Relative energy deficiency in sports (RED-S)

What is RED-S?

Relative energy deficiency in sports (RED-S) is a syndrome caused by consistently not getting enough fuel through food to support the demands of daily physical activity and training. You may be unaware of just how few calories your child is taking in, or your child may be limiting their food intake due to disordered eating or influence/pressure by a parent, caregiver or coach. Over time, if your child does not get enough fuel through food to support the energy demands of their daily training, RED-S can lead to poor health and declining athletic performance.

How is RED-S different from an eating disorder?

RED-S is a group of symptoms that happen at the same time that occurs from not getting enough fuel through food to support the demands of daily physical activity and training. It may overlap with disordered eating, be the result of disordered eating or be a risk factor for developing an eating disorder.

What are the signs and symptoms of RED-S?

Physical

• Feeling tired and/or weak
• Quick and/or significant weight loss
• Dehydration
• Irregular/missed periods (amenorrhea) for people who menstruate
• Frequent/increased injury (e.g., stress fractures, pulled muscles)
• Slow injury healing
• Heart problems (e.g., sudden drops in heart rate and/or blood pressure)
• Delayed puberty
• Frequent illness (e.g., colds, flu)
• Trouble staying warm
  
• Hair loss
• Digestion problems
• Dental and gum problems

Psychological

• Trouble focusing/concentrating
• Irritability
• Anxiety and depression
• Disordered eating
• Impaired judgment

Who is at risk for RED-S?

RED-S can affect athletes of any gender and ability level. However, your child may be at higher risk of developing RED-S if their sport or activity traditionally favours a thin or lean body type (such as ballet, figure skating, swimming, gymnastics, long distance running, cycling) or requires frequent weigh-ins (such as boxing, wrestling and rowing). A sports team's culture can also contribute to RED-S. For example, insulting an athlete's body weight, shape or size may push an athlete to over-exercise or not take in enough energy. If your child is a competitive athlete, they may also be at a higher risk compared to casual athletes.

How is RED-S diagnosed?

The diagnosis of RED-S starts with a good medical, sports, nutrition and training history. Your health-care provider will also ask about your child's eating attitudes and behaviours towards food. Further, your health-care provider should ask about symptoms such as weakness, fatigue, injuries, bone fractures or interrupted menstrual cycle.

After a complete medical history, your health-care provider will perform a full physical exam, which will include measuring your child's weight, height, blood pressure and heart rate.

Based on your child's medical history and physical examination, the health-care provider will determine whether your child has RED-S, and if so, what treatment options are available.

How can RED-S be treated?

Treating a child with RED-S often involves a multidisciplinary team, including a health-care provider, a registered dietitian, a mental health counsellor and coaches. RED-S can be treated gradually by increasing your child's food intake and/or decreasing the duration, intensity or frequency of training.

It is possible that your child will need to be admitted to the hospital if they experience medical or psychological complications of RED-S, with or without an eating disorder, as a result of not getting enough fuel through food to support the demands of their daily physical activity and training.

Depending on your child's signs and symptoms and level of risk, their health-care provider may recommend that they stop training. Practising self-care and getting enough sleep will also help in their recovery.

How to prevent RED-S

• Ensure that your child is getting enough nutrition to establish healthy eating habits. Help them choose foods that are part of a healthy diet in quantities that are appropriate for their level of exercise, age, height, sex and body type. It can help to speak to a registered dietitian who is familiar with RED-S for personalized recommendations.
• Help your child choose activities that complement their natural body strengths and personal goals.
• Help your child to understand that their health is more important than competitive success and will have a greater impact on their life as they get older.
• Remind your child that the thinnest/leanest/lightest athletes are not always the best in their sport.
• Remind your child not to compare themself to others. Their optimal weight, food intake and training routines will be unique to them.
• Teach them to be cautious of people who put their competitive success before their well-being.
• Be a role model for your child and encourage your child to be a role model for others as well. This means practising positive eating habits, supporting others based on their talents and achievements and shutting down negative weight and body talk.

How does RED-S affect health and athletic performance?

Poor athletic performance

Many of the symptoms of RED-S can not only impact your child's overall health but directly impact their performance as an athlete. This often happens in a 'chain reaction', with one symptom triggering the next. Athletes may believe that they will increase their performance if they reduce their food intake and increase their training schedule. However, sport performance is compromised when there is not enough food intake. It is vital for children and adolescents to meet their energy needs, especially when training and in order to meet normal growth and development. Feeling tired and having weak muscles can slow them down. It can also put more strain on their heart and lungs, which are working harder to keep up their body's pace. A lack of proper fuel through food can make your child feel irritable and unable to focus, which can lead to poor performance, increased injury and slow healing.

Irregular/missed periods

For people who menstruate, exercising intensely and not eating enough calories can lead to a decrease in estrogen, the hormone that helps to regulate the menstrual cycle. As a result, your child's periods may become irregular or stop completely. Low estrogen levels can delay puberty and lead to bone loss.

Brittle bones/low bone density

One of the more permanent effects of RED-S can be low bone density (brittle bones). When the body does not get enough fuel in the form of food, it can cause bones to become weak and brittle. This is a risk to anyone, but especially to those who menstruate, and can lead to a permanent change to bone health as your child transitions into adulthood. Weak bones increase the risk of stress fractures, which can impact your child's ability to train and compete. These injuries will also be slower to heal and more likely to happen again over time.

How to help your child with RED-S

• Ensure that your child is involved in sports where the coaches and sports officials prioritize the athletes' health and well-being.
• Ensure that your child is involved in sports where the coaches, sports officials and team doctors are aware of the risks of RED-S and the negative impact of low energy availability.
• Ensure that your child is involved in sports where there is a safe training environment and athletes are not shamed for their body weight or shape or size.