Relative Energy Deficiency
Syndrome (RED-S) in the
Female Athlete
Michelle Rockwell, MD
CAQ Sports Medicine
Virginia Tech Carilion School of Medicine
Family Medicine, Orthopedic Surgery
In the Past…
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It was considered ‘normal’ for athletes to lose their menstrual
cycles
This was seen as good measure that you were ‘training hard
enough’
In 1997 the American College of Sports Medicine (ACSM)
released the Female Athlete Triad Position Stand
Components of the triad were identified as:
Ø DisorderedEating
Ø Amenorrhea
Ø Osteoporosis
In 2007…
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The triad was updated and described as
a continuum
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Energyavailability,menstrualfunction,andbone
mineraldensitychangeinresponsetotrainingvolume,
intensityoftraining,stresslevel,andnutritionalstatus
2007 - The Updated Triad Position Stand,
ACSM
In 2014… IOC Consensus Statement
Progression of
the continuum…
Health Consequences
of Relative Energy
Deficiency in Sport
(RED-S)
In 2014… IOC Consensus Statement
Progression of
the continuum…
Potential Performance
Effects of Relative
Energy Deficiency in
Sport
Let’s Talk About Energy
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Energy: Defined as the capacity to do
work, and in the case of the human body,
this work is of a biological and physical
nature
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Cellularprocesses
Synthesisofcompounds
Growthanddevelopment
Reproduction
Activitiesofdailyliving
Exercise(SkeletalMuscleContraction)
Four Components to Total Daily Energy
Expenditure
①Resting Metabolic Rate (RMR)
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Theenergyexpendedwhilelyingsupineinapost-absorptive,awakenedstatefor
cellularprocessesnecessarytomaintainlife
②Thermic Effect of Food
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TheincreaseinenergyexpenditureaboveRMRinresponsetotheingestionoffood
③Non-Exercise Activity Thermogenesis
(NEAT)
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Theenergyexpenditurefromphysicalactivitywhichisnotconsideredexercise,
suchasADLorfidgeting
④Exercise Energy Expenditure
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Theenergyexpenditurefromvolitionalmovementdoneforthepurposeofimprovingor
maintainingoneormorefeaturesofwithhealthorperformance-relatedphysicalfitness
Energy Availability
The amount of dietary energy remaining
for other body functions AFTER exercise
training
Impacts other areas:
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Activities of daily living
Cellular maintenance
Thermoregulation
Growth
Reproduction
Energy Availability (EA)
(EI - EEE) / kg FFM
EI = Dietary Energy Intake
EEE = Exercise Energy Expenditure
FFM = Free Fat Mass (body comp needed)
Energy Availability is Reduced by…
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Increased EEE above EI
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Inadvertent decrease in energy
intake
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Changesintrainingvolumeorintensity
Nutritionasanafterthought,shorttime
betweentrainingsessions,financial
constraints
Dysfunctional eating behaviors
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Dieting,sub-clinicalandclinicaleating
disorders
Causes of Low Energy Intake
Health Consequences of RED-S
Showing an
expanded concept of
the Female Athlete
Triad to acknowledge
a wider range of
outcomes and the
application to male
athletes
*Psychological consequences
can either precede RED-S or
be the result of RED-S
Prolonged RED-S Consequences
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Immune
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Growth and Development
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Lossofheight/statureprogression,lackofphysical
development(Tannerstages)
Psychological
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LowWBCcount,increasedriskofillnessorinjury,poor
woundhealing
Decreasedfocus,decreasedbrainfunction,anxiety,
depression
Endocrine
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Amenorrheaoroligomenorrhea,lossoflibido,low
bonemineraldensity,infertility
Prolonged RED-S Consequences
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Cardiorespiratory
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Gastrointestinal
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Gastroparesis,delayedgastricemptying,early
satiety,constipation,GERD,decreasedhunger
Hematological
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Heartpalpitations,arrhythmias,SOB,edema,POTS,
syncope
Anemia
General
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Fatigue,weakness,failuretogainweightinchildren
oradolescence(notjustweightloss)
Performance Impacts from RED-S
Potential
Performance Effects
of Relative Energy
Deficiency in Sport
*Aerobic and anaerobic
performance
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Energy Availability and Performance
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Under fueled training sessions
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Delayed recovery from training and
performance
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Decreasedabilitytofullyparticipateandbenefitfrom
trainingsessions,inconsistentperformance
Increasedmusclerecoverytime,increasedriskfor
fatigue-relatedinjuries
Change in hormonal responses to training
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Decreasedestrogenlevels,long-termjeopardyofpeak
bonemasspotential,depressedimmunefunction,
increasedcortisol,epi- andnorepi stressresponse
Mental Health
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Depression
Anxiety
Body Dissatisfaction
à Body Dysmorphic Disorder
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Binge Eating Disorder
Obsessive Exercise
What are Athletes Concerned About?
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Performance Issues
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Fatigue
Inabilitytofinishworkout
Getting‘slower’or‘weaker’
Focusandconcentrationlost
Coaches and ATs hear ‘I need to train
more’, not ‘I’m under fueled’
These findings should launch your
assessment
RED-S Return to Play Model
Steps
Risk
Modifiers
Criteria
RES-SSpecificCriteria
Step1
Evaluationof
healthstatus
Medical
factors
Patientdemographics
Symptoms
Medicalhistory
Signs
Laboratorytests
Psychologicalhealth
Potentialseriousness
Age,sex
Recurrentdieting
Menstrualhealth,Bonehealth
Weightloss/fluctuations,Weakness
Hormones,electrolytes,ECGandDXA
Depression,anxietyDisorderedeating/eatingdisorder
Abnormalhormonalandmetabolicfunction
Stressfracture
Step2
Evaluationof
participationrisk
Sportrisk
modifiers
Typeofsport
Positionplayed
Competitivelevel
Weightsensitive,leannesssport
Individualvs.teamsport
Elitevs.Recreational
Step3
Decision
modification
Decision
modifiers
Timingandseason
Pressurefromathlete
Externalpressure
Conflictofinterest
Fearoflitigation
In/outofseason,travel,environmentalfactors
Desiretocompete
Coach,teamowner,athletefamilyand
sponsors
Ifrestrictedfromcompetition
RED-S Return to Play Model
HighRiskRedLight
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Nocompetition
Supervisedtraining
allowedwhen
medicallyclearedfor
adaptedtraining
Useofwrittencontract
(seesample)
ModerateRiskYellow
Light
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Maycompeteonce
medicallycleared
undersupervision
Maytrainaslongasis
followingthe
treatmentplan
LowRiskGreenLight
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Fullsportparticipation
RED-S Green Light or Low Risk
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Appropriate physique that is managed
without undue stress or unhealthy
diet/exercise strategies
Healthy eating habits with appropriate
EA
Healthy functioning endocrine system
Healthy musculoskeletal system
Healthy bone mineral density as
expected for sport, age and ethnicity
Healthy musculoskeletal system
Thisiswherewewantourathletestobe!
RED-S Yellow Light or Moderate Risk
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Prolonged abnormally low % body fat measured
by DXA or anthropometry
Substantial weight loss (5-10% body mass in
one month)
Attenuation of expected growth and
development in adolescent athlete
Low EA of prolonged and/or severe nature
Abnormal menstrual cycle: functional
hypothalamic amenorrhea > 3 months
No menarche by age 15 in females
RED-S Yellow Light or Moderate Risk
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Reduced bone mineral density (BMD) (either in
comparison to prior DXA or Z-score <-1 SD)
History of one or more stress fractures
associated with hormonal/menstrual
dysfunction and/or low energy availability (EA)
Athletes with physical/psychological
complications related to low EA / disordered
eating
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ECGabnormalities,lababnormalities,etc.
Prolonged relative energy deficiency
Disordered eating behavior negatively affecting
other team members
Lack of progress in treatment and/or noncompliance
RED-S Red Light or High Risk
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Anorexia nervosa and other serious
eating disorders
Other serious medical conditions
related to low energy availability
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Physiologicaland/orpsychological
Example:Repeatstressfractures,Syncope
Extreme weight loss techniques
leading to dehydration induced
hemodynamic instability and other
life-threatening conditions
Severe EKG abnormalities
(bradycardia)
Treatment Approach
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Multidisciplinary Team
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Sportsphysician,nutritionist,psychologist,
physiotherapist,andphysiologist
Education for athletes and coaches
Regularly asses risk for subclinical ED
Consider treatment contracts
Treatment Contracts
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Team physician support is critical
Athletes in the moderate-risk and high-risk
categories should receive a written contract that is
reviewed and presented to them by the team
physician after their initial evaluation.
Although a verbal contract may be sufficient, it is
recommended to utilize a written contract.
The goal of the written contract is to:
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Specifythecriterianecessaryforongoingorfutureclearance
andreturntoplayfortheathletewiththemultidisciplinary
teammembers
Toensureasharedunderstandingofhowtheclinicalstatus
oftheathletewillbefollowedwitheachmemberofthe
multidisciplinaryteam.
Treatment Contracts
The team physician coordinates the treatment goals
with each multidisciplinary team member, and
includes:
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The specific recommendations in the contract
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The requested frequency of visits
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Expectations for each team member
The team physician then reviews the
recommendations with the athlete, and answers
any questions.
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In the case of the written contract, athlete and
team physician sign the contract after it is
discussed
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Written contract which can be modified based on
the athlete's clearance status.
Sample Treatment Contract
Student Athlete Challenges
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High Risk Sports
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Sportswithaestheticcomponentssuchasgymnastics,figureskating,
ballet,distancerunners
Individual Challenges
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Limitedtimeandmoney
Perfectionisttraits
Hightendencytocomparewithinsport,gender,events
Balancingsportperformanceandculturaldefinitionoffemininityor
masculinity
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Cultureofunder-eating
Masculinitydefinedbymuscledefinitionor“size”
Athletesnoteducatedastovalueofnormalphysiology
Perceptions
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Skippingperiodsmeanyouare“fitandtraininghard”
Carbsare“bad”
“Tabloid”Nutrition
Summary
Relative energy
deficiency in sport
encompasses the
female athlete triad
However, RED-S
expands the
assessment areas
which are multifaceted
Recommendations to address RED-S
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For the Athlete:
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EducationalprogramsonRED-S,healthyeating,nutrition,EA,the
risksofdietingandhowtheseaffecthealthandperformance
Reductionofemphasisonweight,emphasizingnutritionand
healthasameanstoenhanceperformance
Developmentofrealisticandhealth-promotinggoalsrelatedto
weightandbodycomposition
Avoidanceofcriticalcommentsaboutanathlete’sbody
shape/weight
Useofreputablesourcesofinformation.
Promotionofawarenessthatgoodperformancedoesnotalways
meantheathleteishealthy
Encouragementandsupportofappropriate,timelyandeffective
treatment
Recommendations to address RED-S
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Healthcare
Professional
Recommendations:
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Identificationofamultidisciplinary
athletehealthsupportteam
includingsportsphysician,
nutritionist,psychologist,
physiotherapist,andphysiologist
Educationofthemedicalteamin
thedetectionandtreatmentof
RED-S
ImplementationoftheRED-SRisk
AssessmentModelinthePHEand
theRED-SRTPModel
Sport Organization Recommendations
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Preventive educational programs
Rule modifications/changes to address weightsensitive issues in sport
Policies for coaches on the healthy practice of
managing athlete eating behavior, weight and body
composition
Research Recommendations
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The etiology and treatment of athletes with RED-S
including males, ethnic, and disabled populations
Design and validation of tools to accurately
measure EA in the clinical setting
The validation of screening tools and treatment
programs such as the RED-S Risk Assessment
Model and RED-S RTP Model
Thank you!
References
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