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AckermanKE, etal. Br J Sports Med Month 2020 Vol 0 No 0
#REDS (Relative Energy Deficiency in
Sport): time for a revolution in sports
culture and systems to improve athlete
health andperformance
Kathryn E Ackerman ,1,2 Trent Stellingwerff,3,4 Kirsty J Elliott- Sale,5
Amy Baltzell,6 Mary Cain,7 Kara Goucher,8 Lauren Fleshman,9
Margo L Mountjoy10,11
Changing a sport system requires the
appointment of new leaders or a grass
roots cultural revolution. ‘I got caught in a
system designed by and for men, which
destroys the bodies of young girls,’ said
Mary Cain as she cast light on her toxic
coach/athlete relationship and exposed
unhealthy coaching and nutrition prac-
tices. Her candour has inspired a social
media movement calling for changes to
women’s sport.1 In the following days,
major news publications followed up with
similar reports of athletic women being
body shamed.2–4
It is time for a drastic paradigm change
in women’s sport, coupled with educa-
tion at all levels to improve the long- term
health and athletic achievement of female
athletes. The shift needs to include:
1. Raising awareness of the negative ef-
fects of chronic low energy availability
(LEA) (calorie restriction) so athletes
can make wise choices for their own
long- term health.
2. Updating and developing best- practice
protocols and safe standards for moni-
toring body composition/weight.
3. Eliminating toxic training environ-
ments featuring abusive body shaming.
Overexercising or underfueling, occur-
ring consciously or subconsciously, can
cause Relative Energy Deficiency in Sport
(RED- S). RED- S is the ‘impaired phys-
iological functioning caused by relative
energy deficiency, and includes but is
not limited to impairments of metabolic
rate, menstrual function (for females),
bone health, immunity, protein synthesis
and cardiovascular health.’5 Chronic LEA
(over many weeks to years) leading to
RED- S can limit training adaptation6 and
substantially increase injury risk.5 7 8 It
cripples performance in both female6 and
male athletes.5 It can occur unknowingly
without a diagnosed eating disorder.7
There is good news: there are oppor-
tunities to mitigate the occurrence and
effects of RED- S through system- wide
education including prevention/awareness
interventions and by optimising energy
intake. One of these system opportuni-
ties to address RED- S was spearheaded
in Canadian elite sport when B2ten—a
philanthropic group—sponsored a
3- day meeting of 30 key stakeholders in
November 2019. At the table were inter-
nationally renowned topic experts, Cana-
dian coaches from at- risk sports, and
athlete support staff representing both
sport science and medicine, all of whom
work in Canadian, American or British
sport. This group examined the science,
sport cultures, gaps and opportunities
associated with RED- S. Some of the key
themes developed included:
Prevention
►We need to implement awareness
education adapted to female and male
athletes of all ages and sport levels,
and tailored for support staff, coaches
and parents. Educational initiatives
should underscore the positive aspects
of energy, namely, that food is fuel;
and fuel is needed for performance.
Content should include RED- S signs/
symptoms; positive communication
around menstrual cycles and body
image; appreciation of athletes/
sports at higher risk; and best prac-
tices pertaining to body composi-
tion/weight assessment protocols.
We developed a conceptual frame-
work outlining when, and when not,
to implement these methods (see
figure 1).
Diagnosis
►Multicentred research is required to
develop and validate a diagnostic tool
for RED- S.
1Divisions of Sports Medicine and Endocrinology,
Boston Children’s Hospital, Boston, Massachusetts, USA
2Neuroendocrine Unit, Massachusetts General Hospital
and Harvard Medical School, Boston, MA, USA
3Canadian Sport Institute, Victoria, British Columbia,
Canada
4Department of Exercise Science, Physical & Health
Education, University of Victoria, Victoria, British
Columbia, Canada
5Musculoskeletal Physiology Research Group, Sport
Health and Performance Enhancement Research Centre,
School of Science and Technology, Nottingham Trent
University, Nottingham, UK
6Author, Consultant, Olympian, Past- President of the
Association of Applied Sport Psychology, Boston,
Massachusetts, USA
7Professional Runner, Bronxville, New York, USA
8Professional Runner and Olympian, Athlete Advocate,
Boulder, Colorado, USA
9Professional Runner, Athlete Advocate, Bend, Oregon,
USA
10Department of Family Medicine, McMaster University
Michael G DeGroote School of Medicine, Hamilton,
Ontario, Canada
11IOC Medical Commission Games Group, Lausanne,
Switzerland
Correspondence to Dr Kathryn E Ackerman, Sports
Medicine, Boston Children’s Hospital, Boston, MA
02115, USA; kathryn. ackerman@ childrens. harvard. edu
Editorial
Figure 1 A conceptual framework on the implementation of body composition assessments (e.g,
height, weight, anthropometrics, skinfolds, etc.) within the context of athlete stage of development
and their nutritional preparation skills. BC, body composition; LTAD, long- term athlete development
model; TBD, to be determined.
on January 10, 2020 at CASEM. Protected by copyright.http://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2019-101926 on 10 January 2020. Downloaded from
2AckermanKE, etal. Br J Sports Med Month 2020 Vol 0 No 0
Editorial
►RED- S- associated diagnostic factors
may include: chronic dietary restric-
tion and/or extreme diets, drive for
thinness, large changes in body weight
or composition in short time periods,
training inconsistencies, prolonged
fatigue, decreased libido, oligo-
amenorrhoea (missing three or more
menstrual cycles in 6 months), two
or more career bone stress injuries
and low bone mineral density for age
(Z- score <-1.0).5
Treatment
►We must ensure athlete access to a
referral network of RED- S and eating
disorder experts, including sport
and exercise medicine physicians,
registered sport dieticians and sport
psychologists, within each country.
The working group also identified
that certain sports have physiological
and energetic requirements that dictate
that certain athlete phenotypes may be
successful. There was much discussion
about methods to safely improve perfor-
mance while ensuring athlete physical and
mental health. Elite athletes may need to
manipulate energy availability for short
periods to change body composition and
improve their power/force profiles for
critical performance windows. On the
other hand, the working group empha-
sised that prolonged LEA impairs health
and performance.
Modeling the work in sport concussion,
we call for national policies requiring sports
to have RED- S prevention, diagnosis and
treatment protocols, targeting athletes,
coaches and the athlete entourage. Media
and sponsors can raise awareness and
support research in the field. Empowering
athletes to identify and protect themselves
from toxic cultures, and to understand the
importance of energy/food as it relates to
RED- S, is paramount.
As signs and symptoms of RED- S are
present in ~2%–60% of female and male
athletes, depending whether athletes are
in endurance, aesthetic, weight categories
and power/sprint sports,5 7 we believe that
a revolution in sport culture and aware-
ness regarding energy availability can
transform the physical and mental health
and performance of athletes globally.
Twitter Kathryn E Ackerman @drkateackerman
Contributors KEA, TS, KJE- S, AB and MLM attended
the B2ten summit and wrote and revised the
manuscript. MC, KG and LF wrote and revised the
manuscript and provided guidance on the athlete’s
perspective.
Funding The authors have not declared a specific
grant for this research from any funding agency in the
public, commercial or not- for- profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned;
externally peer reviewed.
© Author(s) (or their employer(s)) 2020. No commercial
re- use. See rights and permissions. Published by BMJ.
To cite AckermanKE, StellingwerffT, Elliott-
SaleKJ, etal. Br J Sports Med Epub ahead of print:
[please include Day Month Year]. doi:10.1136/
bjsports-2019-101926
Accepted 30 December 2019
Br J Sports Med 2020;0:1–2.
doi:10.1136/bjsports-2019-101926
ORCID iD
Kathryn EAckerman http:// orcid. org/ 0000- 0003- 2626-
7785
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on January 10, 2020 at CASEM. Protected by copyright.http://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2019-101926 on 10 January 2020. Downloaded from
