Friday, March 25, 2016

How To Know If You Are In The RED-S

"Do you exercise?" asked the Doc.

"Yes, I try to do as much as I can.  I am training for my 5th marathon, take Pilates twice a week, kick box on Saturdays and on Sundays try to make it hot Yoga. I know I would do more if I did not have to stay at the office past 10 pm these past 2 months." answered the New York City business woman.

I emphasize NYC not only because this is where I live, work and play but also because the scenario above, while may seem a bit stretched in the sarcasm market, is actually not all that uncommon around these blocks. I have been there myself. Not to the extremes of marathon training and 7 days of structured exercise for weeks on end, but I can compare some of what we call in NYC "the hustle"  to that of an athlete's burnout.  Let me elaborate ( I promise I am great at it).

I moved to NYC in 2009. This was a good time to buy and rent as prices were low (but to me coming from Maine they were sky high.... my current view point of prices has changed since then- when did $7 beers become a great deal)?!

I lived in Park Slope, Brooklyn, which I knew nothing about except that it was just voted the number one city to live out of the 5 boroughs by New York Magazine and that the F train never followed schedules. I learned the word "schlep" and integrated it into my daily life of "schlepping" to and from NYU campuses, to volunteer, to work, to the grocery store, to the gym... you get the idea. My legs were my car, grocery bags and nutrition text books were my hand weights, and balancing everything I lugged with me was my ab work. But why stop there right? I was a New Yorker in training so I also added on yoga and Pilates classes, hip hop dance, ballet,  running, and strapping on Franco Sarto's new Fall season's high heels making pavement pounding a challenge for my poor feet. Add to this stress from grad school and paying NYC rent prices and you have a nice equation for mind and muscle breakdown.

I did not technically breakdown. Well, except that time when I thought I lost my 30 page document at Bobst Library at 1:00 AM. That was a different sort of breakdown though.

I did however lose weight unintentionally, and I was not working out to the extent that athletes do. Part of this weight loss was muscle mass, and even though I may have not realized it at the time, those sleepless nights and times of grumpiness may  not have been just from the loads of school work, but rather the loads of physical, mental and emotional work my mind and body was undertaking without an optimal amount of calories and nutrients. This is a classic example of how a non-athlete can dip his or her feet into the RED-S zone...

Fast forward 3 years. I am finishing up at NYU  and decide a great way to deal with stress is to run it out. So I say to myself "I am going to do the NYC Half Marathon in March this year." This was in June. I then started training in June because in my mind 13.1 miles was an eternity. This was far too early for me to start a dedicated training program and lead to me over training.  I ended cutting back on my training and took away a running day and added in a strength day. I personalized a program that worked for me. I completed the Half Marathon in 2 Hr: 2 Min: 22 Sec - not bad eh. Along the journey from June to March however I did experience interrupted sleep, an extreme urge for meat, which most likely was due to iron deficiency and some lost muscle mass. Another classic example of how an athlete in training dipped into the RED-S zone.

So what is all of this talk about RED-S? RED-S stands for  Relative Energy Deficiency in Sport. According to Mountjoy and colleagues in the editorial Authors’ 2015 additions to the IOC consensus statement: Relative Energy Deficiency in Sport (RED-S) this is a more  broad term of what was known as the Female Athlete Triad and refers to "to impaired physiological functioning caused by relative energy deficiency, and includes but is not limited to impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health."

Furthermore this article published in the British Journal of Sports Medicine explains that the underlying issue of RED-S is  an energy deficiency relative to the balance between dietary energy intake and the energy expenditure required to support homeostasis, health and the activities of daily living, growth and sporting activities.

So in other words there is not enough energy available either by food coming into your mouth or energy stores in the liver or muscle to maintain optimal health and carry out daily living activities to your greatest potential. Nor will your internal activities such as proper digestion run efficiently.

It does NOT only have to do with women either. This applies to men as well.

This is some serious stuff and new athletes or those who put themselves on very restrictive diets over a long period of time are especially susceptible.

This RED-S is also seen in those who participate in recreational exercise and who may not fit the category of professional athlete (think Zog sports or corporate teams and people who lead very active or busy lives, workout a lot and are very stressed- like our NYC business woman at the start of the post).

Lets take a look at how RED-S may effect the body and mind:

  • Immune System
  • Menstrual Function
  • Bone Health
  • Endocrine- such and insulin and thyroid hormones
  • Metabolic
  • Hematologic
  • Growth and Development
  • Psychological
  • Cardiovascular
  • Gastrointestinal
So you get the idea- it hits at many different parts of the body and the mind- so how do you KNOW its effecting any of these areas? Here are some signs:

  • Endurance performance has decreased
  • Injury risk has increased
  • Decreased adaptation to training- its not getting any easier
  • Impaired judgement- you have a hard time making decisions and cannot think clearly
  • Decreased coordination
  • Decreased concentration
  • Irritability
  • Depression
  • Decreased glycogen stores- some may call this ketogenic diet and in the SHORT TERM a variation of this diet while training may help performance but if you have other signs or prolong this diet it could hinder performance
  • Decreased muscles strength 
New and improved calculations have also made it easier for me as a dietitian to pin point how many calories a person undergoing heavy endurance exercise should consume daily and then assure they are getting these in via real foods that are nourishing and not just empty calories. 

Nevertheless, we are NOT ALL BUILT IN A BOX- I am starting to think this is my tag line as I say it so often to my patients and clients. I can punch in numbers to my trusty calculator and get back a  target number range for caloric intake to prevent RED-S and this  is all fine and dandy. But without educating people about the best sources of foods to get those calories from and motivating one about how to adequately attain a healthy lifestyle among the periodical altered diets athletes and very active people undertake I am not doing my job as a dietitian.

My Takeaway:  

1) If you are undergoing endurance training, especially if you are new to this training, you are at an increased risk of RED-S. However this is preventable with proper awareness and education around caloric intake and the signs and symptoms that may be indicative of this issue.

2) A calorie is not a calorie is not a calorie- if you get your calories from bags of chips and swigs of soda these will  not fuel your fire the same way a whole potato will... a purple potato at that... an Okinawan purple sweet potato (Ok ok this is one of my favorites and its also a great source of glucose)!

3) RED-S applies to BOTH female and males. Whereas women are particular susceptible to low iron and calcium levels and disrupted menses, both sexes are susceptible to a plethora of physiological disruptions that may not only decrease performance but disrupt the activities of daily living.

Kelly Ahearn, MS RDN CDN is Owner of Indigenous Nutritionist, a private practice and consulting startup based in NYC. She has partnered with Running This World to offer nutritional education sessions via tele-health for anyone who registers for the complete package at - website is coming soon!


Mountjoy M,  Sundgot-Borgen  J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. Authors’ 2015 additions to the IOC consensus statement: Relative Energy Deficiency in Sport (RED-S) . Br J Sports Med 49:417-420 doi:10.1136/bjsports-2014-094371

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