Understanding Relative Energy Deficiency in Sport (RED-s)

As athletes, we often strive to push ourselves further and faster in the pursuit of marginal performance gains. However, in doing so it is easy - and surprisingly common - to overlook the symptoms of future performance decline. A relatively new term in the world of health and fitness, Relative Energy Deficiency in sport (RED-s) is a condition that can affect athletes of all genders and abilities.

In the first of a series of articles addressing RED-s, Registered Sports Dietician and Best Selling Author Renee McGregor explains what RED-s is, how to identify the warning signs, and how the athlete can start to address the condition.

RED-s: The background

RED-s, or Relative Energy Deficiency in sport, was previously known as the Female Athlete Triad. It was well documented that there was a three-way association in female athletes between low energy availability, resulting in a loss of menstruation, which then had a negative impact on bone health, increasing their risk of injury, bone stress and fractures.

While observation for female athletes was clear, they overlooked how low energy availability became evident in male athletes. Research continued, and a more comprehensive, broader term known as Relative Energy Deficiency in Sport was introduced in 2014 (thanks to the work of Dr Margo Mountjoy, the main author of the IOC consensus paper). This concluded that male athletes are also at risk.

As such, RED-s is still a relatively new term in the world of health and fitness. However, it is a condition that is on the increase, with more and more athletes being diagnosed with it. But while this is great for awareness, it can also lead to confusion as to how to identify RED-s and who can be impacted by the condition.

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What Is RED-s?

RED-s is a condition that can occur in people who are physically active. It can affect everyone anyone from recreational athletes to professionals, from younger generations through to masters competitors. And as we have already said, it can occur in any gender.

RED-s results in a physiological decline that can lead to poor physical and mental health, and consequently have a negative impact on performance.

At its core, it is the result of low energy availability, which means that there is insufficient energy being consumed by the body to do 'the work' that the person wants or needs to do. In this context, 'work' is defined as anything from training to everyday movement, as well as the energy required for the body to function.

Over time the human body has evolved to prioritise movement, meaning that when energy is consumed it will be used first for physical activity. Energy availability is therefore the amount of energy left over once the energy for movement has been removed.

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RED-s can be further complicated by a lack of recovery time and general stresses to the nervous system, such as sickness. So contrary to what a lot of people assume, RED-s is not just about energy intake or even being underweight; it is much more complicated, generally resulting in metabolic injury, meaning that recovery times can sometimes be lengthy.

There are two types of RED-s

Unintentional or accidental RED-s is when a person doesn’t appreciate just how much energy is required to maintain their biological function and training load. While they may have similar symptoms to someone with intentional RED-s, they are easy to work with as there is no psychological basis to the condition. This means they are happy to implement nutritional and training programs that help to get their body back to 'normal'.

Intentional RED-s is when a person makes a conscious decision to restrict their energy intake and / or overtrain. It may involve some aspect of disordered eating and / or exercise dependency, hence is more complex to treat as it generally involves deep rooted beliefs and / or difficult thoughts that the individual is “unconsciously” avoiding.

In many cases, the individual will usually associate the start of their behaviours with the desire to change their body composition - generally weight loss - to fit a societal ideal, or due to the culture often associated with sport regarding improved performance.

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However, because the body prioritises movement this means that, just as when your smart phone starts to run down on battery it shuts down the non-essential apps, your body will do the same. It will regulate your metabolism to preserve energy, hence RED-s does not always equate to weight loss. Indeed, you can have an individual who has low energy availability with a normal or above-normal weight, or who has experienced no change in body composition.

What to do if you have RED-s

Contrary to what has become mainstream information, it is not always necessary to stop training completely when recovering from RED-s. This would only be encouraged if there is a serious risk to an individual’s health, or if they are at a heightened risk of injury due to a severe impact of their RED-s.

That said, in most cases, manipulation and periodisation of training are required. How this develops depends on individual physical, nutritional, and clinical factors.

The key role of a recovery pathway is to restore energy availability - particularly carbohydrate availability - regulate hormonal health, and reduce stresses on the nervous system. When psychological factors are involved, it is important to encourage a more sustainable and appropriate relationship with food, training, and body image.

There is still a lot of misunderstanding surrounding RED-s in the medical and sports community, partly because it is still a relatively new condition. As such, if you are concerned that you have RED-s the first thing you should do is seek out a trained clinical and sport science / medical practitioner for diagnosis and treatment options.

This is the first in a series of articles about identifying and dealing with RED-s. Check back in the coming week for more on this topic.