The Female Triad
August 16, 2018
Archies Thongs
November 13, 2019



WHAT IS RED-S and why is it so serious?

RED-S refers to the Relative Energy Deficiency in Sport and it needs urgent treatment if recognised. It can have potentially harmful effects to short and long term health, as well as contribute to poor performances in sport.

RED-S is the updated version of The Female Triad and demonstrates that there are more than three factors associated with low energy intake. Thankfully, RED-S can now highlight the physiological effects/dangers for both females and males.

Essentially, this refers to an athlete having an insufficient caloric intake and/or a high energy expenditure, which results in LOW ENERGY AVAILABILITY for the body.
Low Energy Availability is where the individual’s dietary intake is insufficient to support the energy expenditure required for normal health, normal daily function and healthy body systems.

The longer an athlete goes with low energy availability, the worse the impact it is likely to have on their long term health.
If you spend time with lots of endurance sport athletes, it is highly likely you are aware of someone who has RED-S as it is very common.
Typically, these athletes are often injured (with both short and long term issues), train excessively hard all the time, don’t eat enough food, have a number of health issues and are commonly sick.

Some common side effects of this condition, for both sexes, include;
-Altered physiological systems
-Decreased immunity
-Decreased bone density
-Increased likelihood of injury
-Decrease in oral and teeth health
-Decreased protein synthesis
-Decreased muscle strength
-Gut issues
-Changes to mood (irritability, short temper, irrational thoughts, mood swings)
-Decrease to immune health
-Increased strain on cardiovascular health
-Chronically dehydrated

And for athletes, some changes that may hit home more:
-Decreased athletic performance
-Decreased ability to recover
-Decreased protein synthesis
-Decreased endurance performance
-Often sick and performance plateau
-No adaption in training

Some health risks associated with female athletes include:
-Altered or ceasing in menstrual cycle
-Decrease in oestrogen
-Decrease in progesterone
-Low iron levels
-Early onset of osteoporosis and osteoarthritis
-Low body fat

Some health risks associated with male athletes includes:
-Decrease in testosterone
-Decreased sex drive
-Decrease in muscle mass
-Increased body fat
-Increased inflammatory markers

There are no gold standard treatment protocols for RED-S as it is usually a muti-layered and complex issue. There may be psychological factors that may need to be considered as to why an individual is not meeting their required calorie intake for their level of physical activity. Or, it could simply be the athlete is not aware of what foods to consume at what times around their training.
If you feel you may be suffering from RED-S or know someone who is, make sure you get it addressed as the long term effects on health may cause permanent damage.

Some things we do know, however, that can help athletes that may be suffering from RED-S is to alter their training program, improve their training, educate them on the importance of meeting their hydration and calorie needs, aim to enhance recovery methods and refer off to another specialist (such as a dietician, psychologist or sports doctor).
Males may require a testosterone injection to restore normal functioning.

One other factor we do know that can help an athlete recover is to increase their dietary intake of Iron. Iron plays a key role in most physiological functions within the body and holds a key role in improving overall health.
We know that the richest source of iron comes from lean red meats and we also know that the branch chain amino acids (proteins) and other enzymes found in red meat aids in increased uptake for the cells located within our muscles and bones. Often other sources of food high in iron don’t get absorbed by the body due to the chemical make up of the iron, the absence of complete amino acid chains and other enzymes.
But you don’t have to eat red meat!
For athletes who choose not to eat red meat, it is important to eat higher volumes of food and to complement the foods high in iron with fortified whole grains and Vitamin C otherwise the iron can’t be absorbed into the blood steam or muscle cells.
It is important for a Podiatrist to determine these risk factors as it plays a key role in trying to get the athlete recovery and return to sport!

If you or someone you know would like more information about RED-S, please email us on

Happy running everyone 
Ryan Twist
Senior Podiatrist BFAAC

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