Stay out of the RED-S
Jason Lam's last article touched on why an increased amount of training may not lead to increased or improved performance and, indeed, may even cause harm. One of these harmful effects is RED-S - a serious concern which not only affects a dancer’s ongoing performance, but may have lasting consequences throughout life.
RED-S stands for Relative Energy Deficiency in Sport. It was previously thought of as the “Female Athlete Triad” (which encompassed disordered eating, menstrual dysfunction and low bone mass). We now know that it is a syndrome with effects which are much more widespread, affecting many more body systems, and does not need to include disordered eating. It also affects male athletes.
RED-S is caused by low energy intake relative to energy expenditure – in other words, not eating enough food to provide energy for training, growth, repair and daily life. Importantly, it can occur without disordered eating, and it can occur without being underweight or experiencing significant weight loss (though obviously disordered eating is a significant risk factor).
We now understand that having reduced energy availability affects many body systems, much more than the more narrowly defined Female Athlete Triad.
One way to think of RED-S is like the “battery save” mode on a phone applied to your body: when you get below 5% battery on your phone, it will reduce performance, shutting down unnecessary systems. The consequence for your body is irregular periods, more frequent infection, more frequent injury, slower recovery, and gut and metabolic dysfunction.
These effects on multiple body systems obviously lead to impaired performance – you will not be getting the expected results from your training in the short to medium term (and you will probably not be feeling your best). Moreover, these effects can leave lasting impacts later in life, particularly with regards to bone health for females, as the teenage and early adult years are really when bone health is set (90% of peak bone mass is achieved by 18 years of age). RED-S can lead to risk for stress injuries now, but also higher risk of osteoporosis (low bone density) and fracture later in life.
There are also concerns regarding long term effects on cardiovascular health, with some studies showing that it can cause the lining of blood vessels to change and higher levels of cholesterol despite exercise and a good diet.
There is no single test to confirm diagnosis of RED-S, and it can present in subtle ways. In other elite sports where there are extremely high training loads, there is growing awareness and recognition for the need for early assessment.
We know that athletes in sports with weight requirements (such as rowing) and aesthetic sports are at higher risk of developing RED-S and it would be reasonable to assume that dancers are as well. Early detection is important. For dancers embarking on more intense training (such as a full- time course), I would suggest seeing a specialist sports doctor and sports dietitian familiar with the rigours of dance to help you understand your body and its requirements. These medical professionals can ensure you are getting adequate nutrition and energy and help develop a plan to best to optimise your training for performance and safety. I would suggest yearly monitoring.
Dancing is hard, easily on par if not surpassing other sports in terms of load and exertion. Feeling tired at times is expected. However, there is the risk that we come to excuse tiredness as normal and just a consequence of training. But it is not normal to be waking up day after day feeling unrefreshed, or finding yourself more irritable than normal, or having too many niggling injuries and coughs and colds. These are all signs that something is not right. If it takes a very long time to recover (weeks to months), if you are experiencing prolonged fatigue; unrefreshing sleep; a long plateau or decrease in performance; increased injuries or niggles; bone stress injuries (late sign); frequent illness; weight loss; irregular periods; persistent altered moods, then you could have something like RED-S.
I recently gave a talk at an elite training institution, and found that many dancers (and teachers) excuse fatigue, injuries and recurring infections as part-and-parcel of training – and full disclosure, I’m certain I did the same when I was dancing. However, we now know that that is not normal to have these symptoms, and that they impair performance. I realised there was also still poor understanding around periods and the contraceptive pill for women. Loss of regular menstrual periods is an important sign to take seriously. Confusing the issue is the fact that many women are on hormonal contraceptives and still get a small bleed every month. This is NOT the same as a normal period. Long story short, if you are on the pill, the presence or not of a period is unreliable – see your doctor.
The other common misconception is that weight loss is a necessary symptom of RED-S. It is not, especially when considered in the presence of other signs and symptoms. In fact, RED-S can sometimes result in weight gain, or the appearance of weight gain (usually fluid retention), which often leads to the person trying further to restrict their energy intake and making the whole problem worse.
The very best athletes in the world have teams of people around them to support their wellbeing and optimise their health and performance. Increasingly, elite dancers are also drawing on the exponential increase in knowledge from sports science.
You aren’t going to be a better dancer through suffering. The best dancer, artist and person you can be is energised, refreshed, happy and injury-free. It’s high time we moved away from the myth of “suffering for your art”.
Jason Lam was originally a professional dancer before an injury changed his career path to a study of medicine. He was the inaugural Crichton Dance Medicine Fellow with the Australian Ballet and Orchestra Victoria. He holds a Masters in Sports Medicine, a Diploma of Child Health and is a Fellow of the Royal Australian College of General Practice. In addition to his interest in performing artists, Jason was the team doctor for the Sandringham Zebras VFL team and has also worked with Carlton VFLW, Combat Sports Victoria and was part of the Medical Team at the Gold Coast Commonwealth Games 2018. He works in private practice as a sports doctor and GP at Bluff Road Medical Centre in Sandringham, Victoria. www.thedancedr.com.au
This article first appeared in the July/Aug/Sep issue of Dance Australia. Did you miss it? Subscribe and have each issue delivered straight to your letterbox!