The female athlete triad has gotten a lot of attention, yet, in recent years it has come to attention that it's not only female athletes who present with these problems, but male athletes are also at risk.
The International Olympic Committee in 2014 drove attention to the ‘impaired physiological functioning status caused by relative energy deficiency in athletes causing all kinds of metabolic, functional, and performance anomalies denominated “Relative energy deficiency in sports” (RED-S) (1)(2) (33)
When an athlete has a negative energy balance they will lose weight from adipose tissue but also protein and muscle mass (1), present adaptive metabolic adjustments to diminish resting metabolic rate, and several detrimental effects on performance and general health (1, 12, 13, 14, 19)
Incidence has been reported in up to 23% of female runners vs 8% of their male counterparts (22)
With an optimal energy balance of 45 kcal/kg of fat-free mass for women and 40kcal/kg in men, an energy intake of less than 30kcal /kg is a useful threshold to consider an athlete's metabolism could start to adapt to low energy availability. (1)(2).
7.4% of International Olympic federations have programs to prevent, guidelines, activities, or screening for RED.S18) (19) (20)
Factors related to a higher risk of RED-S are; women, leanness sports mostly before a competition, low impact, cycling, swimming, dancers, high-calorie restriction, eating disorders and menstrual disorders, duration of weekly exercise, and participation in individual sports(1)(17)
The Low energy availability in females questionnaire has been proven to be a good tool to asses female athletes (11) A similar questionnaire for male athletes and one tool that involves men and the RED-S Clinical Assessment Tool yet none of them are validated (1)(7)(10)
Montjouy, et al 2014 presents the areas of health affected by RED-S such as endocrine and reproductive function. bone health, immunological, metabolic, hematological, growth, development, physiological, cardiovascular and gastrointestinal
All of these alterations prejudice athletes' health, well-being and performance which increases the importance of the entire team to look for red flags in athletes and pay attention to the issue at hand
To appropriately address all of the components that form RED-S it is important to use an interdisciplinary approach with a sports psychologist, nutritionist, trainer, and team physician. Sometimes the assessment of a gynecologist, orthopedist, or endocrinologist might be needed depending on clinical presentation (1)
Interventions such as the increase in energy intake, decrease in training load, educational tools, weight-bearing exercises, and psychological support are proven to restore hormonal, reproductive, bone, and psychological health, therefore increasing productivity and performance and reducing time off training due to sports-related injuries. (30) (2) (31) (5) (7) (8) (32)
To facilitate sports teams to address this we have put together tools to identify who is at risk, address them promptly, establish when it is optimal to return to training, and, if an injury has already occurred, we list some interventions that have been proven beneficial.