, no, no, no, no.


Anyway, so immunity. You already mentioned immunity. Lowered immunity, more illness infection. Obviously, not a good thing to have. I mean, everything you care to really – oh, actually very interesting one I just thought of, to do with neuromuscular skills. Amenorrhea athletes, they have a reduced reaction time and peak power production. If you remember the females that might be at risk of getting RED-S, oh, guess what? Dancers and gymnasts and all these people, who where balance is crucial.


Now if your balance isn't so good and you fall over, your bone density isn't good, it's not going to end well. I mean, literally every system in the body needs sufficient energy to take over, like we said at the beginning; energy availability. By the way, just to really hammer the point home, what happens when you have low-energy availability? The body tries to adapt. The body tries to makes a new set point to try and save energy, just as your phone would do, it goes into the power saving mode, okay.


Same thing for the body. Everything down-regulates, and this includes your metabolic rate. Thyroid function tests, I’ve got very used to looking at these. I look at them both. All three; TSH control, T4, thyroxine T3, they are all low-end of the range. That's not an underactive thyroid. It's not a primary underactive thyroid.


Now what's happened is it's been switched off from the top, from the hypothalamic pituitary axis, which is where the switch-off occurs, by the way, because all the metabolic stress, all the psychological stress, that all gets fed into the hypothalamus. That switches off everything, whether we're talking about the sex steroid pathways for the males and females, whether we're talking about the thyroid axis, that all gets turned down. Growth hormone, IGF-1 goes down and everything's down, apart from cortisol, because it’s – your body’s stressed, cortisol goes up.


Cortisol, although it's great to have some cortisol, obviously, to help you wake up in the morning, unvarying high-ish levels of cortisol perpetuate this. A vicious circle again. Prevent the conversion of T4 to C3. Also, cortisol also tends to favor fat storage, which we go back to the ironic situation, the athlete, or dancer in the very first place thought that, “Oh, by restricting what I’m eating and training more, I might lose weight, or I might change my body composition.”


In fact, studies have shown that yes, at first, of course, that happens. Then actually, it starts to go the other way. I mean, not that you would not putting on weight, but in the terms of your weight just plateaus, because your metabolic rate's gone down, but the person misinterprets that they have to restrict more, but also for the body composition and you probably know more than me about this that the body composition actually, you in that situation, that stress situation of high cortisol and low metabolic rate, actually, you're more likely to put on fat than muscle. The person again, yes, you're nodding, the person gets very frustrated. “Oh, this must be because I’m not really, really restricting.” It just self-perpetuates, doesn't it?


[00:43:26] LB: Yeah, it does. That's why I try and push this message of trying to understand enough about this to understand it. It's those pros and cons. Like I said, you can, but should you? Yes, you talk about body composition and people get obsessed with the term ‘energy balance’. Of course, energy balance is a complex area as it relates to body composition and things like energy availability and fat balance, rather than energy balance and the various mechanisms that influence that.


Absolutely, what is interesting is in a state of energy restriction, particularly chronic energy restriction is the compensatory mechanisms that occur within metabolism. I’ve explored these with numerous experts over the years and over for our listeners, listeners back to Professor Dylan Thompson's podcast, with me and James Betts, where we've got – and Javier Gonzalez, actually. We've gone into that stuff in great detail. It is fascinating and it is a self-defeating process. Absolutely.


[00:44:31] NK: Yes, exactly, exactly. Self-perpetuating parts as well.


[00:44:34] LB: It is. Yeah. Okay. Let's just move forwards from here then. Well okay, so we've explored relative energy deficiency in sports performance, in various areas in society, whether it's recreational athletes, elite athletes, performers and so on. I think an area that I do find of interest is where you've been doing some of your research of late. I thought we'd delve into that, since we've been talking for some time now. If we contextualize this into specific groups, so you did a study very recently on the awareness and indicators of low-energy availability in male and female dancers. We've referred to them. And cyclists, which we'll come to next. Tell us a bit more about that research and what was the main things that came out of that that we can learn from that research?


[00:45:28] NK: Well, in my old age, I’m getting more into psychology. Because actually, it's the reason why a dancer's more likely to end up in low-energy availability, apart from the obvious mechanics. Okay, fine. They're not fueling enough. Why are they not fueling enough? I mean, for sure, there are physical aspects. It's physically difficult if you're performing to fuel after a late performance. Yeah, okay. Given that there are those restraints and restrictions and difficulties, but what's driving that type of behavior anyway?


What I found from that study is that there's a very – the correlation between anxiety about missing class, anxiety about shape and weight. Those actually feed into the physical outcomes, which was what I found fascinating that the drive thinness that this actually manifests itself physically. It's like, wow. Not just because you're eating less, but just because that mindset of so that's really in a nutshell what the whole point of that research was to see what is going on here. Why are dancers at risk? Because of the nature of the dancing and also these as we said, the self-perpetuating anxieties, concerns, self-esteem, all this thing. That is driving them to where they could be in low-energy availability. If they’re in low-energy availability manifest by all the physical things we discussed, no periods, etc., poor sleep, all this thing, then that effectively is RED-S, because low-energy availability is the condition and then RED-S is the clinical outcome.


You have low energy availability, everything is down-regulating. We got clinical signs of that. Then the outcomes are RED-S. Some people, it's like, I only recently myself, I have to say, really formulate this in my own mind. Low energy availability is that's the process. That's what's happening in physiological terms, hormone terms. Then the outcomes, the clinical outcomes are what RED-S is; the stress fractures, the poor sleep, all those things. That's really what that study was all about.


Also, the use of how I assess this was a questionnaire format, one of these identification questionnaires, if you will. It was like the leaf. In fact, I was asked, why don't you just use the leaf? It's like, yeah, I have to be honest and I did borrow quite a lot of the questions on the leaf, because those are validated questionnaires, etc. I then put in some like you say, context, some context for the dancer.


Do you think you'll dance better if you're lighter? Do you think you'll get a better role? Do you feel anxious if you can't do class? All these things. I added in those elements of dance to give it a little bit more flavor context. I’m hoping that as a result of this study, number one to clarify, yes, dancers are at risk. Also, actually to say proactively you were saying, how do we identify people? I said, a practical questionnaire is the way to go. This could be something that could be done.


This study was for dancers entering pre-professional training, or professionals. At that stage, if you can do a questionnaire and spot those ones that are at risk early on before they turn up knocking on the door saying, “I’ve got a stress fracture,” if you can pick them up before that, then obviously, that's proactive. That's the way to go, isn't it? That was the point of doing that survey.


[00:49:15] LB: Yeah. I guess, that's when it starts to become really interesting when you're observing this one way or the other and you're starting to see disordered eating, or is it eating disorders. How does one view that? I guess, again, as people who are in a privileged position to be there with these people and have the responsibility of helping, or pushing them a certain direction is a pretty important thing in my view. It's a difficult area, isn't it?


[00:49:46] NK: Yeah. Well, there's a recent paper from Australia, exactly, that sliding that spectrum, clinical spectrum of disordered eating to eating disorder. I mean, an eating disorder it's a bit like the unintentional intentional RED-S. Eating disorder, I mean, I’m not saying it's super clear-cut, but there are strict DSM criteria, this is how you diagnose an eating disorder, blah, blah, blah, tick and that's them.


People with RED-S don't necessarily have an eating disorder like that that would meet those clinical criteria. It's like you say, the step, the amber area, the disordered eating, which isn't necessarily exact – hasn't got these strict clinical criteria. In that case, those are the ones that typically are avoiding, in my experience, avoiding carbohydrates. I don't know, they've got such a bad press anyway. Orthorexia. It's like, when you talk to someone it's like, well, just give you an outline of what you're eating through the day.


Literally, it's like, there's hardly any carbohydrate in there at all. That's what I mean by disordered eating. Putting out a whole food group like that. Or very typically, well, just really reducing overall. Reducing food groups, but also reducing overall and avoiding certain things that are oh, my goodness. I could never even contemplate that. Or fueling around training is often an issue. I don't particularly like faster training and especially in someone that's on the cusp of RED-S, that sure as hell going to push them into RED-S, or not fueling after the training as well.


I think, the thing about, this is a slight tangent, the thing about carbohydrate, the story there is that having worked in the NHS for way too many years, including some diabetic clinics, it's true. If an overweight, type 2 diabetic comes in who hates exercise, doesn't want to exercise, loves chocolate and whatever, yes of course, I’ll be saying to that person, “Well actually, I think we just need to have a – go a little bit easy on your carbohydrate intake.” After all, we have got an obesity epidemic. That's fair enough.


In these specific groups that we're talking about, athletes and dancers are at risk already of RED-S, who they're hardly – they need carbohydrate. Absolutely need carbohydrate, as you know, for the high-intensity output of exercise. Those are the real warning signs of the disordered eating, which in itself can lead to RED-S. Of course, I guess it could also go on to become a full-blown eating disorder. I think that's also an important thing to clarify. You don't have to have a full-blown eating disorder. Lots of misconceptions. “Oh, I can't have RED-S, so I haven't got an eating disorder.”


It's like, “Yes, but you're only eating a couple of lettuce leaves a day.” You know what I mean? Okay, your weight is stable, but that's because your metabolic rate is dialed down. Yeah, you have to be a little bit circumspect about those details.


[00:52:41] LB: Yeah. That's why I feel there are some translational issues, which I think we need to spend some more time on when becoming aware of the language we use in science and the language we use in practice. There are some issues there, for example. What I mean by that is we eat food. We don't eat macros. We don't eat calories. We don't need carbohydrates. When we talk about, I’m cutting out carbs, what does that even mean?


[00:53:10] NK: I know. I know. Yes [inaudible 00:53:11].


[00:53:12] LB: It's complicated, isn't it?


[00:53:13] NK: Yeah. Quite exactly. Macros, don't even get me started. I mean, nutrition, that's obviously not my area of specialty. Of course, but nevertheless from what my understanding of it is that yeah, it's fraught with misunderstandings. Also, as just a little bit of fun, my husband for a few days, he used – am I allowed to mention a product? Yeah, he used a tracking thing for food. I’ll leave it as that.


[00:53:41] LB: An app.


[00:53:41] NK: Anyway, so he used that. I tell you what, after just a day or two, he drove not only himself mad, he drove us mad, the family, because it's like, oh, no, no. Okay, my son made the dinner. Let's sit down. “Oh, no, no. I’ve got to measure this and that and [inaudible 00:53:57].” For goodness sake. I mean, he's not at all any the signs of disordered eating suffice to say. He's a master cyclist.


I’m sure that after using that for a couple of days, you could easily become one. I’m not a master cyclist. I mean, obsessed and just developed some disordered eating and I’m not sure how great those –


[00:54:18] LB: That's a good point, because what I see in practice is people's use of tools and technologies that they believe to be accurate. They might be if they even knew how to use them. One of the biggest issues we have in nutritional, or dietetics practice is this business of self-reported food diaries and perceived skill, which they most definitely usually don't have is their ability to identify a portion size, or whatever. You start inputting this stuff into these apps for tracking food. The reality is you're quite a way off. That obviously is an area, which could lead you into energy deficiency, of course. You might think you’re consuming –


[00:55:04] NK: [Inaudible 00:55:04], because the algorithms in those things, I mean, they might be accurate for some theoretical thing, but is it relevant for you?


[00:55:12] LB: Also, the practitioner, the nutritionist might be recommending a number of calories per day that that person should be consuming without truly understanding what the energy needs of that individual are. You combine that with the athletes, or the clients, or the patient’s inability to actually measure, quantify what it is they're doing and that mismatch is a massive gap, which is your energy deficiency potentially. That line in the sand is pretty big potentially.


Speaking of the sorts of people that do like to do that thing, and we won't go down the physique athlete path. I don't know how much you enjoy that area. I’ve done some research in that area, they can be very into that. Another one is cyclists. You've done a number of studies on cyclists, a bit like you have with the dancers and your questionnaires and so on. What did you find – what's interesting about cyclists as it relates to energy deficiency risks? What did your studies find and what should we take home from that work that you've done?


[00:56:16] NK: Well, I decided to do cyclists. I have to admit, slightly for personal reasons, because my husband, like I mentioned, is a master cyclist. My eldest son is a Cat 1 racer and a cycle coach. There's a lot of talk, cycling talk in the house, shall we say. Also, so that was the reason for cyclists. The other reason is males. These were male cyclists, because males hadn't had so much research done.


The interesting thing about cyclists is that I’m talking about road cyclists. Track cyclists, they go round and round in a circle. That's very simplified. They go round and round in circle at the same level. The main thing they have to overcome is aerodynamic drag. It's all about the position and the fancy bike and the –


[00:57:00] LB: Massive legs.


[00:57:01] NK: Whereas the road cyclists, if you've been watching back-to-back tour Anjiro and Welter on the TV, you'll see, they have to climb up some steep things. Everybody, not the whole of the Peloton. It's not just, oh, when people talked about sprinters, it's like, yes, but they still have to get themselves off those mountains. Anyway, so road cycling, you always going to have an element of gravity to overcome, especially if you're doing those races. That's when potentially, those cyclists can be at risk of RED-S.


You mentioned James Morton earlier. Of course, he's working with team skies it was. It's fine if you're under someone like James Morton, who’s really knows, obviously, an expert, and will keep them lean and light, but with sufficient energy on board. The problem is that the amateur cyclist watches these grand tours on the TV, wants to emulate through [inaudible 00:57:59] and thinks, “Oh, well the way, I can win, I can do better is by not eating so much.” If only it were that easy, we'd all be winning the tours. That's what the studies that I did to look at what is the incidence of low-energy availability in male cyclists and correlating, using the questionnaire thing I mentioned in a clinical interview.


Then correlating that to their measurements of bone mineral density on the dexa and a couple of blood tests, see what's going on. Actually, the findings are quite scary. That's half of them, pretty much, had low bone mineral density. I mean, you could say, okay, it's a non-weight-bearing sport. Nevertheless, that's aggravated by the fact under fueling. We know the lump spine is particularly affected, because it's trabecular bone.


Also, the other thing is that cyclists and I know this, I can definitely say this. Cyclists are either on their bike, or on the sofa, or in the car. They don't really particularly doing loaded exercise. Again, they are at risk of poor [inaudible 00:58:59] health from that point of view. That was the point of the study, to see, get a picture of what's going on.


Then the second part of the study is what do we do about it? I divided the cyclist into two groups, matched them on their bone mineral density into one lot. I said, “Fine. Go away. Do your thing that you do, normally for race season.” For the other group, it's like, please can you fuel like this? Can you eat a bit more carbs, especially around training? Can you do these exercises during the week, three times a week, just some exercises?

When they came back, the interesting thing was the ones that had taken the education advice, they improved their bone mineral density. Conversely, the ones that I said, just do your own thing, doing your own thing in a lot of them was actually, I’m going into default mode for the race season, which was to eat less. Of course, they're racing. Actually, they lost bone density, the same amount that you would an astronaut in space over just six months. That's pretty scary.


Then short space of time. Also, the actual crucial bit of the findings from that study, which cyclists were particularly, the take home message for the cyclists was that the ones who were under-fueling and going into default mode and losing bone density, they also didn't perform as well as the others. They didn't win so many racing points, VC race points. I mean, I know racing there's always like you say, an element of luck and whatever. Still over the whole season, it was surprising. There was a significant difference that those that were under-fueling just weren't getting the winning race points, or weren't performing as much.


That actually is the crucial message for the athlete, I think, if we're going to sum all of this up, is that the performance can suffer in the long-term. That's hopefully, also the motivator for them to change their behaviors.


[01:00:45] LB: Yeah. Yeah, I guess another mini-sum up of it is short-term gain maybe long-term pain likely. A lot of them are all about the strategy of their training and so on. I guess, if they did have a gadget on their handlebars that showed them not just things, like critical power and where there are on a map, but if they had little dials that said your bone density is going down and your fuel is going in the wrong way and so on, obviously, they would look at this differently. Until such a time, we have to think a bit more about these things.


Wow, what a fantastic conversation we've had, Nicky. I personally have really enjoyed that and I’m sure the listeners will have done so. I will make sure that I add various things that we've talked about, such as papers and resources, including the British Association of Sport and Exercise, medicine resources that you've contributed to. I’ll make sure that's all linked in the show notes of this.


[01:01:45] NK: Yeah. Just to mention that. There's an educational website called helpful performance. We wrote that with contributions from colleagues. It's information for athletes, coaches, parents, healthcare professionals to go and check all the things, basically, it's the thing, or everything we've been talking about into a certain extent. Also, I try and keep it up to date with new papers and webinars and podcasts and that thing. That's probably a very good starting point.


[01:02:12] LB: It's on my computer, on my favorites tab, Nicky. I use it as a resource for practice all the time. I’ll definitely link to that. I know some of the listeners will be keen to follow you and your work. I know you've got a website and you’re on social media. Perhaps, you could just tell the listeners how they can find you on those.


[01:02:29] NK: Yeah. My website is Yeah, all the various social media, things. Although, I have to say I’m not that flash hot about social media to be absolutely honest with you. I have it, but the best way to get contact with me is the old-fashioned e-mail. I’m more likely to see that than social media. I have it, but I’m just warning you, I’m not –


[01:02:52] LB: No, no, no. I have a similar relationship with social media. Well, look. Thank you so much for your time. It's been wonderful. I look forward to talking to you again in the future when there's more on this topic.


For everyone listening, you can get all that information from the podcast website, which you can access via the podcast tab at our main website, which is, the Institute of Performance Nutrition's website, where you can also access a variety of other podcasts on this theme of relative energy deficiency, which I will also link to this podcast, as well as all the other things that we get up to @TheIOPN. I shall leave it at that and everyone can get back on their bicycles and go and do hours of cycling.


[01:03:38] NK: Well-fuel beforehand.


[01:03:39] LB: Well-fueled. Yes. Thank you, Nicky. I am Laurent Bannock. I look forward to bringing another episode of We Do Science back to you all very soon. Take care, everyone.