RED-S (Relative Energy Deficiency in Sport) quick take for endurance coaches

 

     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.

Team USA Athlete's Plate

    

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