Relative Energy Deficiency in Sport (RED-S) and What Every Athlete (& Their Loved Ones) Needs To Know About Changes To The Female Athlete Triad
The Female Athlete Triad (FAT), coined in 1992 by the American College of Sports Medicine, described the intersection of and relationship between disordered eating, irregular menses and osteoporosis (bone less), and is a phenomenon very commonly seen in athletes.
Since 1992, new evidence has emerged, suggesting that this is not merely a triad of symptoms, as inadequate nutrition influences countless aspects of our physical and emotional health.
Further, FAT excluded men, despite the fact that male athletes also suffer from disordered eating, and the subsequent effects on health and performance. This prompted the International Olympic Committee (IOC) to develop a broader framework, Relative Energy Deficiency in Sport (RED-S).
RED-S is defined as “impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular health”, all of which are driven by inadequate calorie intake/nutrition.
The undernutrition then results in a cascade of dysfunctional issues with hormone regulation, mood/cognition and metabolic fitness, to name just a few. This may ‘show up’ in the athlete as a cardiovascular problem, frequent infections or illnesses, anemias, fatigue, depression, lack of menses, premature bone loss or physical injury.
Contrary to popular belief, undernutrition does not only suppress estrogen in females in terms of hormonal dysfunction…..affected hormones include leptin, grehlin, cortisol, growth hormone and insulin (and many others).
As a clinician who often sees this in practice across the gender spectrum, I’m thrilled that we now have a more comprehensive term to describe the dangers of restricted intake, especially in athletes, for whom adequate nutrition is vital for performance, injury prevention and overall health/quality of life.
I tend to see this most in female runners and dancers, and in male runners and cyclists, though this is prevalent across all sports. It requires a concerted effort to fuel properly for activity, and timing and attention to macronutrients, adequate calorie intake and hydration are absolutely crucial concepts for athletes to understand.
It is not always enough just to eat ‘normal meals’ or to mimic what peers are eating, as the needs of each athlete are unique and can vary considerably.
My hope for the future is that uniform screening tools are developed and adopted by athletic programs that allow us to identify these struggles early on (before irreparable damage is done, via injury or bone loss, for example). This would require a multidisciplinary effort (dietitians, therapists and physicians specializing in disordered eating and sports nutrition/athletics), and an openness to collaboration with local athletic departments and family members.
We are fortunate in San Diego in that many of our local university athletic departments are very proactive around collaborating with us in order to best help these individuals return to a state of optimal functioning. It truly takes a village to properly support our hard working and beloved athletes!
At Potentia, we acknowledge how important it is for an athlete to be able to return to their sport, and our collective hope is for them to do so in a way that is safe and sustainable.
Consequences of RED-S (note the limited nature and reach of Female Athlete Triad as depicted). *Psychological consequences can either precede RED-S or be the result of RED-S. Adapted from Constantini.
Effects of RED-S on Athletic Performance (Adapted from Constantini)
Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine 2014;48:491-497.