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Dr Nicola Keay — Relative Energy Deficiency in Sport (REDs) — Injury Rehab Network

The first of two Injury Rehab Network events in April 2024 with BASRaT featured a presentation from Dr Nicola Keay, a Hormone Health Expert. The online event took place on the evening of Monday 8th April with 210 sports rehabilitation practitioners in attendance.

Dr Keay discussed Relative Energy Deficiency in Sport (REDs). The recording is available to watch here.

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Dr Nicola Keay, Hormone Health Expert

Nicky Keay is the author of “Health Hormones and Human Potential: A Guide to Understanding Your Hormones to Optimise Your Health and Performance.” Her next book will explore “The Myths of Menopause.”

Nicky is an Honorary Clinical Lecturer at the Division of Medicine, University College London. She lectures and conducts research in the area of exercise endocrinology, with publications in this field. Nicky’s clinical endocrine work is mainly with active women, exercisers, dancers, and athletes, with a focus on relative energy deficiency in sports (REDs) and those navigating perimenopause/menopause.

Nicky works to provide a more personalised approach to female hormone health. Nicky authored the British Association of Sports and Exercise Medicine Health4performance.co.uk online resource. Nicky is a medical advisor to Scottish Ballet and a keen dancer herself, taking four ballet classes per week.


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Relative Energy Deficiency in Sport (REDs)

Nicky’s presentation, “Relative Energy Deficiency in Sport (REDs),” explored the aetiological factors, clinical outcomes, and management of REDs. Nicky discussed how to identify those at risk and what to do to support those restoring health and recovering from associated hormone and physical injuries.

Learning outcomes:

  • Understand the causative factors of REDs
  • Appreciate that REDs can occur in both males and females, all ages, and at all levels of exercise
  • Appreciate the underlying physiological mechanisms
  • Appreciate how to identify those at risk
  • Understand the principles of risk stratification
  • Know what to do to support those experiencing REDs

REDs Outline

Dr Keay provided an introduction to the presentation and discussed the definition of hormones ‘setting in motion’, all aspects of physiological function in the body. Nicky described athlete behaviours to harness hormones and how unbalanced behaviours can lead to Low Energy Availability (LEA) and Relative Energy Deficiency in Sport (REDs). Nicky discussed the effects of REDs on health and performance, as well as the clinical identification and clinical management of REDs.


Nicky described the importance of hormones and the role of hormones in physical and mental health. Dr Keay considered how hormones can be harnessed through healthy behaviours, including exercise, nutrition and sleep.

Nicky discussed the effects of hormone networks on performance in relation to cardiovascular, psychological, bone, body composition, metabolism, muscular endurance, muscular strength, and cognitive function.

Energy Availability Consequences on Health and Performance

Nicky discussed how good energy availability results in positive adaptation and performance. Dr Keay considered how low energy availability can be intentional or unintentional. Athletes should be aware of energy availability to ensure a fully functioning hormone network drives adaptions to exercise and leads to improved performance.

Nicky described the balancing act that athletes must get right to match energy intake with energy demand.

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Female Athlete Triad

Dr Keay discussed research in relation to the female athlete triad, with studies showing that disordered eating can lead to amenorrhoea and reduced bone mineral density. Optimal energy availability ensures eumenorrhea and optimal bone health whilst reduced energy availability (with or without disordered eating) leads to Functional Hypothalamic Amenorrhoea (FHA) and Osteoporosis.

Significance of Relative Energy Deficiency in Sport (REDs)

Nicky discussed how REDs was formally recognised by the IOC in 2014 as a condition with adverse effects on athlete health and performance. This statement recognised the broader clinical syndrome of low energy availability (LEA) and its multisystem effects, including the female athlete triad. Nicky described how the effects of REDs are reversible if managed correctly. In 2023 there was an updated IOC consensus statement on REDs.

Effects of LEA on Endocrine Networks

Dr Keay described the effects of Low Energy Availability (LEA) on endocrine networks with the hypothalamus as the control centre. LEA impacts bone health, with bone turnover slowing down and resulting in reduced bone mineral density.

Nicky discussed the effects of cumulative energy deficiency and cumulative endocrine dysfunction, with bone turnover being the first system impacted by LEA. The clinical consequences of slow bone turnover are bone stress injuries. Dr Keay described how peak bone mass is sustained if adequate energy is available. Bone mineral density is reduced with LEA, putting the athlete at risk of fractures.

Implications of REDs on Athletic Performance

Nicky discussed the implications of REDs on athletics performance with endocrine system dysfunction leading to:

  • Decreased neuromuscular skills
  • Impaired improvement
  • Compromised Functional Threshold Power (FTP)an

Nicky described how athletes need motivation to implement change, and this is a factor to be considered by practitioners when supporting athletes with LEA.

Dr Keay stated that the ultimate implication of REDs on athletic performance is the inability to achieve full potential.

Athlete Eating

Psychological Factors in REDs

Dr Keay described the differences between a ‘manage’ or ‘control’ approach to training and nutrition. Athletes who adopt a flexible “manage” approach are able to periodise training, fuel for the work required and engage in social contact. This leads to energy balance, optimal performance and success. Athletes with a “control” approach have rigid, obsessive training, restrictive eating and often isolate themselves socially. This leads to LEA, REDs and disappointment creating a cycle of negative reinforcement.

Eating Behaviour

Nicky discussed a spectrum of eating behaviour from optimised nutrition, disordered eating and eating disorders. Addictive behaviours can lead to REDs if energy intake isn’t sufficient to meet the demands associated with energy expenditure.

Nicky provided advice for practitioners on what to look for in athletes’ relationship with food and/ or exercise. Primary indicators include:

  • Growth and development
  • Menstrual function
  • Bone stress injuries

Other factors to look for include behaviour, mood, sleep patterns, body weight, illness, gastrointestinal issues, and performance (stagnation, deterioration).

Diagnosis of Exclusion

Dr Keay discussed how a process of diagnosis of exclusion is used to diagnose REDs. Practitioners should consider history, use validated questionnaires, undertake an examination, and complete investigations with blood tests. This approach can then exclude any underlying medical condition.

Nicky described the IOC REDs CAT2 three-step protocol, which includes:

  1. Screening
  2. Severity and risk assessment and stratification
  3. Clinical diagnosis and treatment

Clinical Management

Dr Keay discussed the clinical management of REDs, including:

  • Nutrition – regular meals and pre/ post exercise fueling.
  • Avoid energy deficits.
  • Ensure good carbohydrate availability.
  • Exercise – reduce intensity
  • Psychological support
  • Do not give the contraceptive pill

REDs Action Plan

Nicky presented a REDs action plan:

  • Raise awareness
  • Identification of those at risk of LEA
  • Diagnosis of exclusion
  • Risk stratification
  • Multidisciplinary team
  • Pharmacological intervention
  • Psychological dimension

Nicky described how the aim is to create resilient individuals with a sustainable long, healthy career.

Harnessing Hormones

Dr Keay described how optimal health and performance can be achieved through a balanced approach to exercise, nutrition, and recovery.


Nicky kindly answered questions put forward by practitioners who attended the session. Please see the presentation recording for the insights from Dr Keay to the questions.

Presentation Recording

The recording of Nicky’s presentation is available to watch here.


Nicky signposted practitioners to her book, “Hormones, Health and Human Potential” and the Health 4 Performance website.

Follow Dr Nicky Keay

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