~ Annie Bothma, Elite Athlete, IOPN Performance Sports Nutritionist (EQF Level 7. Masters), Running & Strength Coach
As athletes, our primary focus is usually reaching for peak performance, striving for personal records, and pushing ourselves to our physical limits.However, it's important to consider the importance of the fuel that drives our performance. If you're not consuming adequate nutrients to sustain both your training and daily activities, you may be susceptible to Low Energy Availability (LEA).
What are the consequences of operating in a depleted state for a prolonged period of time? Ultimately, it can result in a chronic energy deficit, often referred to as Relative Energy Deficiency in Sport (REDs).
What is REDs?
REDs, or Relative Energy Deficiency in Sport, refers to a syndrome that affects athletes when energy intake does not meet the demands of training and other vital bodily functions. This condition impacts not just performance but also overall health. It can lead to a range of negative outcomes, such as impaired bone health, hormonal imbalances, immune dysfunction, and mental health challenges.
The International Olympic Committee (IOC) recently updated its position at the end of 2023 on REDs, emphasizing that it’s not just about female athletes or those who have eating disorders. REDs can affect anyone, regardless of gender or sport, who isn’t eating enough to support their energy needs. The goal is to maintain optimal Energy Availability (EA)—the energy left for essential body functions after accounting for exercise.
How Much Should You Be Eating?
To avoid REDs, it’s crucial to ensure you’re consuming enough energy to support your training load. A basic formula have been established to estimate your Energy Availability (EA):
EA = (Energy Intake - Exercise Energy Expenditure) / Fat-Free Mass (kg)
For optimal health and performance, aim for an EA of ≥45 kcal/kg FFM/day. For weight maintenance, you need to be around 30-45 kcal/kg FFM/day. If your EA drops below 30 kcal/kg FFM/day, you’re entering the danger zone where the risk of developing REDs increases significantly.
Isn't it simply a matter of Calories In versus Calories Out?
It's not as straightforward as the common "calories in vs. calories out" equation that everyone presents it to be.
When a calorie deficit is created, weight loss occurs, but the body reacts with compensatory mechanisms to maintain homeostasis. The body doesn't recognize modern food abundance and instead interprets the deficit as a threat, like famine. To protect itself, the body initiates metabolic adaptation, altering hormone levels, energy, performance, and recovery.
This adaptation impacts all aspects of Total Daily Energy Expenditure, including:
Basal Metabolic Rate (BMR)
Exercise Activity Thermogenesis (calories burned during exercise)
Non-Exercise Activity Thermogenesis (calories burned through daily activities)
Thermic Effect of Feeding (calories burned digesting food).
Basically, your body is running on "low-power mode" when you are in a low-energy availability state.
Metabolic adaptations to calorie deficits are affected by three key factors: the magnitude of the calorie deficit, the duration of the deficit, and the frequency with which it occurs.
Beyond a decrease in Energy Expenditure, these hormonal changes occur:
Decreased leptin (satiety hormone)
Decreased T3 and increased TSH (thyroid hormones)
Decrease in female and male sex hormones like estrogen and testosterone
Increased ghrelin (hunger hormone)
Increased cortisol, affecting the hypothalamic-pituitary-adrenal (HPA) axis.
The type and timing of calories matter as well.
Carbohydrates are particularly important for endurance athletes because they fuel your muscles and brain, helping you perform at your best. Low carbohydrate intake can exacerbate the effects of low energy availability, leading to even greater health and performance risks.
Similarly, research indicates that prolonged periods without fueling, such as fasted training, can contribute to low energy (LE) symptoms and hormonal imbalances. In addition to the increased stress response, fasted training can significantly disrupt sex hormone regulation, particularly in female athletes.
Inadequate energy availability surrounding training can reduce estrogen production, leading to menstrual irregularities, such as amenorrhea (absence of periods). In male athletes, low energy availability can decrease testosterone levels, affecting muscle recovery, libido, and overall performance. These hormonal disruptions, coupled with elevated cortisol levels, create an environment where the body prioritizes survival over reproduction and performance, further intensifying the negative effects on health and athletic outcomes. Proper fueling before, during and after training is crucial to maintaining balanced hormone levels and supporting overall well-being.
Common Misperceptions
It's very important to understand that Low Energy Availability (LEA) can occur even if you are not underweight or have not lost your period. LEA is about not providing your body with enough energy to meet the demands of both daily activities and training, regardless of weight or menstrual status.
Many athletes may experience other symptoms such as persistent injuries, stress fractures, reduced immune function, disturbed mood, and chronic fatigue, even without obvious signs like menstrual dysfunction or significant weight loss.
These symptoms are red flags that your body isn’t receiving the fuel it needs to support both your health and performance, making it crucial to focus on proper fueling and energy availability beyond just physical markers like the weight on the scale or period regularity.
Are You Eating Enough? Ask Yourself These Questions...
If you’re unsure whether you’re meeting your energy needs, consider these self-check questions. They can help you reflect on your eating habits, training, and overall health:
Are you eating only when you’re hungry? For athletes, hunger is not always a reliable indicator of energy needs, especially after intense training sessions. If you’re not hungry, you may still need to eat to refuel and recover.
Do you often go more than 3-4 hours without eating? Regular meals and snacks are essential for maintaining energy levels throughout the day. Long gaps between eating can lead to energy deficits that are hard to make up later.
Has your weight changed unexpectedly (up or down) over the last few months? Unexplained weight changes can be a sign that you’re not fueling properly. I often see athletes struggling to lose weight or optimize their body composition when they are in a state of low energy availability. This is often due to a significant decrease in their resting metabolic rate and insufficient intake of calories or protein, which makes it difficult to gain lean muscle mass.
Have you recently had lab work done that showed irregular values (e.g., low Ferritin, Vitamin D, B12, etc.)? Micronutrient deficiencies can indicate inadequate energy intake and absorption, affecting performance and health.
How is your sleep quality and are you sleeping adequately? Poor sleep can be both a cause and a consequence of inadequate fueling.
Are you recovering well after hard or long sessions? Persistent muscle soreness, fatigue, or lack of progress can signal that your body doesn’t have the resources it needs to repair and adapt.
Any current or recent injuries (e.g., stress fractures)? Recurrent injuries, particularly bone stress injuries, are common in athletes with REDs due to compromised bone health.
How are your energy levels, during exercise and throughout the day? If you’re feeling drained or like you need a nap every day and you are unable to complete your workouts, it’s a red flag that your body isn’t getting enough fuel.
Do you have any gastrointestinal complaints (constipation, diarrhea, etc.)? GI issues can often arise from under-fueling, especially if you’re not consuming enough fiber or fluids. A healthy gut depends on adequate nutrient intake to properly digest and absorb the food you consume. Without sufficient energy, fiber, or hydration, your digestive system can struggle, leading to discomfort and impaired function.
Have you recently had any significant life events occur (good or bad)? Major life changes can impact your energy needs and appetite, making it challenging to meet your nutritional requirements.
How are your stress levels, and how do you manage stress? Chronic stress can increase energy expenditure and disrupt eating patterns, leading to lower energy availability. Stress is a major contributing factor to LEA, and athletes often need to address their overall stress load—whether it’s from work, social, or emotional sources—before they can fully recover from REDs. It’s important to remember that exercise is also a form of stress, so balancing high-intensity and long endurance sessions with adequate recovery is crucial for maintaining energy availability and overall health.
For men, how is your sex drive and are you getting morning erections? A decrease in libido or lack of morning erections can signal hormonal disruptions due to REDs.
For women, are you getting regular cycles? Irregular or absent menstrual cycles are a key indicator of REDs in female athletes. Amenorrhea occurs when a female has lost her period for more than 3 months, but even menstrual irregularities, such as longer or shorter cycles, can be signs of Low Energy Availability (LEA). Monitoring your menstrual cycle is crucial, as it serves as a vital signal of overall hormonal and metabolic health.
How are your moods (compared to baseline)? Low energy availability can affect your mood, leading to increased irritability, anxiety, or depressive symptoms.
How to Ensure You’re Eating Enough
Maintaining adequate energy availability involves more than just eating enough calories. It’s about providing your body with the right balance of nutrients to support optimal health and performance. Here are some strategies to ensure you’re meeting your energy needs:
Eat Regularly
Include meals and snacks every 2-4 hours, even if you’re not feeling hungry. For endurance athletes, hunger signals can be unreliable, especially after intense training. Eating regularly helps maintain steady energy levels throughout the day and supports recovery.
Carbohydrates Are King
Carbohydrates are the primary fuel source for endurance athletes. Include a variety of carbohydrate sources such as fruits, whole grains, starchy vegetables, and low-fiber options like white rice and pasta surrounding intensity training session to keep your energy availability high while minimizing GI upset. Adequate carbohydrate intake not only fuels performance but also helps prevent low carbohydrate availability (LCA), which can drastically increase the negative effects of low energy availability (LEA). Include carbohydrates with every meal and snack to help you meet your daily carbohydrate targets.
Include Healthy Fats for Hormonal Health
Healthy fats are essential for hormone production and overall health. Fats like those found in avocados, nuts, seeds, and oily fish support the production of key hormones, such as estrogen and testosterone, which are crucial for performance and recovery. Omega-3 fatty acids, in particular, play a role in reducing inflammation and supporting brain health. Aim to include a source of healthy fat in most meals to help balance your diet.
Prioritize Protein for Recovery
Protein is vital for muscle repair and recovery, especially after hard or long training sessions. Aim for 1.-2.4 grams of protein per kilogram of body weight per day, depending on your training load and goals. Include a source of lean protein with each meal and snack, such as chicken, fish, eggs, dairy, tofu, or legumes. To enhance mUscle protein synthesis after exercise and minimize amino acid degradation, a nutritional recommendation advises incorporating 0.3g/kg (~ 20-45 g) of high-quality and quickly digestible protein, like whey protein. Post exercise it is important to focus on a combination of protein and carbohydrates to optimize muscle recovery and glycogen replenishment.
Fuel Your Training
Strategic meal timing around your workouts can enhance performance and recovery. Eat a balanced meal 2-3 hours before training, including carbohydrates for energy and a moderate amount of protein. After workouts, refuel within 30-60 minutes with a snack or meal that combines carbohydrates and protein, as well as hydration containing some electrolytes to replenish fluid losses. A good example is a smoothie with a scoop of whey protein, banana, berries, greek yoghurt, honey and peanut butter.
Listen to your Body
Pay attention to how your body feels and performs. Are you consistently fatigued, moody, or struggling with sleep? Are you recovering well between sessions, or do you feel sore and rundown? These can be signs that your energy intake isn’t meeting your needs. Use these cues to adjust your nutrition plan accordingly.
Biofeedback is one of the key strategies I use to assess athletes in my practice. Subjective tools, such as how you're feeling, should always be considered alongside objective data, like blood tests and performance metrics. This holistic approach ensures a more accurate understanding of an athlete's health and performance.
Don’t Forget About Micronutrients
Micronutrient deficiencies can significantly impact performance and health. Consider getting regular blood tests to assess your levels and address any deficiencies with diet or supplementation. For example, some of the most common nutrient deficiencies amongst athletes are:
Vitamin D:Â Supports bone health, immune function, and muscle performance. Deficiency can lead to fatigue, frequent illness and bone injuries.
Iron (Ferritin):Â Essential for oxygen transport and energy production. Low levels can cause fatigue and decreased endurance.
Vitamin B12:Â Important for nerve function and energy metabolism. Low levels can result in fatigue and cognitive difficulties.
When to Seek Professional Help
If you suspect you may be experiencing REDs, it’s essential to get help sooner rather than later. Persistent fatigue, mood changes, recurrent injuries, or a history of disordered eating are all signs that you may need support. The updated REDs Clinical Assessment Tool (CAT2) can help stratify risk and guide treatment, but working with a qualified professional is key to addressing the underlying issues and developing a plan that supports both your health and performance.
Conclusion
Fueling your body adequately isn’t just about eating more; it’s about eating enough of the right nutrients to support your body's unique energy needs. By being proactive and mindful about your nutrition, you can prevent LEA or the development of REDs and ensure that your body has the energy it needs to perform at its best.
Remember, fueling your body is not just about today’s workout but also about supporting your long-term athletic journey!
If you’re unsure about your energy needs or have specific health concerns, consulting a sports nutritionist provide invaluable support. I can offer personalized nutrition guidance tailored to your unique energy requirements, training demands, and lifestyle. This approach is especially helpful if you have a history of disordered eating, are facing unexplained performance declines, or have been diagnosed with nutrient deficiencies.
Reach out at anniesathletes@gmail.com to schedule a consultation and take the next step in optimizing your performance and health
Resources
Kerksick, C.M., Arent, S., Stout, J.R., Campbell, B., Wilborn, C.D., Taylor, L., … & Kreider, R.B. (2021). International Society of Sports Nutrition Position Stand: Nutritional Concerns of the Female Athlete. Journal of the International Society of Sports Nutrition, 18(1), 1-54. https://doi.org/10.1186/s12970-021-00416-9
Lodge, M.T., Ward-Ritacco, C.L., & Melanson, K.J. (2023). Considerations of Low Carbohydrate Availability (LCA) to Relative Energy Deficiency in Sport (RED-S) in Female Endurance Athletes: A Narrative Review. Nutrients, 15(4457). https://doi.org/10.3390/nu15204457
Mountjoy, M., Sundgot-Borgen, J., Burke, L., Ackerman, K.E., Blauwet, C., Constantini, N., ... & Budgett, R. (2023). 2023 International Olympic Committee’s (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2023-105004
Barlow, P., Brown, J. C., & O’Leary, D. A. (2023). "Exploring the Effects of High-Intensity Interval Training on Skeletal Muscle Adaptations in Endurance Athletes." Journal of Sports Science and Medicine, 18(2), 123-135. DOI: https://pubmed.ncbi.nlm.nih.gov/38328685/
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