Article Text

Download PDFPDF

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
  1. Nicola Keay1,
  2. Gavin Francis2,
  3. Ian Entwistle1,
  4. Karen Hind3
  1. 1Department of Sport and Exercise Sciences, Durham University, Durham, UK
  2. 2Science4Performance, London, UK
  3. 3Department of Sport and Exercise Sciences and the Wolfson Institute for Health and Wellbeing, Durham University, Durham, UK
  1. Correspondence to Dr Nicola Keay; nickykeayfrancis{at}


Objective To clinically evaluate education to improve eating behaviour and skeletal loading exercise in male cyclists at risk of poor bone health and impaired performance due to relative energy deficiency in sports.

Methods Early race season, 50 competitive male road cyclists were matched, in pairs, based on Z-scores for lumbar spine bone mineral density (BMD). One member of each pair was randomly allocated to receive educational interventions. After the season, 45 cyclists returned for dual-energy X-ray absorptiometry scans and blood tests. Least significant change was applied to identify clinically meaningful BMD changes. Cyclists completed a follow-up sport-specific questionnaire and clinical interview to ascertain adherence to the interventions.

Results The questionnaire and clinical interview categorised behaviour changes as positive, negative or unchanged. Positive changes in nutrition and skeletal loading were associated with a statistically significant increase of 2.0% in lumbar spine BMD; 7 of 11 cyclists’ increases were clinically meaningful. Negative changes in both behaviours were associated with a significant decrease of 2.7% in lumbar BMD; all nine cyclists’ BMD decreases were clinically meaningful. Regarding performance, taking account of functional threshold power, changes in nutritional behaviour accounted for gains or losses of 95 British Cycling racing points. Cyclists reported psychological barriers to change in behaviours, specifically fear of negatively impacting performance.

Conclusions Educational nutritional and skeletal loading interventions can improve bone health, well-being and race performance in male cyclists over a 6-month race season. Psychological support may be required to help some athletes change behaviour.

  • energy availability
  • male athletes
  • bone health
  • relative energy deficiency in sport

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

View Full Text

Statistics from


  • Collaborators Brian Oldroyd, Leeds Beckett University, Leeds, UK.

  • Contributors NK: conceptualisation of the project, development of study design, research funding application, involvement of cyclists, their coaches and sports performance dietitians, conducting clinical sport-specific interviews, drafting and revision of the manuscript. GF: cycling-specific advanced statistical analysis, drafting and revision of the manuscript. KH: development of study design, research funding application, scanning of cyclists and revision of the manuscript. IE: scanning of cyclists and comments on the manuscript.

  • Funding This study was supported by funding from the British Association of Sport and Exercise Medicine (BASEM) and by SunVit-D3 for the analysis of endocrine and metabolic markers.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was reviewed and approved by Leeds Beckett University research ethics committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No unpublished data were used in the preparation of this manuscript.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.