RED-S Syndrome: Energy Deficiency in Athletes – The Long Haul

FACT: Studies have found that between a quarter and a third of elite female athletes in power-to-weight ratio sports have clinical eating disorders.

There is a stigma in endurance athletes that a leaner athlete will yield a better race performance. In the running world, professional athletes such as Mary Cain and Allie Kieffer have spoken out about the challenges that they have faced as people scrutinized their weight, encouraging them to be leaner to perform better. In recent years, athletes have become more vocal about body-shaming that they have experienced by either coaches or the media.

For high-performing athletes, failure to intake necessary caloric intake to train can have horrible consequences on their health. Low energy availability can lead to serious health complications, of which is Relative Energy Deficiency in Sport Syndrome (RED-S Syndrome).

Mary Cain spoke about her struggle with RED-S Syndrome with the New York Times in 2019.

First described by the International Olympic Committee in 2014, RED-S Syndrome refers to the physiologic impairment that is caused by an athlete who is depriving themselves of nutrients while training.

Each and every person requires a daily caloric intake to maintain their weight. In an athlete who is participating in vigorous exercise daily, they will need to intake additional calories to cover the workout’s demands. An athlete who does not intake enough to cover their daily caloric needs plus the additional workout’s needs, will become energy deficient.

Multiple organs systems can be affected by the lack of caloric intake. RED-S can cause impairments in menstruation, a decline bone health, effect the immune system, and alter the athlete’s metabolic rate, all of which will affect the athletes’ performance.

Signs and symptoms of RED-S Syndrome published on BJSM Blog.

What are the warning signs?

Frequent injuries or poor injury recovery. Frequent stress fractures in particular can be an indication for inadequate nutrients. In runners, stress fractures tend to occur in the hip, tibia, and the pelvis. Stress fractures of the hip and pelvis should trigger a further workup for female athlete triad.

Fatigue or poor response to training. An under fueled athlete will not perform to their best potential and will take longer to recovery in between workouts.

Abnormal menstruation. In female athletes in their reproductive years, a hallmark sign of RED-S Syndrome and the Female Athlete Triad is a failure to menstruate regularly. Prolonged amenorrhea, or failure to menstruate, can cause osteoporosis and bone fracture. Absence of menstruation is a sign of hormonal imbalance and should be referred to a obstetrician-gynecologist and sports nutritionist.


  1. De Souza MJ, Nattiv A, Joy E, Misra M, Williams NI, Mallinson RJ, et al. 2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st international conference held in San Francisco, California, May 2012 and 2nd international conference held in Indianapolis, Indiana, May 2013. Br J Sports Med 2014;48:289.
  2. Dudgeon E, Keay N. BJSM Blog. April 2019.
  3. Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, et al. The IOC consensus statement: beyond the Female Athlete Triad–Relative Energy Deficiency in Sport (RED-S). Br J Sports Med 2014;48:491–7.

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