Low Energy Availability & RED-S: How Athletes and Coaches Can Restore Health, Performance, and Hormonal Balance

As coaches, we have a unique opportunity to serve as health educators and advocates for our clients. Since we interact with them more frequently than medical professionals, we are often the first to notice when something is off. While we are not diagnosing or treating medical conditions, we can guide athletes to the appropriate professional who can and we can take proactive steps to prevent issues in the first place or call out subtle signs and symptoms before they run rampant. 

One issue that runs rampant in the fitness space? Low energy availability. 

The Impact of Low Energy Availability on Health

 Energy Availability (EA) is the amount of energy “available” to sustain all physiological functions, after accounting for energy expended through exercise. It represents the calories needed to keep basic physiological functions going (think breathing, digestion, immune system ) as well as reproduction, fueling for performance, adaptations to training and general health and wellbeing.

Low Energy Availability (LEA)  is the underlying cause of relative energy deficiency in sport (RED-S). RED-S refers to impaired physiological functions caused by relative energy deficiency.

What gets impaired?   

• Bone health

• Digestion

• Metabolism

• Immune system

• Sleep, memory, and mood

Training performance? While the athlete may be able to train and show up for their sport or goals in the gym, they aren’t the athlete they could be. Eventually, they risk injury and decreased strength and endurance performance when chronically under-fueled.

45 kcal/kg FFM/day is typically recommended as the optimal energy availability to ensure sufficient energy for healthy physiological function. And that is the minimum! 

How LEA Affects Reproductive Health and Hormonal Balance

When the body lacks sufficient calories, it conserves energy by slowing down non-essential processes like reproduction. Amenorrhea and anovulatory cycles are often a result of LEA . 

While amenorrhea is a major red flag for many female athletes, it’s not the only sign of RED-S and males can suffer as well, and experience some the same symptoms I will touch on below.   The missing period is the obvious sign, and these others can be sneakier but just as important to flag.

Of note- a female may still have a period (bleed) but not be ovulating due to that low energy intake. For optimal health we do want to support regular ovulatory cycles during a females reproductive years.

In addition, because this is about energy balance, an individual can be at a healthy weight and still be in a state of LEA, putting them at risk for RED-S if there is an imbalance between energy demands and intake.

What are the signs and symptoms of LEA and RED-S ?

• Poor performance and lack of training progress

• Emotional changes like irritability or depression

• Trouble focusing or mental fatigue

• Chronic fatigue and reliance on caffeine to get through the day

• Weight and muscle loss, despite training

• Sleep disturbances (difficulty falling or staying asleep)

• Feeling excessively cold

• Increased food cravings or binge eating (the body is signaling for more energy)

• Slower recovery from training and increased injury risk

• Stress fractures or low bone mineral density

• Amenorrhea and anovulatory cycles 

• GI upset – both loose stool , constipation, bloating and reflux can all result from the stress of low intake

Lab Markers that May Shift :

• Low blood glucose and insulin , or going hypoglycemic

• Subclinically low total or free testosterone

• Low T3 and a down regulated thyroid 

• Elevated Liver Enzymes

• Low white blood cells and frequent illness

• Extreme bradycardia [(HR<40 in adult athletes; HR<50 in adolescent athletes (<18 years)] or Low blood pressure

• High cholesterol (often because of downregulated thyroid and poor liver functioning) 

My advice? Don't wait until you or your athlete checks multiple of these signs and symptoms off. Pay attention to biofeedback, increased training demands and make sure you are appropriately fueling.

How can we help as Coaches ?

First, education matters. Many women don’t realize they aren’t eating enough , under estimate how many calories they need for training and recovery, or as busy go getters, aren’t prioritizing regular meals and snacks - unintentionally leading to LEA.

Disordered eating, eating disorders, over exercising are also causes. Working with a mental health professional is recommended as ultimately, the  root causes have an even deeper mental and emotional cause that goes beyond the scope of coaching.

Here are some considerations to help get out of a state of LEA and restoring health.

Nutrition 

• For athletes with hypothalamic amenorrhea (HA) or recovering from LEA, fasted training is not ideal. These athletes are more sensitive to energy deficits, and training in a fasted state can worsen hormonal imbalances and impede recovery.

• Post training nutrition – consuming a balanced meal with at least 1.2g of carbs/kg of bodyweight and 25 grams of protein within 2 hours of training .

• Adequate carbohydrate intake is essential for athletes recovering from LEA. Carbs are the primary energy source for high-intensity training, and without them, muscle recovery and hormonal function will be compromised

• Cholesterol is the backbone of steroid hormones . At least 20% total daily calories from fat is important for hormonal health- and fats can be an easy way to increase intake . Avocado, salmon, eggs, red meat, nuts and seeds, olive/coconut and avocado oil should be a part of your athlete’s nutrition plan. 

• Skipping meals should be avoided and Extended fasts beyond 12-14 hours probably not smart .     

• Optimize gut health because absorption is just as key as eating enough calories, healthy fats and micronutrients

• Meal planning . Help with calorie dense meals , more fun foods to meet calorie needs with less volume (bowl of honey nut cheerios and chocolate milk may be a lot easier than chicken and rice ) and encourage intra workout carbs or simple grab and go options for busy lives. 

• Encourage Rest Day Nutrition: Athletes should continue to consume balanced meals on rest days. Help them understand that proper nutrition supports muscle recovery, mental clarity, and hormonal restoration, even when they’re not training.

Other Coaching Interventions for LEA & RED-S

• If your athlete is recovering from RED-S consider reducing training volume or reducing training intensity, In some cases, no training at all may be recommended . Perhaps helping them with getting curious about lower impact training modalities or activities OUTSIDE of training and physical activity such as art or hobbies they enjoyed as a kid. 

• Support Mental Health. Encourage athletes to seek support from mental health professionals. RED-S often has underlying emotional or psychological factors, so it’s crucial to address these issues alongside physical recovery.

• Remind them that hard work must be balanced with hard rest. And that they are NOT less disciplined for taking that rest. In fact, for many females this is indeed their definition of discipline. 

• Suggest strategies for Nervous system regulation (breathwork, circadian rhythm optimization, walks without headphones )

• Encourage balanced nutrition and remind them that they need to fuel despite how they may feel in the moment, and that fueling is important on rest days as well 

• STOP THE CHRONIC DIETING AND HYPER FOCUS ON AESTHETICS. We believe firmly a healthy is a respoinsve body to any and all goals. Encourage and model that .

• Track Performance and Health Metrics: It can be helpful to log strength and endurance improvements, set new goals in the gym / with training and monitor that progress as the body gets refueled. As a coach, monitor biofeedback like menstrual health, sleep quality, digestion and energy levels . Regular lab work can help identify any early warning signs of RED-S and ensure your athlete is progressing toward recovery. 

It is important to not brush off a missing cycle or any of the other RED-S consequences even if it’s uncomfortable to address these things with your athlete.  As a coach, it’s essential to foster an environment where athletes feel comfortable discussing their struggles, including body image concerns, fear of gaining weight, or feelings of inadequacy during recover.

By helping athletes recover from RED-S, coaches can significantly improve both short-term performance and long-term health. Your support in navigating this recovery process not only benefits their athletic goals but ensures they thrive in all areas of life.