Relative Energy Deficiency in Sport (RED-S) is a comprehensive medical condition that results from low energy availability (LEA), an imbalance where energy consumed from food is insufficient to meet the body's energy demands for exercise and essential physiological functions. While initially recognized as the Female Athlete Triad, it is now understood to affect athletes of all genders and can impair nearly every system in the body, including metabolic rate, bone health, reproductive function, immunity, and psychological well-being. Treating RED-S effectively requires addressing the underlying energy deficit, and its success hinges on a collaborative, multidisciplinary approach.
The Crucial Multidisciplinary Treatment Team
Effective recovery from RED-S is not a one-person job. It requires a team of specialized healthcare professionals working together to address the condition's multifaceted nature. A comprehensive treatment plan typically involves:
- A Physician or Sports Medicine Doctor: To diagnose RED-S, perform necessary tests (e.g., blood work, bone density scans), monitor physical health, and clear the athlete for a safe return to play.
- A Registered Dietitian (RD): To provide individualized nutrition counseling, create meal plans to restore energy balance, and educate the athlete on proper fueling strategies.
- A Mental Health Professional (Psychologist/Counselor): To address underlying issues like disordered eating, body image concerns, anxiety, depression, and stress management, which are often linked to or exacerbated by RED-S.
- A Coach: To work with the treatment team to adjust training loads and help foster a healthy, supportive environment for the athlete.
Nutritional Restoration for Energy Balance
The cornerstone of treating RED-S is restoring energy balance by increasing energy intake and/or decreasing energy expenditure. The goal is to provide enough fuel for both daily bodily functions and athletic training.
Key nutritional strategies include:
- Gradual Increase in Calories: Initially, increasing caloric intake by 300-600 kcal/day is often recommended, but this should be personalized based on the athlete's needs.
- Prioritizing Consistent Fueling: Eating regular, consistent meals and snacks throughout the day, including before, during, and after training, is vital.
- Nutrient-Dense Foods: Consuming a variety of energy-dense foods helps increase calorie intake without excessive volume.
- Focusing on All Macronutrients: Ensuring adequate intake of carbohydrates for energy, protein for muscle repair, and fats for hormonal health is essential. Athletes should not restrict any macronutrient group.
- Addressing Micronutrient Deficiencies: Deficiencies in bone-building nutrients like calcium, vitamin D, and iron are common and must be corrected through diet and, if necessary, supplementation.
Modifying Training and Prioritizing Rest
While increasing nutrition is critical, modifying exercise is often a necessary component of recovery, especially for athletes who have been in a long-term energy deficit.
Adjustments to training may include:
- Reducing Overall Load: Decreasing the volume, intensity, or frequency of training can help decrease energy expenditure, allowing the body to recover.
- Incorporating Rest Days: Mandating rest days is crucial, as sleep is one of the body's most powerful recovery mechanisms.
- Phased Return to Sport: A gradual, medically supervised return to training is essential to prevent relapse and ensure the athlete is fully recovered. Decisions can be guided by assessment tools like the IOC's RED-S Clinical Assessment Tool.
Addressing Psychological Factors
RED-S can stem from or lead to significant psychological distress, including anxiety, depression, and disordered eating. Therefore, mental health support is a non-negotiable part of the recovery process. A psychologist can help athletes:
- Navigate Conflicting Feelings: Athletes often feel caught between the desire to perform and the knowledge that they need to change their habits, a mental conflict that therapy can help resolve.
- Improve Body Image: Address negative thoughts and body image issues that may have contributed to restrictive behaviors.
- Develop Coping Strategies: Learn healthier ways to cope with stress, pressure, and anxiety that don't involve disordered eating or excessive exercise.
The Recovery Timeline and What to Expect
Recovering from RED-S is a highly individual and gradual process, not an overnight fix. The duration of treatment varies based on the severity and duration of the energy deficit.
RED-S vs. Optimal Athlete Health
| Aspect | RED-S State | Optimal State |
|---|---|---|
| Energy Availability | Low (Energy Intake < Energy Expenditure) | Optimal (Energy Intake = Energy Expenditure + Health Needs) |
| Reproductive Function | Impaired (e.g., amenorrhea, low testosterone) | Normal menstrual cycles / reproductive function |
| Bone Health | Decreased mineral density, increased stress fractures | Strong bone density, reduced fracture risk |
| Hormonal Profile | Disrupted (e.g., low leptin, high cortisol) | Balanced endocrine system |
| Performance | Impaired endurance, strength, coordination | Improved performance, training response, recovery |
| Psychological State | Irritability, anxiety, depression | Stable mood, enhanced concentration |
Conclusion
Resolving Relative Energy Deficiency in Sport is a process that prioritizes the athlete's long-term health and well-being above short-term performance gains. By committing to a personalized treatment plan developed by a multidisciplinary team, athletes can successfully restore their energy balance through nutritional and training modifications. Addressing the psychological factors that often accompany RED-S is also vital for a full recovery. With patience and consistent effort, athletes can overcome this condition, reclaim their health, and build a more sustainable and successful athletic career. For more detailed information, athletes and coaches can visit the National Eating Disorders Association's page on RED-S.
Prevention Strategies for Avoiding Relapse
After recovery, implementing long-term prevention strategies is key to avoiding relapse. This involves ongoing education and a continued focus on health over potentially dangerous, short-term performance gains.
- Focus on Health as Performance: Shift the mindset from achieving a certain body weight or aesthetic to prioritizing health as the foundation for sustainable high performance.
- Monitor Energy Intake Consistently: Athletes, coaches, and RDs should continue to monitor energy intake and expenditure, adjusting fueling strategies during periods of high training load or competition.
- Prioritize Sleep and Rest: Continue to emphasize the importance of sleep hygiene and scheduled rest days in the training plan.
- Create a Supportive Culture: Coaches and trainers should promote body positivity and focus on talent and achievement, rather than body size, to prevent toxic environments.
- Regular Screening: Routine health screenings can help detect early warning signs of LEA or RED-S, allowing for prompt intervention.
