Beyond the Female Athlete Triad
By Carrie Dennett, MPH, RDN
Vol. 24 No. 7 P. 34
Experts weigh in on relative energy deficiency in sport and how it affects athletes’ health and performance.
In October 2021, six female athletes alleged that the focus on body fat percentage—accompanied by body shaming—within the University of Oregon’s track and field program led to their disordered eating, stress fractures, and other injuries.1,2 It was reminiscent of the story of Mary Cain, the 25-year-old Nike Oregon Project track phenom, who faced and succumbed to unrelenting pressure to become thinner and thinner, which eroded her performance, her mental health, and her bones.3-5 Similar scenarios are happening throughout athletics at all levels, and the negative impacts may last for a lifetime, long after the athletes leave their schools or their sports.
This push to reduce body weight to increase performance has some roots in research data, but that data has been over-extrapolated, says Seattle-based Monica Van Winkle, MS, RD, sports dietitian for Pacific Northwest Ballet and Seattle Pacific Athletics, owner of Nutrition in Action, and former sports dietitian for the Seattle Mariners baseball team and University of Washington Athletics. “I think that where this all came from is the published data on different sports and different types of athletes,” she says. For example, if athletes in a certain sport tend to have a certain body fat percentage, that can lead to assumptions that all athletes in that sport need to strive for that same number. “To my knowledge, there’s no single study equating body fat to performance. I think there’s been an overemphasis on this. The longer I’ve done this work, the more disordered our culture becomes with eating, and sports are a reflection of our culture. I’ve seen athletes with a higher body fat be fastest on their team; I’ve also seen athletes with a lower body fat be fastest on their team.”
From LEA to Female Athlete Triad to RED-S
The push for certain athletes to lose weight or body fat has a distinct downside. When someone doesn’t consume enough calories to support exercise, activities of daily living, and basic physiological functions, this can lead to a state of low energy availability (LEA). LEA may be compulsive in nature, due to disordered eating or eating disorders. It may be unintentional, to not increase caloric intake to match a high volume of exercise. Or, it can be misguided but intentional, as when someone decreases caloric intake and/or increases exercise to lose weight or body fat, but without an understanding of proper nutrition.6
If LEA is chronic—occurring over many weeks or months—it may impair physiological function, becoming a syndrome known as relative energy deficiency in sport (RED-S), which can have negative, and in some cases irreversible, consequences for multiple body systems, overall health, and athletic performance.6
The International Olympic Committee (IOC) established RED-S in 2014 as a more comprehensive name for what was previously identified as the female athlete triad—which refers to the relationship between LEA, absence of menstruation, and low bone mineral density—both because the nonmenstrual components also are seen in males and because of the complexity involved.7,8 This complexity makes diagnosing RED-S challenging because there isn’t a gold standard set of risk factors and symptoms. LEA and RED-S can include any of the following symptoms:6-8
• irregular menstrual periods;
• lowered testosterone levels;
• compromised bone health;
• increased risk of injuries;
• lowered immune function;
• cardiovascular deficits;
• altered endocrine function;
• impaired protein synthesis;
• altered metabolism;
• mood changes; and
• disordered eating/eating disorder behaviors.
Athletes competing in any sport may be at risk of LEA and RED-S, but athletes in certain sports categories are at a higher risk.
• Athletes in sports that require a high volume of training, such as endurance and ultra-distance sports, or have a high aerobic component, such as soccer or other team field sports, may have difficulty consuming enough calories to offset the high energy demands of their training.
• Athletes in “weight sensitive” sports—such as long-distance running, gymnastics, figure skating, dance, ballet, diving, and synchronized swimming—and “physique sports” such as wrestling, body building, and mixed martial arts intentionally may restrict food intake to promote weight loss due to direct pressure or unwritten expectations. This may be related to beliefs that being lean or “light” improves physical performance or pleases judges in sports with subjective assessments, such as gymnastics and figure skating.9
Recent studies have shown that 45% of female recreational exercisers were at risk of LEA, while another study found a high LEA prevalence in 56% of male and 51% of female elite young athletes.6 Prevalence of LEA among certain National Collegiate Athletic Association Division I athletes has ranged from 41% in cross country runners to 51% in track and field athletes.9
Health Ramifications of RED-S
Van Winkle says that when an athlete begins to restrict food, they often feel faster and report better performance. They even may have a personal record or two. The body also is upregulating hormones that delay fatigue, and this feels good. “Once they have that felt sense of restriction, it’s hard to reach them. They’ll feel fine in their sport, but underneath the surface, all these systems are breaking down,” she says. “I kind of think of it as the cliff effect: They’re running towards the cliff, and eventually they’re going to fall off. Then they’re malnourished and it takes a lot to heal.”
RED-S presents both short- and long-term physiological, psychological, and medical complications, and it’s unclear how severe LEA has to be for these to develop. The commonly used threshold for LEA is <30 kcal of available energy per kilogram of fat-free mass per day, but research shows that muscle protein synthesis is reduced even at this level.7,9 The following are some examples of the effects of RED-S:
Athletes who suffer from chronic LEA may develop nutrient deficiencies, contributing to anemia, fatigue, and increased risk of infections and viral illnesses due to lowered immune function, all of which can harm health, reduce responsiveness to training, and impair performance.7
LEA causes unfavorable lipid profiles and endothelial dysfunction, which increases cardiovascular disease risk. Athletes with RED-S may show abnormalities on an electrocardiogram, such as bradycardia (slow heart rate).7
LEA activates the sympathetic nervous system and the hypothalamic pituitary adrenal (HPA) axis, resulting in numerous neuroendocrine abnormalities. This includes reductions in reproductive hormones, growth hormones, leptin, insulin and metabolic rate, as well as increases in ghrelin and cortisol levels.7,8,10
In female athletes, LEA can lead to menstrual dysfunction and eventually infertility. Research suggests that endurance exercising males can develop a similar suppression of the reproductive function called exercise-hypogonadal male condition, but it’s unclear if excessive exercise or LEA is the primary mechanism.11
Regarding bone health, LEA is an independent risk factor for low bone mineral density, and not only does this increase the risk of stress fractures, but the bone loss may be irreversible. Even subclinical ovulatory disturbances due to LEA may contribute to bone loss in females, and low-testosterone levels have been associated with low bone mineral density in males. The increases in the stress hormones that occur with LEA also have a negative effect on bone density. High-risk stress fractures, such as those of the femoral neck, have been observed in adolescent athletes with RED-S and can have serious long-term consequences.7
Disordered Eating and Eating Disorders
Psychological stress and/or depression can contribute to the development of LEA and eating disorders, and vice versa. The case of Olympic figure skater Gracie Gold, whose extreme caloric restriction led to a clinical eating disorder and depression, derailing her career, is one high-profile example.12 Research suggests that societal and social media influences are increasingly making athletes feel pressured to conform to a certain body type or appearance, even if it adversely affects their sports performance. The estimated prevalence of both disordered eating and clinical eating disorders is higher in athletes than nonathletes and even higher among athletes in weight-sensitive sports with pressure to maintain a lower body weight.9
How Diet Culture Helps Set the Stage for RED-S
Seattle-based dietitian Amanda Bullat, MS, RD, owner of Alpine Nutrition and host of the Savor Food and Body podcast, started running cross country when she was a high school freshman. The seeds of her future eating disorder were planted when her coach performed bioimpedance scans. “I remember being fixated on the fat mass number and thinking I better be leaner to be a better runner,” she says. Despite getting a new coach the following year who focused on training and team building rather than body size or composition, she was running enough on her own that she briefly stopped having menstrual periods.
Then, as a college sophomore, Bullat ran her first marathon—qualifying for the Boston Marathon, earning a junior year walk-on spot on the school’s cross-country team, and getting compliments on the weight she lost while training for the marathon. “That was where the lifestyle behaviors started to change towards disordered eating and a disordered exercise relationship,” she says. “It was another way for me just to validate that this is what it takes to be a collegiate Division 1 athlete.”
Because Bullat wasn’t a recruited scholarship athlete, she flew under the radar while watching her teammates restrict their food intake to try to hold onto their competitive edge. By her senior year, she was running faster than the scholarship athletes, who were too stressed and injured to perform well. “Even though I was still in a disordered place with food and exercise, I wasn’t as disordered as the girls that had been feeling pressure from the university to perform a certain way—and my body wasn’t injured yet.” Still, her periods stopped again for several years—returning after she sought treatment for her eating disorder—and DEXA scans showed she was on the edge of developing osteopenia.
Kara Bazzi, LMFT, cofounder and head of the Exercise + Sport program at Seattle eating disorder center Opal: Food + Body Wisdom, says overemphasizing weight as a factor in athletic performance is missing the boat, given that so many performance factors—such as genetics, sleep, training, diet, coaching, stress level, and mental health—are not weight related. “More importantly, metrics related to the body are not neutral because we live in a weight-biased society,” she says. “We cannot assume that athletes will use this information as just ‘science’ and helpful data. That is being ignorant of the meaning and impact of the data.”
Bazzi gives the example of an overcontrolled athlete, marked by perfectionism and rigid thinking and behaviors, who has low self-worth that’s affected by external performance. “This athlete likely does not have the skills and tools to use the body metric information in such a way as to build confidence as an athlete. Rather, they are more likely to be fearful, controlling, and rigid with their behaviors to ensure they have the ‘right’ metrics that they are told will offer a peak performance,” she says. “This is a common beginning of disordered behaviors within higher level athletics that regularly uses metrics.” On the other hand, she says, athletes who are flexible in their thinking and behaviors, with intrinsic self-worth that isn’t defined by their sport performance would be more likely to take metric information in stride. “Athletes are complex, and we should be treating them as such.”
Unfortunately, body shaming of athletes isn’t limited to the college and professional levels—it’s starting in adolescence. A coach telling a 12-year-old girl that she can only eat cake on her birthday. A middle school cross country coach giving students a list of “Do not eat” and “Acceptable to eat” foods, claiming this would help the team win every race they participate in.
“Once you pathologize someone’s eating you can’t take it back, and you could be setting them up for a potentially fatal eating disorder,” Van Winkle says. “Kids look up to their coaches for everything, so you need to be careful. That’s when their bodies are going through puberty and they’re coming up on their peak bone building years, and you can’t get that time back. I’ve seen so many athletes have osteopenia [low bone mass] at a young age. It doesn’t take that long to set in.”
How Dietitians Can Support Athletes
While the Mary Cain, Gracie Gold, and University of Oregon cases are dramatic and serious symptoms of a systemic problem, it’s important to remember that body shaming isn’t the only trigger for LEA and RED-S. Athletes may face other barriers that make it challenging to follow sport-specific nutrition recommendations.
Research has found inadequate levels of sports nutrition knowledge among a variety of athlete populations and that college athletes significantly underestimate their energy and carbohydrate requirements. One study found that aside from lack of knowledge, the top barriers to adequate calorie intake among a group of NCAA Division III athletes were financial restrictions (food cost is a well-recognized concern for athletes living away from home with limited income), lack of time, and poor access to food options. Athletes also must balance the demands of their sport—training schedule, game schedule, travel schedule—with other stressors, including school, work, social obligations, and family responsibilities. Any of these can inhibit food preparation.9
The good news is that access to a sports dietitian can positively influence nutritional behaviors. The bad news is that athletes who don’t have access to a dietitian are more likely to get their nutrition information from a coach, which could be a problem. Coaches may lack proper nutrition knowledge, have a poor understanding of the risks associated with LEA, believe that leaner athletes perform better, or all of the above. This can lead to inappropriate instructions to lose weight or eat in a way that doesn’t deliver adequate energy and nutrients.9,13 Dietitians can provide accurate nutrition advice for health and performance and advocate for athletes who are being pressured to restrict food intake—or have internalized the belief that they should.
“If athletes hear that they need to change their body fat, keep the focus on performance over appearance,” Van Winkle says. “I see athletes lose their joy for their sport. The beauty is in how our bodies can move, not what they look like.”
The IOC recommends that the potential cost of recommending the consumption of less energy than is expended should be carefully considered before it’s implemented and that data from athletes studied in lab settings may not apply to athletes in free-living situations, which include more psychological stress and more variability in energy deficiency from meal to meal or day to day.7
Van Winkle says she no longer uses body fat calculations. “In our disordered eating culture, people are prioritizing appearance over performance, and that can derail an athlete’s career,” she says, adding that many of her athletes are already on the cusp of LEA, so focusing on these numbers can put them over the edge. “The problem with focusing on data is that most athletes are overcontrolled and type A, and they feel that if a little is good, more is better and they don’t rest. There’s a place for it, but it’s completely overemphasized, and we’re losing the aspect of just talking to the athletes and seeing them as human beings.”
— Carrie Dennett, MPH, RDN, is the nutrition columnist for The Seattle Times, owner of Nutrition By Carrie, and author of Healthy For Your Life: A Holistic Guide to Optimal Wellness.
1. Goe, K. Women athletes allege body shaming within Oregon Ducks track and field program. Oregon Live. October 25, 2021. https://www.oregonlive.com/trackandfield/2021/10/women-athletes-allege-body-shaming-within-oregon-ducks-track-and-field-program.html
2. Butler, SL. Former Oregon runners corroborate accusations of body composition focus in track program. Runners World. October 29, 2021. https://www.runnersworld.com/runners-stories/a38103818/oregon-track-runners-body-shaming/
3. Cain, M. I was the fastest girl in America, until I joined Nike. The New York Times. November 7, 2019. https://www.nytimes.com/2019/11/07/opinion/nike-running-mary-cain.html
4. Ackerman KE, Stellingwerff T, Elliott-Sale KJ, et al. #REDS (Relative Energy Deficiency in Sport): time for a revolution in sports culture and systems to improve athlete health and performance. Br J Sports Med. 2020;54(7):369-370.
5. Chavez, C. Inside the toxic culture of the Nike Oregon Project “cult.” Sports Illustrated. November 13, 2019. https://www.si.com/track-and-field/2019/11/13/mary-cain-nike-oregon-project-toxic-culture-alberto-salazar-abuse-investigation
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7. Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014;48(7):491-497.
8. Mountjoy M, Sundgot-Borgen JK, Burke LM, et al. IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. Br J Sports Med. 2018;52(11):687-697.
9. Jagim AR, Fields J, Magee MK, Kerksick CM, Jones MT. Contributing factors to low energy availability in female athletes: a narrative review of energy availability, training demands, nutrition barriers, body image, and disordered eating. Nutrients. 2022;14(5):986.
10. Dipla K, Kraemer RR, Constantini NW, Hackney AC. Relative energy deficiency in sports (RED-S): elucidation of endocrine changes affecting the health of males and females. Hormones (Athens). 2021;20(1):35-47.
11. Logue DM, Madigan SM, Melin A, et al. Low energy availability in athletes 2020: an updated narrative review of prevalence, risk, within-day energy balance, knowledge, and impact on sports performance. Nutrients. 2020;12(3):835.
12. Crouse, K. Gracie Gold’s battle for Olympic glory ended in a fight to save herself. The New York Times. January 25, 2019. https://www.nytimes.com/2019/01/25/sports/gracie-gold-figure-skating-.html
13. Charlton BT, Forsyth S, Clarke DC. Low energy availability and relative energy deficiency in sport: what coaches should know. International Journal of Sports Science & Coaching. 2022;17(2):445-460.