REDs Awareness Week: two case studies from the School 

As part of REDs Awareness Week, we are sharing two powerful case studies that highlight the real-life impact of this condition on our students. Through the experiences of two dancers at different stages in their training, these stories underscore the importance of early detection, multidisciplinary support, and the comprehensive care provided by The Royal Ballet School’s dedicated Healthcare and Artistic teams.  

These case studies illustrate not only the physical effects of REDs but also the emotional and psychological challenges that can arise when energy availability is compromised.  

Case Study A 

A 17-year-old male ballet student began experiencing pain in his big toe after an awkward landing from a jump, leading him to seek advice from the Healthcare Team.  Thorough examination by the physiotherapist revealed a soft tissue sprain. During a wellness check-in by the School Nurse, the student shared that he had been feeling fatigued, had lost weight, and was frustrated with his class performance. 

The following day, he saw the School Nutritionist, Louise Gubb, to discuss his energy levels and fuelling habits. The student was new to the School, and before starting his training, he lived at home, where all his meals were cooked for him. He usually eats well and enjoys all foods, but due to his busy dance schedule at school, he often didn’t get time for snacks during the day.  

Louise asked him to keep a food diary for four days of everything he ate and drank, which revealed that he was not fuelling enough. She calculated how much fuel the student should be eating each day based on his age, height, weight, and activity levels. The student was not quite meeting his energy requirements, resulting in a state of Low Energy Availability. 

The School arranged a blood test, which also showed that some of his hormone and vitamin D levels were low, and he had Relative Energy Deficiency (REDs). REDs is the result of the body trying to compensate for low energy availability by down-regulating lower-priority systems, such as reproduction. The knock-on effects of this compensation are seen in other systems, including the musculoskeletal, immune, and hormonal systems. Even the nervous system is affected by REDs which includes your emotional as well as your mental health. This explains why this student struggled with fatigue, concentration, and his ability to dance to his full potential during class. 

Students often do not realise just how much energy their dance training requires, on top of the increased energy requirements of growth and maturation during adolescence, and this can lead to unintentional under-fuelling. 

Treatment  

• Nutrition support to educate about his energy requirements and how to fuel with intent, thinking about the timing, type and total amount of nutrition throughout the day.  

• Artistic Team support to help him progress with his training while managing his participation levels during his REDs recovery journey. 

• School Nurse support including regular check-ins to ensure he was staying on track and repeat blood tests.  

• Psychological support including meeting once a week with the Counsellor to address emotional aspects and promote healthy behaviours. 

Through support from the whole team, this student was able to increase his energy levels, body composition, and dance performance, returning his blood biochemistry to normal levels, safeguarding his long-term health, and benefit from a visibly stronger performance in class than before. 

Case study B 

A 14-year-old female student entered Year 10 at White Lodge, and during a routine health check, the School Nurse noted low body weight, poor circulation, and signs of dizziness. She frequently caught colds and had been missing school due to illness. Blood tests confirmed significant undernutrition and multiple abnormalities. 

A regular menstrual cycle is an important indicator of optimal female health, and this student had not had a cycle for almost 12 months. She was suffering with significant Relative Energy Deficiency (REDs) and if left untreated, this would have serious consequences for her short and long-term health. The School’s Sports Medicine Consultant advised that it was unsafe for her to do any physical activity. 

Being away from home and unable to dance significantly impacted this student’s mental health. Regular engagement with the Mental Health Team is crucial to treating students with REDs. Christian Uitzinger, our Psychologist, worked closely with her to address difficulties with body image, which were interfering with her ability to fuel adequately. Body image difficulties can give rise to an unhelpful and often irrational fear of weight gain, which can negatively impact a dancer’s nutritional intake. 

Over the School year, the student gradually increased her dance activity from minimal floor barre sessions to 15 hours per week. Her periods resumed after nine months, and by 12 months, she had enough energy to continue growing and reach full adult height. 

Dancers are at four times greater risk of disordered eating/eating disorders than the normal population. These case studies underscore the importance of recognising and addressing REDs early. With comprehensive support—including nutrition guidance, training adjustments, medical follow-ups, and psychological care—students can recover and build resilience for their future in dance.