In the world of sports, athletes constantly push their bodies to the limit, striving for peak performance. However, there’s a fine line between optimal training and overtraining, and crossing that line can have serious health consequences. One such concern is Relative Energy Deficiency in Sport (RED-S). This condition, previously known as the Female Athlete Triad, affects both male and female athletes, highlighting the critical balance between energy intake and energy expenditure. Having a team of healthcare professionals in your corner that understand this fine balance and can recognise patterns of injury or early warning signs is important for prevention.

What is RED-S?

RED-S occurs when an athlete’s energy intake is insufficient to meet the demands of their energy expenditure. This imbalance can lead to a cascade of physiological and psychological effects that compromise health and performance. RED-S isn’t just about not eating enough; it encompasses a broad range of issues that impact multiple systems in the body, including metabolic rate, bone health, immune function, and mental health (Mountjoy et al., 2014).

 The Evolution from Female Athlete Triad to RED-S

The concept of RED-S evolved from the Female Athlete Triad, a condition originally identified in female athletes, which included disordered eating, amenorrhea (loss of menstrual cycle), and osteoporosis (loss of bone density). Over time, it became clear that these issues were not exclusive to women, more broad than just these the triad of symptoms, and the condition was affecting male athletes as well. This realisation led to the new, more inclusive term of RED-S, which recognises the wide range of health consequences resulting from energy deficiency in athletes (Mountjoy et al., 2018).

Signs and Symptoms of RED-S

RED-S can manifest in various ways, making it challenging to diagnose without a comprehensive understanding of the athlete’s health and performance. Some common signs and symptoms include:

 1. Decreased Performance: Despite rigorous training, athletes may notice a decline in their athletic performance, such as decreased strength, endurance, and coordination (Mountjoy et al., 2018).

2. Frequent Illness or Injury: A compromised immune system due to energy deficiency can make athletes more susceptible to infections and injuries, particularly stress fractures or bone stress injuries (Heikura et al., 2018).

 3. Menstrual Dysfunction: In female athletes, irregular or absent menstrual cycles can be a key indicator of RED-S. In males, low testosterone levels may be a sign (Torstveit & Sundgot-Borgen, 2005).

4. Mood Changes: Athletes might experience increased irritability, depression, or anxiety as a result of hormonal imbalances and inadequate energy intake (Logue et al., 2020).

5. Chronic Fatigue: Persistent tiredness and a lack of energy, even after adequate rest are common symptoms (Mountjoy et al., 2018).

 The Impact of RED-S on Health

The consequences of RED-S extend far beyond the immediate effects on performance. Prolonged energy deficiency can lead to long-term health issues, such as:

 - Bone Health: Inadequate energy intake can impair bone formation, increasing the risk of osteoporosis and stress fractures or bone stress injuries, which are particularly concerning for athletes in high-impact sports (Heikura et al., 2018).

- Metabolic Rate: The body may respond to energy deficiency by slowing down the metabolic rate, which can lead to weight gain or an inability to lose weight despite increased training (Logue et al., 2020).

 - Reproductive Health: For female athletes, chronic energy deficiency can lead to reproductive issues, including infertility. In men, reduced testosterone levels can impact reproductive health as well (De Souza et al., 2014).

- Cardiovascular Health: Prolonged RED-S can negatively affect heart health, leading to an increased risk of cardiovascular disease (Mountjoy et al., 2018).

Prevention and Treatment of RED-S

Preventing RED-S starts with education and awareness. Coaches, athletes, and healthcare professionals need to recognise the signs and symptoms of RED-S and understand the importance of maintaining a healthy balance between energy intake and expenditure. Key strategies include:

1. Nutritional Support: Athletes can work with a sports nutritionist to ensure they are consuming enough calories to support their training regimen. This includes adequate intake of carbohydrates, proteins, and fats, along with essential vitamins and minerals (Heikura et al., 2018).

2. Monitoring Training Loads: Coaches, clinicians and athletes should monitor training intensity and volume to avoid overtraining. Adequate rest and recovery periods are crucial to maintaining energy balance (Mountjoy et al., 2014).

3. Regular Health Assessments: Regular check-ups with healthcare providers can help detect early signs of RED-S. Monitoring bone density, hormone levels, and overall health can prevent long-term complications. Having a familiar team of clinicians that know your medical history is key. This team might include your osteo, physio, GP, psychologist and dietician. Having a regular clinician or clinic that helps to care for your injuries insures that all of your health data is stored together, decreasing the chance of injury patterns or trends being missed. (Mountjoy et al., 2018).

4. Psychological Support: Mental health is a critical component of overall well-being. Athletes experiencing mood changes or stress should seek support from sports psychologists or counsellors (Logue et al., 2020).

 5. Education: Promoting a culture of health and well-being over performance alone is essential. Athletes should be encouraged to speak up about their health concerns without fear of stigma or judgment (Mountjoy et al., 2018).

Conclusion

RED-S is a serious condition that can have significant short- and long-term consequences for athletes. By recognising the signs, prioritising proper nutrition, and fostering a supportive environment, athletes can maintain a healthy balance between energy intake and expenditure, ultimately protecting their health and optimising their performance. Education and awareness are key to preventing RED-S and ensuring that athletes can compete at their best while safeguarding their long-term well-being. If you have noticed changes in your menstrual cycle, weight, energy or performance then don’t hesitate to discuss this with your clinician.

References

• De Souza, M. J., Nattiv, A., Joy, E., Misra, M., Williams, N. I., Mallinson, R. J., ... & Matheson, G. (2014). 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, CA, May 2012, and 2nd International Conference held in Indianapolis, IN, May 2013. British Journal of Sports Medicine, 48(4), 289-289.

• Heikura, I. A., Uusitalo, A. L. T., Stellingwerff, T., Bergland, D., & Burke, L. M. (2018). Low energy availability is difficult to assess but outcomes have large impact on bone injury rates in elite distance athletes. International Journal of Sport Nutrition and Exercise Metabolism, 28(4), 403-411.

• Logue, D. M., Madigan, S. M., Melin, A., Delahunt, E., Heinen, M., Donnell, S. M., & Corish, C. A. (2020). Low energy availability in athletes: A review of prevalence, dietary patterns, physiological health, and sports performance. Sports Medicine, 48(1), 73-96.

• Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., ... & 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(7), 491-497.

• Mountjoy, M., Sundgot-Borgen, J., Burke, L., Ackerman, K. E., Blauwet, C., Constantini, N., ... & 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.

• Torstveit, M. K., & Sundgot-Borgen, J. (2005). The female athlete triad: are elite athletes at increased risk? Medicine & Science in Sports & Exercise, 37(2), 184-193.