RED-S and Eating Disorders: Is There A Link?

Written By: Dominic Lopez, Dietetic Intern

Athletic and physical performance hinges on a delicate balance between training intensity, frequency, and nutritional intake. When this balance tips unfavorably, athletes may encounter a condition known as Relative Energy Deficiency in Sport, or more commonly known as RED-S. This syndrome, which impacts athletes across all genders and levels of ability can also affect people who don’t play any sports at all but rather, exercise consistently and intensely. RED-S arises when the energy intake from food is insufficient to support the demands of training and daily life. The consequences can be severe, affecting both short- and long-term health and performance. Let’s take a closer look into what exactly this syndrome is, who’s at risk, its connection with eating disorders, and more.

What is RED-S?

RED-S is a complex and multifaceted syndrome that goes beyond the widely known Female Athlete Triad, which focuses primarily on menstrual dysfunction, low energy availability, and decreased bone density. RED-S broadens the scope to include athletes of all genders and considers a wider array of physiological and psychological consequences. It highlights the critical importance of adequate nutrition in sustaining peak athletic performance and overall well-being. RED-S is characterized by low energy availability (LEA), which is a mismatch between an athlete’s energy intake and energy expenditure. LEA indicates that the body is not receiving enough energy to fuel and recover from high-quality athletic performance nor is it receiving enough nutrients to support normal bodily functions.

The information below details how RED-S negatively impacts several body systems.

• Decreased athletic performance: A noticeable decline in endurance, strength, and overall athletic ability
• Reproductive/sexual health: Irregular or absent menstrual cycles in female athletes, low libido (in males)
• Bone health: Increased risk of fractures and osteoporosis due to decreased bone density
• Metabolic problems: Reduced metabolic rate, leading to decreased energy levels and weight gain despite high levels of activity
• Delayed growth/development: Decreased growth curve, failing to gain expected weight and/or height
• Cardiovascular health: Low heart rate, which can result in dizziness and the potential for long-term heart damage
• Psychological health: Impaired concentration and focus, increased stress, irritability, anxiety, and depression
• Impaired immune function: Higher susceptibility to infections and illnesses
• Gastrointestinal complaints: Digestive problems such as bloating, constipation, or diarrhea
• Hormonal issues: Imbalance levels of essential hormones (testosterone and estrogen)

Who’s at Risk?

As mentioned earlier RED-S can occur in any athlete from any sport. It’s been discovered that RED-S is commonly seen in certain sports such as:

• Endurance sports (cross-country, cycling, running)
• Weight-class sports (wrestling, rowing, weight lifting, combat sports)
• Appearance-based sports (figure skating, gymnastics, ballet, swimming/diving)

Likewise, any person who engages in regular physical activity, such as a recreational athlete or someone who exercises very frequently, and is not meeting their daily energy requirements can be susceptible to developing this syndrome. Simply put, RED-S can emerge in anyone who is expending a lot of energy consistently but is not refueling in the amount that their body needs.

RED-S and Eating Disorders

The research on the relationship between RED-S and eating disorders is still in its infancy as RED-S is a relatively new framework, however, there are undeniable similarities among both conditions. First, both involve inadequate energy intake. This can be the result of unintentional under-eating, increased training loads without properly adjusting dietary needs, or conscious dietary restrictions aimed at improving performance or altering body composition. Another similarity is the health consequences of both conditions such as menstrual dysfunction, decreased bone density, impaired immune function, and metabolic issues. The physical manifestations of RED-S have been found to be similar in those with eating disorders as well. Lastly, many people with eating disorders engage in compulsive exercise, making them more vulnerable to the negative health- and performance-related symptoms of RED-S.

Though RED-S and eating disorders are intrinsically linked, it does not mean that everyone with RED-S has an eating disorder and vice versa. The relationship between each is intricate and intertwined, with both requiring an individualized, multi-disciplinary approach to provide sound comprehensive care and support.

How can RED-S be Prevented?

RED-S is a significant concern in the athletic community, but with proper education, nutritional support, and monitoring, it is possible to prevent and manage this syndrome. For any individual who exercises vigorously and consistently, increasing one’s awareness of LEA and its harmful impact on health and performance can be an effective method in preventing RED-S. Talking with your Karuna dietitian about your training and dietary habits as well as personalized fueling strategies specific to your energy needs can be helpful in RED-S prevention as well. Lastly, steer clear of toxic training environments where body shaming occurs, and instead, surround yourself in a positive, non-judgmental atmosphere that celebrates all body types. By fostering a supportive environment that prioritizes both physical and mental well-being, we can help those thrive and succeed in their athletic endeavors.

References:

• Hellner, M. RED-S syndrome: Relative energy deficiency in sport. Equip. https://equip.health/articles/food-and-fitness/red-s-syndrome-relative-energy-deficiency-in-sport
• RED-S (relative energy deficiency in sport). Boston Children’s Hospital. https://www.childrenshospital.org/conditions/reds
• Relative energy deficiency in sport (RED-S). Brown University Health Services. https://www.brown.edu/campus-life/health/services/promotion/nutrition-eating-concerns-sports-nutrition/relative-energy-deficiency-sport-red-s