Despite Increased Awareness, RED-S Still a Major Problem in Endurance Sports

As a 16-year-old runner, Karin DeJong VanBaak saw a regular menstrual cycle as a failure. “I thought if I was getting my period, I wasn’t training hard enough,” she said. Missing a period was thought to be a badge of pride for runners, as it signaled low body weight and intense effort put forth in training. When amenorrhea (the clinical term for the halting of the menstrual cycle) didn’t happen, drastic measures were required, usually in the form of disordered eating and excessive training.

VanBaak’s story is relatively common among endurance athletes. Buying into the mentality of “lighter is faster,” VanBaak engaged in a series of unhealthy behaviors in pursuit of fitness, only to become plagued with injury and illness. Her experience and recovery, in part, led to her becoming a sports medicine physician and professor at the University of Colorado. Today, she conducts research on the Female Athlete Triad, a potentially serious syndrome of three interrelated conditions of health risk factors: amenorrhea, disordered eating, and decreased bone mineral density. The Triad, along with its gender-inclusive counterpart, Relative Energy Deficiency in Sport (RED-S), is something VanBaak encounters on a regular basis. 

“Twenty years later as a sports medicine physician, I meet young women every week who still think the same thing I did when I was 16,” VanBaak said. “In a study of high school athletes, we found that a high proportion of athletes today have the same misconception that I did so many years ago.”

High school athletes aren’t the only ones pursuing fitness through unhealthy means. VanBaak sees RED-S in younger adolescent women all the way through older women, as well as in male athletes. “I have been really interested recently to see the Triad show up as infertility in endurance athletes in their later 20s and 30s,” she said. “I also often see past Triad characteristics in my postmenopausal osteoporosis patients. Men obviously don’t get a menstrual cycle, but will have hormonal suppression that may show up as sexual dysfunction, bone health concerns, or even just fatigue and performance issues.”

Twenty years ago, a lack of awareness would be understandable, as the Triad was still a newly-identified syndrome (RED-S would not be named until 2014) and few people knew about it, much less talked about it. But in recent years, that’s changed. More research exists to show the short- and long-term consequences of insufficient caloric intake and excessive energy expenditure, and more athletes are speaking out about their first-hand experience with these consequences. Elite runner Mary Cain disclosed that coaching at the now-shuttered Nike Oregon Project valued thinness, and she ended up developing the condition. It eventually led to five broken bones, and derailed her mental health and promising athletic career. 2016 Ironman 70.3 World Champion Holly Lawrence has shared her experience in pursuing “lighter is faster” through unhealthy means, which contributed to injury and poor performance. Pro triathlete Jesse Thomas recently shared his experience with disordered eating, adding to a small-but-growing collection of men in endurance sports feeling the pressure to slim down. Social media has made it easier for information about the Triad and RED-S to not only be distributed but to go viral.

But despite this increased information and awareness, the Triad and RED-S are as prevalent as ever. Investigations of the female athlete triad in current high school athletes have found that 36% had low energy availability, 54% had menstrual abnormalities, and 16% had low bone mineral density. In a recent study of collegiate athletes, up to 84% of male and female athletes reported engaging in maladaptive eating and weight control behaviors, such as binge eating, excessive exercise, strict dieting, fasting, self-induced vomiting, and the use of weight loss supplements. One study of adults revealed that 20 percent of females and 8 percent of males met diagnostic criteria for anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified, compared with 9 percent and 0.5 percent for nonathletic females and males, respectively. Sports that emphasize body leanness, such as distance running, track, swimming, and triathlon, are also associated with a higher incidence of disordered eating. Why are athletes still getting caught in this cycle?

“More athletes are aware, and there are more resources available to all these groups, but there is still much work to be done,” said Dr. Nancy Williams, Co-Director of the Women’s Health and Exercise Laboratory at Penn State University. “Often, the interest in improving performance overshadows the interest in athlete health.”

VanBaak agrees: “I think this misconception we have in endurance sports that smaller is better is heavily affected by our culture, which tells us that a certain body type is ‘good’ and all other body types are ‘bad.’ It seems like everywhere we look, we are being told that athletes, especially female athletes, need to look a certain way. It’s really hard to separate those perceptions from the science of high performance and health.”

It doesn’t help that the science on the Triad and RED-S isn’t always clear. Williams says that recent research on the Triad and RED-S has, at times, gone backward in terms of quality. “I wouldn’t characterize the recent research as necessarily ‘better’ or even ‘more,’” said Williams. “Our group has been publishing Triad research for 25 years, and I wouldn’t say the older work is of any lesser quality. In fact, a case can be made that many papers that have been published recently in the area of RED-S are not of good quality. Our group has drawn attention to errors in recent RED-S papers.” 

A lack of consistent high-quality research makes it harder to develop and implement evidence-based solutions. In a 2015 survey of physicians, only one third had heard of Female Athlete Triad, and about half said they were comfortable treating or referring a patient with the Triad. Given the number of physicians who are unable to properly identify the Triad in a clinical setting, it is likely that many females are not diagnosed and subsequently treated. Ditto for coaches and athletic trainers, who often lack awareness of Triad and RED-S and push diet advice centered on weight loss, not fueling for performance.

In a perfect world, Williams would create protocols for Triad conditions to be properly and more thoroughly assessed during pre-participation exams, insurance reimbursement for regular bone density tests, and plenty of education for physicians, coaches, athletic trainers, parents, and athletes.

The biggest challenge in reducing Triad and RED-S is flipping years of societal programming that says “lighter is faster.” This overly simplistic equation ignores the point of diminishing returns, where poor performance, bone stress injuries, and long-term damage to physical and mental health impede athletic goals. To turn the tide, VanBaak said it’s critical to change the way we talk about performance, starting with talking about disordered eating or missed periods as a red flag, not a badge of honor.

“It takes time for research to turn into meaningful change in the real world,” VanBaak said. “That’s why it’s so important to continue to speak about this issue—in publications, on social media, and in everyday interactions with friends, coaches, and teammates. Ideas spread best through personal relationships, and that should make us each feel empowered to speak this truth.”