What is RED-S ?

Some of you may or may have not heared about REDs, former known as Female Athlete triad and now the more defined syndrom of Relative Energy Deficiancy in Sport. I want to talk about this as it something that affected me as well as many other athletes in my sport career and that I was until recently not aware of. But then I listened to a podcast called “Trainbraive” (link down below) which is hosted by Renee Mcgregor a sports and eating disorder diatician who is also author of the book “Orthorexia: when healthy eating goes bad”. In this podcast they talked about the Syndrom as well as the connection to eating disorders which intrested me especially as I personally have struggeld with negative thoughts around food for the past year. That was initially the reason why I stared to inform myself about the warning signals and risks that come with REDs and was shocked to find that everything that they discribed was also a common theme in my life.

REDs was first researched in 2014 and is basically when the energy availability is insufficient for the form of exercise that a person is doing. That generally comes from to low energy intake, simply said just eating to less(undereating) or overexercising. In females that low energy availabilty usually can be noticed by a disruption or stop of menstruation which is the reason for the believe that this Syndrom only occurs in women because it was only noticed there. But lately the reseach has shown that also men are concerned even if the warning signs are harder to notice.

The International Olympic Committee (IOC) defined RED-S as a syndrome of health and performance impairments resulting from an energy deficit.


Why is this an important issue?

REDs can cause many negative side effects. For females the loss of a regular menstrual cycle (Ammanorrhea) also affects their hormones which leads to hormonal imbalances and finally has a huge impact on bone density. A study in 2018 demonstrated decreased BMD, altered bone microarchitecture and bone turnover markers, decreased estimates of bone strength and increased risk for bone stress injuries compared with eumenorrhoeic athletes and those who are energy replete. But these hormonal imbalances of Oestrogen and Progesterone in women also occur in men, mainly with Testosterone ,which has a profound impact on training adaptation and efficiancy. This is due to downregulations because the body thinks it is starving and puts systems into “saving mode” so that the full potential of the body cannot be reached. Furthermore this might lead to even more training because athletes think that they aren’t doing enough because Thea aren’t seeing results. That is also a main cause for stress fractures which are a bone stress response that can be triggered with either too much training or too less fuel. In addition the prolonged low energy availability puts subjects at risk of infection, illness, fatigue and nutrient deficiencies. A study in 2018 reviewed the largest survey of adolescent/young adult female athletes where 1000 girls/women completed online questionnaires on Low energy availability(EA) which was then used to investigate EA in females and it’s consequences on health and athletical performance. It showed that individuals with low EA were at a higher prevalence of menstrual dysfunction, impaired bone heath, endocrine abnormalities, metabolic impairment, haematological abnormalities, psychological disorders, cardiovascular symptoms and gastrointestinal symptoms. Additionally athletes with low EA had a greater prevalence of decreased training response, impaired judgement, decreased coordination, decreased concentration, irritability, depression and decreased endurance performance compared with the control group(1).

Who is at risk and what are signs?

In general REDs can occur in any sport, age group and level of performance but especially in athletes doing sports with a high power to weight ratio such as cyclists, Triathletes, Runners or Dancers. Furthermore particularly young athletes can be affected as puberty is already an energy demanding time. In the trial mentioned above low EA was observed in 47.3% of the sample of female athletes participating in a wide variety of sports presenting to a sports medicine clinic (2). That indicates that a big proportion of athletes of all types and shapes are affected. Meaning that weight loss can be an indicator but doesn’t has to be as every body is different and might manage the energy deficiancy otherwise on short terms. For Females the loss of a regular, menstrual circle can be a good indicator, as well as a history of bone stress fractures or frequent viral infections. The same goes for men but there other signs of REDS are still hard to recognize as the hormonal imbalances are sometimes hard to notice. Studies have also shown that there are also psychological signs because low EA has a direct impact on psychological well-being. Adolescent females with FHA have been found to have a higher incidence of mild depressive traits, psychosomatic disorders, and a decreased ability to manage stress as well as increased depression, social insecurity and introversion and fears of weight gain compared with healthy controls(3).

Furthermore I am going to review some of the signs that I noticed myself and maybe this will help you to recognize some of those tendencies in yourself or other people that matter to you. If this is the case please immediately contact a professional or at least your coach and try to tell them about your issues because otherwise much time can go to waste during which you are not in a good place ,nor is your training. Also I can only tell from my own experience and that does not mean that those signs that I see looking back will occur or matter for everyone.

My experiences with RED-S

I don’t want to through my whole journey with sport including overexercising and under eating in this post as I think that I need to commit a complete other post to this because it is a really important part of my journey and needs a lot more explaning. But part of this is especially important for the issue of RED-S which is why I still want to share some of it.

During the last season I really started to invest more and more time in my training. I knew I had chances to qualify for the European Championships in Trithle/Biathle (which I explained in the “about me” section) but which is simply a part of Modern Pentathlon and includes running, swimming and shooting. So at the start of 2019 I went to a training camp in Greece with my swimming team. As I am not only a swimmer I swopped some of the sessions and did a running Programm instead. Part of the problem was that I don’t have a coach that overlooks all of the disciplines that I need to train but only multiple coaches for swimming and shooting that try to adapt to my training schedule. Even though my swimming coach is brilliant and very understanding she can’t overlook all the training that I am doing or estimate how exhausting the sessions might be as she is not a running coach. In the end that basically resulted in me training too much and recovering to less because I feared that I wasn´t doing enough and I had to coach who could tell me that i was doing enough already. On top of that I was vegetarian at the time and the vegetarian food options weren´t great as the hotel were we were staying at was very small. All in all I was training too much, nor taking enough rest to give my body the time to recover properly ans eating to little as well. This kind of continued when I went back home and over the time of a month I started to notice some changes. Positively I felt a lot better when I was running as I was just lighter and I felt a lot easier to achieve my times. But on the contrary I noticed that swimming was getting harder and harder and I was always cold, outside and in the water as well. My lips started to turn blue after a few minutes into the training and all I could think of was just to get out of the water. Swimming was´t fun anymore, I started to dread every training session because I knew I couldn´t perform as I was always shaking.

It also had a huge impact on my every day life not only on my performance. My mind started to obsess about food in every situation. All that I was think at every free minute was What am I going to eat next?, Is there a better, healthier option? and what have I done training vize to deserve to eat? In the beginning it was only important that the food that I ate was “good”. Good for my training, my recovery and good in general, meaning no refined sugars or too many fats because that was what I had read about on social media and in articles. But it got to the point were I has massive issues with eating out because I could not control what exactly I was eating. eating and food in general meant stress for me and I completely blocked out my hunger cues so that my body had to adapt to the minimum amount of fuel I was putting into it. At the time I didn´t even notice that I had basically no energy. I dind´t want to meet with friends or do anything except numming myself with training. I thought that always training was what made me happy, but truthfully I wasn´t at all happy at the time. Locking back I didn´t even enjoy the feeling when I stood on the podium at the Europeans, having just won the silver medal because I just did not feel anything. I had started to block out all the emotions to ignore the state at which my body was. And all of that just because I wanted to become a better athlete and do my best. Since then I didn´t get my period and now that I have taken some time of training because I chose to focus on my studies I knowticed that I developed a really bad relationship with training in general. I nor longer enjoy running as much as I did before because it reminds me of the time when I used to train soo much.

That doesn´t mean that everyone that trains hard for a competition and wants to optimise their training will fall into this circle or will have the same negative experiences that I did. My situation is very unique as is everyones and symptoms can be different for everyone as well. All I wish to accomplish by telling my story is to rise awareness that overtraining and not resting properly can easily have huge impact on your every day lives without us even noticing. REDs might be a very new subject that I raised in the sports community but in my opinion it is really important to be informed about for coaches as well as for athletes in order to prevent athletes from falling into this cycle of self-sabotaging or just not being well.



1 Relative energy deficiency in sport (RED-S) Siobhan M Statuta,1 Irfan M Asif,2 Jonathan A Drezner3, BJSM

2 Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport Kathryn E Ackerman,1,2 Bryan Holtzman,1 Katherine M Cooper,1 Erin F Flynn,1 Georgie Bruinvels,3,4 Adam S Tenforde,5 Kristin L Popp,6 Andrew J Simpkin,4,7 Allyson L Parziale1 Original

3 IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update Margo Mountjoy,1 Jorunn Kaiander Sundgot-Borgen,2 Louise M Burke,3,4 Kathryn E Ackerman,5,6 Cheri Blauwet,7 Naama Constantini,8 Constance Lebrun,9 Bronwen Lundy,3 Anna Katarina Melin,10 Nanna L Meyer,11 Roberta T Sherman,12 Adam S Tenforde,13 Monica Klungland Torstveit,14 Richard Budgett15 (British Journal of Sports Medicine)

4 Infographic. Relative energy deficiency in sport: an infographic guide Nicola Keay, 1 Alan Rankin2
Figure 1 Relative energy deficiency in sport: effects on health and performance.
on 18 February 2019 by guest. Protected by copyright. J Sports Med: first published