As a sport psychologist, my role involves supporting athletes, teams, and individuals to achieve peak performance while maintaining optimal wellbeing. However, the balance between training demands and mental and physical health can sometimes tip unfavourably, leading to conditions such as Relative Energy Deficiency in Sport (RED-S).
RED-S occurs when an athlete’s energy intake is insufficient to meet the demands of their energy expenditure, resulting in low energy availability. This imbalance can have far-reaching consequences, not only impairing athletic performance but also jeopardising overall health and long-term development. In this blog, we’ll explore what RED-S is, how to identify it, and the steps needed to prevent and treat it.
What is RED-S?
Relative Energy Deficiency in Sport (RED-S) arises when an athlete’s energy intake is inadequate to sustain both their exercise load and their body’s basic physiological functions.
The equation is simple:
Energy Expenditure > Energy Intake = Reduced Energy Availability
In practical terms, an athlete who consistently burns more calories than they consume is at risk of RED-S. While it can occur in any sport, athletes in disciplines that emphasise leanness or weight categories—such as gymnastics, distance running, or combat sports—are particularly vulnerable.
Consequences of RED-S
The impacts of RED-S extend far beyond the immediate inability to perform at one’s best. Insufficient energy availability disrupts multiple physiological systems, leading to consequences in both the short and long term.
1. Impaired Growth and Development
For children and adolescents, RED-S can impede critical growth milestones. During these stages, the body requires extra energy for growth, development, and repair. An energy deficit can delay growth, impair puberty, and increase the risk of chronic health issues.
2. Endocrine Disruption
RED-S can interfere with hormonal balance, particularly affecting the reproductive and stress-regulating systems.
Menstrual disturbance: Female athletes may experience irregular or missed periods (amenorrhoea).
Low testosterone: Male athletes may experience reduced libido and impaired muscle recovery.
3. Musculoskeletal Health
Insufficient energy availability compromises bone health, often resulting in:
Reduced bone density: Leading to increased risk of stress fractures.
Poor tissue maintenance: Injuries take longer to heal, and chronic injuries may develop due to inadequate recovery.
4. Impaired Recovery and Adaptation
Low energy availability hinders an athlete's ability to recover from training, adapt to increased workloads, and develop strength and endurance. This can lead to:
Athletic fatigue: Persistent tiredness and reduced performance.
Injury risk: Increased likelihood of acute injuries and overuse syndromes.
5. Cognitive and Emotional Health
RED-S also impacts mental health, impairing concentration, coordination, and emotional regulation. Athletes may experience mood swings, increased irritability, and reduced motivation.
Long-Term Risks of RED-S
If left unaddressed, RED-S can result in severe long-term health consequences, including:
Bone weakness and osteoporosis: Reduced bone formation during adolescence can lead to lifelong skeletal issues.
Infertility: Prolonged hormonal disruptions can affect reproductive health.
Cardiovascular issues: Severe cases of RED-S can impair heart function.
Signs and Symptoms of RED-S
Recognising the signs of RED-S early is crucial for intervention and recovery. Common symptoms include:
Physical Symptoms
Stress fractures: Often the first sign leading to diagnosis.
Missed or irregular menstrual periods.
Frequent illnesses: Such as colds or flus, due to weakened immunity.
Rapid weight loss or difficulty maintaining a healthy weight.
Iron deficiency and related fatigue.
Performance Symptoms
Reduced performance: Inability to maintain previous levels of training or competition.
Excessive fatigue: Persistent tiredness despite rest.
Psychological and Developmental Symptoms
Mood changes: Increased irritability, anxiety, or depression.
Delayed growth and development: Especially in young athletes.
The RED-S Flag System
To facilitate early recognition, the RED-S flag system is often employed, categorising athletes into risk zones based on their symptoms:
Green Flag: Healthy energy availability; no symptoms of RED-S.
Yellow Flag: Emerging symptoms, such as mild fatigue or irregular menstrual cycles. Athletes in this zone require monitoring and early intervention.
Red Flag: Severe symptoms, such as stress fractures, missed menstrual cycles, or significant weight loss. Athletes in this zone require immediate intervention and medical care.
As a sport psychologist, I work collaboratively with coaches, medical professionals, and dieticians to ensure athletes in the yellow or red zones receive the necessary support.
Preventing RED-S
Prevention is always better than treatment. Coaches, teams, and athletes should prioritise a proactive approach to managing energy balance:
Education
Teach athletes about the importance of energy availability and its impact on health and performance.
Highlight the risks of extreme dieting, overtraining, and unrealistic body image standards.
Balanced Training Programs
Periodise training schedules to include adequate recovery time.
Avoid excessive workloads that might lead to overtraining.
Regular Monitoring
Track indicators such as menstrual health, bone density, and performance metrics.
Monitor athletes’ psychological wellbeing, as mood changes can be an early sign of RED-S.
Team Culture
Promote a supportive team environment that values health and wellbeing over appearance.
Discourage harmful comparisons and weight-focused comments.
Treating RED-S
The good news is that most health consequences of RED-S are reversible with early intervention. Treatment should be individualised based on the athlete’s specific symptoms, sport, and goals.
Key Treatment Strategies
Addressing Energy Imbalance
Increase energy intake to match or exceed energy expenditure.
Focus on nutrient-rich foods, including adequate calcium and vitamin D for bone health.
Optimising Recovery
Incorporate rest days and reduce training loads temporarily to allow the body to repair.
Address injuries promptly to prevent them from becoming chronic.
Psychological Support
Work with a sport psychologist to address underlying behaviours or attitudes contributing to RED-S, such as perfectionism, overtraining, or disordered eating patterns.
Multidisciplinary Care
Involve dietitians, medical professionals, and coaches to create a comprehensive recovery plan.
RED-S is a significant yet preventable condition that affects athletes across all ages and sports. It highlights the delicate balance required to maintain optimal performance, mental health, and physical health in sport.
As a sport psychologist, I advocate for a proactive approach to energy management, including education, regular monitoring, and fostering a positive team culture. Recognising the signs of RED-S and intervening early can protect an athlete’s immediate performance and their long-term health.
If you suspect RED-S in yourself or your athletes, seek support from qualified professionals to develop an effective treatment and recovery plan. Remember, a healthy athlete is a successful athlete.
Leilanie Pakoa
Sport & Exercise Psychologist
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