🥣 A Dancer & Dance Educator’s Guide to Relative Energy Deficiency in Sport (RED-S)

Feb 22 / Emily Everton, DPT
Hi, friends! This is The Dance Scientist, here to introduce my 2nd guest blog writer on The Dance Science blog. Enjoy! The demands of dance are intense to say the least. Not only are the physical demands high, but dancers are also faced with unique mental and emotional demands. Whether intentional or not, chronic under-nutrition often occurs as the result of busy dance schedules and external pressure to maintain a particular physique. 
With this in mind, it’s not surprising that dancers have a high risk of developing Relative Energy Deficiency in Sport, or RED-S.With research evolving and RED-S becoming more well known amongst practitioners, greater emphasis is being placed on spreading awareness and preventing this condition within the dance community. As RED-S is linked to poorer overall health, wellbeing, and performance, it is imperative dancers, dance educators, and the wider community gain understanding and awareness of this condition. Here’s what you need to know!What is RED-S?RED-S is a condition resulting from low energy availability, or LEA. LEA occurs when energy intake from food does not meet the energetic demands of daily activities, growth, and training.

The term RED-S was introduced by the International Olympic Committee in 2014 in an updated consensus (2018 IOC consensus update here). It was introduced as a broader term for the ‘Female Athlete Triad’, which is a spectrum condition of three interrelated components: low energy availability, menstrual irregularities, and impaired bone health. This change in terminology was made to reflect the complexity involved in the condition and to illustrate the fact that men can be impacted, too.1The negative implications RED-S has on overall health expands beyond the originally documented consequences on menstrual function and bone health. If left untreated, RED-S can impair systems throughout the body, including:Immune system functionMetabolic healthThe reproductive system: menstrual function and libidoGastrointestinal system functionCardiovascular system functionEndocrine system functionBone healthGrowth & developmentPsychological healthHematological system function

How Does RED-S Impact Dance Performance?
Perhaps more relatable and concerning to dancers and dance educators is the negative impact RED-S can have on dance performance. Particularly in the presence of amenorrhea, or loss of periods for >3 months, dancers are at much greater risk for stress fractures/bone stress injuries.Common performance-related symptoms dancers with RED-S experience include, but are not limited to:Feeling more fatigued and/or tiredTrouble focusing and picking up on choreographyImpaired judgmentDecreased coordinationDecreased balance, strength, endurance, and powerDecreased response to training (i.e. no progress despite deliberate efforts to improve)Irritability, depression, anxiety, mood changesAppetite changesIncreased injury occurrence and delayed healing/recovery from injury (i.e. overuse injuries)Increased occurrence of bone stress injuries (i.e. stress fractures)It’s worth noting that dancers may actually see a temporary improvement in performance and energy at the start of RED-S. Though this may seem advantageous, it is short lived and the negative consequences arise fairly quickly.Why Dancers May be at Greater Risk for Developing RED-SMany dance schools and companies continue to prioritize a lean physique and particular body ideal. Likewise, from a young age dancers are taught to bring awareness to their bodies, both from themselves and others. The emphasis on body appearance, in addition to the message that low body weight and thinness is advantageous from an aesthetic and performance perspective, places a lot of pressure on artistic athletes. In fact, research has shown that compared to the general population, ballet dancers show a higher drive for thinness and a higher level of food restriction.

Contrary to intentional food restriction, low energy availability also occurs unintentionally in dancers. Unintentional LEA may be a result of increased energy expenditure from increased dance training, auditions, rehearsals, and performances without increased food intake to match the demands. This is of particular concern in young dancers as their bodies already require more energy for growth and development, particularly attainment of peak bone mass.4Prevention of RED-S in Dancers: Dance EducatorsWith a better understanding of what RED-S is, the negative implications on overall health and performance, performance-related symptoms dancers may experience, and why dancers may be at greater risk of developing RED-S, let’s now talk about ways we can prevent it.True prevention of RED-S lies in awareness and shifting dance culture. Perhaps the most influential individuals in the prevention of RED-S are dance teachers/educators and artistic directors.

Here are a few easy prevention tips that can be implemented right away:Eliminate body shaming and foster a climate inclusive of all body weights, shapes, and sizes.Seek education and increase awareness of low energy availability/RED-S for all studio, company, and/or school educators. Awareness and identification are crucial in prevention and early detection of RED-S.Normalize and encourage appropriate fueling, without overemphasis on healthy eating. Foods should never hold moral value, or be labeled ‘good’ or ‘bad’. Doing so can lead to the development of orthorexia nervosa and further contribute to RED-S.Dance educators play a pivotal role in preventing RED-S; this role can’t, and shouldn’t be taken lightly! For more information on prevention tips, check out this post.Tips for Dancers to Reduce their Risk of RED-SIn addition to the essential role dance educators play in prevention of RED-S, dancers can also take action to reduce their risk of developing this condition.As RED-S is a result of low energy availability, the most important thing to ensure is adequate fueling. Try to build a meal plan that consists of at least 3 meals and 2-3 snacks per day. Meals and snacks should be dispersed throughout your day: between the morning, afternoon, and evening.Helpful tip: try meal prepping ahead of time for those days filled with class and rehearsals.

Snacks can be simple, easy to grab options like nuts/seeds or granola barsAdequate rest and recovery is also essential. The average adult should be getting 7-9 hours of sleep per night. Dancers, especially young dancers, require even greater amounts of sleep, closer to 8-10 hours per night. Sleep is crucial to allow for muscle recovery, mental clarity, and proper hormone function to name a few.7Helpful tip: try to create a bedtime routine. This may look like a cup of tea, some light stretching, and/or reading a book within the hour before you go to sleep. Consistency in a sleep and wake routine can be helpful. If possible, eliminate cell phones and electronics leading up to bedtime.And finally, seek help and support from healthcare professionals. Even if you are not concerned about RED-S, a consultation with a Registered Dietitian, for example, can be invaluable to ensure you are meeting the unique needs of your body to maintain optimal health and perform at your best.Helpful tip: try to seek care from health professionals specializing in Dance Medicine. This will ensure they are familiar with the unique demands of dance and result in optimal care for youFinal Take-AwaysRED-S has negative implications on overall health, wellbeing, and performance. It is a condition resulting from low energy availability, or inadequate energy in the form of food to support the demands of daily activities, growth/development, and training. Dancers are thought to be at an increased risk for developing RED-S given the large focus on body aesthetics and a ‘thin ideal’. Dance teachers/educators play a pivotal role in the prevention of RED-S, but dancers can also take action to reduce their risk of developing it.RED-S is both preventable and curable. If you think you, your peers, or your dancers may be struggling with RED-S, contact your nearest Sports Physician specializing in Dance Medicine and RED-S for a consultation. Treatment is multidisciplinary and, depending on the presentation, may consist of collaboration between a Physician, Registered Dietitian, Psychologist or Psychotherapist, Physical Therapist, and Strength/Conditioning specialist. Early detection is key!

Resources on RED-S for Dancers and Dance EducatorsResearch on RED-S is continuously growing, but there are also many great programs and communities dedicated to educating and spreading awareness on this condition. Here is a non-exhaustive list of resources for the female athlete community!Health4Performance: for dancers, athletes, teachers, coaches, health professionals, and familiesBoston Children’s Female Athlete Program: the health professionals working within the Female Athlete Program take a comprehensive approach to diagnosing, treating, and managing sports injuries in female athletesStanford FASTR Program: The FASTR program seeks to help close the gender gap in sports science research with an emphasis on early identification and interventions to prevent injury and identify ways to optimize performance in female athletes.

Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., Meyer, N., Sherman, R., Steffen, K., Budgett, R., & Ljungqvist, A. (2014). The IOC consensus statement: beyond the Female Athlete Triad--Relative Energy Deficiency in Sport (RED-S). British journal of sports medicine, 48(7), 491–497. https://doi.org/10.1136/bjsports-2014-093502Wasserfurth, P., Palmowski, J., Hahn, A., & Krüger, K. (2020). Reasons for and Consequences of Low Energy Availability in Female and Male Athletes: Social Environment, Adaptations, and Prevention. Sports Medicine - Open, 6(1). https://doi.org/10.1186/s40798-020-00275-6Hoenig, T., Ackerman, K. E., Beck, B. R., Bouxsein, M. L., Burr, D. B., Hollander, K., Popp, K. L., Rolvien, T., Tenforde, A. S., & Warden, S. J. (2022). Bone stress injuries. Nature reviews. Disease primers, 8(1), 26. https://doi.org/10.1038/s41572-022-00352-yBMJ. (2018, August 16). What is Dance Medicine? BJSM Blog - Social Media’s Leading SEM Voice. https://blogs.bmj.com/bjsm/2018/08/16/what-is-dance-medicine/RED-S | Boston Children’s Hospital. www.childrenshospital.org. https://www.childrenshospital.org/conditions/red-sValliant, M. W. (2016). The Female Athlete Triad and Relative Energy Deficiency in Sport. Strength and Conditioning Journal, 38(2), 35–39. https://doi.org/10.1519/ssc.000000000000020Watson, N. F., Badr, M. S., Belenky, G., Bliwise, D. L., Buxton, O. M., Buysse, D., Dinges, D. F., Gangwisch, J., Grandner, M. A., Kushida, C., Malhotra, R. K., Martin, J. L., Patel, S. R., Quan, S. F., & Tasali, E. (2015). Recommended Amount of Sleep for a Healthy Adult: A Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society. Sleep, 38(6), 843–844. https://doi.org/10.5665/sleep.4716

Meet the Guest

Emily Everton PT, DPT 

Emily Everton PT, DPT is an Orthopedic Physical Therapist with a specialty in Dance Medicine and treatment of the Artistic Athlete. Emily has helped hundreds of athletes and active individuals rehabilitate from injury, enhance performance, and build resilience to do what they love, for life. Emily spent years working in Boston providing care for dancers from the Boston Ballet, Boston Conservatory, Walnut Hill School for the Arts, Urbanity, DanceWorks, VLA Dance, and other surrounding studios as well as freelance dancers in the Boston region. In addition to her clinical interest in the treatment of the artistic athlete, Emily is also passionate about educating and spreading awareness on the topic of Relative Energy Deficiency in Sport (RED-S) and helping individuals, as part of a multidisciplinary team, navigate complex relationships with food, exercise, and body image.

Emily's expertise and passions are driven by her own background in competitive dancing, acrobatics, and cheerleading. Emily lives in Hopkinton, MA with her husband and rescue pup, Kona. When she's not working, you can find her exploring nature while listening to a podcast, traveling, or spending time with family and friends!Emily is the founder and owner of her practice, Embody Physical Therapy & Wellness, LLC, where she helps active girls and women come back home to their bodies and build resilience to do what they love, for life. She works with clients both in-person and virtually, and also has options for individuals located outside of MA.
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  • Website: www.embodyptwell.comPhone: (508) 686-1414
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