RED-D: Relative Energy Deficiency in Dance
This article talks about RED-D, a term specific for the dance industry developed in the recent years.
What is RED-D?
Relative Energy Deficiency in Sports (RED-S, or for effective hashtagging purposes REDs) is a concept that has emerged more significantly over the past 15 years to describe the collection of negative health and performance outcomes that are experienced by both female and male athletes when there is a mismatch between the amount of energy they are consuming versus the amount they are expending during exercise. This gap prevents the body from being able to support the various processes involved in maintaining optimal health and performance.
Relative Energy Deficiency in Dance (RED-D) refers to when this phenomenon occurs specifically in dancers, due to the unique physical and psychological demands of training and performance. It is estimated that one in three dancers have low energy availability, that is the amount of energy remaining after exercise is completed for normal body functions.
Eating enough food to fuel dance and any extra conditioning can easily slip when you’re trying to sleep in as much as possible because you’re tired, or when you have back-to-back classes. However, when you pair that with one in two dancers excluding at least one food group and two in three dancers believing that weight loss will increase their chances of a leading role, it is easy to see how this energy gap becomes so common.
Signs and symptoms of RED-D
One in three dancers lose their period throughout the course of their training or career, and it seems every dancer has one friend whose stomach seems to get upset no matter what they’re eating. Although it is common, and sometimes even normalised or even praised, having any of the symptoms of RED-D is NOT normal for your body. Your dedication to dance does not have to be proven through sacrifice, especially not at the expense of your health.
Some of the signs and symptoms of RED-D may include:
Unexplained fatigue and lack of energy
Increased irritability
Iron deficiency
Weight loss
Frequent illness
Recurrent injuries
Low libido or change in menstrual function
Disruptions to puberty
Difficulty maintaining warm body temperature
Decreased concentration
Decreased coordination
Slower muscle recovery and improvements in strength
What they usually indicate to us is that your body is in ‘power saving mode’. Because your body can’t stop you from exercising or completing any of your other daily tasks/activities, like walking to the shops, it will try to protect you from extremely low energy availability by slowing or stopping processes it doesn’t deem as necessary for survival. It can be as subtle as your emotional bandwidth flattening from all the highs of excitement and lows of disappointment, to simply anger, guilt and indifference. It could also be your menstrual cycle going from 28 days to 44 days, and days of active bleeding decreasing from five days to two.
So the next time you aren’t able to make it through a number or are falling out of turns/tricks you previously had no issue with, is it a fitness and technique problem or is it really an energy availability problem?
Consequences of RED-D on health and performance
The longer low energy availability persists, the more severe the consequences on our health, since all of our bodily functions exist in balance with each other. What starts as a leak can quickly become a flood. For example, suboptimal hormone production impairs reproductive function, and without enough oestrogen to tell our bones to continue to strengthen themselves, it also increases the risk of fractures as bone density falls.
RED-D can lead to:
Impaired reproductive function
Impaired bone health
Impaired gastrointestinal function eg. sluggish digestion, increased and/or excessive bloating, increased sensitivity to a variety of foods (that you might be able to tolerate if nourished well), constipation, etc.
Impaired energy metabolism and regulation
Reduced immunity
Reduced muscle function
Impaired cardiovascular function (our heart is also a muscle!)
Impaired growth and development
Impaired neurocognitive function
Sleep disturbances
While these health consequences can be harder to identify, or can feel like distant ‘maybes’, they always eventually catch up. They can also be more easily spotted in performance outcomes; such as decreased athlete availability (your ability to attend and effectively participate in classes, rehearsals or other training activities) due to a weak immune system. Another common example might be decreased muscle strength when holding positions or decreased power performance in leaps and jumps due to delayed muscle recovery and decreased responsiveness to training.
Repeated experiences of decreased performance can lead to lower mood and motivation because nothing you’re doing seems to work. It is frustrating to show up and give everything, but be unable to reap any rewards.
What makes dancers prone to RED-D
Dancers’ determination and strong work ethic can be both a blessing and a curse, because once a few of these symptoms start popping up, they know they need to act on it to resolve it. Unfortunately, most don’t realise that all of these symptoms can be linked to one another due to a lack of awareness about relative energy deficiency. Some might guess it could be related to energy levels, but not realise how much higher their requirements are because of the high work or training load, which often can’t be reduced.
Dancers are also more likely to internalise the blame, with some degree of perfectionism being prevalent in the community (84.7% of ballet and contemporary dancers). If training longer and harder has not produced any improvements, 44% of female and 33% of male dancers can recall being advised to lose weight at some point in their training. Most dancers will have heard that companies require certain weight or body measurements in order to be hired, or that their lines would be better expressed using slimmer limbs, and have these thoughts echoed back at them in practice rooms lined with mirrors. Even though carbohydrates are the body’s primary fuel source and can be converted quickly into energy, dancers are most commonly recommended to exclude this food group.
Unlike other athletes, dancers do not have a true ‘off-season’ where they can take an extended period of rest and regroup to assess their health and build a foundation for the next few months. RED-D must be identified and managed in the thick of it.
How to prevent RED-D
Lack of awareness and misinformation have played a large role in allowing RED-D to become so prevalent, however there are some things we can do to prevent it from occuring in the first place.
Increase energy intake
Prioritise eating regularly throughout the day. For most dancers, three meals and three snacks will be a minimum requirement in order to fuel their high training loads adequately and support recovery. To fit this in throughout the day, it will mean eating something once every three hours.
It might be helpful to start with a little inventory check:
How many meals and snacks are we managing at the moment?
How are we able to manage that many meals and snacks currently?
Eg. Is it because someone else is able to cook dinner and have it ready for you to eat in the evening, or because you have some shelf stable pre-packaged snack options ready that have saved you from needing to think too much about it?
Why aren’t we able to manage the additional meals and/or snacks currently?
Eg. Is it because we don’t have time in the mornings or feel sick eating before dance?
From there, we can make some improvements if they are needed. It was found that dancers who increased their energy intake by 330-360 calories per day, with a majority of the extra energy derived from carbohydrates, significantly improved menstrual function after six months, with female dancers able to regain their period, improve the regularity of their cycle, and have more normal phase lengths. Eating more carbohydrates can signal to the body, via our leptin hormone, that we have enough energy entering the body, which can then lead to some of our hibernating systems being switched back online. Dancers’ carbohydrate requirements are often higher than they expect (5-7g per kilogram of body weight per day), with a 70kg dancers’ carbohydrate requirements being equivalent to 70 sushi pieces or 23 slices of bread.
Some convenient snack ideas may include (but not limited to):
Ready-to-drink smoothies
Yoghurt pouches
Muesli bars
Single-serve cheese and cracker packs
Portable fruits such as bananas and apples; also dried fruits such as sultana packets and dates
Sandwiches
Sushi rolls
If meals are where we struggle, is there additional time on the weekend for any preparation to make the weekdays easier?
Cooking a batch of egg and potato muffins for a quick snack or on-the-go breakfast, or bulk preparing overnight oats or a pasta salad for easy meals can go a long way in helping you feel ready to tackle the week.
You can also try to maximise convenient options like canned tuna, canned legumes and edamame, and microwaveable rice.
Smart dance workload management
When it comes to dance, there are the baseline dance hours for training or rehearsals, and then there are often extra classes, practice hours, runs, pilates, stretching, strength training or conditioning exercises on top of this. When you want to perform at a high level, ‘more is more’, right?
If any of the RED-D symptoms are appearing for you, a ‘more is more’ mentality can often drive the energy gap wider and wider. Practically, it can also be hard to fit in meals and snacks when there are that many rigid commitments. It might be helpful to assess which hours are truly compulsory, and treat rest as a scheduled activity as well. This may also require assessment across a timetable as well, such as extra cardio being possible early in a season but being put on pause as rehearsals for a performance become more intensive.
Form a reliable medical team
It can be overwhelming to consider all of the above whilst juggling dance, social commitments, rest and hobbies - so find people who can help lighten the load.
If you are unsure about whether your symptoms might be related to low energy availability, some helpful screening tools may include the:
You can also then take this into any medical appointments or reviews to help the practitioners gain a better understanding of your dance background, diet and physical activity, other lifestyle factors, medical history and previous injuries, and RED-D/RED-S symptoms of concern.
Your General Practitioner (GP) can conduct regular blood tests every six to twelve months to assess your endocrine, renal, and haematological function and check for any nutritional deficiencies. They can also refer you for a bone mineral density assessment if there are any concerns, or after any injuries. In addition to screening and prevention, they can also write scripts for any nutritional deficiencies or refer you to other health professionals if further treatment and support is required.
A dietitian can be seen regardless of whether you have any symptoms of RED-D in order for you to gain a better understanding of what your specific requirements are and how to implement strategies that will suit your schedule and lifestyle.
A psychologist may also be helpful if you are struggling with any body image aspects of dance, or the toll of the training load and how you might be experiencing a very different lifestyle compared to non-dancers.
Health over scales
Because the pressure to be lean can be reinforced by mirrors, costumes, comparison to other dancers, a perceived performance advantage, and castings; it can be difficult to pull away from this pattern of thought. You might find it helpful to listen to podcasts from body positive dancers, alter your social media algorithms if they are providing you with content that feels overwhelming or triggering, and follow professional sports nutrition accounts for snippets of new information or advice.
You can also make a difference on those around you by providing reassurance or reminders to eat, flagging comments that are harmful, or encouraging others to seek medical advice if they are experiencing symptoms of RED-D. Almost 40% of dancers report that difficulty controlling their weight interfered ‘a lot’ with their daily living. Even if your words are not heard in the moment, it may plant a seed that the future version of themselves might remember and feel ready to act on.
Where to seek further support for RED-D treatment
If you are interested in learning more about RED-D and nutrition advice for dance, here are some helpful starting points:
Butterfly Foundation: Provides body positive education for schools and allows you to access free chats and online groups so your journey feels less lonely.
Sports Dietitian Australia: Provides sports nutrition resources and handouts, and has a ‘Find a Dietitian’ tool to help you find Accredited Sports Dietitians near you.
Books, Guides, Others:
‘Nourishing Dance: An Essential Guide on Nutrition, Body Image, and Eating Disorders’ by Monika Saigal
The Library Aesthetic platform
Wellbeing for dancers: Offers informative blog posts for dancers, teachers and parents/caregivers, interviews with professional dancers on how they manage their wellbeing, and more resources.
The Embrace Collective: Offers body kind resources suitable for children and teens.
Also remember: DDD Centre for Recovery have free resources for dancers, teachers and families. Check out our resource page.
References:
Nicholas, J., & Grafenauer, S. (2023). Investigating pre-professional dancer health status and preventative health knowledge. Frontiers in nutrition, 10, 1271362. https://doi.org/10.3389/fnut.2023.1271362
Mountjoy, M., Ackerman, K. E., Bailey, D. M., Burke, L. M., Constantini, N., Hackney, A. C., Heikura, I. A., Melin, A., Pensgaard, A. M., Stellingwerff, T., Sundgot-Borgen, J. K., Torstveit, M. K., Jacobsen, A. U., Verhagen, E., Budgett, R., Engebretsen, L., & Erdener, U. (2023). 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). British journal of sports medicine, 57(17), 1073–1097. https://doi.org/10.1136/bjsports-2023-106994
Nordin-Bates, S. M., Cumming, J., Aways, D., & Sharp, L. (2011). Imagining Yourself Dancing to Perfection? Correlates of Perfectionism Among Ballet and Contemporary Dancers. Journal of Clinical Sport Psychology, 5(1), 58-76. https://doi.org/10.1123/jcsp.5.1.58
De Souza, M. J., Mallinson, R. J., Strock, N. C. A., Koltun, K. J., Olmsted, M. P., Ricker, E. A., Scheid, J. L., Allaway, H. C., Mallinson, D. J., Kuruppumullage Don, P., & Williams, N. I. (2021). Randomised controlled trial of the effects of increased energy intake on menstrual recovery in exercising women with menstrual disturbances: the 'REFUEL' study. Human reproduction (Oxford, England), 36(8), 2285–2297. https://doi.org/10.1093/humrep/deab149
Cialdella-Kam, L., Guebels, C. P., Maddalozzo, G. F., & Manore, M. M. (2014). Dietary intervention restored menses in female athletes with exercise-associated menstrual dysfunction with limited impact on bone and muscle health. Nutrients, 6(8), 3018–3039. https://doi.org/10.3390/nu6083018
Reel, J.J., Jamieson, K.M., Soohoo, S., & Gill, D.L. (2005). Femininity to the Extreme: Body Image Concerns among College Female Dancers. Women in Sport and Physical Activity Journal, 14, 39-51. https://doi.org/10.1123/wspaj.14.1.39
Abraham S. (1996). Eating and weight controlling behaviours of young ballet dancers. Psychopathology, 29(4), 218–222. https://doi.org/10.1159/000284996
