5 Things Coaches Should Know About Relative Energy Deficiency in Sport (RED-S)

5 Things Coaches Should Know About Relative Energy Deficiency in Sport (RED-S)

 By Elissa Rosen, MD, CEDS-S

Today’s blog is geared toward what would be helpful for coaches and other sports team staff to know about relative energy deficiency in sports (RED-S). A key component in prevention and earlier recognition of athletes with RED-S is increased awareness by coaches and other professionals that work with athletes. (1) To start, let’s define what RED-S means and how the word came to be. The term RED-S was coined by the International Olympic Committee (IOC) to describe the physiologic and performance consequences of under fueling in athletes. (2)  RED-S literally means what the term spells out in its name – insufficient nutritional intake in an athlete leading to too little energy for both general life and sports demands. So now that you know the basis for the term, let’s dive into more important details to know about RED-S.

1.     RED-S can occur in athletes of any sex and in any sport

Part of the IOC’s goal in creating the term RED-S was to draw attention to the fact that low energy intake in sport is not unique or exclusive to females. (1) Prior to the IOC consensus statement that first introduced the term RED-S, most medical and sports literature focused on the term “female athlete triad.” The female athlete triad was used to describe how insufficient nutrition in female athletes could lead to menstrual irregularities and low bone density. With the introduction of the term RED-S, the IOC intended to address that the focus on the female athlete triad ignores an entire sex that also can suffer from insufficient energy intake in sports. Therefore, coaches and team staff that exclusively work with male athletes should be aware that RED-S can occur in their athletes too. While certain sports, such as endurance sports, are more commonly thought of as higher risk for athletes developing RED-S, this condition really can occur in athletes participating in any sport. (2)

2.     RED-S can affect the whole body and negatively impact performance

REDS-S should always be a consideration in any athlete who’s been struggling with their performance. Because low energy intake can negatively impact nearly every organ system in the body, declines in performance will eventually occur. This can often be seen as decreased endurance, muscle strength, coordination, and training response. (3) Increased injuries, particularly bone stress injuries, can also be a clue to underlying RED-S. So if an athlete’s performance is declining, be sure to ask about nutritional intake or send them to a knowledgeable sports dietitian to do a more thorough assessment of this. Even in sports where strength to weight ratio is important, strength goals can be achieved while still fueling sufficiently for sport.

3.     RED-S can occur in an athlete of any body shape or size

One assumption about RED-S is that an athlete who is not fueling enough must be losing weight or occupying a smaller-sized body. This is definitely not the case. Each athlete is going to respond to caloric restriction differently and, as our bodies are smartly designed to defend against any perceived starvation by slowing down our metabolism, some people may not lose weight even in the face of severe caloric restriction.

4.     Causes of RED-S range from unintentional on one end or due to a diagnosable eating disorder on the other

There are multiple reasons that an athlete may be under fueling for sport. First, this can be unintentional. Sports demand a lot of energy. Some athletes may not be familiar with how much nutrition they might need to keep up with energy expenditures from training and competing. Other times, RED-S may be due to intentional actions such as restricting calories or eliminating foods/going on a specific diet in order to gain a perceived performance edge. Even further, some athletes may have RED-S due to diagnosable eating disorders. 

5.     RED-S Requires a Multidisciplinary Treatment Team

Worried that an athlete might be under fueling? The next step is to know that there are expert professionals out there that can meet with athletes to better assess what is going on with their nutritional intake, physical, and mental health. Treatment of RED-S often requires not just a knowledgeable dietitian but also a physician for medical assessment and a therapist for when there are concerns for disordered eating or an eating disorder (or other mental health diagnoses such as depression or anxiety). As a coach, you don’t need to have the answers about how to treat or manage someone with RED-S, but rather know your local resources and whom you trust to send your athletes to when these concerns arise.

References:

1.     Mountjoy M, Sundgot-Borgen JK, Burke LM, Ackerman KE, Blauwet C, Constantini N, Lebrun C, Lundy B, Melin AK, Meyer NL, Sherman RT, Tenforde AS, Klungland Torstveit M, Budgett R. IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. Br J Sports Med. 2018 Jun;52(11):687-697. doi: 10.1136/bjsports-2018-099193. PubMed PMID: 29773536.

2.    McConville, Rebecca. Find Your Sweet Spot: How to avoid RED-S by Optimizing Your Energy Balance. March 10, 2019.  

3.    Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. The IOC consensus statement: beyond the Female Athlete Triad--Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014 Apr;48(7):491-7. doi: 10.1136/bjsports-2014-093502. PubMed PMID: 24620037.