If you play sport or take part in some kind of sporting activity you probably do so because you enjoy being active, maybe your sport is your passion, your life purpose. But, in my experience, many recreational athletes don’t take their diet as seriously as they could. I have talked about this a lot on social media, but exercise needs fuel, for us humans that fuel is the Calories we get from food and beverages. If you take your sport or exercise performance even semi-seriously and you aren’t taking 24-hour energy balance (Calories in Calories out) into account you might be reducing your performance potential, not to mention harming your health. There isn’t an evidence-based practitioner in the world who would say otherwise. .
The Female Athlete Triad
Many people get into sport and exercise to either lose weight or to maintain a healthy weight. Often, a person has been led to believe that the only way to lose weight is to do lots of exercise and this leads them to do go to extremes; doing lots of high intensity and high volume exercise while eating a very low-Calorie diet. This isn’t sustainable because a high energy output coupled with a low energy intake is a recipe for disaster.
Mountjoy. M et al (2018)
In times gone by female athletes with concerns over body composition, whether that was due to considerations over power to weight ratio, such as in endurance sports or aesthetic reasons, such as in physique competitions were known to develop a condition called the female athlete triad. This was where a low energy availability resulted in physiological complications such as low bone mineral density and amenorrhea. However, the International Olympic Committee re-categorised this because low energy availability doesn’t just affect female athletes. It’s easy to see why the condition wasn’t considered a problem for men because men don’t have a menstrual cycle and losing that is a really obvious sign that something is amiss. Therefore, the female athlete triad was out and RED-S (Relative Energy Deficiency) was in. Looking at the graphic above you can see where the triad concerns where but the revised model looks at many more factors that are not exclusive to female athletes.
Relative Energy Deficiency Syndrome
RED-S was first defined by the International Olympic Committee in about 2014 and was revised in 2018. Research was done on a number of sporting populations, with sports where body weight plays a big role, either for optimising power to weight ratio or making weight for competition. Burke et al showed that RED-S shows up in male road cyclists, rowers, combat sports competitors, East African runners and jockeys, all sporting disciplines not exclusive to female athletes.
Looking at the graphic above you can see a number of physiological aspects that can lead to RED-S. While, below, you can see the typical signs and symptoms that athletes should be mindful of. Any or all of these could be a sign of RED-S.
Mountjoy. M et al (2018)
Just because men don’t experience a loss of menstruation, they are vulnerable to the other symptoms. If you regularly experience any of these symptoms as a result of a high training volume you need to start taking your diet and recovery more seriously.
Anecdotally speaking, I often hear friends or new clients saying how they have low energy, increased fatigue, increased joint pain, reductions in performance, disruptions in sleep and when I ask them what their Calorie intake is, they often look at me blankly. Let me explain why this is important to get right.
Low Energy Availability
Relative Energy Deficiency Syndrome (RED-S) is caused by a low energy availability (LEA). In other words, the athlete simply isn’t consuming enough Calories to fuel their body during exercise. This, as mentioned above, doesn’t just affect exercise performance. When Calorie intake is too low your body cannot perform its normal biological functions, quite literally, you are using so much energy from exercise that your body cannot function efficiently and starts to break down. Think of it like a car that is being driven with very little petrol in the tank, sooner or later the engine will cut out and, if you do this on a regular basis, the catalytic converter, carburettor or starter motor might burn out and stop working. The same things happen to your body and, over long periods of time, can cause considerable harm to your health that could lead to severe illness. For example, low bone mineral density could lead you to develop fractures or osteoporosis. Or there are the psychological considerations too, eating disorders and depression are common and mental health scars often run deep.
Stratification of populations is important too. Female athletes are more likely than male athletes to develop disordered eating or clinical eating disorders. African American and black African athletes are less likely to experience bone fractures than Caucasian athletes according to the data. That’s not all, eating disorders like bulimia, for example, are known to be common among female fashion models and Ballerinas, but it’s also common among male Jockeys who have similar body composition concerns. But all athletes are at risk if they have an energy availability below 30kcal per kg of fat free mass (FFM).
Calculating Energy Availability
How do you avoid low energy availability and the problems associated with this? Well, you need to do a bit of maths. Because energy balance is an aspect of the laws of thermodynamics and physics is all about maths you have to run the numbers. The equation for energy availability is as follows:
EA: Energy Intake (EI) – Exercise Energy Expenditure (EEE) / FFM.
Less than 30 Calories per kg of FFM is a problem. According to Mountjoy et al (2018) 45kcal/kg FFM is ideal for healthy physiological function, the cut-off point for LEA of EA <30/kg FFM still might be high enough to protect against amenorrhea in some females. Therefore, I would urge you to err on the side of caution, if you do this calculation and your score is 30 or less push up closer to 35 or more on those high-volume training or competition days.
However, it’s important to understand that, although you ought to factor exercise into your predictive calorie equations to estimate your energy requirement it’s the number of Calories burned during high effort sessions that could be the issue, and this is means upping your intake on those days. Therefore, when doing Calorie calculations, you should separate activity and exercise. To do this you have to work out what your energy expenditure from general activity is. Here’s how:
First estimate your resting metabolic rate: kg x 22 (female) or kg x 24 (male)
Then decide your physical activity level (PAL) from non-exercise activity. Unless you are extremely active in your work this is likely to be somewhere between 1.1-1.3.
Let me illustrate this using myself as an example:
- 77kg x 24 = 1,848kcal (RMR) x 1.2 = 2,218kcals (EE).
Now I need to estimate the Calories I have burned during my training. Using the Metabolic Equivalents, or METs, as outlined in Ainsworth’s Compendium of Physical Activities, an example of which is shown in the graphic here.
Böhmer et al (2014)
Having estimated my energy expenditure, I need to work out how many Calories I burn in a training session. Let’s say I go for a 3-hour cross country bike ride, I can look that up on the compendium (here) and see that ‘mountain biking’ is 8.5 METs. This is where things get a bit more complex.
Bear in mind that METs are only an estimate based on averages and don’t specifically stratify populations. METs is based on kcals/kg/hour and don’t allow for rest periods, that’s not an issue with an activity like cycling but for team sports or gym activities you have to take into account how much of the time spent on that activity is rest and how much is exercise. Also, and this is the bit that a lot of people fail to understand, you have a basal metabolic rate and if you don’t take that into account you are in danger of over estimating Calorie expenditure. But, this is simple, your basal metabolic rate is roughly 1kcal per kg of body weight per hour.
Continuing the example, I gave above, based on my own body weight. The energy expenditure for my ride will look like this:
- 77kg x 8.5METs (655) x 3 hrs = 1,965kcals
- But, my basal metabolic rate over those three hours would be: 77 x 3 = 231kcals
- 1,965 – 231 = 1,734kcals
Remember my initial calculation for Energy Expenditure? I need to combine these two figures together.
- 2,218 + 1,734 = 3,952kcals. Remember, this is total energy expenditure for the day.
Putting this all together I need to work out what my energy availability is for this day, using the energy availability equation (EI – EEE / FFM). My average Calorie intake is 2,700kcal per day. With a BW of 77kg and a BF% of 16% my fat free mass (FFM) is (77 x 0.84) = 65.4. The exercise energy expenditure, as already calculated is 1,734kcals, so the energy availability equation looks like this:
(2,700 – 1,734) 966 / 65.4 = 14.8. This is well below the recommended EA<30 recommendation set by the IOC. If I were to consistently under eat by that much I would initially struggle to recover in time for the next session and, as stress on the body continues, I would start to see manifestation of some of those symptoms listed above. But, if I was to consume more Calories, let’s say 4,000kcals on that day my energy availability ratio would be 34.
But, and this is important, most people work out the Calories based on average total daily activity, this means that on low activity days they probably eat more than they need and on training days they eat a bit less than they need and over the week it probably balances out. It’s also worth pointing out that a person with a few extra kilos of body fat to spare has more energy stored in their body and is probably at a much lower risk than a very lean athlete with a very low BMI. So, in conclusion, this is worth knowing but unless you have dangerously low body fat percentages and very low body mass for your height and, possibly, have a somewhat disordered relationship with food or a potential body dysmorphic disorder you’re probably fine. Just make sure you eat to fuel your activity and manage your recovery correctly.
But to circle back to my initial point, energy balance matters, knowing how many Calories you eat and how many you burn are important considerations for even semi-serious athletes and don’t let anyone tell you otherwise.
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- The IOC consensus statement: beyond the Female Athlete Triad–Relative Energy Deficiency in Sport (RED-S). Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, et al.Br J Sports Med. 2014 Apr; 48(7):491-7
- MountjoyM, Sundgot-Borgen JK, Burke LM, et al. IOC consensus statement on relative energy deﬁciency in sport (RED-S): 2018 update Br J Sports Med 2018;52:687–697.
- Dr Nicky Keay. 2018 UPDATE: Relative Energy Deficiency in Sport (RED-S) BJSM March 2018
- Statuta, S. M., Asif, I. M., & Drezner, J. A. (2017). Relative energy deficiency in sport (RED-S). British Journal of Sports Medicine, 51(21), 1570–1571.doi:10.1136/bjsports-2017-097700
- Burke, L. M., Close, G. L., Lundy, B., Mooses, M., Morton, J. P., & Tenforde, A. S. (2018). Relative Energy Deficiency in Sport in Male Athletes: A Commentary on Its Presentation Among Selected Groups of Male Athletes. International Journal of Sport Nutrition and Exercise Metabolism, 28(4), 364–374.doi:10.1123/ijsnem.2018-0182
- Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett Jr DR, Tudor-Locke C, Greer JL, Vezina J, Whitt-Glover MC, Leon AS. The Compendium of Physical Activities Tracking Guide. Healthy Lifestyles Research Center, College of Nursing & Health Innovation, Arizona State University. Retrieved [date] from the World Wide Web.
- Böhmer, Andreas & Wappler, Frank & Zwissler, Bernd. (2014). Preoperative Risk Assessment—From Routine Tests to Individualized Investigation. Dtsch Arztebl Int.