“This is still a taboo in the climbing world. We all see it happen but don’t do anything about it.” Janja Garnbret, one of the greatest competition climbers of all time, is speaking at the first IFSC Climbing Summit on 30th November 2022.
“Do we want to raise the next generation of skeletons? This is the question we have to ask ourselves. It is definitely not going into the right direction and we have to do something about it.”
Climbing has long had an issue with weight as we compete against gravity — a focus on feeling “light” over feeling “strong”. The benefits of losing a kilo of weight are felt immediately, while the health consequences take longer to appear. Reducing eating to remain “light” can lead to athletes developing RED-S. This chronic disease is the result of a long period of prolonged under-fueling. This under-fueling can lead to severe long-term health and performance complications.
Climbing has a RED-S problem.
Now, the IFSC is doing something about it.
What Is RED-S?
Relative energy deficiency in sport (RED-S ) was introduced in 2014 in an IOC Consensus statement that sought to broaden and introduce a more comprehensive term for the effects of low energy availability.
The existing theory of the Female Triad 1 of energy availability, menstrual function and bone health was invented in 1993 and focused on a condition seen in young female athletes. The scientists behind the 2014 Consensus wanted to include other complex factors and male athletes with the definition of RED-S.
Since the 2014 Consensus, there have been two more IOC Consensus on RED-S, in 2018 and 20232. These consensuses aim to stimulate advances in RED-S awareness, clinical application and scientific research to understand the disease better. The 2023 Consensus proposed a new diagnostic tool, IOC RED-S CAT 2, based on research from over 170 articles published since the 2018 consensus.
RED-S has affected athletes from many different sports, including running, swimming, body building, other Olympic sports, and climbing.
What Causes RED-S?
The fundamental cause for RED-S is a prolonged or severe period of problematic low-energy availability. The equation defines energy availability as:
$$\text{Energy Availability} = \frac{\text{Energy Intake (kcal)} - \text{Exercise Energy Output (kcal)}}{\text{Fat-Free Mass (kg/day)}}$$
Fat-free mass refers to a person’s mass minus their fat mass. This measure includes water, organs, and muscle mass. Fat-free mass is a good measure of lean body mass, though it can be hard to calculate without an accurate Bone Mineral Density/DXA scan.
The 2023 Consensus states that a normal energy availability to maintain body mass is around 45kcal/kg per day. A healthy range for people looking to reduce their body mass is 30–45kcal/kg per day2 (p1079).
For a person with a fat-free mass of 50kg, a healthy energy availability would be 2250 kcal a day to maintain body weight and healthy function. An athlete must eat enough to meet this need and fuel for the requirements of their sport on that day.
Low energy availability is considered below 30 kcal/kg per day. The 30 kcal/kg per day threshold was calculated from a specific small study investigating changes in energy availability by tracking hormones.
This threshold is considered a guide, with many recent studies challenging the threshold. They find that the threshold varies depending on the individual, their sex, and among different body systems (p1080, 2 ).
For a person with a fat-free mass of 50kg, the low energy availability threshold would be around 1500 kcal a day.
While this definition is specific, no gold standard exists for measuring energy availability. Measuring energy availability is made more difficult when measuring energy availability in athletes with varied exercise regimens. Instead, screening those at risk to get an early diagnosis and monitoring the condition throughout training is key to preventing illness and injury.
How Is RED-S Diagnosed?
RED-S does not have a simple diagnosis, with other conditions having to be ruled out through a complex screening to understand an athlete’s history and physiology.
The IOC 2023 Consensus on RED-S put forward the IOC RED-S CAT 2, which categorises the main indicators of RED-S (2, p1085). These are then used to assess the severity of a person’s condition.
Severe Primary Indicators (worth two in the scoring)
- A failure to menstruate by age 15 in the presence of normal secondary sexual development, or within 5 years after breast development if that occurs before age 10 (primary amenorrhoea), or absence of 12 or more consecutive menstrual cycles (prolonged secondary amenorrhoea).
- Clinically low free or total Testosterone in men below the reference value
Primary Indicators
- The absence of 3 – 11 consecutive menstrual cycles in females (secondary amenorrhoea )
- Subclinically low total or free Testosterone in men within the lowest25% of the reference range
- Subclinically or clinically low total or free triiodothyronine (T3), a thyroid hormone that affects almost every physiological process, including growth and development, metabolism, body temperature, and heart rate.
- History of ≥1 high-risk (femoral neck, sacrum, pelvis) or ≥2 low-riskbone stress injuries (all other locations) within the previous 2 years or absence of ≥6 months from training due to bone stress injuries in the previous 2 years.
- Low Bone mineral density score at the lumber spine, total hip or femoral neck, or a decrease over previous measurements.
- Negative deviation in the growth trajectory for a child or adolescent.
- An elevated score on an eating disorder questionnaire or a clinical diagnosis of an eating disorder.
Secondary Indicators
- Prolonged and infrequent period (Oligomenorrhoea) with more than 35 days between periods for a maximum of 8 periods a year.
- History of one bone stress injury from the last two years and absence from training for at least 6 months due to the bone stress injury within the last two years,
- Elevated total or LDL cholesterol
- Clinically diagnosed depression and/or anxiety
Does This Really Happen in Climbing?
In 2019, Mina Leslie-Wujasik, a Boulder World Cup finalist and strong outdoor climber, was the first to write about her diagnosis of Relative Energy Deficiency in Sport, despite having a healthy BMI and performing at a high level.
Since then, other athletes have revealed their struggles with eating and its effect on their bodies.
Kai Lightner, US National champion and Youth World Champion, was told at 14 that his liver was close to failure and he had fractured his spine in two places discovered the dangerous consequences of restricting his diet for performance.
Melina Costanza, 2021 & 2023 US national champion, wrote about her struggles with an eating disorder, which came to a head when she broke her foot while weighing a foothold at an IFSC World Cup in 2023. She then quit competition climbing to focus on her health and has only recently returned.
”Not only did my performance suffer from the energy deficit, but everything from my sleep cycle to my concentration in school was also affected. I allowed myself to believe that excellence required starvation and ignored the warning signs from my mind and body. The pain and hunger I endured felt like badges of honor“
– Melina Costanza
The documentary Light by Caroline Treadway highlights the dangers of disordered eating and eating disorders from a desire for better performance both in competitions and outside on rock, including Emily Harrington, Angie Paine, Meagan Martin and Kai Lightner.
Alannah Yip’s “hot mic” moment while co-commentating at the 2023 Innsbruck World Cup with Matt Groom, where she expressed a desire to call out the IFSC for dropping athlete BMI testing this year. Alannah has since spoken about her struggles with eating disorders.
The Medical & Antidoping Commission Chair Eugen Burtscher (Austria) and committee member and researcher Volker Schoeffl (Germany) resigned on the 5th July 2023 because of a lack of action by the IFSC on RED-S. In response, the IFSC subsequently re-introduced the testing of BMI.
In a 2022 study which studied the state of the menstrual cycle in elite female competition climbers, Joubert L, Warme A, Larson A, et al. found that out of 150 IFSC Female World Cup athletes contacted, 18 suffered from the most severe RED-S symptom for women: the loss of a regular period. A further 14 described an irregular period pattern, a secondary symptom of RED-S.
So What Is the IFSC Doing About It?
On 7th February 2024, the IFSC became the first international federation to put in place a policy to safeguard athletes’ health from RED-S.
The policy improves on the previous policy, which focused on Body Mass Index (BMI) - a statistic calculated using an athlete’s height and weight. When an athlete’s weight dropped below the low BMI thresholds (18.5 for men and 17.5 for women), the athlete and National Federation were informed.
The IFSC policy implements the IOC 2023 consensus on RED-S in sport, using the IOC RED-S Clinical Assessment Tool-Version 22.
The policy is made of 3 parts.
- Every athlete will complete two questionnaires to asses low energy availability and eating disorders.
- Complete the IOC RED-S CAT 2 evaluation for athletes who are causes of concern, with potential removal from competition in severe cases.
- The IFSC will perform random and focused testing throughout the season.
Every athlete who applies for an athlete license must complete two questionnaires, one focused on assessing low energy availability and another on eating disorders. Other basic characteristics such as height, weight, heart rate and blood pressure are also captured.
Athletes considered a cause of concern from the questionnaires must undertake a further medical examination to complete the IOC RED-S CAT 2 evaluation with their National Federation. This examination includes:
- Bone Mineral Density/DXA scans,
- Blooding testing for Testosterone for men, Total or Free Triiodothyronine (T3), LDL cholesterol, and
- a review of the growth chart for athletes under 18.
Athletes considered moderate to high risk must be evaluated before IFSC events and throughout the season. Athletes considered very high risk will be allowed to participate in IFSC competitions once they have sufficiently recovered and are cleared by their National Federation.
The IFSC will perform random and focused testing of athletes on the morning before an IFSC event. The testing focuses on various parameters, including BMI, heart rate, and blood pressure. If any serious medical indicator is found during the testing, the athlete’s case will be referred to the RED-S - Independent Advisory Committee for further review. The committee is independent and comprises at least two doctors with expertise in RED-S and one health professional with expertise in climbing. The RED-S - Independent Advisory Committee will not include any members of the IFSC Medical Commission or medical personnel working directly with any National Federation.
“Athlete health, wellbeing and safety has and will always remain a priority for the Athletes’ Commission. The policy announced today is the start of the journey towards making our sport safer by addressing a complex and sensitive topic,” said Shauna Coxsey, Olympian and former Boulder Overall World Cup Winner.
“As President of the Athletes’ Commission, I will continue to work with my fellow Commission members to ensure the athlete’s voice is heard and they are supported as these new policies are implemented. I would like to thank the Medical Commission and Sport Department for the hard work and dedication they have shown in developing this policy. We believe this is a positive step towards protecting athletes.”
If you think you need support, please get in touch with https://red-s.com/get-support.
- Yeager KK, Agostini R, Nattiv A, Drinkwater B. The female athlete triad: disordered eating, amenorrhea, osteoporosis. Med Sci Sports Exerc. 1993;25(7):775–777. doi:10.1249/00005768–199307000–00003 ↩︎
- Mountjoy M, Ackerman KE, Bailey DM, et al.Br J Sports Med Epub ahead of print: [2024–02–27]. doi:10.1136/bjsports-2023–106994 ↩︎
