With the recent breaking of the New York Times op-ed featuring Mary Cain and the mental and

physical abuse she suffered while a part of the Nike Oregon Project, eating disorders and

Relative Energy Deficiency in Sport (RED-s) have been pushed into the spotlight. It is of utmost

importance that parents, coaches, teammates and friends are aware of this phenomenon and

know some basic “first aid” for how to address it.

First of all, what is RED-s? Formerly known as the Female Athlete Triad, RED-s is the umbrella

term for symptoms resulting from low energy availability, or when nutrient intake (food) is

insufficient to meet expenditure (metabolic demands). The result of this long-term energy

deficiency is a negative impact on cardiovascular, bone, reproductive, endocrine and mental

health, as well as poor immune function and stifled protein synthesis. In 2014, the International

Olympic Committee acknowledged that low energy availability also occurs in males, thus

transitioning the terminology from the Female Athlete Triad to RED-s. Physical symptoms of

RED-s can include:

● Missed menstrual cycles (amenorrhea)

● General fatigue

● Bradycardia (low heart rate)

● Weight loss

● Hair loss and brittle nails

● Decreased physical performance/response to training

● Depression/altered mood

● Poor tolerance to cold

It is also important to note that these symptoms can be present even in those with normal

weight, BMI and body composition. While missed menstrual cycles have been the gold standard

to diagnose the condition, this becomes irrelevant in males and in women on birth control,

rendering attention to other symptoms even more important.

Endurance athletes are especially susceptible to the development of RED-s, due to intense

training schedules and the incentive to get thinner in order to run faster. While there may be

some performance gain with lower body weight, there is a fine and dangerous line between

improved races and serious decline in health. Long-term energy deficiency has been linked to

bone stress injuries, infertility, increased cardiovascular disease risk and the potential for early

onset of neurodegenerative disease. It is a very high price to pay for short-term benefit, or

perhaps even no benefit at all.

This topic is one that is near and dear to my heart. Like Mary, I had a “magic number” too. She

mentions that her coaches wanted her to be 113 pounds. She is 5′ 7″. Mine was 112, and I’m 5′

2″. This weight was below my healthy set point and was enough to lead to other health

complications, so you can imagine what this would do for a woman five inches taller than me.

As I pursued faster running times and a body more similar to my running idols, I got my first period very late in life (at the age of 21) and sporadically lost regular cycles while marathon training in college and graduate school.

Knowing what to do if you suspect that a friend, child, teammate, etc. is suffering from

disordered eating or RED-s can be really difficult. The first thing to acknowledge is that no

matter your relationship with the affected person, are not going to fix the problem. This is a team

effort, and the most important action to take is one of support and concern. Starting an open

dialogue and simply asking, “How are you? Are you doing okay?” can be enough. Mention the

symptoms you notice, but try to avoid talking about weight, as weight loss is often a point of

pride in this situation. Express concern for her health, and suggest a check-in with her primary

care physician or general practitioner. The athlete has to come to her own conclusion and

ultimately make the decision to change her habits. More often than not this requires a “team,”

including a psychologist who specializes in eating disorders, a nutritionist and a nurturing


Culture around weight, body composition and performance starts at the team level, particularly

in high school. If you are a coach, you carry the responsibility of creating a positive team

environment and curtailing these issues before they begin. First and foremost, a coach should

promote a healthy relationship with food and body image. Any comments about dissatisfaction

with weight/body should be avoided, and you should only use positive language when speaking

about your own body. Have an open conversation about changes in running performance that

coincide with development. Set expectations that worse race performances during puberty are

normal and that the runner’s best races are ahead of him or her. Lastly, look up local mental

health professionals and counselors, and be ready to refer one of your athletes if needed.

Many athletes have spoken out about their experience with RED-s, and it may be impactful to

refer someone who is struggling to articles and podcasts on this topic:

Amelia Boone:


Mario Fraioli:


Jesse Thomas:

Lauren Fleshman:

Dotsie Bausch:

If I can help anyone navigate this process, please don’t hesitate to reach out to me directly at I am more than happy to offer suggestions or solutions.

Stay happy and healthy,

Dr. Kacy Seynders PT, DPT


Mountjoy M, Sundgot-Borgen J, Burke L, et al Authors’ 2015 additions to the IOC

consensus statement: Relative Energy Deficiency in Sport (RED-S) British

Journal of Sports Medicine 2015;49:417-420.