RED-s (The Female Athlete Triad)

There is a need to understand the underlying causes of what drives RED-s, how it can affect elite performance artists and sportspeople, and what can be done to help people at risk of developing this problem

Originally RED-S (Relative Energy Deficiency in Sport) was know as The Female Triad which referenced the pathology in female athletes which leads to three things: Disordered Eating, Amenorrhea (lack of menstruation) and Loss of Bone Density (Osteoporosis). This disorder can also have an impact on the hormonal, renal, immune, reproductive and cardiovascular system over time.

Athletes can fall along this spectrum with not all these clinical conditions arising at the same time. The basis of this disorder as suggested by its name is energy deficiency. So simply put, energy availability. This is energy intake minus the energy cost of exercise, mechanisms the body uses internally to maintain functioning, and activities of daily living. 

Restrictive eating practised by women and girls in sports and physical activities that emphasise leanness such as dancing or long distance running are of special concern. That being said in male athletes, especially those who compete in long distance or endurance sports, RED-s is on the rise. This is due to their need to be lean but also to have stores of energy for maintaining energy output over long periods of time. RED-s is also seen in recreational athletes and performing artists. Risk factors for developing this disorder include; restrictive eating, injuries and illness, specialisation, decline in performance level, and casual misinformed comments by coaches on physical appearance. 

The chances of developing RED-s can be minimised by athletes, coaches and administrators understanding warning signs and adhering to International Olympic Committee parameters for management and reintroduction to activity after treatment for severe RED-s. Also having an understanding of avoiding critical comments about body shape, educating athletes on the necessity for adequate energy intake for performance and open discussion about eating problems. Athletes often respond when the effect of the disorder is explained in terms of decreased performance. Low glycogen stores inevitably lead to lack of concentration, decreased strength, decreased endurance, decreased improvement with training and increased risk of injury. All of these have a significant negative effect on performance. 

Ballets dancers who undertake rigorous training and have body shape demands are prime candidates for developing RED-s. Some research has shown that as many as 40% of ballet dancers have low bone mineral density. Due to their training indoors for hours they also often have low Vitamin D which can contribute to low calcium and injuries. Given that the average ballet dancers’ career often ends at 24 it is extremely important to keep their long term health in mind.

Although it is tempting to partake in these practices and many athletes are not even aware that they are not taking in sufficient energy to match their output it is crucial to note the long term repercussions of continuing this behaviour. 


1.Medicine & Science in Sports & Exercise:

October 2007 - Volume 39 - Issue 10 - pp 1867-1882

2. Barrack, Michelle T., et al. "Higher Incidence of Bone Stress Injuries With Increasing Female Athlete Triad–Related Risk Factors: A Prospective Multisite Study of Exercising Girls and Women." The American journal of sports medicine 42.4 (2014): 949-958.

3.Highlights from the Female Athlete, BASEM Spring Conference 2015

14 May, 15 | by BJSM 151 Undergraduate perspective on Sports & Exercise Medicine – a BJSM blog series

4. Lecture Series by Margo Mountjoy MD on The Body Matters (edx course McGill University)