Relative Energy Deficiency in Sport (RED-S)- What is it?
By: Nicolet Champan, MPH, RDN, LDN
In athletics, there is this overwhelming, ever-present stigma that you won’t be good enough or the best if you aren’t training hard all day every day, look a certain way, or eat a certain way; that said, there is this constant pressure to be good enough, to be faster, to be stronger, to be the best, which can often result in disordered thoughts and eating patterns. One of the most prevalent of those problems, which has been gaining recognition in the past few years is Relative Energy Deficiency in Sport (RED-S). But, what exactly is that?
Previously known as the Female Athlete Triad, Relative Energy Deficiency in Sport (or RED-S for short) has become increasingly referenced in the past few years, with professional, collegiate, and high school athletes alike coming out about their struggles with the syndrome; however, before I can describe RED-S, I think it is important that I first talk about the previous diagnosis of the Female Athlete Triad.
The Female Athlete Triad, which was first discovered in 1972, is a disorder that is only diagnosable for female (Mountjoy). This disorder is diagnosed when a female athlete has a combination of the three: disordered eating patterns/decreased intake, amenorrhea (irregularity or complete loss of menstrual cycle), and osteoporosis (or decreased bone density), with the etiology (or cause) of the disorder resulting from prolonged, chronic energy deficiency (See Figure 1) (Hobart, 2000).
Figure 1: Figure 1 summarizes the female athlete triad and some accompanying statistics (Straith, 2018).
Despite the severity of this disorder, it is often not diagnosed early enough, and can often be too late (i.e., when a bone is fractured and/or bone mineral density cannot be regained) (Hobart, 2000).
All this said, the Female Athlete Triad is a very narrow, diagnostic disorder, and neglects to include males, who can also suffer from disordered eating patterns or not consuming enough. Going off of this, RED-S “describes a syndrome of poor health and declining athletic performance that happens when athletes [male or female] do not get enough fuel through food to support the energy demands of their daily lives and training” (BCH, 2022). It is important to note that this is NOT the same as “low energy availability” (i.e., neglecting to replenish fuel stores (i.e., carbohydrates, protein, and fat) after a training session or competition)—instead, RED-S is the prolonged, chronic syndrome of failing to take in enough calories (BCH, 2022). RED-S should be treated as soon as possible. If it isn’t, it increases the athlete’s risk for the following:
Issues related to reproductive health (i.e., menstrual irregularity for girls and decreased libido for boys)
Decreased bone density (increasing risk for stress fractures)
Decreased immunity (i.e., you can get sick more often)
Decreased metabolism (please refer back to Metabolic Adaptation blog)
Potential for long-term cardiovascular damage
Increased risk for psychological disorders, such as depression and anxiety (BCH, 2022)
Please see Figure 2 for a summary of the above.
Figure 2: Figure 2 summarizes the effects of RED-S (PSM, 2022).
It is important to note that the energy deficiency surrounding RED-S can either be intentional (i.e., disordered eating patterns, desire to lose weight, etc.) or unintentional (i.e., lack of knowledge on proper fueling, not being able to eat enough, etc.) (BU). Sometimes the unintentional deficiencies are often overlooked.
In addition, the following are signs and symptoms to look for (in yourself and your teammates) for RED-S:
Fatigue
Weight loss
Menstrual irregularity or low libido (Menstruation becomes irregular due to estrogen levels decreasing. It is important to note that adequate estrogen levels are NECESSARY in the body for bone health, providing a direct link between the two (BU).)
Frequent illnesses
Hair loss
Irritability, depression, or anxiety
Trouble focusing
Being “cold”/Hypothermia
Dehydration
Bradycardia (abnormally low heart rate), and/or orthostasis (abnormal changes in heart rate or blood pressure when position is changed)
Muscle cramps
Dental/gum problems
Decreased sport’s performance
Delayed growth/development (for children and adolescents)
Micronutrient deficiencies (specifically iron) (BU; Dudgeon, 2019; PSM, 2022)
But how is this diagnosis related to the Female Athlete Triad? And because RED-S is relatively new, does it replace the previous diagnosis of the Female Athlete Triad?
Well, the answer to the second question is yes and no. The Female Athlete Triad shares a lot of similarities with RED-S (i.e., low energy intake, menstrual irregularity, decreased bone density), and is thus a subset of RED-S (BCH, 2022). In my opinion, I prefer the more inclusive diagnosis of RED-S, since it accounts for both genders.
When it comes to issues related to disordered eating patterns and mental health, I feel as though boys/men are often not included in public health efforts to circumvent the prevalences of these disorders, leading to a stigma that boys/men are immune from acquiring these disorders, when, as public health professionals and nutrition clinicians, we know that is not true. Moreover, I have found that over the past years, the diagnosis of the Female Athlete Triad is almost being weeded out of literature and EMRs, with a push towards RED-S, especially since the International Olympic Committee (IOC) linked the two diagnoses together (i.e., making the Female Athlete Triad a subset of RED-S) in 2014, due to the Female Athlete Triad failing to be comprehensive of the actual entirety of the syndrome of energy deficiency (BCH, 2022; Mountjoy). Furthermore, prolonged, decreased energy intake, like observed in RED-S patients, results in a lot more issues rather than just reproductive health and decreased bone density. RED-S, as outlined above, results in a lot more disruptions in the body’s systems, in addition to reproductive and bone health. Specifically, I want to reference mental health in relation to RED-S and the importance of highlighting nutrition, specifically among collegiate athletes.
In just the past 2 months of this year, five, NCAA student-athletes have died by suicide in the U.S. (Katie Meyer of Stanford, Jayden Hill of Northern Michigan, Robert Martin of Binghamton, Sarah Shulze of Wisconsin, and Lauren Bernett of James Madison) (Young, 2022). Although this is a blog about RED-S, it is so important to recognize and give light to all the components that relate to mental health—including nutrition.
Despite RED-S having more recognition over the Female Athlete Triad over the past few years in addition to the IOC’s consensus statement, it is still “poorly recognized by health professionals, coaches, and athletes” despite the fact that athletes (both female and males) have a 20% higher prevalence of disordered eating in compared to their non-athlete peers; thus putting them at risk for developing RED-S and thus mental health problems, such as depression and anxiety (Dudgeon, 2019). It is important that the NCAA, colleges, athletes, trainers, and coaches be aware of RED-S, the signs and symptoms, and consequences, not only for improving athletic performance, but more importantly, to maintain the integrity of a student-athlete’s mental health, amidst this mental health crisis in sports. Although nutrition is not the only factor contributing to mental health, it is a big factor and should be considered in future public health efforts and mental health campaigns to protect student-athletes.
Bottom-line: Although the Female Athlete Triad is still a diagnosis, it lacks the inclusivity and comprehensiveness of RED-S. RED-S includes the male gender, which had been previously excluded, and pays attention to more body systems that are affected in an athlete when they are energy deficient. It is important to recognize the severity and scope of RED-S in order to treat not only the root cause of the issue (i.e., energy deficiency (i.e., unintentional or intentional)) but subsequent consequences of RED-S, as well (i.e., psychological help to treat mental illnesses that may emerge due to RED-S).
That said, I want to leave you all with this:
Girls, especially those of you who are young: It is NEVER normal to experience menstrual irregularity or amenorrhea EVEN when you are training hard. This lack of menstruation was normalized while I was growing up, and it was an unspoken standard that if you were getting your period on a regular basis, you weren’t training hard enough; that is NEVER the case. Please see your physician and/or dietitian if you are experiencing any of the signs/symptoms described above in order to not only fuel to enhance your athletic performance, but to respect and save your body as well. Every body size, shape, and form is capable of great things, and you do not have to fit yourself into a mold to be successful, healthy, or happy.
Boys: RED-S is not solely a female diagnosis, like the Female Athlete Triad. I feel as though it is not said enough in our culture, but guys can have eating disorders or can not be eating enough, too, which can result in the symptoms described above and development of RED-S. I want to reiterate that it is okay if you aren’t okay. It is okay to ask for help—it is not shameful, embarrassing, or a sign of weakness; rather, a strength that you are prioritizing your health and well-being. Please take care of yourselves, be aware of the signs (for your own sake and for your teammates/friends) and seek professional help if you are experiencing any of the above.
Sources
BCH. (2022). Relative Energy Deficiency in Sport (RED-S). Retrieved from https://www.childrenshospital.org/conditions/red-s#:~:text=Relative%20energy%20deficiency%20in%20sport%20(RED%2DS)%20describes%20a,any%20gender%20and%20ability%20level.
BU. Relative Energy Deficiency in Sport (RED-S). Sports Nutrition. Retrieved from https://www.brown.edu/campus-life/health/services/promotion/nutrition-eating-concerns-sports-nutrition/relative-energy-deficiency-sport-red-s
Dudgeon, E. (2019). Relative energy deficiency in sport (RED-S): recognition and next steps. British Jouranl of Sports Medicine. Retrieved from https://blogs.bmj.com/bjsm/2019/04/22/relative-energy-deficiency-in-sport-red-s-recognition-and-next-steps/
Hobart, J. A. S., Douglas R. (2000). The Female Athlete Triad. American Family Physician, 61(11), 3357-3364. Retrieved from https://www.aafp.org/afp/2000/0601/p3357.html
Mountjoy, M. Relative Energy Deficiency in Sport. Aspetar – Sports Medicine Journal. Retrieved from https://www.aspetar.com/journal/viewarticle.aspx?id=260#.Ym75OdrMI2w
PSM. (2022). Relative Energy Deficiency in Sport (RED-S) – What is relative energy deficiency in sport? Conditions. Retrieved from https://www.perthsportsmedicine.com.au/relative-energy-deficiency-in-sport-perth-claremont-cockburn-wa.html
Straith, M. (2018, March 23). The Female Athlete Triad and Your Bones. Bone-Healthy Living. Retrieved from https://www.algaecal.com/expert-insights/female-athlete-triad/
Young, S. M. (2022). 5 student-athletes’ deaths by suicide show NCAA must better address mental health. Retrieved from https://sports.yahoo.com/5-student-athletes-deaths-by-suicide-show-ncaa-must-better-address-mental-health-183236038.html
