Identifying Relative Energy Deficiency in Sport (RED-S) in Runners

Keywords: female, running, RED-S

In this blog we will explain how to identify RED-S in cross country runners by three different health profiles. We also discuss risk factors for RED-S in this population. Our study (recently published in BJSM), included a random sample of 211 current National Collegiate Athletics Association (NCAA) Division I (DI) female cross country runners carried out by a team of researchers at the University of Michigan (1).

Why is this study important?

Collegiate female runners represent a high-risk population for Relative Energy Deficiency in Sport (RED-S), given the dual pressures of excelling at sport and academic work, as well as the high rates of disordered eating among college students (2) (3). The RED-S framework provides an expansion to the original Female Athlete, which consists of three conditions: low energy availability (EA), functional hypothalamic amenorrhea and low bone mineral density (BMD). The RED-S framework incorporates additional potential effects of low energy availability including metabolic, hematological, immune, cardiovascular, and psychological health, as well as growth and development (4). This study adds to the literature on different clinical presentations of RED-S in National Collegiate Athletics Association (NCAA) Division I (DI) female cross country runners.

How did the study go about this?

This study included a randomly sampled population of 211 current National Collegiate Athletics Association (NCAA) Division I (DI) female cross country runners.  The participants were asked to complete a quantitative survey. Athletes were then grouped based on their responses for the RED-S physical health variables, using a specific type of analysis.  We performed an analysis that grouped athletes together based on shared symptoms. This method allowed us to identify different clinical presentations of RED-S in this population of athletes. We also identified risk characteristics associated with each class, or clinical presentation, of athletes. These risk characteristics included demographic variables, as well as disordered eating and emotional health variables.

What did the study find?

We identified three unique clinical presentations of RED-S in this population of runners:

(1) low probability of RED-S consequences

(2) complex physical and psychological concerns with a high burden of cardiovascular concern

(3) very high probability of anxiety with high burden of menstrual disturbance, bone injury and gastrointestinal concern.

All three of these classes were characterized by high levels of menstrual disturbance and distinguished by the number and burden of other potential RED-S consequences.

What are the key take-home points?

Overall, we found that RED-S health concerns were highly prevalent in this sample of NCAA D1 cross country runners. Over 50% of women in this sample reported cardiovascular, hematological, GI concerns, menstrual dysfunction, a bone injury and high symptoms of anxiety. This study identified three unique presentations of potential RED-S health concerns in NCAA DI female cross country runners:

  • One class characterized by the lowest probabilities of RED-S health concerns.

  • The second class is characterized by a complex set of physical and psychological concerns, most notably greater cardiovascular concern.

  • The third class is characterized by a very high probability of anxiety with additional high levels of menstrual disturbance, bone injury and gastrointestinal concern.

Understanding that RED-S may present differently amongst individuals is vital to understanding different approaches to treatment of RED-S. Some athletes may be best suited for immediate medical care and testing, while others may benefit from psychological treatment in combination with indicated healthcare.

Author and affiliations:

Traci Lyn Carson ,1 Brady T West,2 Kendrin Sonneville,3 Ronald F Zernicke,4 Philippa Clarke,1 Sioban Harlow,1 Carrie Karvonen-Gutierrez1

1 Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA

2 Institute for Social Research (ISR), University of Michigan, Ann Arbor, Michigan, USA

3 Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan, USA

4 School of Kinesiology, University of Michigan, Ann Arbor, Michigan, USA

References 

  1. Carson TL, West BT, Sonneville K, et alIdentifying latent classes of Relative Energy Deficiency in Sport (RED-S) consequences in a sample of collegiate female cross country runnersBritish Journal of Sports Medicine 2023;57:153-159.

  2. Lipson SK, Sonneville KR. Eating disorder symptoms among undergraduate and graduate students at 12 U.S. colleges and universities. Eat Behav. 2017;24:81–8.

  3. Tenforde AS, Carlson JL, Chang A, et al. Association of the female athlete triad risk assessment stratification to the development of bone stress injuries in collegiate athletes. Am J Sports Med 2017;45:302–10.

  4. Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the Female Athlete Triad–Relative Energy Deficiency in Sport (RED-S). Br J Sports Med 2014;48:491–7.

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