Published on September 24, 2024

RED-S Disorder: When Athletes Don’t Fuel Enough

If you are physically active and your periods become irregular or stop all together, it is time to see a doctor.

“Female athletes are not always told this, but it is absolutely not normal to stop your period because of how much you exercise,” said Leah Prestbo, MD, a bone density specialist with Avera. “This means that your body is under stress, and it is not regulating itself properly.”

In fact, missing a period may be a sign that an athlete has relative energy deficiency in sports or RED-S.

“Basically, RED-S occurs in athletes when they’re not getting enough nutrition to fuel the things they do physically,” Prestbo explained.

Symptoms of Energy Deficiency

In addition to missing or irregular periods, moodiness, fatigue and constipation are also signs of RED-S.

And if the condition is not treated soon enough with proper nutrition, stress fractures can occur due to loss in bone density, explained Dustin Volkmer, MD, an orthopedic surgeon and sports medicine specialist with Avera Orthopedics.

“Estrogen helps maintain bone mineral density. If the body goes into energy conservation mode, because it is not getting enough calories, and estrogen levels decrease, bone mass decreases,” Volkmer said. “This creates an increased risk for stress fractures.”

Stress fractures are tiny cracks in bone that occur when a bone is not strong enough to handle the repetitive stress put upon it.

“We commonly see stress fractures in gymnasts, dancers or long-distance runners,” Volkmer said. “We see stress fractures when young athletes who are still growing and maturing are not getting the proper nutrition and calories to support training several hours a day, several days a week.”

Fueling for RED-S and Optimal Workouts

Food is the fuel an athlete’s body depends on for energy, stamina and muscle. A proper diet not only maximizes performance, it helps prevent injury. Watch this video as Avera Registered Dietitian Anna Heronimus explains why poor fueling is leading to RED-S, a growing trend among athletes.

RED-S Affects Men and Women

Because missed or irregular periods are a symptom of RED-S, the diagnosis was initially made in female athletes and referred to as female athlete triad disorder. However, if their nutritional needs are not met, male athletes are just as susceptible to stress fractures resulting from bone density issues.

“It takes more than estrogen to build strong bones,” Prestbo said. “In order to build up bone mass, which we typically do in childhood and adolescence, individuals need proper nutrition – protein, calcium, vitamin D, magnesium, phosphorus. So if you are not fueling your body, it will lead to less dense, less strong bones. It is really important for young men and women to set themselves up to fuel their physical activity properly, so they get to that peak bone mass and reduce risks of stress fractures and breaks.”

A Team Approach to RED-S Recovery

Female Sports Medicine

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When athletes are diagnosed with RED-S, Prestbo and Volkmer are not alone in helping them recover. A team of Avera specialists are called upon.

“This is a very collaborative environment,” Volkmer said. “We take a comprehensive team approach that is very patient-centered.”

He explained that if an athlete comes in with a stress fracture and is diagnosed with RED-S, while the Avera sports medicine team treats the athlete’s stress fracture, the athlete will also work with a dietitian to formulate a well-balanced diet that provides them with adequate nutrition and calories.

“Athletes can take comfort in knowing that if they are diagnosed with RED-S, they will actually be better off in the long run,” Volkmer said. “Because our team will work with them, they have the opportunity to improve their health and long-term athletic goals.”

Read more: Fueling Athletes

Meanwhile, the sports medicine team works on treating the stress fracture. Athletes must quit all impact activity for six weeks to three months depending on the severity and location of a stress fracture.

Talk to your primary care provider if you have concerns about bone health or RED-S.