Everything you need to know about RED-S

·6-min read
Photo credit: Jordan Mansfield/Getty Images
Photo credit: Jordan Mansfield/Getty Images

Jesse Thomas, a retired elite triathlete, didn’t always fuel his long runs in the manner of a two-time Ironman champ. Years before he won his first triathlon, he’d sometimes go 24-48 hours without eating – but still train.

‘It was really, really bad,’ he says. ‘But working hard is part of being an athlete, so it didn’t feel abnormal at the time.’ Plus, he wanted to make the US national team and he thought losing weight would help him to reach his goal. His restriction both worked and backfired. ‘I hit my peak lightness, but I was really weak and consistently injured for a year and a half.’

Unfortunately, this kind of food restriction – though perhaps on the extreme end of the spectrum – isn’t unusual. It has been estimated that up to 20 per cent of athletes aren’t eating enough, and though many aren’t necessarily restricting on purpose, elite runners often don’t take in enough fuel to support their intense training regimes.

Elise Cranny, elite runner for the Bowerman Track Club, in Oregon, US, spoke out recently on social media about this: ‘RED-S, or Relative Energy Deficiency in Sport, needs to be talked about more,’ she wrote. Her post was inspired by her own experience: ‘I was super strict about my diet and would cut out different food groups. I didn’t have a period, and it took me a while to realise that wasn’t a good thing.’

But recreational runners can fall into this underfuelling trap as well, which can lead to a range of negative effects, from poor performance to hormonal imbalances that affect your overall health.

What is Relative Energy Deficiency in Sport (RED-S)?

In the simplest sense, RED-S implies inadequate energy intake compared with the energy you need; it’s a more inclusive version of the Female Athlete Triad, defined by the lack of a period, low energy availability and a decrease in bone density.

RED-S is a broader concept that acknowledges the complexity of the problem, says Anna Melin, an associate professor in sport science at Linnaeus University in Sweden. ‘Low energy availability affects males as well, and there are very few female athletes who have all three aspects of the triad.’

You don’t need to be incredibly lean, either. ‘You can have a normal body weight but still not have enough energy available for normal hormone production, protein synthesis and recovery,’ says Melin.

There’s also an overlap between RED-S and eating disorders, but they’re not one and the same: ‘Low energy availability may be due to disordered eating, but it can also occur unintentionally, owing to poor awareness of sport-specific fuelling requirements,’ says Clare Corish, associate professor in clinical nutrition and dietetics at University College Dublin. Basically, low energy availability could cause an eating disorder, just as an eating disorder could cause low energy availability, but you could still have low energy availability (such as RED-S) without having an eating disorder. ‘Low energy availability could be due to a lack of appetite, which happens with intense training,’ adds Melin.

RED-S: the warning signs and health risks

The symptoms are similar to those of overtraining, according to Fabio Comana, a faculty instructor at San Diego State University, US, and the National Academy of Sports Medicine. That means fatigue, mood changes, reduced performance and increased injury.

To distinguish between RED-S and overtraining, Comana suggests reducing your training volume by 50-70 per cent for 10 days without changing anything else in your life. ‘If you feel recharged afterwards, it may be an overtraining issue,’ he says. However, if your symptoms come back in two days, it could be RED-S. And if that’s the case, you should speak to a health professional as soon as possible, because the long-term risks – such as osteoporosis, heart disease, muscle loss, depression and reduced immunity – go way beyond merely compromised performance.

For a true diagnosis, bone health and reproductive, cardiovascular, endocrine and metabolic functions are relevant areas to investigate. ‘We take blood samples to measure hormones and assess body composition and bone health,’ says Melin.

Treatment and prevention

A treatment plan for RED-S is intended to restore energy, and it could be intertwined with treatment of an eating disorder or unknowingly underfuelling. ‘It can be hard to identify an eating disorder when you’re in the middle of it,’ says Riley Nickols, a counselling and sports psychologist. ‘And, sometimes, a disordered mindset around food, training or body image can be normalised in the context of sport,’ making it even tougher to spot.

Either way, we need more education on the topic – for both athletes and coaches. ‘Sports providers can have good intentions but sometimes veer outside their lane of expertise,’ says Nickols. So, unless your coach is also a registered sports dietitian or a doctor with formalised training in setting goal weights, Nickols says he/she shouldn’t set weight targets or give specific nutritional recommendations.

In fact, working with the right experts is a crucial piece of the recovery puzzle, whether it’s a sports dietitian, a therapist or both, says Nickols. ‘Don’t underestimate the complexity of the problem and overestimate your ability to solve it on your own.’

Thomas and Cranny both hit a crossroads when they realised their strategy wasn’t effective. Thomas rethought his approach when he didn’t make the cut for the US team. And Cranny says a series of stress fractures made her realise the reality of her restriction. She eventually saw a nutritionist who helped her make small, manageable changes to her diet, and a therapist who helped ‘challenge [her] ingrained thoughts and habits’.

Those unhelpful ingrained thoughts – that certain foods are bad, that athletes need to look a certain way, that working yourself into the ground is part of the sport – can be hard to shake. But, as Thomas notes, ‘Once I found balance, I had so much more success.’

Coaches and parents need to be on the front line

Recognising disordered eating – and that athletes are vulnerable to physical and emotional distress – is an additional responsibility for coaches and parents. They need to know enough to recognise the warning signs, know when to act and know where to turn.

Here’s what Paula Quatromoni, associate professor of nutrition at Boston University, US, suggests you can do as a coach or parent:

  • Understand that eating disorders come in all shapes, sizes, genders and sports – at any level of competition.

  • Seek education on the range of behavioural symptoms, from restrictive eating to binge eating and purging.

  • Know that a lost or delayed menstrual cycle is not normal, and it requires an evaluation by a medical professional.

  • Develop an action plan for eating-disorder identification, which includes help from doctors, therapists, counsellors and nutritionists.

  • Raise funds to bring in a registered dietitian to speak to teams or athletes.

  • Discreetly contact athletes you suspect may be struggling, to express concern and connect them to the help they deserve.

You Might Also Like

Our goal is to create a safe and engaging place for users to connect over interests and passions. In order to improve our community experience, we are temporarily suspending article commenting