Relative Energy Deficiency in Sport (RED-S)

What is RED-S?

Relative Energy Deficiency in Sport (RED-S) is a condition that is defined as ‘impaired physiological functioning caused by relative energy deficiency. In plain English, this means a state of being in your body which means there’s not enough energy supply for the demands you’re asking your body to perform, leading to weakening or injury in the system. The relative deficiency of energy has negative consequences for bone health, menstrual health, metabolic rate, immunity, protein synthesis, immunity, cardiovascular health and performance outcomes.

Historically, RED-S was called the ‘Female Athlete Triad’. Research in the last decade or so has increased our understanding of this phenomenon and its far-reaching consequences. Previously, the medical community was aware of the three main ‘symptoms’ of the Triad – high demands of physical activity, impaired menstrual function and decreased bone health. Health professionals believed that this condition was only occurring in females. As the research has uncovered more facets to RED-S, the name and definition had to be expanded to accurately reflect our new ways of measuring Low Energy Availability (LEA), the recognition of males with RED-S, identifying many other health parameters that are affected, and to highlight to the sporting community the negative ramifications for athlete performance. (Mountjoy, et al., 2018)

What Causes RED-S?

RED-S is caused by a prolonged state of Low Energy Availability (LEA). This is where the balance between energy (i.e. food) is tipped out of balance with energy out (i.e. activity). This can occur in many ways and is not always a sudden change, making identifying the causes difficult without help from trained medical professionals and coaches. Some examples might be an increase in sport or training load, decreased food intake or type of foods eaten, increased stress to the body through a lack of sleep, growth spurt, illness, or psychological stress.

What Are RED-S Symptoms?

Symptoms of RED-S are broad and cross over with many other conditions and illnesses. This can make it tricky to recognise and diagnose. (Mountjoy, et al., 2018)

Symptoms and other associated conditions your health professional might ask you about when they suspect RED-S might include:

• Recent weight loss
• Loss of appetite, disordered eating, or a history of eating disorders
• Participation in high demand, weight or aesthetically driven sport (e.g. dance, gymnastics, jockeys, boxing etc.)
• Slow or stunted growth in children and adolescents
• Recurrent coughs, colds and cases of flu
• Recent irritability, mood swings, or a history of mental illness or increased stress
• Poor judgement, poor coordination, decreased athletic performance
• Low iron or anaemia
• Changes in or absence of a menstrual cycle in adults or a delayed or absent onset of puberty in adolescents
• History of stress fractures
• Recurrent or unhealed injuries
• Feeling tired, run-down or exhausted
• Difficulty sleeping or concentrating

How Is RED-S Diagnosed?

Diagnosis can be tricky for RED-S as symptoms vary, and everyone’s body responds differently to LEA. Energy availability is a sliding scale that constantly changes as we eat, move, rest and challenge ourselves. (Couanis, 2017)

Diagnosis can also be made tricky by an athlete’s coping skills and their motivations for revealing or minimising their symptoms to their coaches, trainers, family, friends, and themselves. Generally, the person feels and looks pretty run down because the body isn’t getting enough fuel to perform all the activity.

Often, athletes are recognised as being in an energy deficient state when it leads to them becoming injured or developing other conditions for seeking medical treatment. It is then up to the medical professional they seek help from to recognise the signs and symptoms and get the athlete the appropriate type of help they need to heal well and stay well. Most often, these treatments need to be multifactorial and involve a few different types of practitioners.

What Are Your RED-S Treatment Options?

Treatment options are based on the signs and symptoms each individual has, what their greatest concerns are, and the results of any tests or investigations. A mix usually delivers treatments of professionals, which might include:

• Sports Dieticians, to address food-related behaviours
• Physiotherapists, for injury management and rehabilitation advice
• Exercise Physiologists, for reconditioning and modification of training/performance tasks
• GPs and Team Doctors, to manage symptoms, prescribe medication and order tests, and clear for return to sport
• Sports Psychologists and Psychiatrists, to help develop coping skills and address the thinking and beliefs around the current behaviours which led to RED-S
• Endocrinologists, to help address hormonal imbalances
• Gynaecologists and fertility specialists, to address hormonal and reproductive concerns
• Cardiologists, where heart function has changed
• Immunologist, to assist with the immune system and allergy concerns

Not everyone who has RED-S will require intervention from every single type of medical professional. Everyone is different, but most people who have RED-S have at least 3-4 professionals involved in their treatment team based on their needs.

This team of experts works very closely with the athlete, their family, teammates, coaches and trainers to ensure that the factors influencing energy availability are the most beneficial ones possible for the entire team or club. The best tool we have to reduce further injury and illness risk is education and advising everyone involved about training load, nutrition, coping strategies and sleep hygiene to get the most out of the athletes in a healthy, sustainable way.

Screening and prevention programs are becoming more popular throughout the sporting world. We know that early detection of RED-S is crucial for preventing long-term health consequences.

What Results Can You Expect?

Results for RED-S vary widely, dependent on which symptoms an athlete presents with and their severity and complexity. Each treatment plan is bespoke and will require the collaboration of many professionals.

If RED-S is a result of simply unintentional undereating or over-training, a little bit of knowledge and guidance can resolve RED-S quite quickly. However, if RED-S hasn’t been recognised and other health conditions have developed, treatment timeframes will vary depending on those conditions.

If you suspect that you or your child might be suffering from Relative Energy Deficiency in Sport (RED-S), you can book a consultation with your PhysioWorks physiotherapist.

REFERENCES

Couanis, G. (2017). Relative Energy Deficiency in Sport (RED-S). Retrieved from https://www.perthsportsmedicine.com.au/relative-energy-deficiency-in-sport-perth-claremont-cockburn-wa.html on the 28/05/2020.

Fede, C., Pirri, C., Fan, C., Albertin, G., Porzionato, A., Macchi, V. … Stecco, C. (2019). Sensitivity of the fasciae to sex hormone levels: Modulation of collagen-I, collagen-III and fibrillin production. PLoS ONE 14(9): e0223195. https://doi.org/ 10.1371/journal.pone.0223195

Mountjoy, M. Sundgot-Borgen, J. K., Burke, L. M., Carter, S., Constantini, N., Lebrun, C. … Ackerman, K. (2015). The IOC relative energy deficiency in sport clinical assessment tool (RED-S CAT). British Journal of Sports Medicine. 2015;49:1354

Mountjoy, M., Sundgot-Borgen, J. K., Burke, L. M., Ackerman, K. E., Blauwet, C., Constantini, N. … Budgett, R. (2018). IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update British Journal of Sports Medicine 2018;52:687-697

British Journal of Sports Medicine. (2015) Relative Energy Deficiency in Sport (RED-S) Clinical Assessment Tool (CAT). British Journal of Sports Medicine. Retrieved from https://bjsm.bmj.com/content/bjsports/49/7/421.full.pdf on 28/05/2020