Under-fueling or RED-S (Relative Energy Deficient in Sport)
Relative Energy Deficiency in Sport, otherwise known as RED-S, occurs when an individual's overall energy intake is less than the total needed to support daily activity needs and exercise expenditure demands.
The treatment and recovery plan for an athlete with RED-S will depend on the nature of the path that led them there in the first place. In all situations, RED-S results from a mismatch in energy intake vs that which is required for an athlete’s activity level. Sometimes an athlete increases their training without adequately increasing their nutritional intake along with it and does not recognize that this is occurring. When this occurs, the athlete may begin to feel resulting symptoms including everything from fatigue, poor recovery, amenorrhea, sleep disturbance, decreased performance, mood changes, diminished bone mineral density, as evidenced by increased occurrence of stress reaction/stress fractures, and more.
Once a state of low energy availability is recognized, an athlete should work with an MD and Board Certified Sports Dietitian (RDN, CSSD). The MD will conduct a physical exam, medical work up and laboratory results. The Registered Dietitian will help them better define and understand their nutritional needs and take steps to increase their caloric intake in order to reverse the problems they are experiencing. As part of this process, the Registered Dietitian may conduct Resting Metabolic Rate (RMR) testing to accurately and easily assess the daily needs of each athlete. In general, we often expect athletes' RMR to be higher than average due to training load and resulting muscle mass, however after a prolonged state of RED-S we may see a lower than expected RMR result, which can often be corrected by improving the athletes' intake to meet their needs. Thereafter, we will help the athlete identify specific areas where they can focus, and will work together to add necessary foods and beverages, pre, during, and/or post-training, and throughout their day, to ensure the athlete adequately fuels their body and is meeting their nutritional needs for life and sport.
Once given the proper education and follow-up, these athletes will typically respond by making the changes necessary that resolve their symptoms and allow them to fully return to feeling and performing at their best.
However it is not always this straightforward to correct RED-S in athletes. As we attempt to help an athlete increase their intake to meet their needs, fear, anxiety, negative thoughts and/or guilt around eating are all too often uncovered. Once this inability to increase intake is discovered, an eating disorder (ED) or disordered eating patterns is likely at the root cause.
Once the MD and Registered Dietitian have uncovered an ED or disordered eating pattern, they can guide the individual to add a psychologist/psychotherapist that specializes in athletes with disordered eating patterns to the treatment team. This professional can then provide the athlete with support and encouragement while helping them challenge eating-disordered thoughts and behaviors and also supply them with tools and coping mechanisms to help them break disordered eating patterns. Psychology professionals can also help athletes challenge unhealthy thoughts about food and exercise and encourage a balanced approach to training, fueling, rest, recovery and competition. This process requires a team effort, and work on relationships with food, body and exercise, but can most certainly be accomplished.
There is no one “cookie-cutter” method that works for all athletes when undergoing treatment for disordered eating. Each team of professionals helps each athlete re-learn to honor and nourish their body adequately, ensure they are meeting their body's caloric needs and develop a more healthy relationship with food and exercise. The team will guide the athlete in eating and drinking the right amount to sustain their daily activity and the level of training their sport requires.
In traditional eating disorder treatment, it has been generally recommended that all individuals drastically reduce or completely cut out exercise during treatment. While this is still indicated in situations following prolonged malnutrition, more recent studies show that some athletes undergoing eating disorder treatment can continue to engage in their sport with agreement from and support of their treatment team, albeit generally with a reduction in total training volume and intensity until nutrition intake and state of health are stabilized.
The goal is to combine motivation to return to sport to help an athlete better fuel their body and gradually return them to full participation in sport as medically appropriate.
Meal Plans
When working with an athlete with disordered eating, a Sports Dietitian will generally develop an individualized meal plan to help each athlete understand the differences between what they have been eating vs what they actually need, and then help them reach those intake goals step by step. The meal plan provides structure and support, showing each athlete the total amount of each macronutrient (carbohydrate, protein and fat) that their body requires, and helping them re-learn how to fuel consistently throughout the day. As their nutritional needs are being met, the athletes' dietitian and treatment team will work to increase their variety of foods eaten as well as work towards greater freedom and a healthier relationship with food and their body.
Recovery
Another ultimate goal is to help each athlete regain their ability to identify physical and emotional cues from their bodies and to re-learn what appropriate training and recovery look like for overall health and longevity in their sport. Overall, the mission is to equip athletes with the mental and nutritional skills to achieve their full athletic potential and overall best life while sustaining a positive and healthy mindset.
Ideally the athlete’s coach (as applicable) should have contact with the treatment team and be aware of the parameters to follow in terms of the athlete’s participation in sport. They can also provide the treatment team with information regarding the athlete’s training performance and recovery from their perspective as coach.
Next Steps/Resources:
If this article has you questioning your relationship to food or whether you or someone you know may be experiencing RED-S, we encourage you to use the National Eating Disorder Association (NEDA) Eating Disorders Screening Tool linked below. Additionally, the NEDA helpline is given below, to be used for support, resources, and treatment options. If interested, there is also an Exercise Dependence Scale linked below.
These resources can be the first step toward recognizing and getting the help necessary to live a more fulfilling life complete with food freedom and a healthy relationship with your body and sport.
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https://www.nationaleatingdisorders.org/screening-tool
- The National Eating Disorders (NEDA) provides a helpline for support, resources, and treatment options. Call or Text (800)-931-2237 and for crisis situations, text “NEDA” to 741741 to be connected with a trained volunteer at Crisis Text Line.
