Bone health and RED-S assessment
A careful, non-judgemental assessment of whether you are getting enough fuel for your training and daily life, and how this is affecting your bones, hormones and overall health.
✓ Medically reviewed by a GMC-registered consultant · last reviewed September 2026 · next review September 2027 · how we review
In short
- The assessment checks whether you are getting enough fuel for your training and your health, and how this is affecting your bones and hormones — it is supportive, not judgemental.
- Low energy availability is often unintentional, and the aim is to protect long-term bone health and keep you active, not to stop you training.
- No single test gives the full answer; history, blood tests and a bone density scan are read together, alongside how you feel.
- If disordered eating is part of the picture, kind, specialist support is part of the plan — ask who will help and how.
A plain-English summary. The detail — including risks and recovery — is below.
At a glance
A general guide. Your specialist will give you advice for your situation.
Builds an honest, joined-up picture of your fuelling, hormones and bone health
Someone who is acutely unwell, fainting, or with a dangerously low heart rate or weight needs urgent medical care first, not a routine booked assessment.
You have a detailed conversation and examination, and tests are arranged. Some early thoughts can be shared, but firm conclusions usually wait for results.
A clear, kind explanation of the findings and a plan centred on restoring energy availability.
You have a detailed conversation and examination, and tests are arranged. Some early thoughts can be shared, but...
Blood tests are usually reported within days. The team reviews them alongside your history and symptoms.
Your bone density scan is reported. The findings are brought together and explained, and a plan is discussed with...
If low energy availability is found, the focus is on restoring fuelling and gradually settling training, with...
What is a bone health and RED-S assessment?
This assessment looks at whether your body is getting enough energy (fuel from food) to cover both your training and the everyday work of keeping you healthy. When intake does not keep up with what you burn, the body goes into a state called low energy availability. If this carries on, it can affect bones, hormones, periods, mood, immunity and performance — a pattern doctors call Relative Energy Deficiency in Sport, often shortened to RED-S or REDs.
The assessment is usually done by a sport and exercise medicine doctor, sometimes with a sports dietitian and other specialists. It brings together your training and eating history, your symptoms, an examination, blood tests and usually a bone density (DEXA) scan to build an honest picture of your health and bone strength.
This is an assessment, not a treatment. Its job is to understand what is happening and why, not to judge you. Low energy availability is very often unintentional — for example from a heavy training load, a busy life, or simply not realising how much fuel is needed. The aim is to protect your long-term health, especially your bones, and to help you keep doing the activity you love.
One thing to know early: a single test result rarely gives the whole answer. Bones, blood and periods each tell part of the story, and the picture is read together, alongside how you feel and train, rather than from any one number on its own.
Types, options & approaches
There may be different ways to do this. The right approach depends on the clinical question and your circumstances.
Low energy availability vs RED-S
| Low energy availability | RED-S | |
|---|---|---|
| What it is | Not enough fuel for needs | Health effects from ongoing shortfall |
| May be noticed by | Tiredness, hunger, niggles | Missed periods, stress fractures, low mood |
| Bone effect | May be early or none yet | Lower bone density, fracture risk |
| Main step | Restore fuelling | Restore fuelling plus treat effects |
Low energy availability is the underlying driver; RED-S describes the wider health effects when it continues. Both improve when energy availability is restored.
Preparing for your test
- Jot down your typical training week and a rough picture of what you eat and drink across a few days — honesty helps more than perfection.
- Note any symptoms: tiredness, frequent illness or injuries, low mood, poor sleep, reduced performance, or stress fractures.
- If you have periods, note whether they are regular, irregular, light or have stopped, and when any change started.
- Bring details of past injuries, especially bone stress injuries or stress fractures, and any previous bone scans.
- List your medicines, supplements and any contraception, as some affect periods, bones or blood results.
- It is fine to bring someone you trust; you can also ask to speak to the team on your own.
- If eating feels difficult or stressful, you can say so — the team is used to this and there to help, not to judge.
What happens
The appointment usually starts with a conversation. The doctor will ask about your training, eating, energy, sleep, mood, periods (if relevant) and any injuries, and will explain why each question matters. Questionnaires may be used to help structure this. The aim is to understand your situation, not to catch you out.
An examination may include your height, weight and general health. Blood tests are often arranged to check hormones, iron, vitamin D, bone markers and other causes of your symptoms. A bone density (DEXA) scan is usually arranged to measure bone strength; you lie on an open table while a scanning arm passes over you, and it is usually not painful.
The team then brings the findings together. Some things can be discussed on the day; blood and scan results are reviewed over the following days to weeks. From there, you and the team agree a plan — which usually centres on restoring energy availability, with support from a dietitian and other specialists as needed.
Is this test right for me?
A good consultation should explore whether it's the right choice for you now — including reasons to wait or consider something else.
May not be suitable if…
- Someone who is acutely unwell, fainting, or with a dangerously low heart rate or weight needs urgent medical care first, not a routine booked assessment.
- If a severe eating disorder is already evident, urgent referral to specialist eating-disorder services should not wait for a full work-up.
- Using a bone scan alone, without the wider assessment, will miss the underlying energy and hormone picture.
- This pathway is not a substitute for emergency care if there are warning signs such as chest pain, collapse or thoughts of self-harm.
Delay or rearrange if…
- There is an acute bone stress injury that needs immediate rest and protection.
- You are acutely unwell or unable to engage with the assessment that day.
- Recent contrast dye or a radioactive-tracer scan would affect a DEXA scan, until enough time has passed.
- There is a safeguarding or mental-health crisis that needs addressing first.
- Pregnancy is possible, in which case the bone scan is deferred.
Alternatives to discuss
- Starting with a sports dietitian and education on fuelling, with medical assessment alongside.
- Conservative steps to restore energy availability while monitoring symptoms and periods.
- Referral to a specialist eating-disorder service where that is the main issue.
- Gynaecology or endocrine assessment if missed periods are the leading concern.
- Watchful support if the shortfall is mild and recent, with review if it does not settle.
Before you decide
Use this as a shared-decision checklist. The aim is not just “can this be done?”, but whether it is right for you, now, with the risks and alternatives clearly understood.
What matters most to me?
Think about symptoms, daily life, work, caring responsibilities, sport, fertility, travel, appearance and anxiety — the right choice depends on your priorities, not just the medical facts.
What are all my options?
Ask about waiting, monitoring, medicines, rehabilitation, a smaller or larger procedure, a different test, NHS referral, or a second opinion where that would help.
What would make me pause?
Active infection, pregnancy, unstable medical problems, smoking, medicines that increase bleeding, poor support at home, or feeling pressured are all reasons to slow down and get tailored advice.
What happens if I do nothing today?
For some problems, waiting is safe; for others, delay can make treatment harder. A good consultation should explain the trade-off in plain English.
Benefits
- Builds an honest, joined-up picture of your fuelling, hormones and bone health
- Can explain symptoms such as tiredness, repeated injuries, missed periods or poor performance
- Measures bone strength so that bone loss can be picked up and protected early
- Helps separate low energy availability from other treatable causes of the same symptoms
- Opens the door to supportive, specialist help, including for eating if needed
- Aims to keep you active and healthy in the long term, not to stop you training
Risks & complications
- Talking about food, body or training can feel uncomfortable or emotional
- Needing more than one appointment, or several tests, to build the full picture
- Waiting a little while for blood and scan results
- Finding the conversation surfaces feelings you were not expecting
- A bone density result that is lower than hoped, which can be upsetting
- Being advised to change training or fuelling in ways that feel hard at first
- Results that are unclear and need repeating or further tests
- Discovering another condition that needs its own treatment
- Identifying a serious eating disorder that needs urgent, specialist care
- A bone stress injury found that needs rest and protection straight away
The assessment itself is low-risk and non-invasive; the bone scan uses a very low radiation dose. The harder part is often emotional, because it touches on eating, body image and identity as an athlete. A good service handles this gently, explains that low energy availability is common and treatable, and makes clear that the goal is your health, not blame. If eating feels out of control or distressing, tell the team — kind, specialist support is part of the plan.
Published figures to discuss
There are no meaningful complication rates for the assessment itself, which is non-invasive. What varies is how strongly low energy availability links to harms such as bone loss and stress fractures, and these associations are reported from studies in selected athlete groups, so they do not predict any one person's risk. Figures below are illustrative of the link, not a guarantee of what will happen to you, and are read alongside your own picture.
| Figure | Reported range | How to interpret it | Source / confidence |
|---|---|---|---|
| Stress fracture with low energy availability / RED-S | Reported much more often in affected athletes than unaffected ones in some studies (for example around 70% vs 25% in one elite-athlete series) | From selected athlete groups; shows a strong association but does not predict any individual's risk. | RED-S: scientific, clinical and practical implications — PMCpmc.ncbi.nlm.nih.govPublished figure |
| Stress fracture with absent periods (amenorrhoea) | Around two to four times higher than in athletes with regular periods, in published series | Missed periods are an important warning sign for bone health and prompt closer assessment. | Guide sourcesClinical context |
| Low bone density in affected athletes | Varies widely by sport, sex and how long the shortfall has lasted | Reported in a meaningful minority; read as a Z-score in younger people and interpreted in context. | Guide sourcesClinical context |
These are literature figures, not a personalised prediction. Your own risks and likely benefits depend on your circumstances, your health, and how your care is carried out and followed up.
What happens afterwards
There is no physical recovery from the assessment itself. What matters afterwards is making sense of the findings and agreeing a supportive plan. Some people feel relieved to understand what is happening; others find parts of it hard to hear, which is completely understandable.
- Feeling a mix of relief and worry after the conversation
- Waiting a little while for blood and scan results to come back
- Finding early changes to fuelling or training feel strange at first
- Needing a few appointments to put the whole picture together
- Periods taking some months to return once fuelling improves, if they had stopped
Aftercare
- Work with a sports dietitian, if offered, to restore energy availability in a sustainable way.
- Follow the agreed plan on training load, which may mean easing back for a time to let bones and hormones recover.
- Take any recommended vitamin D, calcium or other treatment as advised.
- Keep follow-up appointments so progress, periods and bone health can be tracked.
- Be honest with the team about how eating and training feel, including any struggles.
- Lean on psychological or eating-disorder support if it is offered, without shame.
- Tell the team promptly if you develop new bone pain, an injury, or your periods stop.
- Be patient and kind with yourself — recovery of bone and hormone health takes time.
- A few days' note of your training, eating and energy
- A record of your periods (if relevant) and when any change began
- Details of past injuries, stress fractures and bone scans
- List of medicines, supplements and contraception
- Questions written down about bones, periods and training
- A trusted person to come with you if you would like support
⚠ Get urgent help if…
- New or worsening bone pain, especially pain that comes on with weight-bearing or training, which can signal a bone stress injury
- A fracture from a minor knock or fall
- Fainting, chest pain, palpitations or a very slow heart rate
- Feeling faint, very weak, or unable to keep up normal eating
- Thoughts of harming yourself, or eating feeling completely out of control — seek help urgently
- Periods that have stopped for three months or more (if you are not pregnant or on a method that stops them)
- Rapid, unintended weight loss or feeling very cold all the time
Who to contact: your clinician, clinic or test provider first (keep their number to hand). For urgent advice when you can't reach them, call NHS 111. In an emergency, call 999.
General guidance — it doesn't replace the specific advice your specialist gives you.
Results & realistic expectations
A helpful result is a clear, joined-up understanding of whether you are under-fuelled, how your hormones and periods are affected, and how strong your bones are. In younger people, bone density is usually reported as a Z-score, comparing you with others your age, because a T-score is designed for older adults. The findings guide a supportive plan, the heart of which is usually restoring energy availability.
Results have limits. Low energy availability cannot be measured directly by a single test, so it is judged from the whole picture rather than one number. A bone scan is a snapshot and does not capture every aspect of bone strength, and blood tests can be normal even when fuelling is low. This is why the team interprets everything together, alongside how you feel and train, and may repeat tests over time to see how you respond.
The findings reflect how things are now. Energy availability, periods and bone markers can improve within months of restoring fuelling, but bone density changes slowly and may take a year or more to respond, so scans are repeated only after a suitable interval. Because bone built (or lost) in your younger years affects your skeleton for life, acting early matters. If your training, eating or symptoms change, the assessment may need revisiting.
Related tests, treatments or support
This assessment often brings together several pieces: a bone density (DEXA) scan, blood tests for hormones, iron, vitamin D and bone markers, and input from a sports dietitian. Where periods have stopped, a gynaecology or endocrine review may be added to look at other causes, and psychological or eating-disorder support is included when needed.
Follow-up & long-term care
Results are usually explained at a follow-up, where a plan is agreed. If low energy availability is found, you will normally be reviewed regularly to support fuelling, track periods and symptoms, and monitor bone health, with a repeat bone scan only after a suitable interval. Onward referral to a dietitian, gynaecologist, endocrinologist or eating-disorder service is arranged as needed.
- Ongoing support from a sports dietitian to keep energy availability adequate
- A sustainable balance between training load and recovery
- Vitamin D and calcium as advised, with a bone-healthy diet
- Regular review of periods and symptoms while recovering
- Repeat bone density scan only at the interval your clinician recommends
- Continued psychological support where it is helpful
Repeat, follow-on and what comes next
- The picture is built over time; tests may be repeated to see how you respond to restoring fuelling.
- Bone density changes slowly, so a repeat DEXA scan is only useful after a suitable interval, often a year or more.
- Periods and bone markers can take months to improve, and the plan is adjusted as they do.
- A normal early result does not rule out low energy availability, so review continues if symptoms persist.
Ask what happens if the result is unclear or needs repeating, and what is included if further tests or follow-up are needed.
What good aftercare looks like
- A clear, kind explanation of the findings and a plan centred on restoring energy availability.
- A named contact and a multidisciplinary team, including a sports dietitian.
- Access to psychological or eating-disorder support when needed, without stigma.
- Sensible monitoring of periods, symptoms and bones, with repeat scans only at appropriate intervals.
- A safe, gradual plan for returning to full training as health recovers.
What affects the cost
Costs vary a great deal between people and providers, and we don't publish prices. What matters is understanding what drives the cost and making sure your quote is complete. The main things that affect it:
- Length and number of appointments, and whether a dietitian is included
- Which blood tests are arranged and how detailed they are
- Whether a bone density (DEXA) scan is included
- Whether specialist input (gynaecology, endocrinology, psychology) is needed
- Follow-up appointments to review results and track progress
- Any onward referral for eating-disorder or other specialist support
- What the assessment appointment includes and how long it lasts
- Whether blood tests and a bone density scan are included or extra
- Whether dietitian and follow-up appointments are included
- Whether a written summary and a clear plan are provided
- What happens, and what it costs, if further tests or specialist referral are needed
- How psychological or eating-disorder support is arranged if required
On the NHS? Assessment is available on the NHS through some sport and exercise medicine, endocrine and specialist services when clinically indicated; private assessment may be used for speed, choice or self-referral.
You're entitled to your total cost in writing — including reports, follow-up and what happens if the result is inconclusive — before you decide.
Consent traps and marketing red flags
These are not small details. They are often where patients lose choice, time to reflect, or realistic expectations.
Consent traps
- Treating the assessment as blame rather than support, which can stop people seeking help.
- Focusing only on the bone scan number and missing the underlying energy and hormone picture.
- Not explaining that, in younger people, a Z-score is the right measure rather than a T-score.
- Failing to make clear who sees the findings and how eating or mental-health support is arranged.
- Giving a plan to change training or eating without dietitian or psychological support attached.
Marketing red flags
- Selling a quick 'athlete bone scan' as a complete RED-S check without the wider assessment.
- Promising performance gains rather than focusing on health and recovery.
- Pushing supplements as a fix without addressing energy availability.
- Framing the issue as a personal failing rather than a common, treatable problem.
- Offering hormonal medication to 'restart periods' without addressing fuelling and bone health.
Choosing a specialist safely
- Check the specialist is on the GMC Specialist Register for this area.
- Make sure they work at a CQC-registered service, and look for membership of the relevant Royal College or professional body.
- You're entitled to time to consider and to have your questions answered before you agree — the specialist who looks after you should explain it, not a salesperson.
- Be wary of pressure: time-limited offers or deposits taken before you've had time to think are red flags, not bargains.
- You're entitled to your total cost in writing — including any follow-up — before you decide.
Questions to ask your medical professional
Take this to your consultation. A good specialist will welcome every one of these.
- Am I getting enough fuel for my training and health, and how do you judge that?
- How are my bones, and is my result a Z-score appropriate for my age?
- Could anything else be causing my symptoms, and have we ruled it out?
- What is the plan to restore energy availability, and who will support me?
- How will we know it is working, and when should tests be repeated?
- Is psychological or eating support available if I need it?
- Are you on the GMC Specialist Register for this area, and which Royal College or professional body are you a member of?
- Will you be the specialist who carries out my test, and who looks after me afterwards?
- What are the risks for someone like me, and how often do your own patients have a problem or need it repeated or redone?
- What does a realistic result look like — and what can this test not achieve?
- What are my options, including waiting, doing nothing for now, or choosing a different approach?
- Can I have written information, results and aftercare instructions in a format I can use, including any accessibility or communication support I need?
- What is the total cost in writing, including any follow-ups, and how much time do I have to decide?
Frequently asked questions
Does this mean I have an eating disorder?
Will I be told to stop training?
Does this only affect women?
Is the bone scan safe?
Why look at my periods?
Can I get this assessment on the NHS?
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How we made this page
Medically reviewed by a GMC-registered consultant. Written in plain English, checked against NHS, NICE, GMC and relevant Royal College / specialist-society guidance, and kept under review. No clinic paid to appear on this page, and we publish no pricing. This is general information to help you prepare — it is not a substitute for advice from your own clinician. How we review our guides →
Source hierarchy: UK regulator and NHS/NICE guidance first, then relevant Royal College or specialist-society guidance, then peer-reviewed evidence for procedure-specific figures where available.
Sources & standards: BJGP — Relative energy deficiency in sport (RED-S) BASEM — Health4Performance (RED-S resource) IOC 2023 consensus statement on REDs — BJSM NHS — Bone density scan (DEXA scan) Royal Osteoporosis Society — Bone density scan (DXA) RED-S: scientific, clinical and practical implications — PMC Beat — eating disorder support
Reviews reflect patients' experience of care, not clinical outcomes. For procedure volumes and outcome data see PHIN.
Last medically reviewed 2026-09-21. Spotted something wrong or out of date? Report an error in this guide.
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