What Is RED-S? Experts Explain the Disorder That May Hit Paralympians the Hardest

In order to talk about RED-S (relative energy deficiency in sport), we first need to talk about eating disorders. While athletes of all genders grapple with disordered eating behaviors, some athletes are hit harder than others. In fact, a report from the International Olympic Committee (IOC) found that a significant population of athletes have been excluded from the research of EDs in professional and recreational sports — namely, disabled athletes. This is where RED-S comes into play.

In essence, RED-S is an energy imbalance that occurs when people (especially athletes) don't get enough fuel — either by restricting or burning too many calories. The IOC study, published in the British Journal of Sports Medicine, found that Paralympians may be fighting a silent battle against disordered eating, which raises concerns that RED-S may be more prevalent in para athletes than in non-disabled athletes.

Of the US para athletes surveyed in the study, 62 percent said they attempted to alter their weight to increase performance, 44 percent said they'd experienced menstrual dysfunctions, and 32 percent received elevated scores on the Eating Disorder Examination Questionnaire (a 28-item self-report designed to evaluate the severity of eating disorder diagnoses). All these factors are considered warning signs for RED-S.

Given these statistics, we spoke to two Paralympic athletes about what RED-S actually is, and how it's affecting disabled athletes. Read on for the full rundown, and find out what more needs to be done to center para athletes in the conversation around nutrition and body image in sports.

Susannah Scaroni, MS, RD, is a three-time Paralympics gold medalist.
Lacey Henderson, CMPC, is a Paralympian and certified mental performance consultant.

"When you boil it down, RED-S is not having a sufficient amount of fuel to provide energy for exercising and the body's essential functions," says Susannah Scaroni, MS, RD, a Paralympic gold medalist. If left untreated, RED-S can lead to poor athletic performance and a decline in health due to inadequate caloric intake (or simply burning too many calories). Brown University notes that under-consumption of calories may be intentional or unintentional — usually from disordered eating or particularly rigorous athletic training. According to a 2020 study, RED-S can also lead to:

At its core, RED-S is caused by an imbalance of energy in and energy out. For athletes, this may be caused by eating disorders, which are often sparked by the pressure to lose weight, intense training, and "lean" (read: insufficient) diets. As American long-distance runner Kara Goucher told The New York Times in a 2019 op-ed, "When someone proposes something you don't want to do, whether it's weight loss or drugs, you wonder, 'Is this what it takes? Maybe it is, and I don't want to have regrets.' Your careers are so short. You are desperate. You want to capitalize on your career, but you're not sure at what cost."

However, capitalizing on a career opportunity by shrinking your body often comes at a great cost. Para athletes specifically face their own, seldom discussed, array of pressures when it comes to nutrition and body image — first and foremost because there is little research on how much food they need to perform at a competitive level.

"There are many limitations when using a single equation to calculate [energy requirements] for able-bodied athletes," Scaroni explains. "In para athletes, different amounts of muscle mass are being used, and muscle groups are performing in ways that [able-bodied] athletes may not use them." For instance, she says, someone who races marathons in a wheelchair relies on their arms to cross the finish line much more than a non-disabled athlete. Thus, they may require distinct quantities of energy to achieve their best performance.

"Para athletes may even have different gastric motility rates, which refers to how efficiently someone's body can use the food they eat," Scaroni says. "Someone's body may use the food that they eat differently because of a spinal cord injury, for example. Or, people with cerebral palsy or those with amputations may have a different type of gait when they're ambulating in their competitions that may be less efficient than someone who is able-bodied."

These factors and many more present a challenge for para athletes deciding what to put on their plates. And it doesn't help that research on energy requirements for people with disabilities is practically nonexistent, making trial and error (and sometimes, nutritional deficiencies) a necessary step in discovering exactly what fuel is necessary for health and performance.

"The whole support system around an athlete — from parents to coaches to physical therapists to doctors — really needs to take an individualized approach to questioning an athlete about how they're consuming and what they're experiencing," Scaroni says.

Research from the National Strength and Conditioning Association indicates that lean body mass is an asset in many sports. But despite the fact that the vast majority of studies on this topic have excluded disabled athletes, many para athletes still incorporate these findings into their own athletic standards. Pursuing this aesthetic may prompt folks to tack on extra miles or increase other forms of fitness, according to Lacey Henderson, CMPC, another Paralympian. Over time, this overtraining can contribute to developing RED-S.

"There are so many old thought processes about what an athlete needs to look like in order to perform in para sports," Henderson says. In her personal experience, many para athletes feel that they must maintain a certain body size for functional purposes. "What I've seen with disordered eating and disordered eating behaviors is that [the size of a para athlete's body] is something that they feel like they might have some semblance of control over," Henderson says, adding that there's also a homogenous idea of how "inspirational" para athletes should look and behave — despite the fact that disabilities encompass hundreds of thousands of different experiences.

"We talk about 'inspiration porn' a lot in Paralympics — seeing this disabled person who overcame all these obstacles and then won a gold medal," she says. "Society doesn't like to see disabled individuals as complex people."

The desire to fit into prosthetics can also "become a huge trigger for RED-S," Scaroni adds. "You're afraid your body will change because that's another $10,000, or more, expense if you have to buy a new customized piece of equipment," she explains. "I've seen this issue for younger athletes. After adolescence, their bodies start growing, and they don't fit into their racing chair or their basketball chair anymore."

As Scaroni begins to take on the dual role of Paralympian and dietitian, she hopes to contribute to research that centers many types of bodies and experiences. And, of course, it's crucial to spotlight the lived experiences of para athletes and the challenges they face.

"We're seeing non-disabled athletes coming forward and talking about RED-S, but it's something that we also need to be included in, too," Henderson says. "Because society paints a picture of disabled people as an 'inspiration,' it almost feels like you're letting people down if you show weakness." Henderson hopes that someday soon, the sports community will stop holding para athletes to standards that force them into impossible standards. What lies beyond the pearly perception of parathletic resilience is a much more complex and human experience — one that deserves just as much discussion, research, and media attention.

Kells McPhillips is a health and wellness writer living in Los Angeles. In addition to PS, her journalism has appeared in The New York Times, Well+Good, Fortune, Runner's World, Outside, Yoga Journal, and others. On the brand side, she regularly works with Peloton, Calm, and Equinox.

Chandler Plante is an assistant editor for PS Health & Fitness. Previously, she worked as an editorial assistant for People magazine and contributed to Ladygunn, Millie, and Bustle Digital Group. In her free time, she overshares on the internet, creating content about chronic illness, beauty, and disability.