REDs and low energy availability

Renee McGregor is a leading sports and eating disorder specialist dietician with twenty years' experience working in clinical and performance nutrition. She has worked with athletes across the globe, including supporting Olympic (London 2012), Paralympic (Rio 2016) and Commonwealth (Queensland 2018) teams, and is regularly asked to work directly with high-performing and professional athletes who have developed a dysfunctional relationship with food. Renee’s specialist area of expertise, REDs (Relative Energy Deficiency in Sport), though often associated with elite athletes, can affect anyone who regularly undertakes physical activity. In this extract from her new book, Fuel for Thought, she explains what causes REDs, what to do if certain symptoms present themselves and the pathway to recovery.

REDs, or Relative Energy Deficiency in Sport, is underpinned by low energy availability (LEA). That is, it occurs when there is not sufficient energy in the body to allow for the work that the individual wants to do. Work is defined as training but also includes daily movement and the energy cost of biological processes within the body, such as the brain, heart, lungs, hormonal and digestive systems. However, while LEA underpins REDs, it is not the only factor – under-recovery, training stress and general life stress all contribute to this.

The human body has evolved to prioritise movement. This means that all energy consumed will first be used for physical activity. Energy availability is the amount of energy left over once energy for movement has been removed. REDs is often associated with professional or elite-level athletes due to their high training loads, competitive environments and aspects of athlete mentality, which may lead to dysfunctional relationships with food and training. However, a recent study concluded that the incidence of low energy availability was around 19% in recreational female runners, so we can see that REDs and LEA are not restricted to the elite. They can and do affect anyone who is physically active.

REDs is a condition that is multi-faceted. While low energy availability, possibly due to dysfunctional relationships with food, is one potential spoke, other key contributors include under-recovery both in day-to-day training and between races, and general stress on the nervous system.

Additionally, while LEA is problematic in both males and females, the female body is much more sensitive, so signs and symptoms tend to show up a lot quicker than in males. However, this is not to say that damage is not occurring when a male is in LEA; it just appears later. We know that studies are predominantly carried out on white males, which means that studies relating to ketogenic (low-carbohydrate) diets, fasting such as intermittent fasting or restrictive approaches don’t show all of the potential negative consequences, especially when the study is over a short duration. If the same study was to be conducted over a longer period over two years, the likelihood is that the negative consequences associated with LEA would start to be demonstrated.

Types of REDs There are two types of REDs – unintentional and intentional:

•Unintentional or accidental REDs is when the individual doesn’t appreciate just how much energy is required to maintain biological function and training load. While they may present with similar symptoms to someone with intentional REDs, they are easy to work with as there is no psychological involvement, which means they are happy to implement nutritional and training interventions to get their body back to optimal.

•Intentional REDs is a conscious decision to restrict intake and/or overtrain. Technically, it involves some aspect of disordered eating and/or exercise dependency. When I am discussing this with individuals, they usually associate the start of these behaviours with the desire to change body composition – in most cases, to lose weight– because they have either been encouraged to do so by the culture within their sport or through comparison with fellow athletes, and they believe that this will improve their performance.

Symptoms of REDs

As we said earlier, the body will always prioritise movement. Just as your smartphone starts to shut down non-essential apps when it is running low on battery, your body does the same and down-regulates your metabolism to preserve energy. One thing to be mindful of is that REDs is not always associated with weight loss. You can have an individual who is in low energy availability at a normal or above-normal weight. The human body does not like being in huge energy deficits and thus results in compensatory behaviours which can stop the body from losing weight. This is also why low-calorie diets do not work in the long term.

WARNING SIGNS

A number of key warning signs can be observed and these should not be ignored.

Physiological

•Lack of three consecutive periods in females or a change to a previously regular menstrual cycle

•Decline in morning erectile function in male athletes (less than five a week is a cause for concern)

•Changes to thermoregulation, and difficulties staying warm in the winter and cool in the summer months

•IBS-like symptoms due to gastroparesis (slow movement of food through the digestive system) and dysbiosis (a change in optimal microbiome)

•Changes to cardiac output

•Peripheral nerve damage

•Potential autoimmune presentations such as Epstein-Barr virus (EBV)

Performance

•Poor recovery between training sessions

•Recurrent injuries, including soft tissue, tendon and stress fractures

•Poor development of muscle mass and adaptation to training

•Increased risk and prevalence of infections and illness, making it difficult to train consistently

While the physiological and performance consequences are applicable to both types of REDs, the following symptoms are mainly associated in those who have intentional REDs.

Behavioural

•Preoccupation with and constantly talking about food

•Poor sleep patterns

•Restricting or strict control of food intake

•Overtraining or difficulties taking rest days

•Training through pain

•Ignoring advice regarding hormonal health restoration

Psychological

•Irrational behaviour

•Fear of food and weight restoration

•Severe anxiety

•Becoming withdrawn and reclusive

•An inability to decipher the difference between fact and intrusive thoughts and limiting beliefs

REDs recovery

While REDs is definitely becoming more mainstream, with many athletes from all walks of life discussing their experience, recovery is not simple or even linear.

I think this is probably my biggest concern – as with most things that are discussed publicly and based on a sample size of n=1, recovery from REDs is not as simple as eating more and moving less. So, what does recovery look like and how do you go about it?

Recovery involves biochemical, physiological and hormonal regulation. This takes time, but everyone’s journey will be different. Contrary to what a lot of athletes portray on social media, no one recovers from REDs with a short-term period of rest or abstinence from sport. While this definitely helps, it is important to appreciate that REDs is fundamentally a metabolic injury and, like any injury, recovery is going to take time. Some research suggests a minimum of eighteen months for full recovery to occur and the body to be able to adapt from training again, but a lot of this also depends on the length of duration of the situation and the individual involved.

A good analogy is to think of your body as a bank account. When you are in REDs, you are way into your overdraft, in the red. A lot of people who acknowledge they have REDs understand that something needs to change, but find it hard to allow their body to return to a place where they can start to actually heal. So, just like an overdrawn bank account, you can save and get back to a bank balance of zero, but if you splash out on a holiday as soon as you get there, you will once again go into the red. In reality, we all have to learn to save up before we spend money on designer boots or fancy holidays, so that we can also continue to make our day-to-day payments without tipping back into our overdraft. The same applies to the human body.

Even once you get back to hormonal balance, you need to give your body sufficient time to store energy so that it can be directed to repair the full extent of the metabolic injury that extends beyond just hormones. This includes the production of red blood cells, healing the gut and digestive system, reversing damage to bone health and repairing grey and white matter to the brain to encourage the development of neural pathways involved in behaviour change; and then the body can finally start adapting to actual training both from a body composition and performance point of view.

Steps to recovery

1.     Diagnosis by exclusion – if you suspect REDs, go and see a sports practitioner who is qualified and can read blood biomarkers and do a full clinical and behavioural assessment. It is unlikely that your GP will have much knowledge of REDs. That said, some do and many are keen to learn, which is why I have created a section later in this chapter about what medics should know about runners.

2.     Those with intentional REDs – that is, whose behaviours around food and training are a conscious decision based on a belief – will not only need support with their physical health, but also psychological/behavioural input.

3.     While not everyone needs to stop all training, it is likely that you will need to modify your training for the foreseeable future. It is a good idea to bring together those on your team who are involved in your training and care to discuss a realistic plan.

4.     Consider adding activities that help to increase parasympathetic nervous system activity, such as mindfulness, drawing, knitting or yoga.

5.     Appreciate that you will need to change your attitude and behaviours going forward. You can’t overcome REDs only to end up repeating the behaviours that got you there in the first place.

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What is wrong with me?

Unhealthy behaviours are not always visible. If you suspect LEA and REDs, it can be worth asking yourself the following questions:

•Do you find it difficult to have complete rest days?

•Have you had recurrent ligament or tissue damage in the last twelve months?

•Have you had a stress fracture in the last twelve months?

•For males, do you have fewer than five morning erections per week?

•For females, have your periods become lighter, become more erratic or stopped completely?

•Do you get anxious eating food away from home or that you have not prepared?

•Do you avoid social situations due to anxiety around food?

•Does your body weight/image impact your mood and ability to accept yourself?

•Do you feel the need to exercise daily to justify eating?

•Have you noticed feelings of worsening low mood, irrational thoughts and increased anxiety? If you answer yes to two or more of these questions, seek appropriate support.