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Madison, Wis. — It’s not uncommon for athletes to watch what they eat, but consuming too few calories for their activity level can trigger a serious condition called Relative Energy Deficiency in Sports (RED-S) syndrome, or what’s more commonly known as the Female Athlete Triad.
“Not eating appropriately for the amount of energy an athlete expends is really the root of this syndrome,” explains Andrea Spiker, MD, a UW Health orthopedic surgeon who specializes in sports medicine and who is the team physician for the UW Badger women’s basketball and men’s and women’s soccer teams.
“Food restriction can mean a lot of things. Many athletes have very rigid food patterns; they may eat the exact same sandwich every day. Or it can be people who are on fad diets, or more extremes of disordered eating like bulimia or anorexia nervosa. Any of those eating habits can lead to less-than-optimal energy availability. There’s not enough energy to meet the demands of the athlete; they’re putting out more energy than they’re taking in.”
Decreased energy affects hormonal pathways in the body. For women, the syndrome usually manifests as disordered eating, loss of menstrual periods and decreased bone mineral density (hence the triad name). But disordered eating can affect men’s hormones as well, which is why some have proposed the more inclusive RED-S name.
RED-S: The signs to look for and how it is treated
Here’s what you need to know about this condition and how to treat it:
You don’t need all three parts of the triad. Although missed periods can be one of the clearest signs for women, it may not be an issue for very young girls or women on birth control. “You may continue to have periods and still have low energy availability and low bone mineral density, which is still problematic. If a patient meets two of those criteria, then they’re at high risk of developing the triad, and that’s enough for me to consider intervention,” Spiker says.
Hormones are key for bone health. Some women may not mind missing their period, but amenorrhea (the medical term for the loss of menstruation not due to pregnancy or menopause) can decrease your estrogen, which can weaken bones and lead to stress fractures. “When you have decreased estrogen, this can mean you don’t have good bone health,” Spiker explains. “Males and females are building bones in their adolescent years. By the time you’re in your 20 or 30s, your bone mass is at its peak, and if you never reach this peak, then you’re starting at a lower level of bone mineral density and declining for the rest of your life because there’s no way to recapture what you lost.”
It affects the whole body. “When you have altered hormonal levels due to energy deficiency, there’s concern for cardiovascular problems,” Spiker says. “You could be setting yourself up for heart disease.” This condition can also affect your immunity, protein synthesis, growth and development, physical endurance and mental energy/concentration levels.
Recreational athletes are also at risk. “We see this condition a lot in sports that emphasize leanness, such as dancing, gymnastics, cheerleading, wrestling and long-distance running,” Spiker says. “But it’s surprising how rampant it is. It’s very easy for even recreational athletes to fall into this pattern, especially with all the fad diets out there and the external pressures to be thin.”
Watch for the signs. “It’s really important that we educate parents of younger and younger athletes and coaches to watch for athletes who demonstrate disordered eating habits,” Spiker says. “These are dangerous cycles to get into.”
Warning signs of energy deficiency could include a young woman who:
hasn’t had her first period by age 16 or who has missed three cycles not due to pregnancy
has repeated stress fractures, shin splits or persistent hip pain
has low body mass index
“A very lean athlete can be an indication of someone who has a low bone mineral density,” Spiker notes.
Don’t ignore it. Left untreated, this condition could not only end your athletic career; it could also harm your long-term health by increasing your risk of heart disease and osteoporosis. And weak bones later in life are no joke: up to 50 percent of older individuals will die after a hip fracture, Spiker notes. “This affects the health of your body for the rest of your life,” she says.
Treatment is multidisciplinary. Depending on your symptoms, you may need to see a physician, dietician, physical therapist and/or sports psychologist. “Attacking the energy availability is the core of treatment. Athletes who exercise excessively really do need to maintain a high intake of nutritious food — it can’t be potato chips and brownies,” Spiker says. “If they have adequate nutrition to compensate for the energy they’re expending, things should reset and go back to normal.”