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What you should know about the syndrome affecting many young athletes

For mother Hanne Hjelbak, it was an eye-opener when her son was told he had brittle bones at 17.

Hanne Hjelbak is the mother of Iver, who is a very enthusiastic middle-distance runner. After several stress fractures, they found out he had low bone density.
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Iver was a dedicated and exceptionally structured young athlete.

He had started to achieve good results on the track, and his motivation only grew stronger.

The training volume increased, and two sessions a day became normal.

Should have consumed more carbohydrates

At home, there had always been a focus on a good and nutritious diet. Mother Hanne Hjelbak was concerned with clean ingredients and a balanced diet with nutrient-dense food.

But at 16, the injuries started to come. He experienced stress reactions and fatigue fractures in both his shin and back, and the injuries just returned every time he resumed training.

Nutritionist Christian Johnston describes REDs as a syndrome that has many different effects on the body.

A DXA scan at the Sports Health Centre would give the family surprising answers. Iver had low bone density and showed many signs of relative energy deficiency in sport (REDs).

“For me, it was an eye-opener. He ate a lot, so I felt confident that he was getting enough. But when I received this information, I immediately felt a kind of guilt. What had I overlooked here?” says Hanne.

What is REDs?

REDs is an abbreviation for Relative Energy Deficiency in Sport, meaning relative energy deficiency in sports. REDs describes a collection of symptoms and findings caused by persistent or repeated episodes of too low energy intake relative to the body's needs. In such a situation, the body prioritises energy for physical activity, while some basic bodily functions are deprioritised and put on 'low power mode.'

(Source: NIH)

The family first shared their story on the Norwegian Broadcasting Corporation NRK earlier this winter.

In retrospect, Hanne sees that there was particularly one thing they had too little of at home.

“He clearly had a great need for calories, preferably in the form of fast carbohydrates. I must admit that I had overlooked this in his diet,” she says.

A syndrome with various effects on the body

Christian Johnston is a clinical nutritionist at the Sports Health Centre and met Iver when he came in for examination.

He has met many adolescents like Iver recently, and they often have many similar characteristics.

“It doesn't have to be eating disorders or nutrition-related illnesses or allergies. Very often we're talking about young, ambitious athletes who train hard and are concerned with eating healthy and being healthy, but who don't quite understand how much energy they actually need,” he says, and adds:

“Maybe they have little time in everyday life and don't manage to eat as much as they need.”

Johnston describes REDs as a syndrome that has many different effects on the body.

They can be vague and vary greatly from person to person.

“If you have a high training load and a high energy requirement that's not met by food intake, it can create problems for a growing body,” he says. 

REDs in 1-2-3: This film is for coaches, leaders, or parents of young athletes or dancers who train a lot, often up to multiple times a day.

In both individual and team sports

Johnston mentions reduced training outcomes and performance, more frequent injuries and illness, but also reduced production of sex hormones and lower bone density.

At WANG Elite Sports School, they are also very familiar with these stories.

Stine Østvold Aamodt is the project manager for Holistic Health at WANG and sees adolescents with REDs in many different sports.

Not just in aesthetic and weight-class sports, which have previously received the most attention. 

“We also see it in some of the endurance sports, and now increasingly in team sports. We find that many get a bit lost in the details and forget the bigger picture,” says Aamodt, who has coaching education from the Norwegian School of Sport Sciences (NIH).

Stine Østvold Aamodt, together with NIH professor Anne Marte Pensgaard, has received funding from the Tom Wilhelmsen Foundation to spread knowledge about REDs. This has resulted in several films aimed at coaches, healthcare professionals, and parents.

Active adolescents need more food than you think

But how much should a growing adolescent who maybe trains twice a day actually eat?

The nutritionist believes the simplest thing to say is that it's more than most people think.

“It's difficult to say something concrete, because it varies greatly and depends on body size and how one trains. But when we're talking about a growing athlete, something that requires a lot of energy, it's difficult to get too much,” she says, adding:

“As long as you have a sensible diet and eat regular, normally healthy food, it's almost like the more, the better.”

Criticism about focus on sugar

Following the NRK article, there was some criticism around the focus on sugar and sweets. Both Iver and Niels, whom NRK also wrote about, incorporated dessert, ice cream, and sweets into their daily routines as part of the dietary change.

“It's not about sugar and sweets, and it never has been. That's not what we talk to the athletes about either. It's about having a relaxed enough relationship with food and the knowledge to understand that you can treat yourself to sweets on the weekend, and snacks on weekdays too. In addition to the regular, healthy food,” says Johnston.

Carbohydrates are more important than many think

He notices that athletes, coaches, and parents are influenced by the discussion in society. Carbohydrates are also viewed as something a bit scary.

“For most young athletes, carbohydrates are much more important than many think. There's a lot of focus on protein these days, but for most athletes, it's actually carbohydrates they should focus on. That's what they get too little of,” Johnston believes.

When treating athletes at the Sports Health Centre, he works specifically on getting them to consume carbohydrates during training sessions.

“We recommend them to get carbohydrates in the form of sports drinks or regular household juice during training. What we see is that it not only positively affects performance, but can also potentially impact bone tissue. It has a positive effect because the body breaks down less during the session. It can potentially lower the risk of injury, but also ensure they get what they need,” he says. 

Does your adolescent have these symptoms?

What should you as a parent or coach watch out for if you're worried your young athlete isn't getting enough energy?

The experts mention these symptoms as common for an athlete who has developed REDs:

  • Mood swings
  • More tired than usual
  • More frequently sick or injured
  • Menstrual disturbances
  • Absence of morning erection

“Some also mention that they're often sore, and that it doesn't fully go away. One of these symptoms isn't enough to be concerned about REDs, but if there's a combination of several of these symptoms, it might be worth checking out,” says Aamodt.

Bread with less fibre

At the Hjelbak family home, things have gone in the right direction after the changes they made.

It wasn't just about fast carbohydrates, but looking at the entire day and Iver's training load.

It became important to eat well early in the day before training, and to consume sports drinks or juice during training, and get enough food after training.

They have also started baking their own bread.

“We got a tip that bread, which he eats a lot of, shouldn't have such a high fibre content. This makes it more easily absorbed by the body,” says Hjelbak.

He was 18 when they took a new DXA scan, a year after the first one.

The results showed that bone density had improved significantly.

“I can't explain that in many other ways than that we did something right with the diet. In addition to our focus on the big picture, on training load, and his whole daily routine," she says. 

In the aftermath of the NRK article, the family has received a lot of feedback.

They had decided that if just a few could learn from and benefit from their story, it would be worth being open in the media.

“It has already happened, and both Iver and I are very happy about that. Our goal is for more people to become aware of the great energy and calorie needs that children and adolescents have when they're so active. It can prevent health problems and, not least, avoid exclusion that occurs when one has to miss training,” she says. 

Listen to the Norwegian podcast episode below:

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