Under Fueling Caused by Eating Disorders or RED-S may Negatively Impact the Pelvic Floor

Under fueling is a state of energy imbalance – an individual consumes fewer calories and nutrients than required to meet their energy demands of daily activities, exercise training and basic bodily functions. Examples of under fueling include:

• Anorexia Nervosa
• Avoidant or Restrictive Food Intake Disorder (ARFID)
• Binge Eating Disorder (BED)
• Bulimia Nervosa
• Other Specified Feeding and Eating Disorder (OSFED)
• Relative Energy Deficiency in Sport (RED-S)

How can under fueling impact the pelvic floor?

Having low-energy availability disrupts hormones, muscle function, connective tissue health and your nervous system. Because the pelvic floor is hormonally sensitive, and has all these components, pelvic problems may emerge when the body is under-fueled. In many cases, the pelvic floor becomes overactive as the nervous system becomes dysregulated.

There can be a loss of coordination impairing the muscle’s ability to contract and relax effectively, or a loss of coordination of the diaphragm and pelvic floor, as your diaphragm is connected to your vagus nerve – a key part of the parasympathetic system. Symptoms may include pain, incomplete emptying of the bladder or difficulty relaxing the pelvic floor rather than just “weakness.” Under-fueling may cause other issues in addition to muscle weakness. The brain needs specific nutrients to produce neurotransmitters which are critical for proper nervous system function.

Commonly discussed eating disorders include:

• Anorexia Nervosa is a severe restriction of food intake, an intense, irrational fear of gaining weight and a distorted perception of body image.
• Avoidant or Restrictive Food Intake Disorder (ARFID) – An eating disorder involving restricted, selective or inadequate food intake.
• Binge Eating Disorder (BED) – an eating disorder characterized by recurrent episodes of eating large quantities of food in a short time, often to the point of discomfort.
• Bulimia Nervosa– is a serious, potentially life-threatening eating disorder and mental health condition characterized by a cycle of bingeing and purging actions.
• Other Specified Feeding and Eating Disorder (OSFED) – is a mental health condition characterized by disordered eating behaviors that cause significant distress or impairment, but do not meet the full criteria for anorexia, bulimia or binge eating disorder.

Eating disorders are associated with chronic stress. A chronically activated stress response can increase muscle-guarding which the pelvic floor is vulnerable to. This can present as pelvic pain, urinary leakage, incomplete bowel evacuation and more.

With Bulimia, for example, repetitive vomiting causes a large increase in intra-abdominal pressure. This pressure is transmitted downward to the pelvic floor in a similar way that over-straining due to bowel tension and pain. Repetitive loading along with any constipation or diarrhea creates a problem for proper pelvic floor function.

Symptoms of Restrictive Intake

Constipation is a frequent symptom of under fueling due to reduced gut motility. When food volume decreases and your body is dehydrated, gut motility slows down and can alter gut-brain signaling. If you have read previous posts, you will remember that chronic constipation has negative effects on your pelvic floor.

Constipation increases strain on the pelvic floor muscles contributing to pelvic floor tension and pain. This creates a negative loop making bowel evacuation even more challenging. Addressing bowel habits is foundational to pelvic floor rehabilitation.

Amenorrhea is the absence of a menstrual period. It is a symptom of hormonal disruption, extreme weight changes, intense exercise, stress or other underlying condition.

Hormonal suppression is common with RED-S. One important hormone affecting the pelvic floor is estrogen. Estrogen plays an important role in collagen production, tissue elasticity, blood flow and muscle recovery. Low estrogen levels can affect the pelvic floor and surrounding tissues, contributing to pain, irritation, dryness and increased injury risk.

Let’s talk about RED-S

RED-S (Relative Energy Deficiency in Sport) is usually associated with female athletes. But women and men can experience it at various activity levels.

RED-S is the under-consumption of calories such that the number of calories consumed does not match a person’s high energy expenditure. This may lead to impaired health, hormonal issues, poor bone density, mental health problems and decreased athletic performance. The term “Female Athlete Triad” is used to encompass various physiological and psychological problems due to low energy availability

RED-S occurs when the body does not receive enough energy or food to keep up with the demands put on it. This can occur due to a lack of education or proper training, or due to outside pressures. When your body does not have adequate energy, it disrupts physiological functions.

Symptoms of RED-S, Eating Disorders, The Female Triad include:

• frequent bone fractures/low bone density
• frequent injury
• gut problems
• low energy
• low libido
• menstrual dysfunction
• mood changes (such as anxiety and depression)
• pelvic floor dysfunction and much more

Males may experience erectile dysfunction, low testosterone and/or reduced fertility.

Athletes and the risk of RED-S

Athletes in aesthetic or endurance sports are at higher risk for RED-S due to performance and body image pressures. When energy availability is low, recovery and tolerance to outside pressures decrease. The pelvic floor already has a key role in sport – managing repetitive impact and pressure – making it vulnerable to other pelvic floor stresses.

Athletes may experience symptoms such as leakage or pelvic pain reflecting physiological stresses. The desire to perform at your highest level needs to be coupled with proper fuel and energy to keep your system functioning in its optimal state.

Healing the Pelvic Floor

Pelvic floor rehabilitation is most effective when the body is adequately fueled. Muscles require energy, coordination and the ability to recover. Without addressing bowel function, nervous system regulation and how you are fueling, physical therapy interventions may have limited impact. Sustainable pelvic health requires a whole-body approach. If you need help, speak with a trained specialist.

Culture, expectations and personal ambitions can move someone away from becoming their healthiest self. It is important to fuel your body with the proper nutrients, maintain healthy training levels and lifestyle habits to keep your physiological functions operating in an optimal state. Learn to recognize when your body may be malnourished, learn to adjust for it, and learn to reach out to professionals for help and guidance.