Prevention and Treatment of REDs

With improved education, understanding, and awareness of REDs, we can work together to prevent REDs before it begins and treat those presently impacted by REDs, athletes and non-athletes alike.

A multidisciplinary team is crucial in the prevention, diagnosis, monitoring, and treatment of REDs. REDs is multifactorial, and treatment must be tailored to each athlete’s individual needs, making sure medical, nutritional, physiological, and psychological professionals are involved in supporting the athlete (7, 8). Read below for specific information regarding prevention and treatment. For treatment and diagnosis, please contact a sports medicine physician trained in REDs, as well as a registered dietitian with experience in sports nutrition and REDs.

Prevention

Our goal is to catch REDs before it begins. We can do so through education, nutrition, and screening.

  • Increasing awareness among athletes and those around them is the foremost strategy to prevent REDs. Surveys in athletes, coaches, and healthcare personnel have shown:

    • Around 50% of surveyed individuals who identified as women did not know that menstrual dysfunction was related to poor bone health (1).

    • Less than 50% of surveyed physicians, coaches, physiotherapists, and athletic trainers were not able to identify the components that make up the Triad (2).

    • 1 out of 3 of surveyed individuals who identified as women thought menstrual dysfunction was a normal effect of exercise (3).

    By learning more about REDs and sharing these understandings with others, we can correct misinformation and inform both research and clinical practice that prevents REDs.

  • Ensuring one’s body is receiving the necessary nutrition and hydration is a crucial step in preventing REDs (4). It can be extremely easy for athletes to under-fuel when activity level is high, whether or not this under-fueling is intentional or by accident. Strategies to improve nutrition can include, but are not limited to:

  • Recent research has highlighted the ability of screening tools to assess individuals for energy availability. These tools, however, are currently only applicable under administration and guidance from a knowledgeable physician. To be screened for REDs and/or REDs risk factors, individuals should seek out medical treatment and guidance from a provider. The IOC REDs CAT2 (REDs Clinical Assessment Tool - Version 2) provides medical providers with a screening tool to categorize an athlete’s risk/severity of REDs.

Treatment

REDs can have significant health and performance consequences, both in the short and long term. It is important that REDs is treated in order to enhance recovery, to restore health and wellbeing, and to promote athletic performance.

  • To recover from REDs, which is defined as an imbalance of energy, one must restore the energy balance that has been perturbed. Our tips for restoring this energy balance are similar to those tips provided for proper fueling for REDs prevention, which includes:

    • Increasing energy intake by:

      • Consuming energy-dense food

      • Eating consistently throughout the day

    • Decreasing energy expenditure due to exercise, if one’s energy expenditure is too high

    • Ensuring proper nutrient distribution, which may include:

      • A focus on carbohydrate intake

      • Adequate intake of bone building nutrients, such as:

        • Calcium

        • Protein

        • Magnesium

        • Phosphorus

        • Vitamin D

        • Potassium

        • Fluoride

  • One driving factor behind the development of REDs symptomology can be disordered eating, or an underlying clinical eating disorder, whether it has or has not yet been diagnosed by a medical professional. Addressing these eating, psychological, and medical concerns can help to improve an athlete's relationship with food, as well as prevent future under-fueling. Current guidelines suggest that the best treatment for such conditions will arise from a multidisciplinary care team comprised of:

    • A physician

    • A dietitian

    • A mental health professional

    Seeking appropriate treatment from a specialized care team will best support the full recovery of individuals impacted by REDs.

  1. Belsha JP, Eissa MA, et al. Female adolescent athletes' awareness of the connection between menstrual status and bone health. J Pediatr Adolesc Gynecol 2011;24:311–4.

  2. Curry EJ, Logan C, Ackerman K, et al. Female athlete triad awareness among multispecialty physicians. Sports Med Open 2015;1:38

  3. Brown KN, Wengreen HJ, Beals KA. Knowledge of the female athlete triad, and prevalence of triad risk factors among female high school athletes and their coaches. J Pediatr Adolesc Gynecol 2014;27:278–82.

  4. Kuikman MA, Mountjoy M, Stellingwerff T, Burr JF. A Review of Nonpharmacological Strategies in the Treatment of Relative Energy Deficiency in Sport. Int J Sport Nutr Exerc Metab. 2021;31(3):268-275.

  5. Ackerman KE, Holtzman B, Cooper KM, et al. Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport Br J Sports Med 2019;53:628-633.

  6. 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;52:687-697.

  7. Stellingwerff T, Heikura IA, Meeusen R, et al. Overtraining Syndrome (OTS) and Relative Energy Deficiency in Sport (RED-S): Shared Pathways, Symptoms and Complexities. Sports Medicine. 2021;51(11):2251-2280.

  8. Torstveit MK, Ackerman KE, Constantini N, Holtzman B, Koehler K, Mountjoy ML, Sundgot-Borgen J, Melin A. Primary, secondary and tertiary prevention of Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the IOC consensus on REDs. Br J Sports Med. 2023 Sep;57(17):1119-1126. doi: 10.1136/bjsports-2023-106932. PMID: 37752004.