Coaches / Teachers

Implications of RED-S for coaches and teachers

Information for coaches/teachers on RED-S

RED-S is a clinical model, which describes the potential detrimental health and performance consequences of low energy availability on health and athletic performance, applicable to male and female athletes/dancers of all ages and level of exercisers from recreational to elite and professional. Coaches and teachers are ideally placed to evaluate their athletes/dancers and identify those at potential risk of RED-S

Evolution of female athlete triad to RED-S

In 2014 the International Olympic Committee described Relative Energy Deficiency in Sport (RED-S), published in the British Journal of Sports and Exercise Medicine. Prior to the description of RED-S, the effects of low energy availability had been well researched in female exercisers. The female athlete triad comprises of low energy availability, resulting in menstrual disruption and ultimately impaired bone health. This triad is now recognised not to be a rigid structure, rather a clinical spectrum in each component, to reflect varying degrees and time scales of energy availability, menstrual function and bone health. So energy availability can range from adequate, with healthy eating patterns matched to requirement, through to low energy availability due to disordered eating and severe energy deficit with an eating disorder involving a psychological aspect. Menstrual functional can vary from regular menstruation, to lack of periods (amenorrhoea) and bone health from normal for age, through to weak bones (osteoporosis). Further evolution of this female athlete triad model, to reflect the growing evidence that the consequences of low energy availability are not limited to the menstrual function and bone health of female athletes, resulted in description of RED-S clinical model. RED-S includes males and a broader range of potential adverse health and performance effects of low energy availability.

Low energy availability in male and female athletes

Key to optimising health and performance is integrated periodisation of training, nutrition and recovery. Low energy availability arises when nutritional intake is insufficient to meet the energy demands of exercise training and fundamental physiological function.
  • Unintentional low energy availability can arise with an increase in training load that is not matched with an appropriately timed increased of nutritional intake. Or underestimation of energy expenditure from exercise outside of training schedule, for example active transport to/from training sessions, study or work.
  • Intentional low energy availability is more prevalent in sport or dance where low body weight confers a performance or aesthetic advantage.

Integrated Periodisation of Training, Nutrition and Recovery (BJSM 2018)

Input from coaches/teachers

Unravelling the causes of under performance in an athlete or dancer is challenging. Coaches and teachers are ideally placed and trained to review the situation.

Low energy availability arises due to non-integrated periodisation of training load, nutrition and recovery. In cases of intentional low energy availability a possible cause is that athletes/dancers may misinterpret corrections to be directed at physical attributes, rather than technique. Where there is an element of subjective selection in athletes, if this this is favoured towards the thinnest candidates, this could also be misinterpreted as endorsement of this physique, rather than on ability. Even where body weight is steady, low energy availability may be present due to high training loads and/or endocrine and metabolic adaptations have occurred to prevent weight loss. So a steady body weight does not rule out low energy availability. There are many examples, including road cycling, long distance running, triathlon, ski-jumping, rhythmic gymnastics, aquatic sports and ballet, where there is a high incidence of RED-S, to mention just a few disciplines (see IOC consensus statements on RED-S)

The symptoms of RED-S in terms of adverse health and performance consequences are not unique to low energy availability, or indeed any issues of non-integrated periodisation of training, nutrition and recovery. Medical conditions per se, not related to training, can potentially cause these symptoms. In other words RED-S is a diagnosis of exclusion. So medical advice may be advisable, not only to rule out treatable medical conditions, but also to quantify parameters such as hormone and nutritional markers reflecting severity of energy deficit. Combined with training metrics such as training load, heart rate, heart rate variability, times/power production etc, this information can be used to track response to strategies aimed at addressing low energy availability and hence return to optimal health and fitness.

Under performing athletes (BASEM 2018)

What to look out for?


Early sport/dance specialisation can place extra energy demands on young athletes already in a high demand state to support their on going growth and development. Therefore careful monitoring of training load is especially important in this age group. Young athletes/dancers not maintaining anticipated gain in height and weight according to their centile line on growth charts should be medically addressed in the first instance.


The timing of puberty varies between individuals of the same chronological age. The onset of puberty may be slightly later in athletes/dancers compared to non-exercisers. Delayed puberty can potentially have long term health consequences, for example in accumulation of peak bone mass (PBM) and hence adverse impact on bone health and increased risk of bone stress injuries with increased age and training load. In girls, regardless of the training load, if periods have not started (menarche) by age 16 years, this is a medical condition called primary amenorrhoea (definition according to Royal College of Obstetrics and Gynaecology), which requires medical investigation to exclude underlying medical causes.

Female Athletes / Dancers

Regardless of how much exercise is being undertaken, any woman of reproductive age, should have regular menstruation (unless pregnant). If this is not the case this indicates that hormones are not at healthy levels. In the first instance medical investigation is required to exclude treatable medical conditions causing amenorrhoea (lack of periods) before a diagnosis of RED-S can be made. Note that hormonal contraception does NOT produce periods, rather withdrawal bleeds due to external synthetic hormones. This can mask amenorrhoea.

Fatigue Levels

Fatigue in an athlete beyond that anticipated for periodised training load and recovery.

Physical Performance

Athletes/dancers not achieving the training response anticipated for given training load.


Recurrent illness requiring time off training


Recurrent soft tissue and bone injury. In particular stress fracture in weight bearing sport. Bone stress response injuries are most likely to occur with increased training loads on moving from junior to senior ranks and on a background of long standing low energy availability as accumulation of peak bone mass can be compromised in young athletes /dancers.

Mental Performance

Impaired concentration, coordination, adaptability and judgement

Disordered Eating and Eating Disorders

Restricted nutritional intake, disordered eating patterns, eating disorders (see Loughborough educational course for coaches on eating disorders in athletes in Resources section)

Mental Health

Psychological factors such as isolation from training peers
Trinity Laban Conservatoire of Music and Dance Health Clinic. JK Photography
Download the Clinical Assessment Tool for Risk Stratification of RED-S

What to do?

Discussing with athlete/dancer that you are coaching is the priority, to determine what steps need to be taken to support optimal health and performance

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 – Coach / Teacher

Female Dancer Case Study – Coach / Teacher

Case Study, Coach / Teacher

“Dancers have to be slim. However it can be difficult to distinguish between those that are naturally slim and those that are eating too little.”

Male Cyclist Case Study – Coach / Teacher

Male Cyclist Case Study – Coach / Teacher

Case Study, Coach / Teacher

“Focusing on resolving nutrition issues alongside reduced training intensity and increased recovery has been key to improving health in this cyclist. From this position, training intensity has been increased, whilst carefully monitoring response to this”


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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