By Andrew Walen, LCSW-C, LICSW, CEDS Elite athletes look for total control of their body and mind. For a significant number of those athletes, the drive for their best performance can lead to an obsession with how and what they eat and over-training. The resultant disordered eating and exercise can lead to decreased performance, bone fractures, heart disease, and even death. Sounds a lot like an eating disorder, right? But try telling an athlete they have an eating disorder, let alone their coaches and trainers, and you’re likely to get looks of incredulity and disbelief. There may be another way to frame the conversation that can be more effective, which is why the International Olympic Committee came up with the term Relative Energy Deficiency in Sports (RED-S).
In the past, eating disorders (ED) were commonly and inaccurately thought to be a female-dominated disease. As a result, the term Female Athlete Triad was gaining traction when discussing athletes with ED symptoms. The triad included disordered eating behaviors (commonly restriction of calories, fats, or rigidity in thinking about “good” versus “bad” foods), loss of menstrual periods, and decreased bone mineral density. As disordered eating behaviors and over-training are common in all genders, a more comprehensive term of RED-S is the better option.
Careful meal planning and high intensity training are considered very normal for athletes. It may be easy to overlook or even dismiss concerns from therapists and medical staff that the behaviors meet pathological criteria. However, by focusing on low energy availability (LEA) and its health impact on the body, athletes and stake holders are more likely to see it as a problem that needs attention. LEA is defined as a mismatch between an athlete’s energy intake and the energy expended in exercise. The result is inadequate energy to support the body to maintain health and performance.
In my own clinical work, I’ve seen several high school and college athletes, female and male, who thought if they lost weight and trained harder, they would be faster, stronger, and have better endurance in their sport. These athletes tended to compete in soccer, lacrosse, swimming, gymnastics, ice skating, cross country, and track and field. But that’s not to say that any athlete from any sport is invulnerable. The result of their caloric restriction and over-training left them with worse performance, fatigue, passing out, bone fractures, injuries that won’t heal, and in one case (due to additional abuse of a weight loss product) total liver failure. In addition to their physical decline, these clients suffered low self-esteem, anxiety, depression, and suicidal thinking.
Some signs of RED-S include:
- Avoiding certain types of foods that the athlete deems “bad” (e.g., foods that contain fats)
- Binge episodes (often due to the body’s response to being under-fed)
- Use of diet pills, laxatives, diuretics, enemas
- Irregular or loss of menses
- Low testosterone levels in males
- Osteoporosis or osteopenia
- Low bone density or frequent bone fractures, shin splints, persistent hip pain
- Decreasing BMI
- Decreased glycogen stores
- Decreased muscle strength
- Decreased endurance and performance
- Decreased training response
- Impaired judgement
- Decreased coordination
- Decreased concentration
So how do you treat RED-S? The truth is the treatment is no different than someone diagnosed with an eating disorder. From a physical standpoint, it requires less exercise and increased caloric intake. Doctors may suggest medicine to improve bone density or treat osteoporosis. Dietitians may add supplements such as calcium, vitamin D, and specific nutritional changes to address other concerns. A psychiatric evaluation is recommended to assess the need for medication for underlying mental health issues such as anxiety and depression. Just as importantly, therapy should be a part of the treatment plan to deal with self-esteem, perfectionism, anxiety, depression, and body image that may have played a role in the development of the disorder.
For those who seek care quickly, the prognosis for recovery is quite good. However, significant delay in addressing RED-S often leads to loss of an athletic career, development of a serious eating disorder, and life-long health complications. Only 33% of those who develop an eating disorder fully recover, and the mortality rate is about 10%.
While the research on athletes has focused on the highest level of performers, athletes of all levels should be evaluated and treated with the same degree of care and thoughtfulness.
If you or someone you know is struggling with RED-S symptoms, you don’t have to tell them you think they have an eating disorder. Consider taking the first step of getting them evaluated by specialists who understand the concept of low energy availability and RED-S, and who can guide them into the treatment they need. Yes, it may be an eating disorder, but the name is less important. Get them treatment, and perhaps save a life.