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Relative Energy Deficiency in Sport (RED-S) Targets Women


When Pippa Woolven was offered an athletic scholarship to run cross country and track at her dream school, Florida State University, she was thrilled. Moving from England to Florida, she embraced the sport with passion. However, what began as an exciting adventure soon turned into a challenging ordeal, highlighting the dangers of relative energy deficiency in sports (RED-S).

The Passion and the Struggle

Initially, Woolven loved being part of a community of athletes who shared her passion for running. However, her enthusiasm soon gave way to months of illness, consistent injury, and overwhelming fatigue. Woolven initially believed these symptoms were just part of being an athlete. But as they persisted, she realized something was wrong.

What is RED-S?

RED-S occurs when an athlete expends more energy than they consume through food. This energy deficit means the body lacks the necessary fuel for essential functions, including fighting infections, rebuilding bone, regulating emotions, and maintaining muscle and menstrual cycles. While RED-S is a relatively new term, it is related to the older concept of the female athlete triad.

The Female Athlete Triad

The female athlete triad includes three interrelated conditions: disordered eating, menstrual cycle irregularity, and low bone mineral density (osteoporosis). This triad was first identified in 1992 by the American College of Sports Medicine, highlighting the impact of intense training and weight concerns on female athletes.

Disordered Eating

Disordered eating involves behaviors like restricting food intake, obsessing over calories, skipping meals, and inducing vomiting, often driven by sport-related pressures. In sports emphasizing a certain body image, such as ballet or gymnastics, athletes may face immense pressure to maintain a specific look, leading to disordered eating.


Dysmenorrhea, characterized by menstrual cramps and pelvic pain, or amenorrhea, the absence of menstrual periods, can result from disordered eating. When the body lacks proper nutrition, it ceases hormone production necessary for a regular ovulation cycle, prioritizing survival functions instead.


Low bone mineral density, commonly associated with aging, can affect young athletes experiencing the female athlete triad. Disordered eating and irregular periods lead to low estrogen levels, crucial for bone health, increasing the risk of stress fractures and osteoporosis.

Expanding the Concept: RED-S


In 2014, the International Olympic Committee introduced the term RED-S to describe the broader health impacts of low energy availability (LEA) across genders. LEA occurs when an athlete’s energy expenditure exceeds their dietary intake, leaving insufficient energy for vital bodily functions. This energy deficit can cause a range of symptoms, including psychological issues, fatigue, gastrointestinal problems, and more.

Symptoms of RED-S

RED-S affects the entire body, and its symptoms can vary widely. Some of the symptoms include:

  • Increased Injury Risk: Frequent injuries, especially stress fractures, are common in athletes with RED-S.
  • Mental Health Issues: Depression, anxiety, and irritability are often seen in athletes with RED-S.
  • Menstrual Irregularities: Loss or dysregulation of menstrual function is a significant symptom.
  • Decreased Muscle Strength: Difficulty building or maintaining muscle strength due to hormonal imbalances.
  • Iron Deficiency: Low nutrient intake can lead to iron deficiency anemia.
  • Gastrointestinal Problems: Constipation and stool leakage are common gastrointestinal issues.
  • Reduced Athletic Performance: Overall performance declines, often prompting athletes to seek help.

Causes and Risks

RED-S can affect any athlete, regardless of gender. The transition from the female athlete triad to RED-S underscores that anyone can be impacted by low energy availability. Factors like sport-specific pressures, intense training, and inadequate nutrition contribute to the development of RED-S.

Athletes in sports that emphasize body weight, like running and cycling, or those focusing on aesthetic performance, like ballet, are particularly vulnerable. Even older athletes can experience RED-S, especially when they diet to manage age-related weight gain, inadvertently creating an energy deficit.

Recognizing and Preventing RED-S

Recognizing RED-S can be challenging because symptoms develop slowly and are often ingrained in sports culture. Early warning signs include restrictive eating habits and a decline in physical and mental health. It’s crucial for athletes to talk about their experiences and seek help.

Preventing RED-S involves understanding proper nutrition and viewing food as fuel. Athletes should balance their energy intake with their expenditure to avoid energy deficiency. Working with a registered dietitian can be instrumental in developing healthy nutrition habits.

Pippa Woolven’s journey inspired her to create Project RED-S, an organization providing information and support to athletes struggling with energy deficiency. Her story highlights the importance of awareness, conversation, and proper nutrition in preventing and managing RED-S.

Have you or someone you know experienced symptoms of RED-S? What strategies have helped you manage or prevent this condition? Share your thoughts and experiences in the comments below. Your insights could help others navigate their own health journeys and contribute to a supportive community for athletes facing similar challenges.


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Say Goodbye to BMI: Here’s the New Metric For Measuring Healthy Weight


For decades, Body Mass Index (BMI) has been the go-to method for estimating a person’s body fat and categorizing their weight status. However, new research suggests that BMI might not be the best tool for this job. A study published in JAMA Network Open introduces the Body Roundness Index (BRI) as a more precise alternative.

The Limitations of BMI

BMI, developed in 1832, has been widely used since the 1980s. Despite its popularity, BMI has significant limitations. It calculates body fat based on height and weight alone, without considering other crucial factors like muscle mass, bone density, and fat distribution. This means BMI can misclassify individuals with different body compositions. For example, athletes with high muscle mass often have a higher BMI, which inaccurately suggests they have excess body fat. Conversely, older adults with less muscle mass might have a lower BMI, overlooking excess fat.

What is the Body Roundness Index?

The BRI aims to address these shortcomings by incorporating additional measurements. Unlike BMI, which only uses height and weight, BRI also considers hip and waist circumferences. These extra measurements help estimate total body fat and visceral fat more accurately. Visceral fat, a deep belly fat surrounding the organs, is particularly harmful to health.

How BRI Works

BRI is based on the concept that the human body is more egg-shaped than cylindrical. By comparing waist or hip circumference to height, BRI provides a more nuanced picture of body composition. Developed by Diana Thomas, a mathematics professor at the U.S. Military Academy at West Point, BRI uses the mathematical concept of eccentricity. Essentially, the closer someone is to being circle-shaped, the closer their BRI will be to zero. Conversely, the more they resemble a straight line, the closer their BRI will be to one.

Why BRI is More Accurate


The study analyzed data from the National Health and Nutrition Examination Survey, involving around 33,000 Americans over nearly 20 years. Researchers found that BRI was better at categorizing individuals’ weight status and estimating their body composition. When plotting the risk of death based on BRI, the data formed a bell curve, clearly showing higher risks at both extremes. BMI data, on the other hand, produced a flatter curve, masking important variations in the middle range.

Practical Benefits of BRI

One of the main advantages of BRI is its accessibility. Unlike specialized scales or scans, which are not always available or accurate, BRI only requires a measuring tape. This simplicity makes it easier for more people to use, promoting better health tracking across various settings.

While BRI is a significant improvement over BMI, it’s not without its own limitations. It still doesn’t measure muscle mass, which is a crucial component of overall health. However, experts believe BRI is a step in the right direction toward more accurately measuring body composition.

As we learn more about the complexities of body composition, it’s clear that BMI is not a one-size-fits-all measure. The Body Roundness Index offers a more accurate and accessible way to assess obesity and related health risks. Have you ever measured your BRI or used another method to understand your body composition? Share your experiences and thoughts in the comments below!


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Overweight and Obesity in Youth Linked to Increased Stroke Risk in Women

A comprehensive analysis of over 50 years of health data has revealed a significant correlation between being overweight or obese at a young age and the risk of experiencing an ischemic (clot-caused) stroke before the age of 55 in women. This research, published in Stroke, the journal of the American Stroke Association, highlights the long-term health impacts of early life weight issues.

The study, conducted in Finland, examined the influence of body weight at ages 14 and 31 on stroke risk. It found female participants who were overweight by 14 had significantly increased chances of strokes later in life –  even if they lost the weight by 31. Similarly, women who were overweight at age 31 had a higher risk of stroke regardless of their weight at age 14. Notably, this increased risk was not observed in men who were overweight at ages 14 or 31. However, men with obesity at age 31 showed a higher risk of bleeding stroke compared to women with obesity at the same age.

Long-term Health Effects of Early Weight Issues

Long-term Health Effects of Early Weight Issues

Lead study author Ursula Mikkola, B.M., from the Research Unit of Population Health at the University of Oulu, emphasized the long-term health effects of being overweight, even if the excess weight is temporary. She advocates for healthcare professionals to address overweight and obesity in young people by promoting healthier eating patterns and physical activity, but to do so in a non-judgmental and non-stigmatizing manner.

Data from the Northern Finland Birth Cohort 1966

Data from the Northern Finland Birth Cohort 1966

The researchers utilized data from the Northern Finland Birth Cohort 1966, which has followed more than 10,000 individuals from birth into their 50s. This extensive dataset allowed for a thorough analysis of the impact of body mass index (BMI) at different ages on the risk of early stroke.

The study found that approximately 1 in 20 participants experienced a clot-caused stroke or transient ischemic attack (TIA) during the follow-up period. Women with obesity at age 14 were 87% more likely to experience a clot-caused stroke, and those with obesity at age 31 were 167% more likely to have a stroke compared to their peers at appropriate weight. Women with obesity at age 31 also had nearly 3 ½ times the risk of bleeding stroke, while men with obesity at the same age had more than 5 ½ times the risk of bleeding stroke.

Implications for Preventive Health

Implications for Preventive Health

The findings suggest that addressing weight issues early in life can have a significant impact on reducing stroke risk later on. Mikkola advises that adopting a healthy lifestyle, including balanced eating, regular physical activity, avoiding smoking, and managing other health parameters like blood pressure and cholesterol, can help mitigate the risk of stroke even if one was overweight during youth.

The study found that the increased risk of clot-caused stroke was specific to women, with researchers currently investigating the underlying reasons for this gender disparity. This research will help to better understand the complex interactions between gender, weight, and stroke risk.

Editorial Insights

Editorial Insights

In an accompanying editorial, Dr. Larry Goldstein, a member of the American Heart Association Stroke Council, noted the significance of these findings. He highlighted that while the data supports the association between early-life overweight/obesity and stroke risk, further research is needed to determine if reducing overweight/obesity in younger populations will lead to lower stroke rates in adults.

The analysis included 10,491 participants in their 50s, with BMI measured at ages 14 and 31. The study identified ischemic strokes and TIAs using national hospital and death registers and adjusted for various factors, including smoking status, education levels, and age at first menstrual period for women.

However, as an observational study, it cannot definitively establish a cause-and-effect relationship between weight and early stroke risk. Additionally, the study’s population was exclusively Finnish, which may limit the generalizability of the results to other populations.

This study underscores the critical importance of early weight management and healthy lifestyle choices in reducing the risk of stroke later in life. Addressing obesity and overweight issues during youth can have profound long-term health benefits, particularly for women.

What steps have you taken to manage your weight and reduce health risks? How do you think these findings should influence public health strategies? Share your thoughts and experiences in the comments below. Your insights could help others take proactive steps towards a healthier future.

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Overweight? Here’s WHEN You Should Exercise


Recent research from Spain suggests that exercising in the evening can be particularly beneficial for managing blood sugar levels in people who are overweight or obese. This study underscores the importance of precision in exercise prescription, highlighting that the timing of physical activity can significantly impact its effectiveness.

Conducted by a team led by Jonatan R. Ruiz, a professor of physical activity and health at the University of Granada, the research tracked the blood sugar levels and physical activity patterns of 186 overweight or obese adults. Participants were divided based on their exercise times: between 6 a.m. and noon, noon to 6 p.m., or 6 p.m. to midnight.

The results were striking. Those who exercised in the evening exhibited lower blood sugar levels throughout the day, at night, and overall, compared to those who exercised earlier in the day. This effect was even more pronounced in participants with prediabetes, a condition that significantly increases the risk of developing Type 2 diabetes.

The Importance of Timing in Exercise

Study author Jonatan R. Ruiz emphasized that certified sports and medical professionals should consider the optimal timing of exercise to enhance the effectiveness of the physical activity programs they prescribe.

The findings, to be published later this year in Obesity, the flagship journal of the Obesity Society, contribute to a growing body of evidence suggesting that the timing of exercise can influence metabolic outcomes. For instance, a UK study released in April found that nighttime physical activity could lead to lower morning blood sugar levels. Additionally, research from May 2023 indicated that adults with Type 2 diabetes saw the best blood sugar control when they were most active between 1:43 p.m. and 5 p.m.

Why Evening Exercise?

The reasons why evening exercise may be particularly effective for blood sugar management are not yet fully understood. However, it is hypothesized that exercising later in the day may better align with the body’s circadian rhythms, which regulate many physiological processes, including metabolism.

Additionally, post-meal exercise is known to help manage blood sugar spikes. Given that many people consume their largest meal in the evening, engaging in physical activity afterward could help mitigate these spikes and improve overall blood sugar control.

Practical Implications

Dr. Lucy Chambers, head of research communications at Diabetes UK, commented on these findings, noting that while afternoon exercise appears to offer significant benefits, the most crucial factor is consistency. This could be before work, during a lunch break, or in the evening.

For individuals with Type 2 diabetes or those at risk, incorporating evening exercise into their daily routine could be a strategic way to manage blood sugar levels. Activities such as brisk walking, jogging, cycling, or even engaging in a group fitness class can be effective.

Broader Context

With over 38 million Americans living with diabetes, characterized by elevated blood sugar levels, finding effective management strategies is crucial. Alongside dietary modifications and medications, exercise is a cornerstone of diabetes management. This new research provides an additional layer of nuance, suggesting that not only the amount and type of exercise but also the timing can make a significant difference.

In summary, evening exercise could offer a strategic advantage for blood sugar management in overweight and obese individuals. While further research is needed to fully understand the mechanisms behind this effect, the current findings support the inclusion of evening workouts as part of a comprehensive approach to managing blood sugar levels and overall metabolic health.

Have you tried adjusting the timing of your exercise routine to see if it affects your blood sugar levels? What strategies have worked best for you? Share your experiences and insights in the comments below. Your contributions could help others find effective ways to manage their health through exercise.


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