Erin Kloster, Dietetic Intern
Reviewed by Dana Eshelman, MS, RDN, CSSD, METS I
Female Athlete Triad and RED-S
The female athlete triad is recognized as a disorder involving the interrelationship between menstrual dysfunction, low bone mineral density (BMD), and low energy availability (EA). The underlying cause of the triad is an imbalance in an athlete’s energy intake and energy expenditure.
It’s also important to note that while the triad is referred to as the “female athlete triad”, it can also affect men. In fact, the term relative energy deficiency in sport (RED-S) is an extension of the triad that explains both the physiological and psychological implications of under fueling for all genders.
When an athlete consistently burns more energy than they are consuming, over time the body begins to have difficulty carrying out basic physiological functions. This causes complications of multiple systems in the body:
Cardiovascular - increased risk of abnormal heart rhythm, low heart rate (bradycardia), orthostasis (change in heart rate and/or blood pressure with positional changes), congestive heart failure
Gastrointestinal - increased incidence of leaky gut and irritable bowel conditions
Endocrine - hormonal imbalance, thermoregulation and dehydration
Metabolic - slowed metabolism, rapid weight loss (muscle and fat loss)
Growth and development - poor recovery (low glycogen stores) and training response (decreased muscular strength and endurance) leading to high injury risk
Immunological - increased risk of illness and fatigue
Skeletal - decreased bone mineral density
Menstrual dysfunction - missed periods, amenorrhea
Hematological - biomarkers in suboptimal ranges and deficiency
Psychological - decreased coordination and concentration, impaired judgment depression, anxiety, irritability
Who is at risk?
Various factors can contribute to an imbalance in energy intake and energy expenditure. For example, it could be due to a lack of knowledge around how to meet energy requirements and/or misguided attempts to lose body and/or fat mass. However, disordered eating is often the major cause for this imbalance.
Any athlete who is not consuming enough calories to support the amount of energy they are burning is at risk of relative energy deficiency, or under fueling. Specific individuals at risk include competitive athletes, athletes who play sports where they are required to track and maintain their weight, athletes who participate in sports where thinness is highly emphasized, athletes with eating disorders (ED) or disordered eating (DE) or a history of ED/DE, and athletes who struggle with anxiety and/or depression.
Warning signs indicating energy deficiency?
Some signs to watch for that can indicate an athlete may have RED-S :
Menstrual irregularity and/or loss of period (amenorrhea)
Hypothermia (cold intolerance)
Decreased performance -- endurance, strength, speed, power, lactate threshold
Increased risk of stress fractures and overuse injury
Significant weight loss
Muscle cramps, weakness, fatigue
Poor muscle recovery
Insomnia and/or difficulty sleeping
Dental and gum problems
Mood changes - irritability, anxiety, depression
Preoccupation with weight, eating, and/or food
Avoidance of eating and eating situations
Use of diet pills, laxatives, etc.
Preventing Relative Energy Deficiency
Prevention is key here. Once an athlete shows physiological signs of RED-S, it can be very difficult to treat. Some things an athlete can do to prevent the triad are:
Eat a nutrient-dense, balanced diet that accommodates both daily basal energy needs and activity needs
Properly fuel the body before, during, and after exercise
Allow for adaptability with exercise/ training regimen
De-emphasize weight as a factor in performance. Thin DOES NOT equal fast.
Appreciate your health FIRST. Understand the importance of nutrition as nourishment for your muscles , bones, brain, etc.
Think of fuel as the number one performance enhancerWork with a sports dietitian to understand the best way to fuel your body for your specific sport and exercise routine
It is always best for an athlete who has RED-S or the triad to work with an interdisciplinary healthcare team including a dietitian, physician, psychologists, coaching staff, and/or athletic administration. Working with an interdisciplinary healthcare team is especially important when it comes to athletes who struggle with disordered eating or eating disorders to best support mental and physical health.
If you are unsure of whether you have RED-S, the triad, or are at risk of energy deficiency it is always a good idea to consult with a health professional to understand how to best support yourself and your body.
At DDN, we stress the importance of fueling to perform in BOTH life and sport. Food is fuel, friends. It provides nourishment to your body so you can support it in doing all that you love to do every single day.
DDN has resources and a referral network to help support you if you feel you are struggling with under fueling, disordered eating habits, or an eating disorder.