Relative Energy Deficiency in Sport (RED-S)

-a commentary by Dr Campbell Thompson, psychologist.

Relative Energy Deficiency in Sport (RED-S) (or dance and other forms of physical activity) is where more energy is being used than is being consumed, and over time, in women* and girls* this can cause menstrual periods to become infrequent or stop, and this is associated with low oestrogen levels. When persistent, this can lead to a number of symptoms and complications related to low oestrogen such as low bone density and reduced physical performance. 

RED-S also occurs in males* , resulting in low testosterone levels and again over time this can lead to a number of symptoms and complications such as low bone density and reduced physical performance.     

Have you been diagnosed with relative energy deficiency, or hypothalamic amenorrhoea due to calorie deficit?

Sometimes this diagnosis can come as a shock, especially when you have worked hard to stay fit and healthy or are an athlete.  And it can be a real challenge to come to terms with the idea that lifestyle adjustments are needed, let alone implement the changes.  A psychologist can be a great addition to your team when it comes to navigating this diagnosis so that you can sustain health, productivity and performance. 

Our endocrinologists at ERH Associates have successfully helped many people with their battle with REDs we know that people who have a multidisciplinary team supporting them—both a sports dietitian and a sports psychologist—often achieve recovery much faster and more successfully.   

 Below, Dr Campbell Thompson, a counselling psychologist with extensive experience in athletic performance and mental health, discusses how a psychologist can help with  your RED-S recovery plan, as well as what to ask for and what to expect when you see your psychologist.    

Managing mental conflict and hard-to-change habits. 

In recent research (Langbein et al 2021), athletes having treatment for RED-S described their recovery as a “mental battle zone”. On the one hand, athletes described wanting to recover and improve health, but on the other hand they felt conflicted about letting go of old habits around  food and training that they had held onto for so long.  

As one elite endurance runner recovering from RED-S said: 

“I think in some ways being a runner made that [guilt] worse … you are hungry and you do need to fuel but you’ve been socialized to feel guilty for it…It’s like you have two sides to your brain: the irrational and rational side, and it’s (an ongoing struggle) to decide which one is actually correct. You know the rational side is there but in moments where you’re really stressed out you just forget about it.” 

As this athlete described, the “no-man’s land” of feeling guilty about your health and anxious about performance and body-image, can be highly distressing. 

It’s hard to break out of this cycle on your own, but when you find ways to manage the healthy vs the unhealthy urges, improvements in RED-S and general quality of life usually follow. Working with a psychologist can help you to spot when the conflicts are occurring, and help you develop strategies and tools to resolve these conflicts and succeed in your recovery. 

Dealing with underlying issues and stresses 

Over-controlled eating, or excessive exercise, can also become ways of masking issues in other areas of life – difficulties in relationships, worries about the future, or worries about identity and self-image.  

“Looking back…[at when RED-S first showed up]…work at the time was stressful and the relationship I was in was really confusing. I started to doubt myself in lots of areas. Exercise and diet were things I could control that made me feel good, but I can see now I took it over the edge and that’s when I started to get sick and injured.” 

The job of a psychologist is to help you decide on the best path for you, and to stick to it even when pressure – outside or inside– is driving you into to a “perform at all costs” mindset.   

It’s also helpful to remember that stresses and pressures in work, or family life can make it easier to “fall off the wagon” even when you are in treatment. With personalised support from a psychologist, and by addressing psychological factors such as stress management, coping skills, relaxation strategies and effective communication, people can better manage stressors in daily life, as well as the challenges and setbacks associated with their treatment. This leads to more rapid recovery and helps you move faster towards the life you want. 

Depression and Anxiety 

Untreated anxiety and depression frequently contribute to the development of RED-S. RED-S can also lead to anxiety and depressive symptoms. Low energy availability affects the brain just as much as the body – leading to irritability, overwhelm and sadness, and withdrawal from friendships and intimacy. RED-S can also keep you from the usual activities that “make you feel like you”, and that give you a sense of accomplishment.  

Anxiety and depression symptoms can make it more difficult to fuel yourself effectively, and to see your body, your weight, and your performance objectively. Working with a psychologist to address these symptoms can help with your RED-S recovery , which often times also improves your overall quality of life.  

Learning to fuel for performance and wellbeing. 

Our beliefs and attitudes about food, body shape, and weight play a big part in what we eat to fuel our life and performance.  But these beliefs aren’t always helpful. Unhelpful assumptions about how elite athletes really fuel their bodies can lead to poor performance health. What’s more, beliefs about food, body and weight can become entangled with beliefs about our worth and our desirability. These are emotional topics, which can make it harder to be objective about nutrition and eating.  

“To start with, you train harder, get leaner, performance goes up. Friends, teammates, gym people – it’s not their fault – but they reinforce it without knowing. To start off with you get the comments about “looking good” the leaner you get.” (semi-professional team sport athlete). 

For some athletes, an initial increase in training and restriction of diet leads to short-lived performance improvements. They come to see unhealthy and excessive approaches – avoiding certain food groups, skipping mealtimes, or withholding food as an “essential part” of  dedication to their sport or discipline. But these sort of restrictions leave little room for simply enjoying where you are, what you are doing, and who you are with: essential qualities of mental health. Even when we know that we need to change, for the sake of our physical and mental health, and performance, there can be a real fear of backing away from these approaches. Changing these habits, can feel like giving up on something important. 

A confidential, safe setting, where your choices are understood and respected, can make this easier. Psychologists, like medical specialists and dieticians, who have experience in working with athletes, can help you learn how perform at the highest levels, be well, manage life stress AND enjoy healthy nutrition. 

Optimising sport performance

Psychological factors such as confidence, focus, and motivation are essential for athletic performance. RED-S can affect all these mental capabilities. A psychologist specalised in performance and exercise can you help you identify and address psychological barriers or challenges to achieve your performance potential.  

 Summary of how a psychologist can help 

A psychologist first helps create a confidential, safe setting to understand what you want to change and why, and to help you spot where you are getting stuck. Second, you work together to develop the tools and approaches to help you break out of any patterns that are holding you back. It’s also important to know that progress happens at the pace that you choose, and that you remain in control of your recovery plan and the changes you want to make. 

What to expect in the first session 

The first session with a new psychologist gives you a chance to meet them, and to find out how you could work together and what you can get out of the process. I usually start with an overview of 5 key building blocks in the process: 

1. Confidentiality – what is discussed stays between you and your psychologist unless you disclose that you or someone else is at risk of imminent serious harm. It’s a high bar, and important to know that it’s a safe place to discuss what’s going on for you. 

2. Non-judgment: I’ve worked with people from a wide range of backgrounds, identities and life experiences. Like most psychologists, what you tell me will be understood as just part of the range of human experience: to be understood, but not judged. 

3. Pace and the ‘self-censor’: when meeting someone for the first time it normally takes a little while to get comfortable with what to share. Most experienced psychologists have been a psychology client themselves, especially during their training programmes, and will be familiar with this process. As humans, we sometimes hold things back until we feel comfortable. That’s normal. Sometimes the sentences that start with, “I’m not sure exactly how to say this but…” can be the most important. 

4. A plan: the first one or two sessions you come up with a plan on how you can work together, and what you will work on. 

5. Collaboration: an experienced psychologist will have worked with hundreds of people, have studied psychology formally for 6 or 7 years at least, and will do annual professional development to stay equipped with up-to-date, evidence-based methods to help you. But you will be the expert in your life and what works for you. Psychology works best when client (you!) and psychologist both put their heads together to come up with a great plan. This can seem obvious but it is hugely important. If something’s not working well, or making sense, let your psychologist know. They’ll be highly motivated to make your work effective and efficient so you can get the best outcome.  

If any of these issues sound relevant, talk to your specialist doctor, your GP, or get in touch with Campbell at www.actionpotential.nz for either an initial online or in-person session, or a free 15-minute introductory call.   

Reference: Langbein, R. K., Martin, D., Allen-Collinson, J., Crust, L., & Jackman, P. C. (2021). “I’d got self-destruction down to a fine art”: a qualitative exploration of relative energy deficiency in sport (RED-S) in endurance athletes. Journal of Sports Sciences, 39(14), 1555–1564. 
 

*assigned at birth