Alice Leveque – Testimony on RED-S syndrome

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Presentation by Alice Leveque

Today, I’m hosting Alice Leveque, physiotherapist, dietician nutritionist and former professional handball player. She also writes the nutrition articles on La Sportive Outdoor.

Alice is here to talk about her experience with RED-S syndrome. In French, this is the syndrome of relative energy deficiency due to sport. It’s a syndrome that’s still relatively unknown, even among health professionals, and I thought it was important for her to talk about it so that you can find out more and perhaps take action if you’re affected. Welcome Alice! Can you introduce yourself?

Yes, I’m Alice Leveque. As you said, I’m a dietician-nutritionist. I work with the CREPS de Bourgogne-Franche-Comté with young athletes, and I also do follow-up work in my own practice. I specialize in sports and micronutrition.

I’ ve also been a physiotherapist for about ten years and I work in the field of prevention in companies. So, I wear two hats: half the week as a physiotherapist, and half as a nutritionist. I was a professional handball player for over ten years, and it was during this time that I was affected by RED-S syndrome.

That’s why I wanted to talk about it today, so that it happens less often, and to offer solutions to athletes who suffer from it.

Understanding RED-S syndrome

How did it work out for you? At what point in your career did you begin to notice changes or problems related to your health?

That was around 2015, so almost ten years ago now. At the time, I had just graduated from physio school and was devoting myself fully to my career as a professional handball player. I had started to rejoin the French national team, and I decided that I needed to work on all the factors involved in performance, including my diet. So I changed my diet, thinking I’d be making up for what I’d been missing. Very quickly, maybe two or three months later, I started to feel sluggish. I had trouble getting up in the morning, I was bradycardic with very low pulse rates (30, even 28 at night), and I wasn’t responding to training. My body couldn’t keep up, and I didn’t understand what was going on.

It’s very impressive. For those of you unfamiliar with RED-S syndrome, can you explain what it is?

RED-S syndrome, or sport-related relative energy deficiency syndrome, occurs when your body doesn’t get enough energy for what you expend. This can be caused by insufficient food intake, overtraining, or a combination of both. If you burn more calories than you consume, you’re at risk of developing this syndrome, which can have numerous health consequences. It mainly affects women, but also men, although this is rarer.

The International Olympic Committee (IOC) published a consensus in 2023. In 2024, an article by Asker Jeukendrup called the syndrome’s name into question. It’s not just about eating disorders or low energy availability, but also factors such as mental health, immunity or sleep problems. The term RED-S therefore seems reductive, and I think it will evolve over the next few years.

The range of symptoms is very broad, from sleep disorders to bone problems (early osteoporosis), difficulties in building muscle mass, cardiovascular problems, immunity problems, and even fertility problems. And the list goes on.

I think that as health professionals, particularly those specializing in sport, it’s crucial to detect these signs as early as possible in athletes. As soon as a symptom appears and something seems suspicious, we have to go further and find out what’s really going on. Once the syndrome has set in, it’s very difficult to get out.

Personally, I work with young athletes suffering from this syndrome, some of whom haven’t had their period for years, are constantly injured and can’t get back to their competitive level. They experience real emotional distress because they can no longer train, and are asked to eat more while reducing physical activity, which is very difficult to accept. The return to good health and competition takes a long time– months, even years.

That’s why, as soon as warning signs appear, it’s imperative to seek support and talk to qualified healthcare professionals.

That’s right. You mentioned the cessation of menstruation. Is this a symptom that should immediately raise an alarm?

The cessation of menstrual bleeding should indeed be a cause for alarm, even if it doesn’t necessarily mean that RED-S syndrome is present. An absence of periods is never normal, nor is a menstrual cycle that exceeds 34 days. A cycle this long is a warning signal that something is going on. This may be linked to overtraining, overtraining or other factors, such as eating disorders, which are often seen in young athletes.

When a change occurs in the menstrual cycle, it’s essential to talk to a healthcare professional.

Above all, I want to make it clear that the pill is not a solution. It’s not because you have irregular, heavy or painful periods that you should take the pill to “mask” these symptoms. The pill doesn’t solve the underlying problem. There are other solutions, such as functional biology, which involves taking hormone measurements to understand what’s going on. Then, whether through diet or micronutrition supplements, there are many things you can do to regulate these problems before turning to contraception.

Yes, this is a very important point. Conversely, if you continue to menstruate normally, does that rule out the possibility of Red S? Or is it not always associated with a disturbed cycle?

As I mentioned earlier, RED-S can also affect men, so missing your period isn’t the only symptom to watch out for. Just because you continue to have normal menstrual cycles doesn’t mean you aren’t affected by RED-S. Similarly, it used to be thought that this syndrome only affected very thin or skinny people. Today, we know that people with a perfectly normal BMI can also be affected by Red S. So it’s crucial to consider all the causes and examine the wide range of possible factors.

It’s really multi-factorial and there are many aspects to take into account. So you have to keep that in mind and think about it to explore the different avenues, just in case.

When an athlete comes to see me and says she hasn’t had her period for six months and is having trouble eating, we immediately investigate this possibility. On the other hand, when menstruation has not stopped, a more subtle approach is required. It may indeed take longer to detect the syndrome.

Alice’s experience: nutrition and RED-S

And in your case, were you diagnosed quickly, or did it take a while to figure out what was going on?

So, you were telling me earlier that even some sports doctors today don’t necessarily know about RED-S. Imagine ten years ago! To be honest, I was never officially diagnosed with RED-S syndrome. In a way, I self-diagnosed when I started to understand what it was. At first, I was classified as “overtraining”, or even burn-out. I was told that there was probably something mental at work. And even I thought that was it.

As soon as I’d set foot in a handball hall, I’d start crying, for no apparent reason. I’d get this oppressive feeling inside me, and I’d have to leave the room. I couldn’t watch the games anymore. It was very difficult. At that point, I said to myself: “You’re in burn-out, you can’t take handball anymore, you can’t live, eat and breathe handball anymore.” I too had concluded that this was the reason. It tooka long time before I really understood what was happening to me.

And how did it go? At the time, you didn’t have a doctor specifically to help you get over it. How did you manage to heal? Did you manage to identify the problem and put measures in place on your own, or were you still accompanied, even though the term Red S had not yet been used?

In fact, they mainly helped me with my medical check-ups. In the beginning, I had a lot of tests. I wore a holter for 48 hours to measure my blood pressure and resting heartbeat at night. That’s when we realized that my heart rate was very low, my body was functioning in slow motion. I also had blood tests and a whole battery of tests, but nothing abnormal came up. I even took a stress test, and again, my cardio was fine. The only thing they suggested was that I see a shrink and stop training for a few months, telling me I’d feel better afterwards.

So I stopped training for almost two months. Then I resumed with a French team training camp in Corsica. But to be honest, I had no desire to go. Fortunately, the sun was shining, but I wasn’t enjoying training any more. And of course, you don’t dare talk about it, because the ultimate goal of a professional athlete is to be in the French national team. So you say to yourself: “What more do you want? You’re on the national team, and you’re complaining that you don’t want to be there.” It’s very difficult for other people to understand.

From the outside, it may seem incomprehensible. But when you experience it from the inside, it’s horrifying, because you’re suffering from physical and mental symptoms, and no one is offering you any solutions. You’re left to your own devices, without any support. After this course, I changed clubs to join Metz, one of the biggest women’s handball clubs in France, a real challenge for me. But from August to November, every evening I came home from training crying. I didn’t tell anyone about it, apart from my close circle who supported me, but my team-mates, my coaches, nobody knew about it.

It was very hard. In the end, that’s what got me interested in nutrition. I started reading a lot and that’s when I met Anthony Berthou, who is a micronutrition trainer and used to work with the French triathlon teams. He helped me a lot, especially on the digestive front, as I had serious digestive problems. He didn’t immediately identify RED-S, but when I went on a training course with him, we talked about it. That’s when I realized I was ticking all the boxes.

At that time, to give you an idea, I was being followed by a micronutritionist in Bordeaux, and she had asked me to stop all sources of sugar, whether starchy foods, carbohydrates, and even slightly sweet vegetables like carrots and beet. I stopped everything, without really understanding why. It had worked for other athletes, so I thought, “Why not me?” I sharpened up very quickly, but in reality…

It’s not just sharpening at this stage, it’s downright dangerous, isn’t it?

Exactly. I was allowed one “joker” a week, when I could eat a little sugar. But I was so deprived that every time I saw sugar, I became obsessed with it, craving it. In training, I would see stars. After not even two months, my body slowed down completely. My heart rate plummeted, and mentally, I felt at my lowest ebb. Then my periods stopped for six months.

So the starting point was this change in nutrition?

Ah yes, clearly.

So you’ve given up all carbs?

Exactly. I’d never had an eating disorder before that. I stopped eating starches when I was training twice a day. I was eating almost no carbs, which was just unbearable.

It’s completely crazy.

It’s completely crazy, yes. What frustrates me the most today, working in this field, is thinking: why did I listen to him? Why did I take advice from someone like that? That’s one of the dangers of consulting a poorly trained or unqualified person, who makes you do things that aren’t good for you.

That’s what’s complicated. Basically, you went to someone who was supposed to be a professional, with the right title. There’s a tendency to trust him and think he must be right, but there are good and bad professionals…

Exactly. If you like, I developed every possible symptom. I even had a bone scan, and by the age of 25, I hadearly-onset osteoporosis.

That’s what’s important to explain: the consequences can be very serious, and they’re not easy to correct afterwards.

Exactly. Fortunately, I still had a healthy lifestyle, which enabled me to counterbalance the negative effects fairly quickly. I kept to this diet forfour months, but my body just couldn’t keep up. So I quickly changed my habits.

As for my periods, it took me almost a year to get back on track. I’d gone through a phase of total amenorrhea, then had very heavy periods for two or even three months at a time. That too was very complicated.

Even ten years later, I still don’t have regular menstrual cycles. They’re irregular, but long, lasting up to 40 days. So, even though the diet only lasted four months, the repercussions on my body have been very long. Imagine the women who tell me they haven’t had a period for two years. It takes a long time to get back to normal, and it really does take a lot of effort.

That’s where prevention comes in, to avoid falling into this situation. Once it starts, it’s really complicated to get out of. I didn’t realize it could have such a long-term impact. Four months on a diet, and ten years later, the effects are still being felt, it’s crazy.

As far as menstrual cycles are concerned, it’s very difficult to get back to normal. There are periods when I say to myself that this is it, my cycles are back to 28 or 30 days, then, for no apparent reason, they go back to 40 days. I haven’t stopped training; I’m now a runner. I also know that when I train a lot, especially in preparation for a trail run or a marathon, it disrupts my cycle again. So I’ m really careful, because I know it can lead to other problems, like bone, cardiovascular or thyroid problems. It’s crucial to keep this in mind.

Yeah, totally. And what did you do then? You were still a professional handballer, so you readapted your diet once you understood what was going on. Did you feel better quickly, or did it take some time on a day-to-day basis to really feel good?

I readapted my diet simply because my body couldn’t take it anymore. So I did it without really understanding what was going on. I listened to my body, to my feelings of hunger. I was hungry, I ate, and that was that.

Then I was accompanied by Anthony Berthou, who helped me a lot to understand my body’s needs. In addition to the symptoms I’ve already mentioned, I also had intestinal permeability disorders and a major dysbiosis. We know that this can affect the intestinal microbiota, and we had to take charge of this and treat these problems.

For about six weeks, I had to stop eating gluten and dairy products, then gradually reintroduce them, as they were causing me inflammation at the time. These were adjustments I had to make to be able to eat normally again. After that, the following year, I was able to return to a more or less normal diet, according to my needs and the training I was doing.

Yes, it’s incredible. So, after that, did you resume your handball career, or did you stop at that point?

As I said, I was off for two months. Then, when I went back to Metz, it was very difficult. In January 2016, I seriously asked myself: “Should I stop? I can’t take it anymore, maybe I’ll quit handball.”

Fortunately, the people around me were very supportive. They said, “Look, you’ve got two choices: either you stop now, and you might regret it, or you go all out, get over it, and see your season through. Then you’ll see what happens.” I told myself that I still had things to accomplish in handball. I couldn’t just stop like that. In the end, the problem wasn’t handball, but my physical health and mental well-being. I’m back on track.

I also read a lot about mental preparation. I didn’t take any specific coaching, I worked on my own, with meditation and cardiac coherence, and that helped me a lot. I finished my season at Metz. It was a very complicated season, but with what I’d been through before, it wasn’t surprising. Then I came back to Besançon to finish my career. For four years, I played with great pleasure. Frankly, I’m so glad I made this decision and didn’t stop everything.

I’m really glad I didn’t stop at that point. Playing again for four years and, above all, having fun on the pitchwas incredible. I had a great team and top coaches. I was able to spend those four years really enjoying myself. And above all, I told myself that handball wasn’t the problem.

Yes, it’s very important. You’ve really rediscovered the pleasure of the game. It’s true that when you’re not feeling well, you don’t want to do anything, let alone lead such a demanding career. It requires an enormous amount of effort. And if you don’t feel good about your body, it’s even more complicated. You were talking about the people around you. They helped you make this decision, but did they also help you realize that there was a problem? Whether it was your friends, your family, or even your trainers, did they also accompany you in your recovery, or not especially?

No, not really. They encouraged me to consult a psychologist or a mental trainer, and that could have helped. But as the syndrome was little-known, I don’t think they appreciated the extent of the situation. They stopped at the medical diagnosis, thinking that it was overtraining and that it would pass with time.

Even today, when I explain this to relatives or people who are not familiar with the subject, they still have trouble understanding what happened. They saw the effects on me, but I don’t think they really understood the impact it had on my health. They were there for me, but on the overall healing journey, I kind of went my own way.

Lessons learned

Yes, congratulations, because it can’t have been easy. Now that you’re ten years on, what lessons have you learned from the experience, both personally and in sporting terms?

On a personal level, I’ve learned to be much more suspicious, especially of certain healthcare professionals. Not to accept everything and not to implement things lightly, simply because we’ve been told to. But at the same time, this experience made me grow, and that’s what led me to become interested in nutrition today.

I think failures make you grow, even if you don’t realize it at the time. It’s a bit like climbing a mountain: once you reach the top, everything becomes a little easier. Personally, I’ ve grown from it, even if it has left me with a few physical scars. I’ve also been working on my personal development and mental preparation, and that helps me on a daily basis, whether in my personal or professional life.

From a sporting point of view, this experience has left me very vigilant. When you run too much and strive for performance, you’re always walking a tightrope. Even when you know it, you can quickly fall into excess. That taught me to recognize the warning signs. Today, I take better care of myself and my health. I’ve even had another check-up to make sure there were no deficiencies.

It does leave its mark, though. After this experience, I developed eating disorders for a few years, whereas I’d never had any before. These are marks that stay with you for life. But you deal with them and move on.

Above all, once you’ve been through it, you tell yourself that you absolutely must prevent it from happening to others. This may help me to better identify the signs, although of course, each individual is different, and the causes are not always the same. We do different sports, we have different bodies, but this experience allows me, I think, to better understand those who are talking about it today.

Advice for sportswomen

Yes, that’s for sure. And what advice would you give women to avoid falling into the Red S syndrome?

The first piece of advice would be to follow your menstrual cycle. It’s essential. Use an app or simply monitor the changes to ask yourself questions if there are any disturbances. When you feel a drop in performance or start having eating disorders, you need to question yourself. It doesn’t have to go as far as anorexia or bulimia; it can be more subtle, like avoiding certain food groups.

For example, I often meet athletes who avoid starchy foods, saying they have no energy expenditure and there’s no point in eating them. They make do with proteins and vegetables. That’s a warning sign. This is not normal.

If you’re having trouble sleeping, if you get sick easily after intense training, these are signs that need to be taken into account. It doesn’t necessarily mean that something is wrong, but it’s worth exploring. At times like these, you need to seek professional help to understand what’s going on and not let it drag on.

And perhaps don’t hesitate to ask for several opinions. If, for example, you have a family doctor who is not very aware of the subject, it may be worth consulting someone else. As we said at the beginning, there are still many doctors who are not familiar with Red S syndrome. To avoid going in the wrong direction, it’s sometimes useful to consult several experts to be sure.

This is a certainty. You need to get several opinions, even if you trust your doctor. If, deep down, you think there’s something else to explore, look for the person who can guide you properly. This could be a sports doctor, and if he or she is not familiar with RED-S, he or she may be able to recommend another health professional. It could also be a dietician, or someone specializing in micronutrition. Some gynecologists are also well-informed in this field. If you feel there’s something more to investigate, don’t hesitate to dig deeper.

Thank you very much. We’ll conclude with this message: pay attention to the smallest signs and don’t hesitate to get several opinions. Thank you very much Alice for your testimony, I hope it will help some women. It’s really important to talk about this RED-S syndrome. Thank you all and see you soon!

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