What is RED-S and why should you know about this if you are a pole dancer or aerial artist you ask? Well, the name is kind of self- explanatory, but let us explain in a bit more detail about how it can affect your performance in pole and even your health in the long-run.
Previously RED-S was known as “the female athlete triad”. This terminology however only described female athletes who experienced amenorrhea (absent periods), osteoporosis (weak bones) and eating disorders. In 2014, the International Olympic Committee (IOC) coined the term Relative Energy Deficiency in Sport (RED-S) to acknowledge that energy deficiency can impact athletes of all genders and ages and can happen not only to professional athletes but also to amateur and social athletes.
What is RED-S?
RED-S occurs when there is not enough energy available to keep up with the high demands of exercise on top of your normal physical functions. It can affect many of our systems:
This energy mismatch is caused by low-energy availability (LEA), which occurs when you are not getting enough fuel into your body to meet the energy demands of the activity; i.e the energy consumed is more than the energy available.
When this happens, your body will use all the energy available and distribute it to the most necessary organs and functions, but this results in your body making a compromise. Ultimately, this may have an impact on your exercise performance and even health in the longer term! Some signs and symptoms that may alert you to RED-S include:
Altered menstrual cycle: absent periods (amenorrhea) or irregular periods (oligomenorrhea)
Fatigue or low energy
Altered mood
Poor concentration
Failing to improve or progress in pole
Under-performance
Recurrent injuries
Low mood and libido
Poor sleep quality
Gastrointestinal problems
Stress fractures and/or other overuse injuries
Mind you, the body is pretty incredible, it’ll try to hold on for as long as possible. But over time our energy availability will continue to deplete if we aren't receiving enough energy through means of dietary intake. And as a result, your overall health and performance in pole will also suffer. So be mindful of these signs and symptoms, especially if you are deliberately trying to “shred” for a competition.
How does RED-S occur?
So how is it possible for you to reach a point of low energy availability (LEA) - when energy IN is less than energy OUT? Well depending on the person, LEA can occur either intentionally or unintentionally. Some examples of this include:
Intentionally dieting by calorie restriction
Intentionally cutting out out macronutrients, most often carbohydrates (which are LITERALLY brain food)
Underestimating how much energy you expend to exercise in a day (i.e 3 hours of pole, + gym, + running etc) and not appropriately fuelling for this
Not progressively increasing your food/calorie intake as you progressively overload your body when training
Continuing to train normally whilst affected by illness that suppresses your appetite or causes nausea/diarrhoea
Clinical eating disorders or disordered eating behaviour
At different points throughout life some of us may consider reducing calorie intake as a way to reduce our body weight. Calorie reduction under a healthcare professional (i.e dietician) is a great way to ensure you are receiving best advice on how to remain adequately fuelled for your workouts. Don’t forget that LEA can make you too fatigued to train and perform well. It puts you at greater risk of injuries and can impact your strength, endurance and ultimately your ability to progress in pole.
Be mindful that if you are doing any of the above whilst training super hard, you are more susceptible to RED-S. My advice - Don’t forget to eat more nutritious and a filling amount of food on your big training days, and keep an eye out for any of the RED-S symptoms we mentioned earlier.
How does it affect your performance?
RED-S can significantly impact your performance, particularly when you are required to gain strength, endurance or even maintain your current level of fitness. In a sport like pole dancing where our bodies are visibly on show, it is easy to feel the pressures of society to look a certain way. From the desire for defined abs to a juicy butt, many think about reducing our calorie intake to achieve that elusive dream of being what society perceives as “fit” (Spoiler alert: You don’t need to change boo, you are AMAZING as you are!!).
However, for those reducing calorie intake for whatever reason, an excessive caloric deficit while you are training can lead to some negative changes to your physiological and psychological functions. As a result, your ability to adapt to increased training loads, recover from injuries and perform can be significantly affected. Adapted from an article by Charlton, Forsyth & Clarke (2022), the following list shows how RED-S and LEA can affect your pole progress and performance:
LEA reduces energy available to working muscles which can lead to rapid onset of fatigue
Reduced adaptation (ie. ability to make gains) during training sessions as a result of LEA, can increase your risk of injury. In addition to this, it also results in poor recovery of injuries as there is also insufficient energy available to assist in tissue repair and healing, which can lead to recurrent and chronic injuries.
Similarly, reduced coordination, concentration, increased fatigue and impaired coordination can also lead to a greater risk of injuries which again make you more susceptible to reinjuring yourself and even sustaining chronic injuries.
LEA is also known to impair cardiovascular function and growth, both of which are important in adaptation to exercise and endurance. This will impact your ability to improve and make gains from previous training sessions.
Impaired recovery can also occur when the body struggles to meet the energy demands for future training sessions, which can often lead to chronic fatigue, reinjuries and underperforming.
Increased risk of osteoporosis and stress fractures due to decreased bone density. A cohort study by Barrack et al. (2014) found that young female athletes had an increase in risk of bone stress injuries by 15-20% if presenting with one risk factor, while there was an increase by 30-50% if presenting with all risk factors which included low body mass index (BMI), amenorrhea (absent periods) or oligomenorrhea (infrequent periods), diet restraint and or participation in a leanness sport. Interestingly, bone health is also impacted in male athletes with RED-S. The current hypothesis is due to reduced testosterone and hormonal levels; however, it is not yet well researched (Tenford et al., 2016)
Reduced muscle strength as a result of muscle breakdown or reduced muscle synthesis. This occurs because LEA causes changes to growth hormone levels, which is usually responsible for bone health, muscle synthesis, growth and repair. A reduction in insulin levels due to LEA, also accelerates the breakdown of proteins to maintain blood glucose levels. Both of these occur during RED-S, which has a huge impact on your strength, performance and risk of injury.
Increase risk of ligamentous and tendon injury due to low oestrogen availability as a result of LEA. Logue et al. (2019) suggests that low estrogen levels can cause increased connective tissue stiffness, thus potentially increasing the risk of injuries in high impact athletes.
Fuelling the body
What does this mean for you as a pole dancer? Well, if it’s not obvious, pole dancing requires you to do a fair bit of lifting of your own body weight. Although weight loss can make you lighter, if you are also losing muscle, not making strength gains or simply feeling too fatigued, lifting your own body weight will remain heavy and challenging, thus halting your pole progress. Seems counterproductive to us!
So again, if you are dieting for a comp or some other purpose, be careful that you are not under-fuelling yourself. Getting through that comp routine will get more and more difficult the more you train and less you eat. Remember: symptoms of LEA include difficulty to concentrate, rapid fatigue, increased risk of injury and underperforming. If you are noticing any of these symptoms whilst reducing your dietary intake and maintaining or increasing your training load, be sure to seek medical attention from a sports doctor. We recommend if altering your diet for whatever reason, speak to a qualified dietician for guidance on how to do so for your body.
Worried that this might be you? Some visible signs to look out for when you are on reduced calorie intake that may mean you are at risk of RED-S include:
Increased skin bruising
Increased hair loss
Fatigue and exhaustion despite good sleep hygiene
Reduced endurance
How does RED-S affect your brain and mood?
Despite that amazing body reprioritising your energy and distributing it to areas of the body required to keep you alive, that very small pool of energy you have left remains scarce and difficult to distribute.
So, while we can argue that the brain is one of the most important organs in our body and it deserves all the energy, decreased brain function can occur and affect you psychologically.
This is because the brain literally NEEDS glucose to survive and function. As such, with an insufficient amount of fuel or ‘brain food’, the brain can exhibit some of the following symptoms:
Increased brain fog
Decreased coordination
Impaired judgement
Decreased concentration
Depression
Increased irritability
A study by Ackerman et al. (2019) suggests that athletes with LEA had a 2.4 times increased susceptibility to the above symptoms compared to athletes with adequate energy availability! That's a huge increase! Obviously, you do not want to experience any of these symptoms, let alone want it to affect your ‘pole-gress’. Decreased coordination, concentration, judgement and brain fog can affect your ability to retain information in classes, learn or remember chorey or simply remembering where to put your hands in that new trick. So, whilst there are physiological changes that have an impact on your exercise performance, the psychological changes can also pose a greater risk of injury and underperformance
How does it affect your menstrual function?
Amenorrhea (absent periods) or oligomenorrhea (infrequent periods) can be a sign and symptom of RED-S. When you are not eating enough, the brain goes into protective mode and tells your reproductive system to stop producing hormones because it knows you won’t be able to fuel and support a baby.
As such, the ovaries stop secreting oestrogen and progesterone, and re-distribute the energy available to other parts of your body that require it for survival. While for some females, periods are bothersome and an inconvenient time of the month, the reality is, the body is pretty amazing and you menstruate for more than one reason. These monthly hormonal changes are not just vital to your menstruation and reproductive system, they also play a huge role in maintaining bone health. The significant reduction in oestrogen as a result of amenorrhea or oligomenorrhea can lead to a loss of bone mass which makes you more susceptible to osteoporosis and stress fractures, as mentioned earlier.
So, while it can feel like one less bothersome thing you need to think about monthly, your infrequent or lack of period is a strong indicator of how your general health is going. Please do note, that this can also be a sign of other disorders like polycystic ovary syndrome (PCOS), which is why it is important for you to seek medical attention to enable appropriate investigations as required.
Long term effects
While RED-S and LEA can have a significant impact on your exercise performance, it can also lead to some long-term chronic health issues if not treated early. It has the potential to impact the following:
1) Reproductive Health
Let’s start with why not having a period can lead to long term health issues. We now know that LEA can impact your menstrual cycle significantly. From oligomenorrhea (infrequent periods) to amenorrhea (absent periods), the lack of regular hormonal levels, specifically oestrogen, has been shown to impact reproductive function in those who have experienced this both short and long term (Loucks & Thuma, 2003). The hormonal fluctuations have also been speculated to impact fertility long-term, although this is not yet well researched.
2) Cardiovascular Risk
Long term low oestrogen levels have also been found to be a risk factor for cardiovascular disease and increased arterial thickness in adult female athletes, despite participation in regular exercise (Soleimany et al. 2012).
3) Bone Mineral Density
The reduction in hormones in both male and female athletes have been shown to reduce bone mineral density (BMD) which makes athletes more susceptible to stress fractures and osteoporosis (weak bones).
Management
Well, the first step to management is really identifying that you may have RED-S. Studies looking at elite athletes always recommend coaches to be weary of signs and symptoms. However, often pole dancers and aerial artists don’t have coaches that overlook their entire training and eating schedules the way other sport coaches do. We tend to book in our own classes and have 1-2 sessions with our chosen coach to learn new tricks, but they don’t really manage what we do externally to those sessions. This means that you need to keep an eye out yourself for any of the RED-S symptoms above, especially if you are intentionally increasing your training load or reducing your caloric intake. Talking with a sports doctor or a dietician is particularly helpful here when it comes to diagnosis.
So how do we treat this? First of all, we need to address dieting or diet culture. Despite the popular diet catchphrase “a calorie in, a calorie out”, safe dieting is a bit more complex. Where you get your calories from and the metabolic impacts of appropriate caloric intake requires greater understanding. The first step to managing RED-S is ensuring proper nutrition, which we strongly recommend you seek professional advice from a dietitian and further medical assessment from a sports doctor. You may require further assessment such as blood tests or imaging etc.
Prevention
To prevent RED-S whilst increasing your training load and or dieting, it is important to receive individualised advice from a nutritionist or dietician. However, there are some basic nutritional principles you need to go by:
Firstly, you need to eat ENOUGH calories for YOU. Your energy requirements will differ to mine as it depends on your age, sex, body mass, training load, genetics etc. While there are recommended “daily energy needs” for certain genders and age-groups, it is important to note that they should only be used as general guides as your training load and weekly progressions can vary significantly.
Secondly, your diet should have a balance of macronutrients. What does this mean? Well, macronutrients include carbohydrates, fat and protein, which are important for overall brain, muscle, gastrointestinal and immune function.
Why carbs?
A lot of popular diets encourage “low carb” to promote quick fat-loss, however the effects of it actually impact your performance as carbohydrates are usually the first fuel used in exercise at particularly higher intensities.
Why Protein?
Protein is known to be essential for muscle repair and muscle synthesis. It is therefore often recommended in the fitness industry to eat more protein to accelerate recovery, reduce muscle breakdown.
Why fat?
Well, interestingly, there’s a reason why we need fat in our diet. It is important in aiding the function of our immune system as well as hormone regulation. Whilst excess fats and different types of fat can cause weight gain, it is important to eat a well-balanced diet with sufficient fat to allow enough nutrients.
Interestingly, eating more of the right foods actually increases your metabolism, which doesn’t necessarily result in weight gain, but enables muscle adaptation, recovery and overall improved performance. So, in some cases, to reduce weight you actually might need to be eating more!
In summary, as you can see, ensuring that you are eating enough to fuel your training sessions is vital in your longevity as a pole dancer and for the importance of your overall health. The lack of energy available can lead to a variety of symptoms that, if not addressed early, can not only impact your performance as a pole dancer, but your health outcomes in the long-run. It is important to identify your risk factors and symptoms, and seek early medical attention.
Have you experienced an injury from RED-S that is in need of rehabilitation?
Online telehealth appointments can be booked with the Pole Physio via our ‘Book Online’ page that can be found here. Assessment and tailored rehabilitation are provided in accordance with best practice and evidence-based treatment to help you unleash your 'pole-tential'.
Until next time, train safe.
The Pole Physio
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References
Ackerman, K. E., Holtzman, B., Cooper, K. M., Flynn, E. F., Bruinvels, G., Tenforde, A. S., Popp, K. L., Simpkin, A. J., & Parziale, A. L. (2019). Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport. British journal of sports medicine, 53(10), 628–633. https://doi.org/10.1136/bjsports-2017-098958
Barrack MT, Gibbs JC, De Souza MJ, Williams NI, Nichols JF, Rauh MJ, et al. Higher incidence of bone stress injuries with increasing female athlete triad–related risk factors: a prospective multisite study of exercising girls and women. Am J Sports Med. 2014;42:949–58. https://doi.org/10.1177/0363546513520295.
Charlton, B. T., Forsyth, S., & Clarke, D. C. (2022). Low Energy Availability and Relative Energy Deficiency in Sport: What Coaches Should Know. International Journal of Sports Science & Coaching, 17(2), 445–460. https://doi.org/10.1177/17479541211054458
Hoenig, T., Ackerman, K. E., Beck, B. R., Bouxsein, M. L., Burr, D. B., Hollander, K., Popp, K. L., Rolvien, T., Tenforde, A. S., & Warden, S. J. (2022). Bone stress injuries. Nature reviews. Disease primers, 8(1), 26. https://doi.org/10.1038/s41572-022-00352-y
Logue DM, Madigan SM, Heinen M, McDonnell S-J, Delahunt E, Corish CA. Screening for risk of low energy availability in athletic and recreationally active females in Ireland. Eur J Sport Sci. 2019;19:112–22. https://doi.org/10.1080/17461391.2018.1526973.
Loucks, A. B., & Thuma, J. R. (2003). Luteinizing hormone pulsatility is disrupted at a threshold of energy availability in regularly menstruating women. The Journal of clinical endocrinology and metabolism, 88(1), 297–311. https://doi.org/10.1210/jc.2002-020369
Soleimany, G., Dadgostar, H., Lotfian, S., Moradi-Lakeh, M., Dadgostar, E., & Movaseghi, S. (2012). Bone Mineral Changes and Cardiovascular Effects among Female Athletes with Chronic Menstrual Dysfunction. Asian journal of sports medicine, 3(1), 53–58. https://doi.org/10.5812/asjsm.34730
Tenforde AS, Barrack MT, Nattiv A, et al. (2016) Parallels with the Female Athlete Triad in Male Athletes. Sports Med; 46: 171-82.