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June 2021
June 24, 2021 | Issue #134
Under Fueling and RED-S Among Athletes
Recognition and the Pathway to Treatment and Recovery
Under-fueling or RED-S (Relative Energy Deficient in Sport)
Relative Energy Deficiency in Sport, otherwise known as RED-S, occurs when an individual's overall energy intake is less than the total needed to support daily activity needs and exercise expenditure demands.

The treatment and recovery plan for an athlete with RED-S will depend on the nature of the path that led them there in the first place. In all situations, RED-S results from a mismatch in energy intake vs that which is required for an athlete’s activity level. Sometimes an athlete increases their training without adequately increasing their nutritional intake along with it and does not recognize that this is occurring. When this occurs, the athlete may begin to feel resulting symptoms including everything from fatigue, poor recovery, amenorrhea, sleep disturbance, decreased performance, mood changes, diminished bone mineral density, as evidenced by increased occurrence of stress reaction/stress fractures, and more.

Once a state of low energy availability is recognized, an athlete should work with an MD and Board Certified Sports Dietitian (RDN, CSSD). The MD will conduct a physical exam, medical work up and laboratory results. The Registered Dietitian will help them better define and understand their nutritional needs and take steps to increase their caloric intake in order to reverse the problems they are experiencing. As part of this process, the Registered Dietitian may conduct Resting Metabolic Rate (RMR) testing to accurately and easily assess the daily needs of each athlete. In general, we often expect athletes' RMR to be higher than average due to training load and resulting muscle mass, however after a prolonged state of RED-S we may see a lower than expected RMR result, which can often be corrected by improving the athletes' intake to meet their needs. Thereafter, we will help the athlete identify specific areas where they can focus, and will work together to add necessary foods and beverages, pre, during, and/or post-training, and throughout their day, to ensure the athlete adequately fuels their body and is meeting their nutritional needs for life and sport.

 Once given the proper education and follow-up, these athletes will typically respond by making the changes necessary that resolve their symptoms and allow them to fully return to feeling and performing at their best. 

However it is not always this straightforward to correct RED-S in athletes. As we attempt to help an athlete increase their intake to meet their needs, fear, anxiety, negative thoughts and/or guilt around eating are all too often uncovered. Once this inability to increase intake is discovered, an eating disorder (ED) or disordered eating patterns is likely at the root cause.

 Once the MD and Registered Dietitian have uncovered an ED or disordered eating pattern, they can guide the individual to add a psychologist/psychotherapist that specializes in athletes with disordered eating patterns to the treatment team. This professional can then provide the athlete with support and encouragement while helping them challenge eating-disordered thoughts and behaviors and also supply them with tools and coping mechanisms to help them break disordered eating patterns. Psychology professionals can also help athletes challenge unhealthy thoughts about food and exercise and encourage a balanced approach to training, fueling, rest, recovery and competition. This process requires a team effort, and work on relationships with food, body and exercise, but can most certainly be accomplished.

There is no one “cookie-cutter” method that works for all athletes when undergoing treatment for disordered eating. Each team of professionals helps each athlete re-learn to honor and nourish their body adequately, ensure they are meeting their body's caloric needs and develop a more healthy relationship with food and exercise. The team will guide the athlete in eating and drinking the right amount to sustain their daily activity and the level of training their sport requires.

In traditional eating disorder treatment, it has been generally recommended that all individuals drastically reduce or completely cut out exercise during treatment. While this is still indicated in situations following prolonged malnutrition, more recent studies show that some athletes undergoing eating disorder treatment can continue to engage in their sport with agreement from and support of their treatment team, albeit generally with a reduction in total training volume and intensity until nutrition intake and state of health are stabilized.

 The goal is to combine motivation to return to sport to help an athlete better fuel their body and gradually return them to full participation in sport as medically appropriate.
Meal Plans
When working with an athlete with disordered eating, a Sports Dietitian will generally develop an individualized meal plan to help each athlete understand the differences between what they have been eating vs what they actually need, and then help them reach those intake goals step by step. The meal plan provides structure and support, showing each athlete the total amount of each macronutrient (carbohydrate, protein and fat) that their body requires, and helping them re-learn how to fuel consistently throughout the day. As their nutritional needs are being met, the athletes' dietitian and treatment team will work to increase their variety of foods eaten as well as work towards greater freedom and a healthier relationship with food and their body.
Another ultimate goal is to help each athlete regain their ability to identify physical and emotional cues from their bodies and to re-learn what appropriate training and recovery look like for overall health and longevity in their sport. Overall, the mission is to equip athletes with the mental and nutritional skills to achieve their full athletic potential and overall best life while sustaining a positive and healthy mindset.

Ideally the athlete’s coach (as applicable) should have contact with the treatment team and be aware of the parameters to follow in terms of the athlete’s participation in sport. They can also provide the treatment team with information regarding the athlete’s training performance and recovery from their perspective as coach.
Next Steps/Resources:
If this article has you questioning your relationship to food or whether you or someone you know may be experiencing RED-S, we encourage you to use the National Eating Disorder Association (NEDA) Eating Disorders Screening Tool linked below. Additionally, the NEDA helpline is given below, to be used for support, resources, and treatment options. If interested, there is also an Exercise Dependence Scale linked below.
These resources can be the first step toward recognizing and getting the help necessary to live a more fulfilling life complete with food freedom and a healthy relationship with your body and sport.
  • https://www.nationaleatingdisorders.org/screening-tool
  • The National Eating Disorders (NEDA) provides a helpline for support, resources, and treatment options. Call or Text (800)-931-2237 and for crisis situations, text “NEDA” to 741741 to be connected with a trained volunteer at Crisis Text Line.
Summer BBQ Ideas
Ahhh....BBQ season is here! Now is the time for outdoor dining, grilling, and fresh fruit juices running down kids faces LOL.

Summer is a great time to bring out the smorgasbord of all the amazing seasonal fruits and veggies - and not just the traditional watermelon triangles. While BBQs can focus mainly on the meat - the 'sides' play great supporting roles that often upstage the main event! No matter what you make - remember to keep your items chilled and covered to keep them fresh and safe-to-eat!

Our admin Brandy found some great recipes to share with you - keeping the fresh seasonal produce front and center!
Fresh Mango Salsa
SERVES: 4-6 (double recipe to serve 10-12)
TOTAL TIME: 15 minutes

Super refreshing for a hot summer day. I made this when I had to quickly use up mangos that I bought from Costco. I had this with chips and also topped my grilled chicken with it! (grilled fish or even tofu would be great too). The only tweak I did was added a bit more lime juice and jalapeno (I like things on the spicier side):

  • 1 large firm avocado, cut into chunks (just very slightly ripe)
  • 1 1/2 heaping cup diced mango (from 2 large ripe mango)
  • 1 red bell pepper, finely diced
  • 1/4 cup finely diced red onion
  • 1 jalapeno, seeded and minced
  • 1/4 cup fresh chopped cilantro
  • Zest and juice of 1 small lime
  • Salt and pepper to taste

  1. Place all ingredients in a medium bowl and mix to combine.
  2. Garnish with extra cilantro. Serve with multigrain tortilla chips. Also great served on salmon, fish tacos or shrimp.
Grilled Vegetables
PREP TIME: 30 minutes

One of my favorite things to grill is vegetables. As they cook the flavor really intensifies. For anyone who will have access to a grill this weekend this is a fantastic way to prepare veggies. Pro tip: make extra so you have some to add to dishes over the next few days.This bonappetit article gives you examples of the best vegetables to grill as well as their cooking times. We also suggest topping with a chimichurri sauce. This is one of our favorite recipes to use

  • 2 portabello mushrooms
  • 1 eggplant
  • 1 zucchini
  • 1 yellow squash
  • 1 onion
  • 1 bunch thick asparagus
  • 1 red bell pepper
  • 2 tablespoons extra virgin olive oil
  • 1 tablespoon kosher salt
  • 1 tablespoon freshly ground black pepper

  1. Prepare the grill with clean grates and preheat to medium heat, 350°F to 450°F.
  2. Trim the ends of the eggplant, zucchini, yellow squash and onion and cut into 1/3" to 1/2" slices. Seed the red bell pepper and cut into quarters. Trim the ends of the asparagus.
  3. Drizzle the vegetables with olive oil and sprinkle evenly with salt and pepper. Grill the vegetables with the lid closed until tender and lightly charred all over, about 8 to 10 minutes for the bell peppers, onion, and mushroom; 5-7 minutes for the yellow squash, zucchini, and eggplant and asparagus.
  4. Serve warm or at room temperature.
Recipe: Strawberry Lemonade Cupcakes
Super simple and easy lemon cupcake, with the best strawberry butter cream frosting.

YIELD: 24-26

For the Cupcakes:
  • 2 cups (380g) granulated sugar
  • 1/2 cup (118ml) vegetable oil or canola oil
  • 3 large eggs
  • 2 Lemons, zested
  • 1 teaspoon (5ml) pure vanilla extract
  • 1/2 cup (118ml) sour cream
  • 2 1/2 cups (350g) all-purpose flour
  • 3 teaspoons (11.2g) baking powder
  • 1 teaspoon (5g) salt
  • 1/4 cup (59ml) lemon juice, (2–3 small lemons)
  • 1 cup (236ml) buttermilk

For the Strawberry Butter cream:
  • 1 heaping cup freeze dried strawberries (I find them at Target, Whole foods, or Trader Joes)
  • 1 cup butter (2 sticks), at room temperature
  • 2 ½ cups powdered sugar
  • 1 teaspoon vanilla extract
  • 2-3 tablespoons milk of choice*

Optional top with a fresh sliced Strawberries.

  1. Preheat the oven to 350°F. Line a cupcake pan with cupcake liners.
  2. In a large mixing bowl, combine the sugar, vegetable oil, eggs and lemon extract. Beat on medium speed until the eggs and oil are well incorporated and the batter is lighter in color, about 2 minutes. Scrape down the bowl as needed. Next, add the lemon zest and the sour cream and beat until well combined.
  3. Combine the dry ingredients in a separate bowl. Alternate adding half the dry ingredients followed by half of the liquid ingredients (buttermilk and lemon juice) and mix just until the flour starts to incorporate. Use a spatula to scrape down the sides of the bowl and stir the batter from the bottom to the top to ensure it’s well mixed.
  4. Using a large cookie scoop, divide the batter evenly, filling each liner 2/3 full. Careful not to overfill. Bake at 350°F for 15-18 minutes. Test the cupcakes for doneness by inserting a toothpick into the center of the cupcake. If the toothpick comes out clean, the cupcakes are done. Cool Completely.

Frosting :
  1. Add your freeze-dried strawberries to a high-powered blender (or a food processor) and blend until they become a fine powder.
  2. Next, add the freeze-dried strawberry powder, powdered sugar, vanilla extract and beat for 2-3 minutes more, starting on low speed and slowly increasing to high.
  3. Add in a few tablespoons of milk to thin the frosting out, beat again until smooth.
  4. Spread frosting onto cooled cupcakes with Knife or pipe frosting onto the cupcakes for extra flare. Ether way they taste great. Optional top with sliced strawberry.
Final Chance on Human Kinetics Discount!
For those of you still interested in purchasing Lauren's book - take advantage of the discount from Human Kinetics before June 30!

The discount code HKSAVE20B will provide 20% off anything on their website, including Lauren's book 'High Performance Nutrition for Masters Athletes'!

You can also purchase Lauren's book through Amazon HERE
A Note From Lauren
I always look forward to running clinics and training kickoff events. What a great way to learn from leaders and professionals of the field, as well as join/build a community of support - and possibly meet new friends!

I just spoke at the Finish Line PT Marathon Kickoff Event last week and we had a great crowd, especially considering we're still finding our back to 'normal'. I want to call out the individuals in the photo above - who all spoke at the event and are great resources for anything you need while training!

I wanted to include some information about salt, especially with the weather getting warmer and athletes now training during heat and humidity. Salt is usually overlooked by athletes when training - which can result in fatigue and tight muscles following a session if not properly replenished with other electrolytes lost through sweat. Now is the time to find a product (or products!) to try if you haven't already found one you like. It's okay to try a few different kinds to find the one (or couple!) that's right for you. You can find these products in almost any grocery/health food store or athletic store. If you need help finding the best product for you, or have any questions regarding your nutrition plan for training, feel free to reach out to us at our office, or on Twitter @NutritionEnergy, Instagram @NutritionEnergy and @NutritionEnergy_Fuels, or Facebook!

Lauren Antonucci
Nutrition Energy