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Review of the scientific rationale, development and validation of the International Olympic Committee Relative Energy Deficiency in Sport Clinical Assessment Tool: V.2 (IOC REDs CAT2)—by a subgroup of the IOC consensus on REDs

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Stellingwerff, Trent, Mountjoy, Margo, McCluskey, Walter TP, Ackerman, Kathryn E, Verhagen, Evert, Heikura, Ida A·2023·British Journal of Sports Medicine
DOI 10.1136/bjsports-2023-106914
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Abstract

Relative Energy Deficiency in Sport (REDs) has various different risk factors, numerous signs and symptoms and is heavily influenced by one’s environment. Accordingly, there is no singular validated diagnostic test. This 2023 International Olympic Committee’s REDs Clinical Assessment Tool—V.2 (IOC REDs CAT2) implements a three-step process of: (1) initial screening; (2) severity/risk stratification based on any identified REDs signs/symptoms (primary and secondary indicators) and (3) a physician-led final diagnosis and treatment plan developed with the athlete, coach and their entire health and performance team. The CAT2 also introduces a more clinically nuanced four-level traffic-light (green, yellow, orange and red) severity/risk stratification with associated sport participation guidelines. Various REDs primary and secondary indicators have been identified and ‘weighted’ in terms of scientific support, clinical severity/risk and methodological validity and usability, allowing for objective scoring of athletes based on the presence or absence of each indicator. Early draft versions of the CAT2 were developed with associated athlete-testing, feedback and refinement, followed by REDs expert validation via voting statements (ie, online questionnaire to assess agreement on each indicator). Physician and practitioner validity and usability assessments were also implemented. The aim of the IOC REDs CAT2 is to assist qualified clinical professionals in the early and accurate diagnosis of REDs, with an appropriate clinical severity and risk assessment, in order to protect athlete health and prevent prolonged and irreversible outcomes of REDs.

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  • Hypogonadism symptoms such as a decrease in morning erections, decreased libido, and erectile dysfunction have been identified as possible symptoms of LEA in male athletes.

    “Such a survey could replace questions about menstrual cycles with questions designed to identify symptoms of hypogonadism, such as a decrease in morning erections, decreased libido, and erectile dysfunction, as these have been identified as possible symptoms of LEA in male athletes [10][11].”

    From Low Energy Availability and Relative Energy Deficiency in Sport: A Systematic Review and Meta-analysis (2025) · cites this paper as [10]

    The Review section says decreased libido and fewer morning erections may reflect low energy availability in male athletes; the REDs indicator list also names both. Our copy does not identify erectile dysfunction as an indicator, so it supports only two of the three symptoms attributed to this source. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • The IOC REDs CAT2 introduces a four-colour traffic-light severity/risk categorisation, in contrast to the three-colour stratification in the 2015 RED-S CAT, due to the appreciation that the 2015 yellow zone had an extensive clinical severity/risk range of very low to very high.

    “The IOC REDs CAT2 25 introduces a four-colour traffic-light severity/risk categorisation, in contrast to the three-colour stratification in the 2015 RED-S CAT, 141 due to the appreciation that the 2015 yellow zone had an extensive clinical severity/risk range of very low (a few minor symptoms) to very high (a few indicators away from removal from sport).”

    From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [25]

  • The IOC REDs CAT2 has undergone internal expert voting statement validation and external REDs expert clinical cross-agreement validation.

    “which has undergone internal expert voting statement validation (see online supplemental files 2-4) and external REDs expert clinical cross-agreement validation.25”

    From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [25]

  • Early identification of symptoms using screening instruments, individual health interviews and objective assessment of REDs biomarkers may be useful as secondary prevention.

    “Furthermore, early identification of symptoms using screening instruments, individual health interviews and objective assessment of REDs biomarkers may be useful as secondary prevention.25”

    From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [25]

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Cited by

Sorted by citations

Authors
Stellingwerff, T., Mountjoy, M., McCluskey, W. T., Ackerman, K. E., Verhagen, E., & Heikura, I. A.
Affiliations
  • University of Victoria (CA)
  • McMaster University (CA)
  • Canadian Sport Centre Pacific (CA)
  • Boston Children's Hospital (US)
  • Health & Safety in Sports (NL)
Corresponding author
Stellingwerff, Trent
ORCID
Venue
British Journal of Sports Medicine
Publisher
BMJ
Published
2023-09
Volume
57
Issue
17
Pages
1109-1121
ISSN
  • 0306-3674 (ISSN-L)
  • 1473-0480
DOI
10.1136/bjsports-2023-106914
OpenAlex
W4387036479
Cited by
119
References
17
Citations by year
2026: 47 · 2025: 35 · 2024: 30 · 2023: 7
FWCI
34.69
Type
journal article
Language
en
Update notices
correction (2024-02-07)
Open access
Locations
  • British Journal of Sports Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion, other-oa)
  • HighWire Press Open Archive (submittedVersion)
  • VUBIR (Vrije Universiteit Brussel) (submittedVersion)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
  • Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports Performance and Training
  • Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports injuries and prevention
Keywords
relative energy deficiency in sport, athlete health, expert consensus, athlete health protection
MeSH terms
Relative Energy Deficiency in Sport, Humans, Physicians, Sports, Consensus, Athletes

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