My personal experience with RED-S covers most of my lifetime and for the majority of those years, I did not have an eating disorder. I simply wasn't keeping up on replenishing what I burned through training. Because my training volume is less that it has been in the past, I have not struggled with symptoms of RED-S since 2018. With a possible start in triathlon in 2021, I'll need to stay vigilant to keep it from coming back. The short paper below is a synopsis about what RED-S is, who is vulnerable to it and how coaches can prevent it.
In
2014, the International Olympic Committee re-defined the term “female-athlete
triad” to update the term with current and relevant information that
acknowledges the role that the condition also plays in male athletics. They
re-coined the condition as “RED-S” or “relative energy deficiency in sport.”
They defined the condition as “impaired physiological function including, but not limited
to, metabolic rate, menstrual function, bone health, immunity, protein
synthesis, cardiovascular health caused by relative energy deficiency”
(Mountjoy et. al., 2014). The cause is a depletion of energy that is available
for optimal functioning due to an imbalance between training loads and
nutritional intake.
The IOC agrees that “EA (energy
availability) is calculated as EI (energy intake) minus the energy cost of
exercise relative to fat-free mass (FFM) and in healthy adults, a value of
45 kcal/kg FFM/day equates energy balance” (Mountjoy et. al., 2014). This
precise measurement allows physicians and coaches to accurately define exactly
how much their athletes need to take in to support healthy functioning while
engaging in intense training.
BMJ Blog
Who Is at Risk?
All athletes, regardless of gender are
potentially at risk of developing RED-S. This was part of the IOC’s mission in
re-defining the term because it became obvious that men were being affected by
the phenomenon as well. A 2019 study found that men who had high levels of
exercise dependency were more likely to display eating disorder tendencies and
lower energy levels due to their reduced energy intake. They also had higher
cortisol vs. insulin levels, indicating a catabolic state (Torstveit et. al.,
2019). Although we now know that men are at risk of RED-S, alongside women, it is
female British teenage running phenom, Bobby Clay’s case that shows the
significant impact of the IOC’s terminology change. Clay was one of the top
junior runners in the world, claiming the 2015 European 1500m championship
title after years of national domination. After breaking her foot from simply
pushing off the wall in the pool in 2017, she underwent bone density tests that
revealed she had osteoporosis (Athletics Weekly, 2017). This was followed by a
series of stress and full fractures in her lower extremities that would happen
during mundane activities like cycling and jogging on grass. She maintains that
she never struggled with an eating disorder and that the main culprit to her
hormonal disorder was overtraining combined with accidental under fueling
(Let’s Get Running, n.d.). In my own personal coaching experience, it has been
male athletes that struggled with RED-S. I had a series of athletes who trained
together for at least a season who had unhealthy relationships with food and an
extreme focus on remaining thin and lean during the season. I referred two of
them to speak with their doctors about the obsessive behavior.
What are the Signs of
RED-S?
It is important to note that only medical
professionals can diagnose and treat RED-S but it equally important for coaches
to be aware of the signs:
·
Decreased glycogen
stores
·
Decreased muscle
strength
·
Decreased endurance
performance
·
Increased injury risk
·
Decreased training
response
·
Impaired judgment
·
Decreased coordination
·
Decreased concentration
·
Irritability
·
Depression
(British Journal of Sports Medicine, 2015).
Because
RED-S may be exacerbated by an eating disorder, coaches should also be aware of
unhealthy relationships with food. This is not easy to recognize as a coach.
Parents, siblings and teammates may have better insight into this. Athletes do
not have to have all of the markers to land in the “moderate risk” zone as
defined by the British Journal of Sports Medicine. They could have only one or
two risk factors and qualify for intervention by a team of health care
providers including a dietician, sports medicine doctor and psychologist. It is
important not to stigmatize RED-S and approach recovery in a positive manner, emphasizing
how important recovery is to performance and overall health.
What are the
Consequences of RED-S?
The ultimate
consequences for an athlete are reduction in the level of performance due to
the body breaking down and being unable to sustain endurance training. But
there are also consequences outside of sport that may affect an athlete’s
health for the rest of his or her life.
·
Immunological
·
Gastrointestinal
·
Cardiovascular
·
Psychological
·
Growth + development
·
Hematological
·
Menstrual function
·
Bone health
·
Endocrine
·
Metabolic
(British Journal of Sports Medicine, 2015).
Because hormonal function is integral to
the body’s entire system, RED-S victims can see a wide range of health consequences,
with the most severe cases leading to bradycardia (low heart rate) and dangerously
low bone density that may lead to osteoporosis.
What Can Coaches do to
Combat RED-S?
Information combined
with a healthy approach to training is the best defense against RED-S becoming
a problem on your team. Ply your team with information about healthy eating
habits that support endurance training and emphasize the need for adequate
nutrition for optimal performance. Print out team USA’s “Athlete’s Plate”
handouts and post them in the locker room for athletes to use as a guide (Team
USA, n.d.). Bring in a sports nutritionist to speak with the athletes and
answer their questions. Gradually increase their training load as they age in
order to help them keep an AE equilibrium. Youth athletes are an inspired,
driven bunch who are always looking for ways to improve their performance. If
they know that taking care of their energy needs will lead to increased
performance, they will follow those guidelines. Finally, be a good example for
them by taking care of your own nutritional needs. If they watch you counting
calories at a team spaghetti dinner or conversely, downing a coke and candy bar
while overseeing practice, they may conclude that fueling is not an important
factor.
References
Bobby
Clay – my osteoporosis nightmare. 2017. Athletics Weekly. Retrieved from https://www.athleticsweekly.com/performance/bobby-clay-my-osteoporosis-nightmare-70422/
Coping
with RED-S and disordered eating: Bobby Clay. (n.d.). Let’s Get Running
Podcast. Retrieved from https://www.letsgetrunning.co.uk/coaches-log/reds-bobby-clay
Mountjoy,
M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C.,
Meyer, N., Sherman, R., Steffen, K., Budgett, R. & Ljungqvist, A. (2014).
The IOC consensus statement: beyond the female athlete triad – relative energy
deficiency in sport (RED-S). British Journal of Sports Medicine, 48,
491-497.
Mountjoy,
M. et. al. (2015). RED-S CAT. British Journal of Sports Medicine. Retrieved
from https://bjsm.bmj.com/content/bjsports/49/7/421.full.pdf
Nutrition. (n.d.). Team USA. Retrieved from https://www.teamusa.org/nutrition
Torstveit,
M., Fahrenholtz, I., Lichtenstein, M., Senqvist, T., & Melin, A. (2019).
Exercise dependence, eating disorder symptoms and biomarkers of Relative Energy
Deficiency in Sports (RED-S) among male endurance athletes. BMJ Open Sport
Exercise Medicine, 5(1), doi: 10.1136/bmjsem-2018-000439
