Relative Energy Deficit in Sport
   - Formerly Known as Female Triad

Female Triad was officially described as a syndrome of: disordered eating, lack of menstrual cycles, and osteoporosis in females.  In 2007 the American College of Sport Medicine changed the disordered eating criteria to energy availability. Energy availability was defined as the difference between the calories eaten minus the calories used in training that is available for normal body functions. This redefinition shifts the focus from athletes with disordered eating to athletes with chronic inadequate calorie intake; regardless of the cause and includes males.

 In 2014 the International Olympic Committee updated the term Female Triad to Relative Energy Deficit in Sport (RED-S) to emphasize the condition effects all athletes; not just females. Due to the energy deficiency in RED-S normal body functioning is impaired and can affect metabolic rate, immunity, cardiovascular health, protein synthesis, as well as menstrual function, and bone health. 

RED-S may also lead to a gradual reduction in the athlete’s performance including decreased endurance, poor response to training, decreased coordination, decreased muscle strength, decreased glycogen stored, increased risk of injury, decreased concentration, irritability, depression, and  impaired cognitive function.

RED-S can develop in athletes when there is a pressure to change eating habits to meet the demands of a sport, especially those with an emphasis on appearance, low body weight and endurance.  Young athletes can turn a desire to “eat healthy” into food restriction and rigid dieting in the hopes of improving athletic performance

Parents and coaches play an important role in preventing RED-S. Educate young athletes on the energy demands of their sport.  Create an environment that supports eating three meals and one to two snacks daily.  Talk about having a regular breakfast, a full lunch at school, and a pre-practice snack to provide energy for training.  Watch for weight loss, changes in mood, poor performance.  Contact a member of your health care team with any concerns.  Treating athletes with RED-S requires a team effort including a sport dietitian, licensed athletic trainer, sport physician, and a counselor.

Sport Participation Model

Risk Assessment for RED-S

Screening for RED-S is challenging and symptoms can be subtle. Early detection is critical to improve performance and prevent long term health consequences. Below is a list of criteria to assist in evaluating athletes who might be at risk. Br J Sports Med 2014;48:491-497 doi:10.1136/bjsports-2014-093502

Low Risk – Green Light

  • Healthy eating habits.  Adequate energy availability
  • Normal hormone and metabolic functioning
  • Healthy musculoskeletal system

Moderate Risk: Yellow/Caution Light - Cleared for supervised sport participation as part of a medical treatment plan. 

  • Substantial weight loss (5-10% body mass in l month)
  • Lack of expected growth and development of adolescent athlete
  • Failure to start menstruation
  • History of 1 or more stress fractures associated with menstrual dysfunction
  • Abnormal hormonal profile in males
  • Prolonged energy deficit
  • Disordered eating behavior negatively affecting other team members
  • Lack of progress in treatment and/or non-compliance with treatment plan
  • Re-evaluate every 1-3 months.

High risk: Red light-No Participation

  • Anorexia Nervosa or other serious eating disorder
  • Other serious medical condition related to low energy availability
  • Extreme weight loss techniques

Treatment Strategies

Treatment Strategies for RED-S: the medical care plan for athletes with RED-S who have been cleared to participate in supervised sport should address issues of adequate energy/nutrient intake and a safe level of sport participation.  The medical plan should be re-assessed every 1-3 months.

  • 25% reduction in training
  • Increased intake 200-500Kcal daily
  • Weight gain of 2-3% body weight
  • Calcium supplement – 1500 mg/d
  • Vitamin D supplement – 1500-2000 IU q d
  • Bone Mineral Density by DXA if amenorrhea x 6 mo

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Wisconsin Interscholastic
Athletic Association
5516 Vern Holmes Drive
Stevens Point, WI 54482-8833
Phone (715) 344-8580
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