Relative Energy Deficiency Disorder in Sport –Nutrition

Renee McGregor BSc (hons) PGDIP (DIET) PGCERT(sportsnutr) RD SENr

Performance and Clinical Dietitian

Author of  “Orthorexia” “Training Food” and “Fast Fuel” books

Science and in particular nutritional science is fast advancing and evolving. What we know is that nutrition plays a huge part in sports/dance performance at all levels from recreational, pathway to elite level. It has an integral role in regulating immune, bone, hormonal and physical health. In high pressure environments, chronic stress and competition can have a negative impact on mental and physical health, resulting in poor performance and outcome. This may manifest in different forms from dysfunctional relationships with food; compulsive obsessive traits; poor sleep or a depressed immune system, increasing prevalence of infections and illness.

RED-S is a phenomenon we are seeing more commonly in sport/dance, in both male and female athletes; it is important to highlight that it is not always intentional.

In some cases, it simply comes down to the athlete not being aware of their nutritional needs and significantly underestimating both overall energy intake or carbohydrate, specifically. This has been observed regularly in triathletes who are nutritionally challenged due to training over 3 disciplines but also who do not consider their nutritional requirements beyond this training; for example, they will not consider the additional demand on their bodies if they are cycling to their swim session. While the swim session will count as training, the cycling is just the means of transport to get there. Over time this lack of attention to detail, will lead to an athlete becoming chronically energy deficient; whether intentionally or non-intentionally. Regardless the impact on the body, will be the same.

Intentional RED-S is more complex. Athletes/dancers personality traits –ambitious, perfectionists, highly self critical, obsessive and sensitive, do put them at a higher risk of developing anxiety related issues. The desire to be the best is obviously something that anyone who wants to perform will possess and in many cases, results in exceptional outcomes. The difficulty comes when this desire is not managed; no matter how hard an athlete pushes, or what extent they go to through training or manipulating their diet, nothing is ever enough. They are never light enough; or training hard enough. They constantly compare themselves to others –the difficulty being that when they view themselves negatively from within, whoever they compare themselves to, they will never perceive themselves as good enough.

Many athletes/dancers with intentional RED-S start with the desire to change body composition, in most cases, lose weight. Most common methods include increasing training load or intensity and reducing nutritional intake. This may follow new nutritional fads such as low carbohydrate, high fat, “eating clean” or becoming predominantly plant based, gluten and sugar free. The bottom line is the nutritional intake becomes compromised and insufficient to meet the demands of training, resulting in severe consequences as the figure from the IOC consensus statement demonstrates. One hurdle is that initially when an athlete/dancer makes such changes to their lifestyle, performance outcome can actually improve. They see this as success and thus continue to believe in these methods, pushing a little harder still. They may thus go unnoticed as having real issues until it becomes visibly noticeable, they become injured or their performance starts to decline.

The difficulty in these cases is that they have an added psychological element to their RED-S –they become irrational; food and weight restoration becomes a threat and causes huge amounts of anxiety, which they want to control –nobody likes to feel anxious. Restricting food intake can temporarily numb the physical feelings of anxiety and this is why this method is employed – in this case not intentionally but subconsciously.

In both intentional and unintentional cases of RED-S, energy balance needs to be restored. Monitoring of nutritional biomarkers such as TSH, T3, LH, FSH, Testosterone/oestrogen, ALT can provide a good picture of present nutritional status and also progress.

Weight loss may be a feature or it may not, particularly in unintentional cases but either way advice regarding appropriate intakes of complex carbohydrates around training sessions; sufficient recovery options, dairy to optimise bone health, essential fats to encourage hormonal recovery and micro-nutrients to regulate metabolism are all critical. In those athletes where RED-S has been unintentional, this should be a fairly easy process – an assessment with a sports dietician/nutritionist and a nutritional plan tailored to requirements will help the athlete to get back on track. Regular contact and monitoring is recommended to ensure that intakes are being tracked as training load changes. Regular monitoring of training load and nutritional biomarkers are also recommended.

For those cases where RED-S is intentional, training will need to be curtailed and even stopped in some cases (red category of RED-S) this may have already happened as the athlete presented with an injury or over training symptoms as a consequence of intentional low energy availability. Weight restoration is usual critical in these athletes, male and female, in order to restore biological processes within the body and start to reverse the negative impact. These intentional RED-S cases need to be managed by a multi-disciplinary team of, the coach, sports/dance medics and sports dieticians (who have both clinical and sports qualification –sports nutritionists rarely have clinical knowledge of disordered eating). These athletes may require weekly contact with a clinical psychologist and a sports dietician in order to effect change in their beliefs around food, body composition and performance.


Potential adverse consequences of RED-S on multiple body systems (IOC consensus statement on RED-S first published in BJSM 2014)

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