Defining and Managing REDS; more than just ‘overtraining’
Athletes who are passionate about their sport and driven to perform often push boundaries in the quest to achieve specific goals, targets and reach success in their sport. However, for many athletes, there is a fine line between maintaining optimal health status and toeing the line into the space of overtraining. Periods of prolonged overtraining can have ongoing consequences and can often lead to the diagnosis of a syndrome defined as REDs (Relative Energy Deficiency in Sport). Relative Energy Deficiency in Sport is a condition characterized by low energy availability, affecting both male and female athletes of all levels and ages. It has adverse effects on various systems and can affect long term health. The quest to achieve athletic potential can come with a cost to bone health, reproductive function and immune function to name a few. Up to 80% of athletes are at risk of developing REDs and early diagnosis is key. That is why we are exploring this concept today in an effort to educate athletes on what it is and how to prevent it.
The syndrome of REDs is defined as syndrome of “impaired physiological functioning caused by relative energy deficiency and includes but is not limited to impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health.” It refers to a much broader problem which can have implications for mental health status, bone health and reproductive function. Professor Louise Burke, sports dietician says “REDs is a diagnosis of the dysfunctions that can occur with problematic low energy availability.” In a simple sense, REDs implies inadequate intake compared to the energy expended, otherwise referred to as Low Energy Availability (LEA). Professor Margot Mountjoy states “The true prevalence of relative energy deficiency in sport (REDs) syndrome varies by sport and ranges from 15 per cent and 80 per cent,” and is most common in endurance sport athletes.
Put simply: Energy Expenditure > Energy Intake = decreased Energy Availability.
Previously the sports medicine world referred to REDs as the Female Athlete Triad; defined for females as a cluster of symptoms related to LEA, low bone mineral density and the absence of a period for more than five months (secondary amenorrhea). However, Anna Melin, Ph.D., an associate professor in sport science at Linnaeus University in Sweden says, “Low energy availability affects males as well, and there are even very few female athletes who have all three aspects of the triad.” The most recent REDs research encapsulates both male and female populations. Problematic LEA in males specifically is associated with negative effects on hypothalamic–pituitary–gonadal (HPG) axis and associated hormones, changes to metabolic hormones, impairments to immune function, bone health and decreased lean body mass acrual. We now see that REDs is not specific for female athletes only and has high rates in male athletic populations.
Restricted Eating
Restricted eating and overtraining can put athletes at risk of developing RED-S. Disordered eating and diagnosed eating disorders exist on a spectrum. Disordered eating behaviours include restrictive eating or inflexible eating patterns, whereas a diagnosed eating disorder involves meeting defined clinical criteria. Seek guidance and help if you may be exhibiting signs of disordered eating patterns or more significant mental health concerns.
Symptoms of REDs; what to look for.
Weight loss/underweight
Absence of period/period becoming irregular
Gastrointestinal problems
Bone stress injuries (stress fractures)
Sleep disturbances
Recurrent illnesses and decreased immune system function e.g. colds and flu
Decreased sports performance
Mood Changes- anxiety, depression
Difficulty concentrating
Delayed/disordered growth/development (children and teenagers)
Iron deficiency
Severe RED-S can affect the heart.
At the end of 2023, the IOC (International Olympic Committee) published updated guidelines on the management of REDs. The consensus was developed by a panel of experts which summarised the findings of latest research in REDs science over the past five years, with the aim to recognise the far-reaching consequences of the syndrome and consequently intervene and reach a diagnosis early. The goal was to educate athletes, coaches and parents in order to optimise athlete health, psychological well-being and performance. The statement highlights how we may go about both preventing and managing REDs, along with recognising the associated symptoms early.
Athletes involved in competitively judged sports such as gymnastics which place emphasis on physical appearance have high rates of REDs. The emphasis on a certain "look" and perception that carrying less weight is essential for performance, can lead to disorderd eating patterns.
Far reaching effects
Side effects of REDs
As the effects of REDs vary greatly, professor Margot Mountjoy says the long list of risks to athletes of inadequate energy intake include reduced immunity, impaired growth and development, reduced muscle function, impaired cardiovascular function, sleep disturbances and many other negative impacts. ‘The detrimental outcomes include, but are not limited to, decreases in energy metabolism, reproductive function, musculoskeletal health, immunity, glycogen synthesis and cardiovascular and haematological health, which can all individually and synergistically lead to impaired well-being, increased injury risk and decreased sports performance.’ Not only does energy deficiency have negative effects on athlete performance, up to 80% of athletes diagnosed with REDs face a variety of serious medical conditions such as serious fatalities, reduced reproductive function, urinary incontinence and mental health issues.
Sports Medicine Australia CEO Jamie Crain stated; “The research is clear: Over training can adversely affect an athlete’s health. Over training and not eating enough can be dangerous.” REDs can have consequences and relate directly to impairments in a number of body systems (see image). Low energy availability means that the athlete is likely to be slower, weaker and underperform. Without adequate nutrition and intake of fuel, performance will almost always become impaired.
Management
What do we do if our child, athlete or we suspect that even ourselves may be experiencing REDs? Firstly, understand that it is important to have a support circle to help the individual through this time. It is important to seek advice from a sports dietician or sports physician to address the impairments of various body systems. The first line of treatment for REDs is to reverse the underlying cause and improve energy availability; essentially, having enough fuel to match the energy output. This is where advice and a nutrition program by a qualified healthcare practitioner is essential. It is essential for coaches, parents and dieticians to emphasise the critical role adequate nutritional programming plays in long term health.
With so much emphasis being placed on performance, athletes, coaches and parents should be reminded that health should always be put first, with performance second. If you’re not fueling well and feeling well, your body won’t have the capacity to perform at its best. Appropriate nutrition, and expert advice for athletes not only optimises athletic performance but also safeguards them against injury and health problems.
It is important to encourage athletes that it’s NOT normal to feel tired all the time, for skills that once seemed easy to now feel difficult and it’s NOT ok to consistently be injured or unwell. For female athletes, it is being educated on the importance of having an adequate and safe level of circulating hormones and understanding that regular periods are a barometer of hormone health. Recovering from REDs is not an easy journey as many underlying aspects play into how the athlete is functioning and feeling. If disordered eating, depression, concerns around body image or restricting calorie intake is part of the underlying health picture, seek professional advice from a sports psychologist.
Final words
In closing, REDs is a syndrome characterised by Low Energy Availability whereby an athlete is expending more fuel than they are consuming.
Adequate fuel intake is essential to not only performing well, but to ensuring that all body systems are functioning effectively. This includes the reproductive, skeletal, gastrointestinal, hematological, immune and cardiovascular systems.
If you, a friend or loved one has symptoms consistent with REDs, seek professional guidance from a health practitioner.
Mental health aspects such as depression and disordered eating can become apparent with a diagnosis of REDs. Ensuring care of mental health is just as important as addressing physical symptoms.
Support resources for eating disorders
https://edfa.org.au/parents-and-carer-support/eating-disorder-organisations/
Local health practitioners
https://www.sportsmedsc.com.au/
https://www.sunshinecoastsportsmedicine.com.au/
https://www.outoftheboxperformance.com.au/about
References
Ackerman KE, Rogers MA, Heikura IA, et al Methodology for studying Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the International Olympic Committee (IOC) consensus on REDs British Journal of Sports Medicine 2023;57:1136-1152.
Mountjoy, M., Sundgot-Borgen, J., Burke, L., Ackerman, K. E., Blauwet, C., Constantini, N., Lebrun, C., Lundy, B., Melin, A., Meyer, N., Sherman, R., Tenforde, A. S., Torstveit, M. K., & Budgett, R. (2018). International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update. International Journal of Sport Nutrition and Exercise Metabolism, 28(4), 316-331. Retrieved Mar 23, 2024, from https://doi.org/10.1123/ijsnem.2018-0136
Mountjoy M, Ackerman KE, Bailey DM, et al Avoiding the ‘REDs Card’. We all have a role in the mitigation of REDs in athletes British Journal of Sports Medicine 2023;57:1063-1064.
Mountjoy M, Sundgot-Borgen J, Burke L , et al The IOC consensus statement: beyond the female athlete triad-relative energy deficiency in sport (RED-S).Br J Sports Med2014;48:491–7.doi:10.1136/bjsports-2014-093502pmid:24620037
Grabia M, Perkowski J, Socha K, Markiewicz-Żukowska R. Female Athlete Triad and Relative Energy Deficiency in Sport (REDs): Nutritional Management. Nutrients. 2024; 16(3):359. https://doi.org/10.3390/nu16030359
Written by Brigitte Grofski
Brigitte is a physiotherapist and co-director of Back to Bounce Sports Physiotherapy. Brigitte is passionate about bone health and loves working with female athletes to stay injury free and remain engaged in their sport.
For more information, see our blog on Symptoms of Overtraining; https://www.backtobounce.com.au/blog/could-you-be-overtraining and Adolescent Injuries https://www.backtobounce.com.au/blog/growing-pains
