Relative Energy Deficiency in Sport (REDs) represents one of the most pressing health challenges facing today’s elite athletes. REDs encompasses a broad spectrum of physiological and psychological consequences that occur when athletes fail to consume adequate energy to support both their training demands and basic physiological needs..
The condition affects multiple body systems simultaneously—from bone health and cardiovascular function to immune response and mental well-being. Unlike traditional eating disorders, REDs can develop unintentionally as athletes struggle to match their massive energy expenditure with appropriate nutritional intake.
Key Prevention Takeaways
- Education over restriction: Some REDs cases result from knowledge gaps rather than intentional restriction
- Systematic screening: Implement organization-wide protocols rather than relying on individual recognition
- Culture change: Address environmental factors that can create and normalize energy deficiency
- Interdisciplinary approach: Coordinate care across multiple specialties
- Early intervention: Use validated screening tools and clear referral pathways
- Coach education: Involve coaching staff as partners in prevention efforts and identification
Leading Voices in REDs Research and Treatment
Four pioneering specialists brought their expertise to a recent webinar on REDs prevention and treatment:
Dr. Kathryn Ackerman, MD, MPH, FACSM
- Sports medicine doctor, endocrinologist, and former US lightweight rower
- Associate Professor of Medicine at Harvard Medical School
- Member of the IOC REDs Working Group that developed REDs CAT2 clinical assessment tool
- Director of the Women’s Health, Sports, and Performance Institute
Laura Moretti Reece, MS, RD, CSSD, LDN
- Sports dietitian with personal REDs experience as a former athlete
- Director of Nutrition at Women’s Health, Sports, and Performance Institute
- USOPC REDs expert advisory panel member
- Former Head of Healthcare at The Royal Ballet School for 8 years
- Developed systematic, multidisciplinary REDs prevention programs with measurable results
- Founder of Project RED-D for international dance community advocacy
Emilie Burgess Horvath, MS, RDN, CSSD, LDN
- Senior Product Success Manager, Teamworks Nutrition
- 2025 Female Athlete Conference Co-Chair
- Sports Dietitian with USA Track & Field experience
The Hidden Cost of Energy Deficiency
As part of a forward-thinking approach, Karen Sheriff’s research at The Royal Ballet School explored the hidden costs of REDs in a new way, showing that the financial and performance impact of REDs extends far beyond the individual athlete’s health, highlighting that £132,000 was spent annually on REDs-related issues and 4,302 training days were lost or affected due to injuries, illnesses, and performance decrements tied to energy deficiency.
“We did a fundamental and broad cost analysis of what we think we spent on REDs in a year,” Sheriff explained. “That’s through injury & illness, but that’s huge. It affects everyone. It means our athletes are not training, which is why they’re there.”
This analysis provided a proactive approach to highlighting the often-overlooked costs of REDs, underscoring the importance of early identification and prevention.
How Lack of Knowledge and Coaching Challenges Fuel REDs
Many cases of Relative Energy Deficiency in Sport (REDs) stem not from intentional restriction but from a lack of awareness about athletes’ true nutritional needs. Dr. Kathryn Ackerman of the IOC REDs Working Group explains, “There are people who just don’t even know how many calories they need. We have open weight male rowers who just need to eat huge volumes of food. Sometimes they’re opting for a nap rather than going to the dining hall again, thinking they’re doing what their body needs.” The problem is compounded by exercise-induced appetite suppression, which, as Ackerman notes, can dull hunger cues and make it easy for athletes to underfuel.
In prevention, coaches play a pivotal role—but only if properly informed. As Sheriff stresses, “Coaches don’t want to do deliberate harm, right? But they only know what they know. So firstly, how do we educate or change and improve understanding and collaboration?” That education requires space for dialogue between coaches and healthcare providers, a process Sheriff admits is difficult to safeguard but essential. Yet even with awareness, challenges remain: “In a perfect world, the coaching staff is involved and there’s a trusting relationship,” Ackerman says. “There are other times when the coach frankly is the problem, and that’s really hard because the coach might be using old school techniques.”
Systematic Screening: Moving Beyond Individual Assessments
Prevention requires systematic approaches rather than reactive individual treatment. The experts advocated for leveraging the IOC REDs 2023 Consensus Paper, which gives a comprehensive overview of the assessment of REDs and access to the REDs CAT2 clinical assessment tool, which provides a point-based categorization of risk levels.
“The way to use the REDs CAT2 is basically to start by asking screening questions,” Dr. Ackerman explained. “You could do this in a really broad group. You could use one of the validated screening questionnaires.” She emphasized that different questionnaires have been validated in specific populations—the LEAF-Q for elite female endurance athletes, the BEDA-Q for adolescent female elite athletes.
The systematic approach involves three sequential steps: clinical diagnosis through initial screening, comprehensive testing including DXA scans and laboratory work, and application of a point system to determine appropriate intervention intensity based on the collected data.
Practical Screening Strategies for Early Identification
Laura Moretti shared specific screening questions that reveal energy availability issues before they become severe. Her most effective diagnostic question: “Does your fueling change season to season? Does it change when your volume is ramping up? Does it change in periods of lower training?”
“It really should. Nutrition doesn’t look the same all the time,” Laura Moretti-Reese explained.” I am still surprised that I get that answer a lot that no, my food basically looks the same all the time.
Additional warning signs include:
- Unwillingness to fuel before or after workouts
- Consistent fatigue despite adequate sleep
- Recurring stress fractures or injuries
- Loss of menstrual periods in females
- Declining performance despite maintained training
The Culture Change Imperative
Perhaps the most significant prevention strategy involves shifting organizational culture rather than focusing solely on individual athletes.
“We need to step back from just trying to fix the athlete and fix the dancer,” Sheriff emphasized. “If we talk about the athlete or the dancer as the symptom and the problem is the culture.”
Multi-Disciplinary Team Approach
The experts emphasized that effective REDs prevention requires coordinated multi-disciplinary teams rather than individual practitioners working in isolation. This approach recognizes that REDs affects multiple body systems and requires diverse expertise to address comprehensively.
Laura stressed the importance of this collaborative model: “REDs is multifactorial. And it needs to be treated and recognized in such a manner, as well. When we’re discussing our patients, we’re all bringing in our mental health clinicians, dietitians, physicians… we can have broader specialties in these discussions and rounds as well to really put the puzzle pieces together.”
Sheriff’s team at the Royal Ballet School operationalized this approach through systematic data integration. They implemented a “REDs dashboard” using Teamworks AMS, combining multiple health indicators into a comprehensive monitoring system. “We pulled in the relevant bloods, last menstrual cycle, percentage body weight change, the height, their weight, injuries, illnesses, and their wellness score,” Sheriff explained.
The systematic screening occurred three times annually, enabling proactive identification rather than reactive treatment. “We profiled three times a year so we could then go, right, how do we make sure no one’s missed?” This approach allowed the multi-disciplinary team to sit down together, review and integrate the dashboard findings, with any additional clinical and contextual information, to guide timely investigations and interventions, before any symptoms became severe.
The prevention team should include:
- Sports medicine physicians
- Registered dietitians specializing in sports nutrition
- Mental health professionals
- Physiotherapists
- Strength and conditioning coaches
- Athletic trainers
In some contexts, nurses are also integral to ensuring dancers receive comprehensive support.
Implementation Framework for Organizations
Systematic Screening Protocols:
- Implement validated screening questionnaires appropriate for your athlete population
- Create integrated health monitoring dashboards combining multiple indicators
- Establish regular profiling schedules (the Royal Ballet School used three times yearly, reflecting the needs of young athletes)
- Develop clear referral pathways when screening identifies at-risk athletes
Multi-Disciplinary Team Development:
- Coordinate care between sports medicine physicians, registered dietitians, mental health professionals, and strength coaches
- Create regular case review meetings to discuss at-risk athletes
- Establish clear communication protocols between team members
- Include coaches as partners rather than adversaries in the process
Educational Initiatives:
- Provide REDs education for all staff who interact with athletes
- Implement athlete education programs focusing on energy availability concepts
- Create parent education components for youth programs
- Develop coach-specific training on recognizing warning signs
The Path Forward
The experts emphasized that prevention requires sustained effort and cultural change. “Nothing changes until it does,” Sheriff reflected. “There’s just such incredible work going on here and so many impressive people pushing for change.”
Dr. Ackerman highlighted the importance of collaboration: “We have colleagues around the globe who are coming together to spread the same message. And I think that’s going to bring strength in numbers. It’s going to enhance the authority and the reliability of what we’re saying.”
The data is clear: REDs affects a substantial percentage of elite athletes and carries significant costs in terms of both performance and healthcare expenses. However, with systematic prevention strategies, organizational culture change, and interdisciplinary collaboration, sports organizations can protect their athletes while optimizing performance outcomes.
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