Understanding and Preventing Relative Energy Deficiency in Sports (RED-S)

By now, many of you have lined up your first race of the season. You may have already raced, and perhaps your entire 2024 calendar is set.

When you enter a race, the goal is to show up to the starting line in peak condition.  Hours, days, weeks, and months of hard work accumulate to ensure you perform your best.  You may sacrifice social events, forgo alcohol, and try to prioritize sleep and proper nutrition.  It’s game on, and you plan to bring it.  

In addition to the physical side of training, mentally you are tested.  If you are a triathlete, you likely are considered a type A personality.  We tend to be go-go-go individuals with big goals and high expectations.  We can be quite the perfectionists and overachievers.   

When the high-performance physical and mental collide, great things can happen.  But sometimes things don’t go according to plan.  Unfortunately, for some women (and men) it’s a slippery slope to low energy availability (LEA).  And when this continues for a prolonged period of time, it can be detrimental to your training progress, your immune system, recovery, performance, and overall well-being.  

LEA refers to a state in which an individual’s dietary energy intake doesn’t meet the energy demands of exercise and basic physiological functions. It can occur when you intentionally restrict energy intake to achieve a lower body weight or body fat percentage.  Disordered eating behaviors may also impact it. Unintentionally this can happen too.  If you fail to consume enough calories to match your energy expended through training and daily activities, you can find yourself in LEA.  

Endurance athletes are among the most common individuals to experience this.  For multi-sport athletes like triathletes, you are incorporating three disciplines, along with strength training (hopefully). This can further amplify the situation.  For example, in triathlon our volume and training intensity can change day to day and week to week.  This has a direct impact on the amount of daily energy we expend.  If not mindful of ensuring our diets match this ebb and flow, we run the risk of toeing the low-energy line. Enter RED-S.

WHAT IS RELATIVE ENERGY DEFICIENCY IN SPORTS?

Relative Energy Deficiency in Sports (RED-S) refers to a condition where there is an inadequate caloric intake relative to the amount of energy expended during physical activity. It goes beyond just LEA and not consuming enough calories to fuel athletic performance.  RED-S encompasses a spectrum of issues related to energy balance including disordered eating, low energy availability, menstrual dysfunction, impaired bone health, decreased immune function, and psychological disturbances.

Formerly known as the Female Athlete Triad, which focused primarily on the interrelationship between energy availability, menstrual function, and bone health in female athletes, the term RED-S acknowledges the broader impact of energy deficiency on athletes’ health and performance, regardless of gender.

SYMPTOMS OF RELATIVE ENERGY DEFICIENCY IN SPORTS

RED-S is a syndrome that can lead to a range of physiological and psychological symptoms that can impair athletic performance and overall health.  It’s important to keep in mind that not all athletes with RED-S will exhibit every sign and symptom, and the severity can vary.  Please note, if you are experiencing several of these symptoms, it’s essential to consult with a healthcare professional experienced in sports medicine or eating disorders for proper evaluation and management.

A common symptom and often the first sign that something is off is lack of recovery. Your body is unable to absorb and respond to your training efforts.  You may even feel like your progress is regressing as your training volume is increasing. 

Another symptom that is often discussed is loss of your period.  Keep in mind, this can come later on when you’re already deep into RED-S.  As an athlete, you want to be in tune with your body and track your cycle.  Especially during the racing season.  We get so caught up in our training and upcoming races that we hardly notice the weeks and months going by without a cycle or with irregularity.  Be mindful of any changes in your menstrual cycle, which can be an indicator that you are dipping into LEA.

Stress fractures are also common due to hormonal dysfunction leading to impaired bone turnover – your body’s ability to make bone – and low bone density. 

Psychologically, moodiness and irritability are also noted.  This can be the result of low energy from insufficient nutrition, sleep patterns being impacted, and low recovery.  Hormone fluctuations also play a role.

WHAT CAUSES RED-S?

RED-S can arise from various factors that contribute to an imbalance between energy intake and energy expenditure in athletes. 

• Inadequate Caloric Intake: Athletes may not consume enough calories to meet the energy demands of their training and physical activity. This can result from restrictive eating patterns, dietary preferences, disordered eating behaviors, or simply not consuming enough food to fuel their activity level.
• Excessive Exercise: Engaging in high-volume or high-intensity training without sufficient recovery time can lead to an increased energy expenditure. Some athletes may over-train or participate in multiple training sessions per day without adequately replenishing the calories burned, leading to an energy deficit.
• Weight Concerns: Athletes, particularly those in sports with weight categories or aesthetic requirements, may restrict their caloric intake in an attempt to achieve or maintain a certain body weight or physique. This can result in chronic energy deficiency, even if the athlete appears to be at a healthy weight.
• Pressure to Perform: The pressure to excel in sports, meet performance goals, or conform to certain body ideals can contribute to disordered eating behaviors and unhealthy attitudes towards food and body image. Athletes may prioritize performance over their nutritional needs, leading to inadequate fueling and energy deficiency.
• Psychological Factors: Psychological stressors such as anxiety, perfectionism, low self-esteem, or body image concerns can impact eating behaviors and contribute to RED-S. Athletes may use food restriction or excessive exercise as coping mechanisms for managing stress or controlling emotions.
• Sociocultural Influences: Societal norms, cultural beliefs, and media portrayal of body ideals can influence athletes’ perceptions of body image and dietary behaviors. Pressure to adhere to unrealistic beauty standards or fit a certain athletic aesthetic may contribute to disordered eating patterns and energy deficiency.
• Lack of Education and Awareness: Some athletes may be unaware of the importance of proper nutrition for athletic performance and overall health. Lack of education about fueling strategies, nutrient requirements, and the signs of RED-S may contribute to inadvertent energy deficiency.

It’s important to note that RED-S is a multifactorial syndrome with complex interactions between physiological, psychological, and environmental factors. Addressing RED-S requires a comprehensive approach that involves nutrition education, monitoring energy availability, promoting positive body image, and providing support for mental health and well-being.

For triathletes, RED-S poses several significant risks that can impact their performance, health, and overall well-being.  

✔️Reduced Performance

✔️Increased Risk of Injuries

✔️Impaired Recovery

✔️Muscle Loss and Weakness

✔️Endocrine Disruption

✔️Immune Suppression

✔️Psychological effects, such as mood disturbances, anxiety, depression, and disordered eating behaviors. 

✔️Long-term health consequences including impaired bone health, increased risk of osteoporosis, infertility, and cardiovascular complications. 

PLAN OF ACTION

I cannot emphasize this enough – if you are concerned that you are experiencing LEA or are exhibiting symptoms of RED-S, please consult with your primary care physician as an initial step.  Preventing and managing RED-S requires a comprehensive approach that addresses nutrition, training, and psychological factors.  Below are some recommendations on ways that you may prevent or manage RED-S.

The first step is education and awareness around the importance of proper nutrition, energy balance, and menstrual health. This can help you catch symptoms early on. Whether you are an athlete, coach, or healthcare provider, understanding the symptoms and how to manage it is paramount. (Had I known ten years ago what I know now, I would’ve dug deeper into things that were going on with my body.)  As a female, I think there is a learning curve with becoming your own advocate – but education makes more confident in speaking up!  

“You can’t out-train a bad diet” – this phrase holds true here.  You need proper nutrition to maintain the right energy balance for YOUR unique needs and expenditure.  Triathletes should work with qualified sports nutrition professionals to develop individualized nutrition plans that meet their energy needs for training, competition, and recovery. Emphasis should be placed on consuming a balanced diet rich in carbohydrates, proteins, fats, vitamins, and minerals to support athletic performance and overall health.

Athletes should monitor energy intake and expenditure to ensure they are meeting energy needs for training and daily activities. Tools such as food logs, energy expenditure trackers, and metabolic testing can help athletes assess their energy balance and make adjustments as needed.  This does not need to be an ongoing task, but when trying to assess the situation and your needs, logging energy in and energy out is a baseline tool. Work on developing a healthy mindset around the inclusion of foods rather than the exclusion. By focusing on what you should add to your nutrition, by default you may naturally exclude the less healthy options from your diet.

Periodize your training to help ensure you are not compounding issues.  The goal is to cycle your training program in a way that balances training volume and intensity with adequate recovery periods. Periodization helps prevent overtraining and allows for optimal adaptation to training stimuli while minimizing the risk of energy deficiency and related complications.

Incorporate strength training that compliments your endurance training.  You want to support strong and healthy bones, joints, and muscle mass.  Something to think about: running is considered a weight-bearing exercise, which should support healthy bones and joints.  However, running primarily takes place in the frontal plane (same goes for cycling).  The repetitive nature of running and the limited planes of motion can increase injury risk. Incorporating strength training exercises targeting multiple planes of motion is essential for maintaining muscular balance, joint stability, bone health, and overall performance while reducing the risk of injury.

Additionally, make sure you prioritize sleep and recovery.  Quality sleep can facilitate physical and mental recovery from training stress. Support this with relaxation techniques and rest days to support hormone regulation, tissue repair, and overall well-being. 

Psychological factors also play a role.  Address stressors like perfectionism, body image concerns, and disordered eating, as these can contribute to RED-S. Providing mental health support, stress management strategies, and promoting a positive training environment can help reduce psychological stress and improve overall resilience.

FINAL THOUGHTS

It’s important to note that every athlete is unique.  Prevention and management of RED-S should be tailored to the specific needs of the individual.  Monitoring and screening should be a regular practice.  Staying on top of things like bone density assessments, hormonal evaluations, and menstrual cycling can help you identify early signs of RED-S. When in doubt, seek professional support. If you would like to review your current nutrition and training program, I’m here to help! Shoot me a message and let’s connect. It’s your journey, your pace, and all my support.