RED-S
RELATIVE ENERGY DEFICIENCY IN SPORT
From mid 2012 to late 2013 I was on an athletic high. I lost 12 pounds in three months (10% loss in body weight) during the summer of 2012 and was hitting PR's in all distances and was feeling invincible. However, I was turning a blind eye to the fact that I was not menstruating (and would go on to not get my period for 1.5 years), my hair was falling out, I experienced low back pain ALL of the time, and had lost a significant amount of muscle (all signs of relative energy deficiency syndrome that I did not recognize at that time).
I did recognize that a lack of menstruation was unhealthy and shared this concern with my OBGYN, but she was not the least bit concerned and told me that when the time was right it would return (I have since had a discussion with this doctor with how wrong I feel her care was at the time). So, feeding my ego, I kept pushing my body while fueling it on a vegan diet. Shortly after achieving success my fitness drastically declined. Finally, in December of 2013, during a very easy run where I couldn't control my heart rate and had trouble breathing, I came to grips with the fact that what I was doing to myself was not healthy and I needed to make a change.
I was completely uninformed as to how my lifestyle was contributing to how I felt at that time. I was sleeping 5-6 hours night, under a significant amount of stress related to my job, and barely consuming three meals a day. I naively pushed myself into a severe state of Relative Energy Deficiency in Sport (RED-S).
At the time I had no idea how hard it would be to slowly crawl back of out of the hole I had dug. Early on I thought my health was restored when my menstrual cycle finally returned after 3 months of cutting back on my athletics and returning to a traditional American diet. But, it's been 6 years now and I'm still struggling to regain the fitness I once had and I’m still dealing with some residual minor health concerns (very grateful that I didn’t cause myself more harm than I did). Overall, however, I'm currently much healthier and I would never trade the fitness I had then for the health that I have now.
Listening to Mary Cain's brave recount of the negative health effects she experienced related to RED-S, while under the care of Coach Alberto Salazar, created a visceral reaction for me and ultimately drove me to share what I’ve learned about RED-S below. Although I erroneously created this problem for myself, Mary Cain did not. She was under the guidance of a professional that should know better and should always put the health of the athlete first. Mary Cain does not deserve to be in the position she is in; she deserves better care. My hope in spreading the word about RED-S is that we can all do better in helping ourselves, friends and Teammates.
WHAT IS RED-S
Relative energy deficiency can most basically be described as a deficit in energy intake (calories) versus expenditure. Without enough calories to meet daily caloric demands the body won't shut down and boycott your activity, but it will steal energy from non-essential body functions to help sustain essential body functions (functions that keep you alive) creating a myriad of health consequences.
CONSEQUENCES OF RED-S
Listed below and in the diagram to the right are a few of the consequences related to low energy availability (McConville 15-16):
Slowed metabolism
Menstrual dysfunction (females)
Testosterone reduction (males)
Compromised bone density
Decreased immunity
Decreased protein production
Compromised cardiovascular system
RECOGNIZING RED-S
First and foremost our ability to help someone starts with the ability to recognize the physical signs related to RED-S (see below).
Once RED-S is suspected, consultation with a team of qualified health professionals including a sports medicine physician, registered dietician, physical therapist, and sports psychologist/sports psychiatrist is recommended. Initial treatment should focus on understanding the root cause that may have lead to a state of energy deficiency and then to build a safe and supported environment for the athlete to increase energy intake and decrease energy output until health is restored.
Listed below are common presentations and helpful questions to ask related to RED-S (McConville 75-77). Please consider that diagnosing RED-S must come from a qualified medical professional and a diagnosis is often based on a multitude of factors and not just based off of one presenting factor.
Common Food Mistakes:
Decrease in overall caloric intake
Increasing high fiber/high protein foods by more than recommended
Cutting out particular foods or food groups
Eating Competence Questions:
Are foods being enjoyed for pleasure?
Is time carved out each day for appropriate fueling?
Is there variety in food intake?
Is there awareness of hunger signals?
Is there an awareness of fullness?
Common Body Composition Mistakes:
Females with body fat percentage less than 12%
Males with a body fat percentage less than 7%
Weight changes greater than 10% in 3 months
Weight change greater than 5% in 1 month
Gaining weight when restricting calories
Growth:
Youth should stay consistent on a healthy growth curve (watch for changes from the predicted growth patterns)
Menstrual Cycle:
Primary Amenorrhea is diagnosed when a female fails to start her menses by age 16
Secondary Amenorrhea is where one's period has stopped for 90 days consecutively
Your periods are less than 21 days apart or more than 35 days apart
Digestion Problems of Concern:
Early fullness accompanied with bloating
Altered GI function with associated constipation, diarrhea or both
Recently diagnosed with Irritable Bowel Syndrome (IBS)
Sudden Intolerance to foods such as dairy, gluten, etc.
Potential Heart Changes:
Lightheadedness or spotting in eyes upon standing
Decreased ability to maintain exertion
Sleep Changes:
Inability to get to sleep
Disruptive sleep
Signs of RED-S in Regards to Injury:
Stress reaction
Stress fracture
Increased length of time for recovery from injury
Frequency of injuries that seem abnormal
Abnormal bruising
Laboratory Values of Concern:
Decreased ferritin
Confirmed anemia
Low Vitamin D
Low WBC (possible immune system dysfunction)
Elevated liver enzymes (AST/ALT)
Elevated cholesterol
Low B12
Low folate in vegetarians
Significant Mood Changes:
Depressed mood
Irritability
Increased anxiety
Performance:
Decreased reaction time
Inability to withstand training load (with a normal load progression)
Delayed muscle soreness
Problems concentrating
Impaired judgement
Decreased endurance performance
If you even have the slightest suspicion that a friend or teammate is experiencing RED-S, please ask questions and help direct him/her to care. You could save this athlete from a career-altering injury such as a stress fracture or long term health consequences such as heart disease.
PREVENTING RED-S
This idea of preventing RED-S in itself deserves another blog. However, the short answer is that I strongly recommend consulting with a registered dietician to determine the answer to this equation:
Available Energy (AE) = (Energy Intake - Energy Expenditure)/Fat Free Mass. Fat Free Mass (FFM), measured in kilograms (kg), is made up of internal organs, bones, muscle, water, and connective tissue (McConville, 7).
Knowing the answer to this question is not a panacea, but it does provide a tool for making educated choices in regards to daily fueling to decrease the risk of transiting into a RED-S state.
Thank you for your time in reading this blog!
Reference:
McConville, Rebecca. Finding Your Sweet Spot: How to Avoid RED-S (Relative Energy Deficit in Sport) by Optimizing Your Energy Balance. 2019.
