Female Health in Sport – Under-fueling and its connection to RED-S

It is a struggle for many female athletes to deal with their health, despite how crucial it is to their performance. This is largely due to a lack of understanding and research; but arguably the media plays a role in it too. In the past, the majority of research surrounding athletic performance and health was conducted on male subjects and few researchers directed their work on female athletes, thus pushing the topic out of focus. In more recent years, the number of studies dedicated to women in sport has grown tremendously, with many charities and support groups to supplement these developments.

One key issue faced by many female athletes is under-fueling. Simply put, athletes are not consuming enough calories to fulfil their training needs, and when sustained over a longer period of time, the health and performance of these athletes begins to deteriorate. It may seem simple to many: just eat more. However, there are many factors to take into consideration when looking at why under-fueling is so common amongst athletes, especially in women.

Many people find themselves in a position where they are unintentionally under-fueling, whether it be because they lack sports nutrition knowledge or perhaps, they have increased their training time or intensity to the point that they have actually lessened their appetite. In both scenarios, there is a deficit of knowledge, and the athletes often realise these mistakes when it’s too late and they’ve developed a sports-related injury. Some athletes, on the other hand, are intentionally underfueling. This can be split into two categories: Disordered Eating and Eating Disorders. While they seem similar, one is far more extreme than the other. Disordered Eating often feeds into eating disorders as many athletes begin by cutting out food groups (such as carbohydrates as they heard that they were “bad”), skipping meals or training a few extra hours in the week. This situation is common especially in aesthetic sports or sports that focus on thinness (e.g. long-distance running, dance, gymnastics, etc.). When we let these ideas breed over a longer period of time, the individual soon develops intense fear or anxiety towards food or certain food groups.

In more recent years, social media has played an important role in athlete’s under-fueling with many videos circulating the Internet that promote eating less and exercising more. This glamorisation of undereating is detrimental to athletes, especially those who are young or less experienced in terms of sports nutrition, as they become influenced to under-fuel with the common aim of being thinner. Under-fueling is common; it not only affects inexperienced athletes but is also a problem amongst the elite, hence why it is so important that athletes receive the support they need to overcome these issues.

You might be wondering, what happens to the body when it is under-fueled? Previously called the Female Athlete Triad, RED-S stands for Relative Energy Deficiency in Sport and is characterised by low energy availability resulting from a long-term/ongoing calorie deficit. RED-S manifests itself in different ways but can often begin with a benign cold or general fatigue, resulting in it going unnoticed. As the condition worsens, the immune system becomes impaired and athletes are at higher risk of infection and illness, which makes performing at high standards incredibly difficult. Additional symptoms may include low ferritin due to low iron intake and is often linked with RED-S. Anaemia is a real problem for many female athletes because many females do not consume as much red meat or animal protein as male athletes do. When underfueling has extended over a long period of time, female athletes could experience a severe reproductive dysfunction called amenorrhea, which is defined as the absence of menstruation. When you’re not menstruating, you’re not producing oestrogen – this is vital for healthy bones. This can have serious implications for athletes, including poor bone health, resulting in stress-fracture injuries and eventually the development of osteoporosis. While amenorrhea is on the extreme end of the scale, menstrual disturbances can also be experienced with even a subtle energy deficit, which emphasises just how important it is to correctly fuel your body.

RED-S has only recently been categorised and in 2014, the term was introduced by the International Olympic Committee (IOC). As a result, very little is actually known about the condition in both the medical and athletic world. It can therefore go completely overlooked until the athlete has done irreparable damage. In fact, the uncomfortable truth about RED-S is that its early symptoms can actually enhance performance. Missing periods can be convenient, particularly around competitions, while excessive training and restrictive eating leads to lower body weight, which results in faster times – but only in the short-term.