What Is Relative Energy Deficiency In Sport And How Can We Prevent It?

!! Trigger Warning: This article discusses eating disorders !!

Despite the fact that up to 80% of elite and semi-elite athletes experience RED-S, it is not widely discussed in the athletic community (1). While Relative Energy Deficiency in Sport (RED-S) is often referred to in competitive sports, it is a condition that can be experienced by ANY woman who is active and exercises. RED-S is a psychologically and physically taxing disorder that often gets overlooked.

In 2016, I left home to attend University. What at first promised to be the “best time of my life” soon turned into one of the worst. Shortly after I arrived, I started eating less and exercising more. I lost my period, something I thought meant I was becoming a better athlete. I went to bed hungry, had chronic constipation, and horrible acne. I started isolating myself from people I didn’t even know yet, and was sad all. the. time. By the time I came home to seek help, I was always tired, severely underweight, lost a good bit of my bone mass, and had many other health issues. What I came to discover was that my experiences were not uncommon among those that exercised. In fact, I even found out that it had a name: RED-S.

What is RED-S?

In 2014, the International Olympic Committee released a statement on what they referred to as Relative Energy Deficiency in Sport, or RED-S. Prior to its release, the effects of Low Energy Availability (i.e., having less energy available than what’s burned) were thought to be low bone density and menstrual cycle disruptions, more commonly referred to as the Female Athlete Triad. However, RED-S expanded this understanding to include various other bodily functions such as growth, digestion, immunity, etc.

Before diving into what we, as an athletic community, can do to limit the prevalence of RED-S, it’s important that we understand what Low Energy Availability means, and how it might affect some of the bodily functions listed above.

Low Energy Availability:

Energy Availability is essentially how much energy you have after subtracting what is used for intentional exercise relative to your fat free mass (i.e., structures that don’t have fat in them). To put it plainly, Low Energy Availability is a mismatch between how much energy is available versus how much is burned during exercise (2).

Something important to note here is that Low Energy Availability is most often associated with disordered eating or a diagnosed eating disorder, but it also can be the result of drastic increases in training volume without adequate fueling to match.

The effects of Low Energy Availability are wide reaching. Rather than explaining all the physiological processes involved, here is a (kind of) brief list of what athletes can experience when suffering from RED-S.

1. Thyroid Dysregulation (2) -> !! Your Thyroid is an important regulator of your metabolism!
2. Decreased metabolic rate (2)
3. Increased hunger, decreased suppression of appetite (2)
4. Disrupted menstrual cycle and menstrual hormones usually characterized by amenorrhea or oligomenorrhea (missing or irregular periods) (2)
5. Increased breakdown of fuels, decreased building of things like muscle (2)
6. Lower bone density and bone strength leading to increased risk of fractures (2)
7. Higher "bad cholesterol" levels (2)
8. Gastrointestinal disruption (such as increased constipation) (2)
9. Increased risk of illness (2)
10. Increased psychological disruptions (i.e., depression, anxiety) (2)
11. Trouble sleeping
12. Chronic fatigue (3)
13. Decreased mental capacity (2)
14. Decreased or inconsistent performance (2, 3)

This is all of the physiologic areas that RED-S effects in athletes, as taken from the International Olympic Committee Consensus Statement.

In my experience, I was struggling to focus and retain information in my classes, for others, this could mean issues meeting deadlines or focusing on meetings while at work! Unfortunately, this creates a vicious cycle of being stressed about struggling, not doing well because of the inability to focus, leading to more stress and more withdrawal.

In addition, I was constantly hungry, which contributed to my insomnia. I was rapidly losing weight, but continued to push my body to the brink. However, I should mention that one does not have to be underweight, or even losing weight, to experience RED-S. As a 20 -year-old, my doctor informed me that I had high levels of cholesterol and low bone density. Needless to say, the effects of RED-S were rapidly taking hold. Older individuals may be more resilient to the effects of this condition, but all those who exercise should be careful in modulating the risk of exercising more and eating less (3).

How can we prevent it?

There is good news and bad news when it comes to prevention of RED-S for active women.

The bad news: early detection of RED-S is difficult. Often, when related to an eating disorder/disordered eating, individuals will try to conceal their weight loss with baggy clothes, avoidance, etc (4). Outside of eating, it can be hard for people and coaches to look at poor performance and not seek to increase intensity, duration, or frequency of training in hopes of improving. However, in the face of decreasing performance, the best option may be to take a rest day, week, or month to allow the body to relax before demanding more.

The good news: it is possible to intervene early and prevent the worst from happening. The earlier the intervention, the easier it is to mediate the effects of RED-S. Identifying and monitoring those that may be at risk for developing an unhealthy relationship with food and/or exercise is one of the easiest ways to minimize the risk of RED-S (2). However, other tools are available for coaches and clinicians that allow better monitoring of athletes.

More good news: there are actionable ways coaches can help in early detection.

1. Create an environment that fosters positive eating habits and openness regarding body image and health status (5). Focus on health not appearance.
2. Educate individuals, coaches, and parents on the risks and warning signs of RED-S so they can help in early detection (2).
3. Create an environment in which everyone feels comfortable discussing feelings of disordered eating or overtraining to help limit the risk of RED-S.
4. Facilitate an environment where the athlete feels that they are an active participant in their training, in terms of planning, adapting, etc. This can improve self-esteem and create a feeling of self outside of being an athlete (5).

Six years later and I’m proud to say that I have overcome my experience with RED-S. While I can’t say that I wish to relive that portion of my life, I would be lying if I said that it didn’t teach me anything. Here are some things I learned:

-The value in rest days (I’m talking couch potato rest days)

-To give myself grace in eating junk food now and then (I love some good french fries)

-Confidence in setting boundaries as it relates to comments on my body, eating habits, or exercise routine.

I learned the lasting effects of neglecting my body has on my health. I still have low bone density for my age, I still struggle with my body image now and then, and I constantly struggle with my relationship with food.

In sharing my story, I hope that coaches, and those exercising, learn to respect rest as much as they do training. I hope that it provides inspiration for those struggling to get help. But most importantly, I hope that it provides a story for RED-S outside of the International Olympic Committee, and outside of elite athletes, that can help encourage education and early intervention for those with RED-S, even if they are not Olympians.

To help spread awareness and promote interventions, we hope that this overview of RED-S is something that you can bring into your exercising circle! Monitoring athlete performance, menstrual cycle tracking (including the presence of a regular period), and nutrition recommendations with Wild.AI are easy-to-use tools that can help identify early warning signs of RED-S!

If you think you may be struggling with RED-S, please seek help from a medical professional. They can help in your diagnosis, and provide you with more information and develop a plan for recovery.

If you or someone you know may be suffering from an Eating Disorder, please visit the National Eating Disorder Association in the US, or Beat Eating Disorders in the UK for more information and support. There is also an organization called Project RED-S to provide coaches, athletes, and women with information and resources for the condition.

‍

Originally published: 06.02.2023

‍

References

1. Dave, Sona C., and Martin Fisher. “Relative Energy Deficiency in Sport (RED – S).” Current Problems in Pediatric and Adolescent Health Care, vol. 52, no. 8, 2022, p. 101242, https://doi.org/10.1016/j.cppeds.2022.101242.
2. Mountjoy, Margo, et al. “IOC Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update.” British Journal of Sports Medicine, vol. 52, no. 11, June 2018, pp. 687–97, https://doi.org/10.1136/bjsports-2018-099193.
3. Holtzman, Bryan, et al. “RELATIONSHIP BETWEEN AGE AND RED-S OR FEMALE ATHLETE TRIAD RISK.” Orthopaedic Journal of Sports Medicine, vol. 7, no. 3 Suppl, Mar. 2019, p. 2325967119S00011, https://doi.org/10.1177/2325967119S00011.
4. Eating Disorders (Young People) - Secrecy and Eating Disorders. https://healthtalk.org/eating-disorders/secrecy-and-eating-disorders. Accessed 18 Jan. 2023.
5. “RED-S.” Issuu, https://issuu.com/renaissancepublishing/docs/tech_novfinal/s/11205791. Accessed 18 Jan. 2023.

‍