Understanding RED-S: Balancing sporting performance with health

With several high level sporting events of late, we want to shine the spotlight on RED-S. In this post, we speak with Dr Lauren Coles, Clinic Manager and Highly Specialist Psychologist at Altum Health, to understand the symptoms of RED-S, its impact on health and wellbeing, how best to prevent RED-S, and the support available.

What is RED-S (Relative Energy Deficiency in Sport)?

Relative Energy Deficiency in Sport “RED-S” happens when athletes have an imbalance in the amount of energy they burn through training and how many calories they consume. 

Essentially, the body simply doesn’t have enough fuel to perform well, which can affect overall health and athletic performance. 

How does RED-S happen?

Most athletes who compete in high level sports commit to regular training sessions. These sessions typically ramp up in intensity as the training programme develops, building towards the next performance or competition. 

Training at this elite level means hours of physical activity. If the athlete is not in tune with how many calories their body needs in order to ‘keep up’, there’s a risk of slipping into RED-S.

Why are athletes at risk of RED-S?

The achievement levels in sports get higher every year. The bar is constantly rising and the speed, strength, and ability we witness seem to continually reach new heights. 

We saw it at events such as the Olympics and the Tour de France. New records were set and then broken again and again.

Coaches have more knowledge about sporting performance nowadays and the best way to get the most out of athletes, which can mean they’re pushed harder to reach higher limits. Of course, this also means they use more energy to keep up and perform well at this high intensity level.

But we’ve not suddenly developed superhuman abilities; some athletes push their bodies to the limit without realising the toll it takes. 

Any athlete at any level has the capacity to get into RED-S territory – across all sporting disciplines. However, we tend to see RED-S more often in sports where athletes believe that being leaner and lighter will help them to perform better, such as ballet, gymnastics, and cycling. This is a dangerous misconception.

What are the signs and symptoms of RED-S?

RED-S can play out in many different ways, affecting a person’s physical and mental health. 

Missed periods

For athletes who menstruate, one of the major signs of RED-S is missing periods. The body just doesn’t have enough energy to produce the hormones needed to complete the menstrual cycle. 

Poor bone health

In younger athletes especially, bones are not yet fully formed – they are still developing bone mass. RED-S can cause low bone density (Osteopenia), increasing the likelihood of fractures. In extreme cases, RED-S can lead to the development of Osteoporosis. 

Other physical symptoms include:

• More aches and pains 
• Regular injuries
• Feeling tired or lacking energy
• Frequently catching colds due to a weakened immune system
• Slow recovery time
• Reduced muscle strength and endurance – not being able to get past a certain point in your training
• Decrease in physical performance
• Gastro problems, including bloating, constipation, and general discomfort

Emotional symptoms of RED-S

For an athlete experiencing the symptoms of RED-S, it can be incredibly disheartening. 

If you’ve committed so much time and effort to a sport that you’re at risk of developing RED-S, you’re likely to be pushing yourself to the upper limits. However, instead of feeling stronger and more capable as your training regime progresses, with RED-S, your performance actually gets worse and you feel slower and more sluggish. 

Suddenly being unable to keep up in a sport you’ve dedicated your life to will undoubtedly have an impact on self confidence and can lead to low mood and irritability. 

This combined with the possibility of losing chunks of training time due to injury (as a result of RED-S), can cause a strong sense of falling behind.

The athlete will want to push on to catch up and maintain their position among their peers, but without listening to their body and its needs, they could slide further into RED-S. It can be a vicious cycle.

What are the long-term effects of RED-S?

The key with RED-S is catching it as soon as possible. All the physical symptoms of RED-S are recoverable: calcium supplements can be prescribed to help with bone health and weight can be regained. Tour de France cyclist, Jonas Abrahamsen, recently spoke about his sporting success after gaining 20 kg – strengthening his muscles and his career simultaneously. 

However, if left untreated, it can lead to more serious long-term problems such as anxiety and depression. 

As an athlete, your sport is a huge part of your identity and your life. Imagine feeling that your body is working against you all the time. It’ll affect your motivation and leave you feeling quite hopeless and low – you may even start to question your sense of self, asking, “Who am I if I don’t have this?” When you feel exhausted from a day’s training, picking yourself up to do it all over again, day after day, can feel like an impossible challenge. 

Preventing RED-S

The good news is that we’re starting to see a greater focus on the importance of recovery and nutrition for athletes. The more we’re aware of the risks, the easier it is to create a safe environment for athletes to thrive.

At higher level sport, coaches can screen for signs of RED-S, and hormone levels can be tested to look for low testosterone and low oestrogen. 

If you’re managing your own sports training and this is something you’re concerned about, there are things you can do to keep yourself safe. Simply keeping an eye on energy levels, respecting recovery time, and maintaining open communication is key in helping to prevent RED-S: 

 

• Monitor energy levels: Make sure you’re eating enough to match your training intensity.
• Focus on recovery: Rest is just as important as training – don’t skip it.
• Talk openly: Whether you’re an athlete, parent, or coach, talk about the importance of fuelling your body properly.

The key message – at whatever level you’re playing sport – is to eat a nutritious, balanced diet and not have long periods of time when you’re not eating. 

Support and recovery from RED-S

We all have times when we don’t feel our best, but if the signs of RED-S are apparent for a few weeks, please reach out for professional help.

The first port of call should be your GP, who can investigate whether you’re suffering from RED-S and rule out other possibilities. 

Many people suffering from RED-S feel a sense of relief when they receive their diagnosis – especially if they’ve not intentionally limited their calorie intake.

However, in some cases, athletes do intentionally try to eat less, and this is where RED-S can cross over into an eating disorder and issues with body image become apparent.  

A dietician and psychologist specialising in eating disorders will be able to offer tailored treatments to help you on the road to recovery.

Seeking help for RED-S

It’s a myth that being lighter will make an athlete faster or better. We need to shift this mindset. It’s not about weight, it’s about strength, energy, and feeling good in your body. 

You’re more likely to develop an eating disorder and other mental health and physical problems the longer you head into RED-S. It can also shorten your sporting career. So please don’t hesitate to reach out to a parent, friend, coach, or clinician for help and support.

If you, or someone you know is suffering from RED-S, please get in touch to book a free, 20-minute consultation with our licensed professional therapists.

Take care,

Dr Lauren Coles