Relative energy deficiency (RED-S)
Relative energy deficiency in sport (RED-S) refers to a diagnosis where a person has insufficient energy intake relative to the amount of training being undertaken. This results in low energy availability for not just exercise, but all physiological systems to maintain health.
The term RED-S has been adapted from a previously recognized condition, the female athlete triad, which comprises three components: low energy availability, menstrual problems (irregular or absent periods) and low bone density.
RED-S was developed to reflect the emerging complexity of the associated health consequences of the condition and to incorporate the understanding that it can affect both men and women alike. It is recognised that it can affect any physically active individual, irrespective of the level of sport or age.
Low energy availability can occur either unintentionally through poor nutritional strategies or intentionally with restrictive eating patterns. Irrespective of the cause, the result is an imbalance between energy intake (nutrition) and energy output (training). In women, low energy availability can affect the menstrual cycle with irregular or absent periods. In recreational sports women, it is important to recognise that loss of menstruation is not a normal part of training and irregular or absent periods need to be evaluated so that any underlying medical problems can be excluded and treated appropriately.
RED-S can have detrimental effects on sports performance, as our hormones are important for driving adaptations to exercise.
Low energy availability can affect muscle strength, co-ordination, concentration, reduce your training response and ultimately put someone at increased risk of injury. In addition, people can feel very fatigued and exhausted with training. If left untreated, energy deficiency also has longer lasting effects on menstrual function and fertility, bone health, metabolic rate, immune function, cardiovascular health, and psychological wellbeing.
The identification of RED-S can be challenging and requires the expertise of a multidisciplinary team. It is important to know that weight loss is not necessarily a sign of low energy availability.
At your first consultation, we will discuss your symptoms and evaluate your energy balance and menstrual status.
It is important to know about your sporting activities and training schedules, any previous injury history, dietary intake, medications that you may be taking, and whether there is a family history of osteopenia or osteoporosis.
We will undertake screening questionnaires, a physical examination, and in most people, blood tests to assess metabolic and hormone levels. It is then often beneficial to have a nutritional review with one of our specialists.
The management of RED-S most often requires several clinicians, including a sports medicine doctor, sports nutritionist (or eating disorder specialist), physiotherapist and psychologist. The treatment focuses on reversing the underlying issue of low energy availability by working with specialists on nutritional intake and training plans. This can include addressing any vitamin or mineral deficiencies as outlined in blood tests. Menstrual issues are assessed by a specialist Gynaecologist in this area, and in some patients, further investigations to assess their bone health are required.
It is important to note that oral and injectable contraceptives are not recommended to regulate the menstrual cycle as they have a potential negative effect on bone health and mask any recovery of a women’s normal menstrual cycle.
Patients are encouraged to undertake high impact loading and resistance training at least two to three days per week, especially those in non-weight bearing sports and/or those with low bone density.
Following your initial appointment and diagnosis, we recommend routine follow up for several months to monitor your recovery, and ultimately, a safe return to your sporting activities.