Relative Energy Deficiency in Sport
by Melinda Burris

If you are asking, “What is relative energy deficiency in sport?” Don’t feel bad; only in recent years has the syndrome come to be properly understood and diagnosed. Initially believed to be a condition that only affected female athletes, physicians, and other health care providers who specialize in sports medicine have recently come to a better understanding and now accept that Relative Energy Deficiency in Sport (RED-S) is a serious issue that both female and male sports competitors face. This article will discuss the warning signs and symptoms of RED-S as well as how it should be effectively treated to avoid short and long-term injury to the body and mind.
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Defining RED-S

RED-S occurs when a person is not taking in an adequate amount of nutrients to fuel the physical demands placed on the body through intensive training practices and competition.^1,2 In short, the body is being asked to perform at a level higher than the amount of caloric intake it is being given to sustain itself. As the body continues to be pushed to exceed its energy level due to insufficient diet, a phenomenon known as Reduced Energy Availability (REA) sets in. In the short term, REA affects the athlete’s ability to perform at optimal levels. If this condition continues unchecked, it can cause serious damage to the core body systems as the body begins to wear down.¹

‘The Female Athlete Triad’

When this condition first came to light, it was misunderstood and mislabeled, becoming known as the “Female Athlete Triad”. This name was a nod to three of the most common symptoms associated with what is now referred to as RED-S:

1. Irregular menstrual cycles or amenorrhea (absence of monthly periods)^1,2
2. Disordered eating (characterized by over-zealous workouts, a preoccupation with food that often manifests in extreme dieting, and experiencing shame when eating)³
3. Low bone density (which puts athletes at higher risk for injuries like stress fractures and over time can lead to the development of serious, chronic health conditions such as osteoporosis)^1,2

The term Relative Energy Deficiency in Sport or RED-S first came into popular use in 2014 when the International Olympic Committee renamed the condition in a consensus statement the body published titled, Beyond the Female Athlete Triad: Relative Energy Deficiency in Sport (RED-S). This was an important step because the name Relative Energy Deficiency in Sport Syndrome better reflects the root causes of this medical and often psychological condition. It is also important to note that referring to the condition as RED-S is a necessary acknowledgment that this disorder is not a “female problem” but a serious health condition that occurs in women and men.^4,5

Common Symptoms of RED-S

Pippa Woolven, a British long-distance runner and steeplechaser who has secured her place in the history books as an Olympic gold medalist, suffered from what she found to be a mysterious and incapacitating disease for more than five years^.4 At first, she felt fatigued, and then she suffered continually from colds — symptoms that are extremely common and all too easy to ignore.

Looking back, Woolven realizes the symptoms she experienced for so long make sense because her body did not have the energy stores it needed to keep up with her grueling training and competition schedule and maintain the healthy balance needed to keep primary body systems including the immune, cardiovascular, and digestive systems working properly.⁴

Since early signs of RED-S are often seen as relatively benign, in many instances a major event that causes pronounced injury to the athlete must take place before they are properly diagnosed. Stress fractures are common among individuals with RED-S, and this can bring about the needed scrutiny to evaluate the overall health and wellness of the athlete.

Additional symptoms frequently seen in those with RED-S include the following:¹

• Extreme fatigue
• Being underweight or constant fluctuations in weight
• Reduced performance and endurance levels
• Fluctuations in mood
• Iron deficiency
• (Delayed growth and development (in youths)
• Left unchecked, RED-S can strain and negatively affect the heart

An Inconvenient Truth

A sound argument can be made that one of the reasons this condition went undiagnosed and improperly treated for so long is because one of the primary symptoms experienced by female athletes who suffer from this syndrome is no longer having a monthly period (hypothalamic amenorrhea). Pippa Woolven experienced this symptom and initially saw it as a good thing, one less thing for her to worry about as she continued striving to reach her goal of earning elite athlete status. Pippa recalls thinking at the time, “It seemed more convenient not to have them.”⁴

When Pippa was dealing with this disease, she found little help from the medical community or her coaches and trainers. Despite having seen a variety of primary care physicians and specialists, it took years before she was properly diagnosed with RED-S. At that time, little was known about the condition and its symptoms. It is also a deceptive disease in that because it causes weight loss, in the short term, athletes become leaner and faster — a common goal and often a recipe for success at the finish line, for a while.

The cons far outweigh the pros as this condition can lead to a host of medical issues later in life. For women, a regular menstrual cycle is vital because it demonstrates that hormones essential for maintaining proper bone, heart, and cognitive health are at proper levels.

There is often a psychological component to this disease that is important to address in recovery. Pippa Woolven discovered this when she received her RED-S diagnosis and tried to aid in her recovery by working to change her attitude toward diet and food control on her own. She found that relearning how to properly fuel her body was more difficult than she imagined and found success after seeking help from a professional who could help her see her relationship with food more objectively, allowing her to restructure her priorities and lead what she believes is a more balanced and rewarding life.

It is important that athletes have a knowledgeable and watchful support system that is as invested in protecting the health of the athlete over a lifetime as they are in winning at the finish line.

Remember, RED-S is a condition that develops over a lengthy period. Just as it takes time for the body to break down, the recovery process and building the body back up will also take time, patience, and commitment.

References:

1. Perth Sports Medicine. (n.d.). Relative Energy Deficiency in Sport (RED-S).
2. Brown University (2022). Relative Energy Deficiency in Sport (RED-S).
3. Anderson, M. (26 October 2018). What Is Disordered Eating?
4. Dooney, E. (28 August 2020). RED-S: The Condition All Runners Need to Know About.
5. Mountjoy M. et al. (2018). IOC Consensus Statement on Relative Energy Deficiency in Sport (RED-S).

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