Understanding Relative Energy Deficiency in Sport (RED-S): Definition and Causes
UT Health Austin clinicians discuss the importance of adequate caloric intake for young athletes
Reviewed by: J. Mica Guzman, Jr., MD, MBA, DABFM, CAQSM; Mia Roldan, LCSW, LCDC; Akua Afriyie-Gray, MD, FACOG; Lizette Taboada, RD, LD
Written by: Lauren Schneider
In recent years, high-profile athletes have opened up about their experiences with Relative Energy Deficiency in Sport (RED-S), a health condition that arises when a person’s caloric energy intake is insufficient for their level of physical activity. While much of this coverage centers on elite female athletes, RED-S impacts athletes at all sporting levels, regardless of sex.
Defining RED-S and the Triads
The term “female athlete triad,” first used in 1992, originally referred strictly to female patients presenting with an eating disorder, amenorrhea (absence of menstruation), and osteoporosis (weakening of bones). In 2007, this definition was recognized to involve any large deficit in caloric intake relative to output, regardless of whether the patient displays disordered eating patterns.
This focus on available caloric energy rather than disordered eating behaviors has marked subsequent attempts to define the condition. The International Olympic Committee coined the term “relative energy deficiency in sport (RED-S)” in 2014 to encompass health problems resulting from caloric deficit in athletes regardless of sex. In 2017, the male athlete triad was characterized by the Female and Male Athlete Triad Coalition as the unique clinical profile associated with RED-S in young men. Along with an energy deficiency and low bone mineral density, their definition included the decreased production of sex hormones.
“Patients do not have to present every symptom of the male or female athlete triad to be treated for RED-S,” says J. Mica Guzman, MD, a board-certified family medicine specialist who serves as the Primary Care Clinical Director of the Sports and Injury Clinic within the Musculoskeletal Institute. “RED-S is an umbrella that is thought to have at its core the low energy Intake or excessive energy expenditure, which then leads into a myriad of problems with effective metabolism, menstrual function, bone health immunity, protein synthesis, and mental health.”
High Energy Demands of Intensive Sports
According to Mia Roldan, LCSW, a licensed clinical social worker UT Health Austin’s Pediatric Psychiatry at Dell Children’s, a clinical partnership between Dell Children’s Medical Center and UT Health Austin, “Even when young athletes do not have an eating disorder, they may not recognize that it is normal to supplement intensive exercise with a higher caloric intake.” “Some of this caloric deficit can be attributed to the demanding schedules of young athletes, such as long practices on top of a full school day leaving little time for proper nutrition.”
Additional Risk of Eating Disorders Among Athletes
“In addition to athletes not eating enough to compensate for energy expended during exercise, many athletes do develop disordered eating patterns, which often result from the hyper-focus on one’s body inherent to any sport,” continues Roldan. “This focus can trigger disordered eating thoughts and behaviors in adolescents already struggling with body image concerns.”
“In other cases, these patterns start as a desire to eat healthy to improve athletic performance,” shares Lizette Taboada, RD, a registered dietitian in UT Health Austin’s Musculoskeletal Institute and Women’s Health, a clinical partnership between Ascension Seton and UT Health Austin. “If an athlete begins to feel pressure, they can start to restrict their diet by eliminating food groups and/or lowering their calorie intake, which can lead to an eating disorder.” Taboada also serves as the Nutrition and Behavior Change Lead for UT Health Austin’s Integrated Behavioral Health care team.
A University of Wisconsin survey of over 300 girls involved in high school sports during the 2006-2007 season found that more than a third of participants reported disordered eating behaviors like skipping meals, purging, or abusing diet pills. These behaviors were reported by over 40% of respondents in sports with an aesthetic focus, such as gymnastics.
While eating disorders are traditionally associated with young women, any athlete can develop disordered eating patterns. According to the National Eating Disorders Association, this is especially true in sports like wrestling where athletes are sorted into weight classes.
What to Know
Sports and exercise have important physical, social, and emotional benefits for children and teenagers, but sustainability is key. Growing athletes need adequate fuel to power both their development and their performance on the field.
Many young athletes do not consume enough calories to match their high energy exertion. This challenge is often compounded by the body image issues that many adolescents experience, and this form of improper nutrition can result in long-term health problems.
Learn more about health complications associated with RED-S and the approach UT Health Austin clinicians take in treating the condition.
<br>For more information about the Integrated Behavioral Health care team at UT Health Austin, visit here.
For more information about UT Health Austin’s Pediatric Psychiatry at Dell Children’s or to make an appointment, visit here.
To learn more about the Sports and Injury Clinic within UT Health Austin’s Musculoskeletal Institute or to schedule an appointment, call 1-833-UT-CARES (1-833-882-2737) or visit here.