RED-S: The condition all runners need to know about

Endurance athletes might look like the last people who would need to worry about their health. With their impressively low resting heart rates, high VO2 maxes and lean physiques, they win praise and kudos for having the strength to go further, higher and faster than most of us.

But it is possible to push yourself too hard, and short-term performance gains could lead to longer term negative consequences and a range of health issues.

RED-S is a memorably catchy acronym for a condition that is less well known than it should be. It’s worth raising awareness because, as you’ll see when you read on, its symptoms are easily misattributed or missed. 

What is RED-S?

It was previously known as the Female Athlete Triad because of three combined issues that were prevalent in women, but because some aspects are also seen in men, the name was broadened. As the name suggests, the main symptom is low energy caused by an ongoing or long term deficit of calories.

RED-S as a term was coined by the Bruised toenail? Expert tips on how to heal them. But this is not simply a condition that affects only elite athletes - it can in fact affect anyone - male, female, elite or amateur. And it can lead to irreparable damage, impairing almost every system in the body if left untreated.

So as it only got its name relatively recently, it hasn’t been studied as much as it perhaps should have been, and the athletic community remains somewhat unaware. It might only be spotted once something bigger like an injury or collapse has taken place.

'It is still a relatively new condition,' explains Sports and Eating disorder specialist dietitian, Renee McGregor. 'It is a clinical condition within a sporting community, so only practitioners trained in both clinical and sports science/medicine will have a full understanding of it.'

Things, though, are changing. As evidence of its dangers mount, more people are speaking out to try and raise awareness about the syndrome. One of these voices belongs to Team GB runner Pippa Woolven, who suffered from the debilitating condition for over five years. Woolven’s full-time job is now focused on improving awareness, prevention and recovery outcomes among sports and medical communities. Her recently established organisation, Project RED-S, provides a web platform signposting athletes to the right medical, nutritional and psychological support.

Warning signs of RED-S

At first, the signs of RED-S are easily dismissed or barely noticed. Perhaps a series of colds, or some general fatigue, which are thought of as so common that they probably wouldn’t serve as a loud enough warning about something more serious.

'It was worryingly easy to dismiss the initial warning signs, since they were all relatively subtle in isolation,' Woolven says of her own experience.

But in retrospect, it becomes clear that these seemingly minor symptoms are in fact indicative of the body slowly breaking down. 'Biological processes become depressed,' McGregor explains. 'When there is not enough energy in the system, digestion slows, resulting in bloating, discomfort and IBS symptoms.'

Stubborn sniffles and chronic coughs are another side effect of this deficit. 'The immune system also becomes impacted, which puts the individual at a higher risk of infections and illness' explains McGregor.

In female runners, the most obvious symptom is known in medical terms as hypothalamic amenorrhea, or more commonly Bruised toenail? Expert tips on how to heal them. However, for the most serious athletes, this development can actually be seen as a good thing, with the lack of tiresome monthly headaches, cramps and mood swings feeling like a boon to their training.

'It seemed more convenient not to have them,' Woolven reveals. 'I didn't have to worry about being on my period during competitions or buying tampons anymore.'

That’s why RED-S might be hard to recognise early on as a real problem: awkwardly, in its initial stages, it can make you feel like you’re performing better. If you’re training excessively and restricting eating, lower body weight can mean quicker race times in the short term. You might know that these behaviours are unhealthy, but the praise and rewards can outweigh the negative aspects and entrench the condition.

'In my mind, I was just doing what it took to reach my potential in sport. I thought the odd illness, body image issue and low iron levels were just part of the challenge,' Woolven says.

Why you get foot cramp when running as symptoms.

So much of the messaging we receive from society is unhelpful here: ‘No pain, no gain’; ‘eat less, move more’ and other such tough slogans can convince people that they are doing themselves good when in actuality they may be harming themselves internally. RED-S has clear warning signs but they can sound an awful lot like signals of strength and resilience. That makes it harder to notice.

The responsibility of others

With athletes often unable to identify the issue objectively, it’s therefore crucial that their support team develops an understanding of RED-S.

Unfortunately, the initial ‘pros’ of the condition are often applauded by coaches for the same reasons as the athletes themselves - because of the short term positive results it may bring. Many doctors also have little knowledge of the condition, which further delays diagnosis. Despite displaying all the symptoms, it took years for Woolven to discover she had RED-S.

'I’d had countless blood tests, seen multiple doctors and endocrinologists and not once was RED-S or the Female Athlete Triad suggested' she explains.

Woolven also stresses that we need to talk more freely about menstruation as athletes. The clearest signpost towards RED-S is the loss of periods, but this can tend to be thought of as normal among the best female runners and thus be thought not worth discussing.

'Every doctor who looked at my body weight and food consumption reassured me: no period - no problem,' Woolven reveals.

The female body requires a certain amount of energy to make sure reproductive hormones regulate and produce a monthly period. Hormones such as oestrogen are also crucial for bone health, cardiovascular health and cognitive health.

'During amenorrhoea, when these hormones are reduced and often non-existent, individuals put their health and performance at risk,' explains McGregor.

The diagnosis

When health professionals failed to diagnose a clear cause of her issues, Woolven started researching the matter herself. The online articles that she found about RED-S sounded as if they were talking about her, so accurately did they describe her symptoms.

Despite the relief of finding an answer after years of confusion, Woolven felt frustrated by the vagueness of the condition. 'At first, I couldn’t believe that the simplicity of the RED-S description could possibly explain the complicated nature of my problem.'

It was especially distressing for her to realise that this had been going on for years – her undernourished body causing the lack of energy that she couldn’t shake.

'Advertisement - Continue Reading Below far from replenished during the "reset" I thought was behind me,' she admits.

This prolonged energy deficit is far from benign. The long-term consequences of RED-S include, but are not limited to, decreased bone density, cardiovascular issues, gastrointestinal disturbances and decreased immunity. Armed with this new information, Woolven embarked on a plan to salvage her deteriorating health.

Recovery

As it can take so long to be spotted, a diagnosis of RED-S also means a lengthy recovery process. As we’ve seen, its physical symptoms are caused by a mindset that can be very hard to shift away from. To treat it effectively there must be consideration of mental as well as physical health. At first Woolven tried to make these changes by herself, beginning to alter her own training schedule and nutrition.

But despite her good intentions, the process was a lot harder than she had expected. 'I seemed to be stuck in an agonising middle ground; motivated enough to start the process but continually falling short, time and time again,' she says.

After 'a series of half-hearted efforts and frustrating partial comebacks', Woolven took a crucial step in her recovery – seeking professional guidance. With the help of a psychotherapist, she dug deeper into her disordered eating patterns and established a plan to combat these unhealthy behaviours. 

One of the most surprising positive steps was to spend more time doing things other than running, either nurturing her close relationships or taking up unrelated hobbies. Adding more variety to her life actually helped her training, and she realised that athletic goals didn’t have to exclude every other part of life.

'Ironically, I performed at my worst when I was overly focused on sport,' she explains.

Project RED-S

Woolven's experience inspired her to establish Project RED-S – the go-to RED-S resource, where athletes – both amateur and professional – can learn about the condition and find access to the right support.

During the first Covid-19 lockdown, Woolven started a blog about her personal journey with RED-S. It amazed her that so many people started to get in touch with her for help and advice. She decided that there should be a full online resource to inform people and provide a virtual community for those suffering from the condition.

Right now, Woolven is offering one-to-one mentorship for affected athletes via the website, but is also in the process of building a community platform where athletes can provide each other with peer-to-peer support. ‘The people who can help you on your journey extends so far beyond a medical doctor or a dietician, because even when you know, “I need to eat more and do less”, it’s not always easy for people who have been conditioned to believe that’s the path to success.’

At first the website was something she was building on the side while continuing to work full-time for the National Trust. However, a parent of another athlete who had experienced RED-S got in touch to offer the funds for her to quit her job and give all of her time to this project.

‘It’s been a whirlwind,’ she says. ‘Since then, I’ve been making connections and raising awareness by building a team of ambassadors and advisors, populating the website, and delivering presentations. This is a seriously common problem, yet there’s an overwhelming lack of knowledge and understanding about it.

‘We want every athlete, coach and other member of their support team to know what RED-S is, how to avoid it, and how to recover if they’re already struggling. We’ll be looking to some financial sponsors for some long-term support because at the moment, I’m just a one-woman band and we need money to grow this – to create awareness campaigns, educational courses and fund more research.’

Right now, one of Woolven’s main goals for the organisation is to provide athletes, who believe they may be experiencing symptoms, access to a trusted database of experts. ‘So many nutritionists and GPs aren’t clued up on this. As is the case for a lot of female runners, a number of doctors and even endocrinologists actually encouraged me to go on the contraceptive pill – there's been some badly misinformed research out there that suggests the contraceptive pill protects your bone density, which is based on inconclusive science and isn’t supported by any substantial evidence. This is a common misconception and sadly, leads to many women masking the issue of irregular missing menstrual cycles.

‘The sooner you can get help from the right resources, the sooner you’re more likely to recover, and the more chance you have of turning it around without it reaching an extreme.’

If you think you may be suffering from RED-S and need someone to talk to, Woolven can be contacted here.

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