Parents / Friends

Implications of RED-S for family/friends

What about RED-S for parents/friends?

Participation in sport and dance is to be encouraged for the range of health benefits in terms of physical, mental and social well-being. However, mismatch of training, nutrition and recovery can have adverse effects on all these aspects of health and performance. Parents and friends are ideally placed to pick up on these warning signs of RED-S.

Why are young athletes/dancers at particular risk for developing RED-S?

Nutrition is especially important for young athletes. This is because exercise training incurs an extra energy demand, on top of the high-energy requirement to support growth and development. The energy demands of daily activities also need to be factored in, such as walking/cycling to and from school/college/ training sessions and within school PE and games activities. Insufficient nutrition intake to cover all these energy demands can result in what is termed low energy availability. This situation can cause adverse effects on growth and development, health and athletic performance, as described in the clinical model of RED-S.

Risk factors for developing low energy availability

  • Early sport specialisation with high training loads and energy demand at a young age
  • Young athletes can be at particular risk in sports/dance where the emphasis is on being a slim physique for performance and/or aesthetic advantages. However there is no doubt that some of these skill-based sports/dance do require acquisition of specific techniques from an early age. Therefore training focused on neuromuscular skills, rather than training intensity may to some extent mitigate low energy availability. Nevertheless, a young athlete aiming to achieve a slim physique, can result in intentional restrictive nutrition practices.
  • Adolescence can be challenging psychologically and physically with changes in body proportions and composition, especially if this means changes that do not conform to favourable physique for a particular sport. The timing of these changes associated with puberty vary from individual to individual, even within the same sport/dance. Comments, corrections and approach from coaches /teachers can be misinterpreted by young athletes, to be directed at physical appearance, rather than technique.
  • The situation can be further complicated if the young athlete/dancer moves to train at a boarding school where it is difficult for parents to monitor behaviour and nutrition intake. Peer pressure can have a big effect: either positive or negative.

What is the significance of RED-S in young athletes?

A young athlete/dancer in low energy availability state is at risk of developing the adverse effects on health and performance in the RED-S clinical model. These young people will not be able to attain their full potential as an athlete/dancer for their training load, as there is insufficient intake of energy to cover demands of growth and development, maintenance of health and exercise training. Therefore training will not produce the anticipated beneficial adaptations to improve athletic performance. Low energy availability can delay puberty, which has been shown to impair accumulation of peak bone mass (PBM), compromise bone health and increase the risk of bone stress injuries. This may not become evident immediately, rather with increased training loads moving from junior to senior ranks when the incidence of stress fracture peaks.

Low energy availability results in suboptimal performance (BJSM 2017)

What about older athletes/dancers?

RED-S can occur at any age and in any level of athlete, both male and female. In older athletes, as friends and teammates, you may notice changes in behaviour, mood and physical appearance and/or performance. Athletes with RED-S may not realise the impact of low energy availability, or be able to accept that anything is wrong. There is a fine line between RED-S and exercise addiction. The key difference is that RED-S stems from a desire to improve athletic performance, whereas exercise addiction is not necessarily performance driven. Primary exercise addiction is where nutrition is not compromised, but adherence to a rigid training plan has social and psychological consequences. Secondary exercise addiction is adherence to a rigid training and nutrition regime in order to control body weight. In other words a version of RED-S which is not necessarily performance driven. Obsession to adhere rigidly to a exercise and nutrition schedule eclipses the original goal of improving athletic performance. Nevertheless, in all scenarios, support from friends and family is key in enabling return to health and fitness.

Addiction to Exercise – what distinguishes a healthy level of commitment from exercise addiction? Dr N Keay BJSM 2017

What to look out for?


Changes in behaviour, for example becoming secretive about nutrition. Tendency to anxiety and/or depression regarding food, physique/weight or training. Problems in interactions with family/friends. Withdrawing from social interactions. Check out the psychological aspects written by Renee McGregor in resources below.


Any deceleration in growth both/either height and weight

Body Weight / Shape

No weight gain with increase in height, loss of weight


Delayed onset of puberty.


Regular menstruation is normal, regardless of how much exercise is being undertaken. Periods are a sign of healthy hormones. In girls, periods not starting by 16 years of age, or in women once started menstruation then stopping for >6 months require medical investigation in first instance to exclude any underlying medical condition. Note that oral contraceptives do NOT produce periods, rather withdrawal bleeds due to external, artificial hormones.


Recurrent illness requiring time off training


Recurrent injury, either soft tissue and/or bone injury


Undertaking extra exercise training. This may mean not “being able” participating in social activities, especially if food involved

Download the Clinical Assessment Tool for Risk Stratification of RED-S

What to do?

Talking with your son/daughter/friend is the first step to addressing any issues. Low energy availability may have arisen inadvertently, or intentionally and will determine what further input and support is required

Case Studies

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

Male Cyclist Case Study – Parent / Friend

Case Study, Parent / Friend

“Living with an athlete with RED-S is not easy! The psychological effects of RED-S have been the most challenging to contend with”

Female Dancer Case Study – Parent / Friend

Female Dancer Case Study – Parent / Friend

Case Study, Parent / Friend

“In full time training away from home, it is difficult to appreciate what is being eaten and the challenges in this closed environment. Apart from overcoming internal conflict, peer pressure to eat less were difficult factors to negotiate. With attentive, informed and integrated support, the motivation to overcome RED-S has come with the realisation that eating well means becoming a fitter, stronger, leaner, more resilient and robust ballerina”


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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