Athletes / Dancers

What are the implications of RED-S for athletes and dancers?

Reaching your goal: performing at your best

To reach your full potential as a dancer or athlete you need to be healthy both physically and mentally. In practical terms this means achieving the optimal timing, amount and type of: Training, Nutrition, Recovery Integrated periodisation of these key factors is crucial to achieve the adaptations to training to achieve your objectives: whether this be competing in an Ironman or dancing in a role on stage.

Issues with inputs for performance: low energy availability

Low energy availability arises if nutritional intake is insufficient to cover the energy demands of both training and resting metabolic “housekeeping” processes. In the situation of low energy availability, which can often be combined with the effects of external psychological stress and inadequate sleep, the body goes into an energy saving mode. For example many hormone pathways are dampened, such as the hormones of the reproductive axis in both male and female exercisers. Even short-term troughs of low energy availability during a day can cause adverse changes in hormones. Everybody is individual and you may have different fuel requirements to a fellow athlete/dancer doing the same training. Tailored timing, quantity and quality of nutrition according to gender, age, sport/dance is important to support health and effective training.

Cumulative low energy availability over days and months results in suboptimal growth and development in young athletes, impaired health and ultimately below expected athletic/dance performance for given training loads.

  • Low energy availability can arise unintentionally, for example an increased training load, race or performance schedule not matched by an increased energy intake. Or a situation of underestimating energy requirements for exercise outside of formal training: for example cycling to/from a training session. Small daily energy deficits accumulate.
  • Low energy availability can also result from an intentional strategy to achieve and maintain a low body weight for a performance or aesthetic advantage. You will not necessarily lose weight in the face of sustained low energy availability, due to  biological compensatory mechanisms to slow metabolism. Although initially you may feel that nothing is wrong and your athletic/dance performance is maintained, or even improved; in the long term energy deficit is not sustainable for either health or athletic performance.

The longer a low energy availability situation continues, the harder it can become to restore health and performance from a physical and psychological point of view.

What to look out for?


In females, menstrual dysfunction this is a warning sign that hormones are not at healthy levels. All women of reproductive age, whether an exerciser or not, should have regular menstrual cycles. Regular periods are a barometer of health.

  • Regardless of the amount of exercise being undertaken, if periods have not started (menarche) by age 16 years, this is known as primary amenorrhoea.
  • Once menstrual cycles have started, if periods stop for >6 months, this is called secondary amenorrhoea 
  • Oligomenorrhoea is where <9 periods occur during a calendar year. In all cases, in the absence of pregnancy. These are definitions from Royal College of Obstetrics and Gynaecology.

Note that hormonal contraception does NOT produce periods, rather withdrawal bleeds due to external medication (rather than your own internally produced hormones). Hormonal contraception masks underlying menstrual issues and does NOT protect against the adverse effects of RED-S



In male adult athletes/dancers lack of morning erections can be a sign that testosterone levels are low due to low energy availability

Young Athlete / Dancer

Growth issues with deceleration of expected height and weight gain (“falling off” growth centiles for an individual) can indicate insufficient energy availability. Individuals mature and go through the changes of puberty at different chronological ages. So don't directly compare yourself to other dancers/athlete of your age. Rather very delayed, or arrested puberty can be warning signs of low energy availability in an individual.

Injury and Illness

Although injury is a risk in all athletes/dancers, recurrent injury (bone and/or soft tissue) and illness in both male and female athletes/dancers > 3 months and requiring time off training can be a consequence of low energy availability

Bone Injury

Bone stress responses, in particular stress fractures in weight bearing exercise, when increasing training load moving from junior to senior ranks

Disordered Eating Patterns

Behaviour around food, including restrictive nutrition, avoidance of certain food types (eg carbohydrates: orthorexia), or extreme exercise patterns directly related to eating patterns.

Eating Disorder

Disrupted eating patterns, with a psychological overlay

Body Weight

Intentional rapid weight loss and/or sustained low body weight (not limited to duration of race season). Note that even in absence of weight loss, you may be in a state of low energy availability as the body has compensated for low energy intake by reducing resting metabolism and adopting an energy saving mode

Digestive Problems

Constipation, bloating

Sleep Patterns

difficulty sleeping, disrupted sleep. Feeling tired, lethargic

Mood/Behaviour Changes

Feeling anxious, depressed, lacking motivation

Impaired Athletic/Dance Performance

For example, not hitting times in training, or getting slower. In dance reduced balance, or lack of sharpness picking up steps/corrections.
Download the Clinical Assessment Tool for Risk Stratification of RED-S

What to do?

Note that these symptoms are not diagnostic of RED-S: in other words can be caused by other conditions or situations. These conditions should be excluded and treated as required before arriving at a diagnosis of RED-S. If in doubt, discuss with your coach/teacher/parent/physio initially to see if medical input required. Ask your GP to refer you to NHS clinic at RNOH, London, Dr Roger Wolman
Note that you don’t have to experience all of the symptoms above to have RED-S. Most likely you will only experience a few and maybe none in the early stages of low energy availability.

Case Studies

Throughout this site we will relate the resource to real life case studies experienced by a Female Dancer and a Male Cyclist
Female Dancer Case Study – Athlete

Female Dancer Case Study – Athlete

Athlete / Dancer, Case Study

“I have always been a slim build and told I have an ideal physique for Ballet. However, on starting full time training there were other students who were thinner and eating less. I did the same. However, I did not become a better dancer. My periods stopped and I couldn’t dance due to bone stress response. Logically I knew this was not a good situation, but I found it really difficult to accept that I had to eat more again and regain my lost weight. However with support from my…

Male Cyclist Case Study – Athlete

Male Cyclist Case Study – Athlete

Athlete / Dancer, Case Study

“The holy grail of competitive road cycling is to achieve maximal power to weight ratio in terms of Watts/KG. What started out as “healthy eating” to achieve this goal became an unhealthy obsession to restrict nutrition and lose weight. Sleep and mood changes became problematic and my on bike performance suffered.”


RED-S discussion Sunday 10 February St John’s College, Cambridge

RED-S discussion Sunday 10 February St John’s College, Cambridge


Workshop to discuss Relative Energy Deficiency in Sport (RED-S) with clinically qualified professionals. All welcome athletes, dancers, coaches, students. Sunday…

Relative energy deficiency in sport (RED-S): What all health professionals need to know

Relative energy deficiency in sport (RED-S): What all health professionals need to know


Sports Injury Bulletin, Dr N Keay, Sport and Dance Endocrinologist writes: RED-S can occur in athletes of all ages and…

Successful Ageing BASEM

Successful Ageing BASEM


British Journal of Sports and Exercise Medicine, Dr N Keay, Sport and Dance Endocrinologist writes: RED-S can occur in athletes…

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