Written by Abi Woodliffe-Thomas
Treatment for Relative energy deficiency in sport (RED-S) can be complex, especially if you are an athlete and need to take a break from your sport or challenge having a "fit" identity. When looking at the different avenues of treatment options for RED-S, one key point to recognise is that everyone is individual, and therefore treatment will look different for everyone. (If you missed it, we have a blog on What is RED-S? too)
Through understanding potential triggers, physiological, psychological and behavioural signs and symptoms, as well as environmental changes you can adapt, treatment for RED-S is 100% possible.
Physical and psychological side effects of RED-S
There are many side effects which result from inadequate energy intake and excessive energy expenditure (over-exercise), which are outlined below in Table 1. It is important to note that the majority of these are reversible with adequate nutrition, returning to a healthy level of physical activity and a healthy weight for you. Reproductive and bone health however, are two side effects to spotlight.
People assume it is normal not to have a period, especially for athlete’s, it seems almost ‘fashionable’ or accepted in the sporting world. However, not having a regular cycle is never a good sign for anyone, and can have significant long-term consequences. In the UK, six consecutive months without menstruation is a warning sign for RED-. S. Alongside amenorrhea (loss of menstrual cycle), the other two symptoms completing the formally recognised ‘female athlete triad’ consist of low energy availability and bone health (3). Low energy availability refers to being in a consistent energy deficit which results in your body reduction in the energy available for most body systems leading to a decline in physiological functions, such as menstruation and digestion. It is important to note that not all individuals with RED-S will lose their period and also that you can be in a clinically defined "healthy" or "overweight" category and experience reproductive health changes, it isn't just if you are underweight.
"It is not normal to not have a period, even as an athlete"
It is slightly harder to diagnose reproductive issues in males, however, <5 morning erections per week, along with a reduction in libido as a result of the low levels of testosterone are the primary physiological predictors. Like oestrogen, testosterone is essential for performance and muscular and physiological adaptations.
Bone health is impacted in RED-S. Low energy availability means vital nutrients such as calcium and vitamin D aren’t consumed in large enough quantities and if oestrogen levels are low, bone production reduces. Having a regular menstrual cycle and/or reproductive system is protective of bone health. Bone density can be reduced in RED-S and lead to osteopenia and osteoporosis, which can be irreversible if not corrected early.
Treating RED-S is an incredibly individualised approach, and we recommend to consult a medical professional for advice suitable for you and your lifestyle. There are three main areas in which individuals must consider during recovery:
RED-S develops due to an energy deficiency and commonly inadequate carbohydrates and fats Carbohydrates are the bodies preferred energy source, providing the same amount of energy as protein (4Kcal/g) and are essential for health. There are some considerations when recovering from RED-S:
Meals and snacks should be regular, with no more than 4 hours between meals
Fasted training is not advised as this can lead to further reductions in overall energy intake and can increase cortisol levels (as a stress response) which can impact recovery
Adequate nutrition pre and post physical activity with good sources of carbohydrates, fats and protein. Examples can be a hot cross bun with peanut butter before training and then beans on toast with cheese post training. Both providing you with adequate sources of the three macronutrients, fueling you for performance.
The frequency, duration and intensity of physical activity will need to be adjusted for recovery. For some, this will mean avoiding high level of physical activity (or all forms) for some time to allow the body to rest. It is important to consult health professionals with expertise in RED-S to guide return to safe exercise.
It is important in life to have fun, let your hair down and laugh, and this can be a great treatment option for those willing to challenge themselves and push for recovery. However, it is also important to consider the energy you expend on a daily basis, known as NEAT (non-exercise activity thermogenesis). Activities such as walking the dog, cleaning your room or even walking to school all require energy to move, just like a car requires fuel to drive. So, remaining consist with snacks and meal timings, as well as reducing daily step count will help you on the road to recovery.
Other lifestyle factors such as sleep and stress need to be addressed as part of recovery. Inadequate sleep or other stressors such as demanding work, travel or a busy social life can delay recovery from RED-S as these stressors keep the body in "flight or fight" mode and increase energy requirements that can be hard to meet without adequate rest and stress reduction.
Treatment will be individual for everyone and recovery is 100% possible. Abi Woodliffe-Thomas
Abi is a personal trainer and is working towards becoming an exercise nutritionist. Follow Abi on Instagram at @Happeitite_for recipe inspiration and nutrition tips!
 Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., Meyer, N., Sherman, R., Steffen, K., Budgett, R. and Ljungqvist, A., 2014. The IOC consensus statement: beyond the female athlete triad—relative energy deficiency in sport (RED-S). British journal of sports medicine, 48(7), pp.491-497
Talia Cecchele Nutrition is a team of registered dietitians specialising in eating disorders and disordered eating. We aim to bring balance back to nutrition, help you to break free from food rules and find food freedom. To enquire about private consultation please fill out a contact form.