The Relative Energy Deficiency in Sport (REDS): The Illusion of Health
- Giovanna Zerial
- 2 hours ago
- 5 min read
There are stories one hears at the gym that are impossible to forget.
I am Giovanna, a passionate pharmacist with a deep commitment to pharmaceutical care, mental health, and healthcare communication. As a former athlete and dedicated “gym rat”, I translate the discipline and resilience gained from competitive sports (I was in the Italian kayak Olympic team in 2010-2012) into my professional practice, and I have learnt that the deepest wounds are frequently the invisible ones.
These injuries are concealed behind the social media profile of a fit, smiling individual whose running shoes are eternally ready. That is precisely why I wish to discuss REDs, or Relative Energy Deficiency in Sport: a silent, frequently undiagnosed condition that afflicts athletes of all abilities. I choose to address this now because society is finally beginning to speak openly about mental health within the sporting arena. Indeed, ITM has already published pieces on women in sport and on Simone Biles’s struggles with mental health. I now want to add this piece, on the fact that true healing in sport commences in the mind.
Sara’s Story
Sara is thirty years of age and works in the public sector. When you see her at the gym, your immediate assumption is “This person possesses total control over her life”. Her routine comprises a morning run, the weights room in the evening, swimming on Tuesdays, and cycling or climbing at the weekend. She boasts a lean physique and iron discipline. She smiles at you whilst discussing personal bests and rigorous training sessions. Then, gradually, she reveals the rest.
She has not had a menstrual cycle for more than five years. Medical professionals have diagnosed her with osteoporosis - at the mere age of thirty. She suffers from insulin resistance and high cholesterol. And her relationship with food? “Sometimes, it is complicated…” she states, selecting her words with evident caution. However, the ordeal Sara is enduring has a clinical designation: REDs.
What is REDs and Why is it So Hard to Detect
Relative Energy Deficiency in Sport (REDs) is a syndrome wherein the energy one consumes through nutrition is insufficient to sustain both the energy demands of physical exertion and the body’s vital physiological functions: hormonal balance, bone health, immunity, and metabolic rate. It is akin to attempting to power a metropolis with only half the electricity it requires; inevitably, essential systems will shut down.
The central concept is low energy availability, and it does not necessarily manifest as a diagnosed eating disorder. It can simply, and insidiously, be the consequence of an increase in training intensity without a corresponding elevation in caloric intake. This deficit can be entirely intentional or wholly inadvertent.
The International Olympic Committee has formally recognised REDs as a multifaceted syndrome affecting both sexes, although female athletes have historically been the primary focus of research. The physical ramifications are thoroughly documented: metabolic alterations, loss of bone mineral density, reproductive dysfunction, and immunosuppression. Yet, the psychological dimension - the aspect concerning who you are, how you process thoughts, and how you feel - has long languished in the shadows.
The Link Between Mind and REDs: Cause and Effect
Mental health in the context of REDs is not a peripheral issue; it rests at the very core of the matter. Furthermore, the relationship is bidirectional. On one hand, particular psychological traits, such as perfectionism, a rigid athletic identity, a pervasive fear of weight gain, and an overwhelming need for control, can prompt an athlete to unconsciously restrict their caloric intake or compulsively escalate their training regimen. Eating disorders, across all their manifestations, remain among the most prevalent causes of low energy availability; however, even in the absence of a formal clinical diagnosis, distorted cognitive patterns regarding body image and nutrition can prove equally destructive. Conversely, the energy deficiency itself profoundly alters brain chemistry. Scientific research published in recent years documents that the early warning signs of REDs include mood fluctuations, chronic fatigue, sleep disturbances, irritability, and general psychological distress. Over time, anxiety, depressive symptoms, a marked decline in subjective well-being, and, in severe instances, psychiatric disorders begin to emerge.
“At first, I was happy. I felt light and full of energy. Then, I began waking up tired, becoming annoyed over trivial matters, and thinking about food obsessively. But I assumed it was down to work or stress” Sara recounts.
When the Body Heals, But the Mind Does Not
This is where the most vastly underestimated aspect of recovery comes into play. If REDs could be cured simply by the directive to “eat more”, a nutritionist alone would suffice. However, clinical research is unequivocal: physical recovery, the stabilisation of hormonal biomarkers, the restoration of bone density, and the return of reproductive function cannot occur unless the psychological dimension is simultaneously addressed.
In truth, if rigid dietary habits, negative self-talk, compulsive exercise routines, and anxiety linked to body weight are permitted to persist, the destructive cycle will inevitably repeat itself. The modern treatment pathways proposed by the most recent scientific literature converge upon an integrated, multidisciplinary team model. This includes a sports physician, a nutritionist, a sports dietitian, and a mental health professional equipped to explore the underlying factors that predispose, trigger, and perpetuate the condition.
For Sara, this required the profound realisation that controlling her physical activity and nutritional intake was merely a mechanism for managing a more deeply rooted anxiety, one that was linked to something entirely different.
Psychological Flexibility as the Key to Healing
There is a pivotal concept that scientific research is increasingly bringing to the forefront: psychological flexibility. It is the absolute antithesis of the rigidity in dietary rules, the inflexibility of training programmes, and the damaging identity of the “high-performing athlete at all costs” that fuels REDs from within.
It involves learning to adjust your training regime without feeling like a failure. It means accepting a meal that is not part of your original plan without viewing it as a catastrophe. It requires recognising your inherent worth, entirely independent of the distance you have covered on the track. It sounds remarkably simple, but it is not. Nevertheless, this is the precise direction in which the most effective therapeutic journey lies.
Sara is still training today. She trains less, but she trains better. She has embarked upon a multidisciplinary treatment programme. She notes that the most difficult hurdle was to stop perceiving treatment as a personal defeat.
Health Must Come First
Whether you are an athlete, a coach, a parent, or simply an individual who trains and recognises a reflection of yourself in this article, take careful note: REDs does not solely afflict elite competitors. It affects those who train with unwavering dedication, those who constantly strive to improve, and those who have woven sport fundamentally into their identity.
And if something feels wrong - if you are so exhausted that sleep does not provide relief, if your menstrual cycle has ceased, if you obsess over what you consume or what you burn - asking for professional help is not a weakness. It is, in fact, the crucial first step towards achieving truly sustainable performance.
