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Blog 45- Raising awareness of RED-S. By Dane Verwey.

Hey all, I’m back again with another blog.

Last month, I went to the ‘endurance conference’ for coaches held by Athletics Australia after the Zatopek athletics meet in Melbourne.

One of my key take always from the day was listening to head AA sports doc, Dr Paul Blackman talking about RED-S.

With this blog today I want to cover this taboo topic in endurance sport, a topic that shouldn’t be taboo any more. I want to use my platform to create cultural change and improved understanding about RED-S, a new term for what used to be better known as the ‘female athlete triad’.

A few months ago I wrote a blog about load and why I thought abusive loading was more often than not the key reason why I see runners each week in the clinic with an injury. However, I feel a blog on loading and injury is amiss if I don’t cover one of the keystone’s to assisting regeneration and recovery in our bodies; fueling.

When we train hard, we stress our bodies. Our bodies then set about trying to repair and regenerate from the stress. This process of repair and remodelling requires energy.

Like a car, runners need fuel! We need to stop at the ‘servo’ and ensure we have enough in the tank and more to safely move around all day without bonking or breaking down.

When runners don’t fuel appropriately for their daily exercise requirements there is an energy deficit. Or case in point, an acute but minor case of (RED-S) relative energy deficit syndrome.

The body quickly metabolizes body fat reserves to make up for this deficit. Fat however is hard to metabolise so it only helps so much.

Soon the body starts shutting down/slowing down other bodily physiological processes and borrowing energy from them.

The body starts borrowing energy and compromising the optimal function of; the immune system, hormone production, protein synthesis, bone re-modelling and mental processing, in a desperate bid to make up for the relative energy deficit and meet daily energy demands.

We all have been here, be it acutely or chronically. Be weary of the grumpy, irritable, sick, tired, vague runner- they need to eat! I admit, I’m guilty of this state all too often!

As you can see, suddenly the athlete is at greater risk of injury as their ability to heal and recover is being hampered.

So, when runners don’t adequately fuel, it inversely affects the loads their body can handle.

So to optimise training response and ultimately become a faster runner (if that’s your goal) it’s not all about training hard is it?!

Yes, first of all we need to train hard enough, to elicit a stress response.

However, for training adaptation to take place we need a surplus of energy. If we are constantly in deficit the rate at which your body regenerates/heals/strengthens is compromised.

In such times, dialing training back and nourishing your body with some wholesome food will actually hastily get your health and energy balance back on par but also help you perform better in the long run.

This goes against the grain doesn’t it, being keen distance runners we all won’t to; push, push, push and the mere thought of training less and eating more sounds rather counterintuitive and lazy.

Nontheless, how good is it?! Food can actually help us get better! Well, that is certainly true to a point but we don’t want to go too far the other way either.

Haha and that’s where it gets tricky doesn’t it?! It’s a fine line! Just alike our cycling counterparts, runners run well when they are fit and have a good power to weight ratio. So, when we are at our most lean we are often running our best. There will be certain times in a build up where it is completely normal to be in a very slight energy deficit as we push training to get to peak shape. As we all know, this needs to be done very carefully overtime to avoid overtraining and injury.

Anyway, much of the stigma surrounding RED-S began when it was labelled ‘the female athlete triad’. If you suffered from ‘the female athlete triad’ everyone was painted with the one brush; you must have an eating disorder, you suffer osteoporosis (brittle bones) and amenorrhea (no menstrual cycle).

The term ‘female athlete triad’ is outdated. Firstly, running at a energy deficit can effect males and females equally. Secondly, RED-S negatively effects so many more physiological functions than just one’s bone health and menstrual cycle. And thirdly, the female athlete triad or RED-S as it has recently become known as is a continuum. So, their is a range in the severity of physiological signs and symptoms of RED-S pending on the chronicity and extent of the energy deficit.

See the three diagrams below:


Case in point, say your lifestyle is impacted for a 3 week period. You continue to train hard but for some reason or another you’re malnourished and run at an overall energy deficit for this period (be it work demands, or quite simply your life just got too busy!).

So for this period you are suffering from an acute and minor version of RED-S. You may not be emaciated in appearance or have deliberate disordered eating. However, you must know that your response to your training stimulus will be impeded, as is your immune system and you run at a higher risk of sustaining an injury during and shortly after this period.

On the other hand, If you have been running at a energy deficit for a long time then you can have more severe, chronic forms of physiological deficits. Be it; poor bone density, amenorrhea, infertility, stunted physiological development, low sex hormone/endocrine levels, lack of libido, mood disturbances (depression/suicidal ideation), cardiovascular side effects: ECG abnormalities, clear signs of restricted eating, poor immunity and/or GI trouble.

If running coaches and support crew are worried about an athlete struggling with a worrying case of RED-S we have a moral responsibility to look out for our athlete’s health first and foremost. RED-S in its most chronic form can be fatal. We need to ask the tough questions.

If they are coeliac/paleo/vegan/vegetarian and aren’t aware of just how many calories they need to consume then you should urge them to see a dietician to work this out.

If you suspect they have an eating disorder, you need to openly express this concern with the athlete you are worried about. This is a hard ‘convo’ to have but a necessary one. Eating disorders (once again) can be fatal and can result in lasting health consequences. Immediate allied health input should be advised and sought.

In reference to quickly screening for ‘Training suitability’ I believe Adam Didyk, coach of team tempo, Jess Trengove and head distance coach for Australia at the 2016 Rio Olympics has an excellent quick check list that all athletes and coaches should use (or a variation of) to monitor their athletes for overtraining, injury and/or potential tell tale signs of RED-S. He explains it in this great article he wrote for Strava below.

Adam, would get his athletes to rate themselves out of 5 (1 being great, 5 being poor) in terms of fatigue, stress, health and soreness. If the athlete comes in under 10 they were generally good to go and could train as per normal, if 10-15 training would be modified and >15 training would be postponed.

I feel this approach (albeit simplistic and it is relying on an athlete’s honesty) is really worth all our while when we are trying to better match training intensity and energy availability. It is a quick handy screening tool for identifying any athletes that may be suffering from RED-S too.

Awareness is the key to prevention, yet RED-S continues to go unrecognised. Less than 50% of clinicians, physiotherapists and coaches are reported as being able to identify the components of the female athlete triad.

If you are really concerned a more official tool is the RED-S CAT form. The RED-S CAT is a clinical assessment tool created by the IOC for the evaluation of athletes suspected of having relative energy deficiency and aims at helping guide return to sport decision making.

Ok, that’s all from me today. I hope this piece goes some way to better educating the running community about RED-S. I hope it also gets people talking about the importance of fueling and how this is just as important as training hard when it comes to fascilitating adaptation in our training.

Please, if you feel this piece will be useful to any keen distance runner out there to help keep them healthy, fit, strong, happy, in the sport and performing well with stacks of energy please share!

As always, please continue to!

Another ‘Tokyo bound’ blog will be out next week as we follow Craig Appleby’s journey (I hope to quiz him about his goals for race day, so stay tuned!)

I’ll try to do another blog myself too in the next couple of weeks.

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