RED-S – what?!

This is something pertinent, as in the past year I have gone from not having heard of RED-S, to suggesting that patients really start thinking about it as a cause for stress fractures, and enabling them to swerve a downward spiral into long term injury and depression.

Where has this come from?

You may have heard of the Female Athlete Triad. Effectively it is a combination of Low energy availability, Menstrual disruption and Poor bone health. It was originally seen as a rigid structure – a diagnosis, which was not particularly useful when you have someone turning up with a stress fracture. We want to catch people prior to that happening! Also, if you have a bloke turning up to clinic with all these things and you tell him he has what is effectively the Female Athlete Triad (hormonal imbalance – not menstrual disruption) he probably isn’t going to be very impressed with your clinical reasoning.

Further evolution of this clinical thinking reflects low energy availability consequences are not simply confined to bone health and the menstrual cycle, especially in load bearing sports. We now look across multiple systems with particular focus on training load, nutrition and recovery.

So- what is it?

RED-S is Relative Energy Deficiency in Sport and is a diagnosis of exclusion. Initially low energy might not produce symptoms that are obvious in the clinic. There is a very subtle line between RED-S and overtraining. The main point about RED-S is that it has a detrimental effect on the Endocrine system – it is not simple stagnation from overtraining or an inability to perform despite good training/nutrition balance.

Endocrine balance has an effect upon a number of things, including cardiovascular, psychological and bone health, body composition, metabolism, muscular endurance and strength as well as cognition. If hormonal health has been depressed to the point of amenorrehea for an extended period then you can guarantee that ALL of the above have been compromised. It is interesting how women at the top end of sport don’t tend to talk about lack of periods until it is apparent that something is very wrong (stress fractures etc) and it begins to affect their ability to do their sport. The menstrual cycle is a pretty important indicator for hormonal/endocrine health – and to be contraversial here – women are lucky to have it as such an obvious indicator. Men have no such indication of endocrine health until stress fractures occur.

Yes- there is a whole lot of stuff that RED-S affects. The Traditional triad is simply a part of it.

So What?

Perhaps this is all an elaborate way to say- if I end up asking about menstrual cycles in a consultation, there is probably a pretty good reason for it. Only recently I had a patient who has had semi-regular stress fractures or stress fracture scares despite being pretty intelligent about not overloading in terms of distance or speed etc. It turns out that she was looking at hormone replacement therapy due to early menopause, which may well have been contributing to hormonal health (or lack of it). This had not been even considered as a contributing factor to her slowly declining ability to run distances without pain or potential stress fracture. I was able to signpost her to the fact this could be an issue, and she has been able to address it along with her doctor.

I personally don’t have many more anecdotes or stories about RED-S, but consider this a big pointy sign post to send you on to other resources if this sounds like you.

Further Resources

Anna Bonniface has written a MUCH better introduction to RED-S than I could ever do. It’s comprehensive – but a but more physio focussed, and it is here.

My good friend Jo Zakrezewski did an interview with athletics weekly about her experience with RED-S, and considering she is a race doctor, it is a pretty good insight. Find that here. She also wrote a decent personal blog about it- and that is here.

There is also a very good BJSM article about it- the doi number is 10.1136/bjsports-2017-097700 and I absolutely wouldn’t suggest that if you want to read it, surf to wherever sci-hub is hosted at the moment and copy paste the doi number into the search engine.

Chris showing his nutrition strategy…. keeping his energy up

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