RED-S: What Every Exerciser Should Know
RESOURCES
If you're training for a marathon, competing on horseback, or logging serious mileage week after week, you already know that performance depends on more than willpower. It depends on fuel. When the body consistently takes in less energy than it burns, a condition called Relative Energy Deficiency in Sport (RED-S) can quietly take hold, and it affects far more than the number on the scale.
At RICERP, we work with athletes across Rhode Island who are pushing hard toward a goal, whether that's a marathon finish line, a competitive season, or simply staying strong for the sport they love. RED-S is one of the most under-recognized conditions we see, in part because it can masquerade as "just being disciplined."
What Is RED-S?
RED-S was formerly known as the "female athlete triad," but healthcare providers broadened the term because it can affect athletes of any age, sport, or gender. At its core, RED-S happens when an athlete's energy intake isn't enough to support both daily bodily functions and the demands of training — a state clinicians call low energy availability (LEA).
The body responds to this deficit the way it would to a genuine famine: it starts conserving energy by scaling back "non-essential" functions like reproductive hormones, bone remodeling, and immune defense — even while the athlete keeps training at a high level.
Who Is Most at Risk?
RED-S is most common in sports that emphasize leanness, endurance, or weight class, including:
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Distance running and triathlon
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Cycling
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Equestrian sports (particularly disciplines with weight or aesthetic pressures)
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Gymnastics, figure skating, and dance
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Rowing and wrestling
It can also develop gradually in dedicated recreational athletes who increase training volume without adjusting nutrition to match — a pattern we see often in adults training for their first marathon or triathlon.
Warning Signs to Watch For
RED-S symptoms are often subtle at first and easy to attribute to "just training hard." Signs worth paying attention to include:
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Performance plateaus or declines despite consistent or increased training
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Frequent illness or infections, reflecting a weakened immune response
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Recurrent stress fractures or slow-healing injuries
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Missed or irregular menstrual cycles
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Persistent fatigue or unusually long recovery times after workouts
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Mood changes — increased anxiety, irritability, or low mood
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Preoccupation with food, weight, or body composition that starts to feel rigid or distressing
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Low testosterone or other hormonal shifts in male athletes
Individually, any one of these might seem minor. Together, they're a pattern worth having evaluated.
Why Early Evaluation Matters
Left unaddressed, RED-S can lead to long-term consequences including impaired bone density, cardiovascular strain, fertility issues, and a progressively harder road back to full performance. The encouraging news is that RED-S is treatable, and most athletes can return to their sport — often performing better than before — once energy availability is restored.
The key is distinguishing between a straightforward fueling gap and a more complex relationship with food and exercise, which may indicate an underlying eating disorder. That distinction matters because it changes the treatment approach, and it's exactly the kind of assessment a multidisciplinary team is built for.
How RICERP Approaches RED-S
RICERP was founded specifically to serve the overlap between eating recovery and athletic performance — a space that a single provider often can't cover alone. Our team-based model brings together:
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Psychiatric care to evaluate mood, anxiety, and the psychological patterns that can drive under-fueling
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Therapy to address the beliefs and behaviors around food, body image, and exercise
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Nutrition counseling from a registered dietitian who understands athletic fueling, not just general nutrition
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Movement coaching to help athletes rebuild a healthy, sustainable relationship with training
This combination allows us to help athletes fuel appropriately, protect their long-term health, and stay connected to the sports they love — rather than choosing between performance and wellbeing.
When to Reach Out
If you're an athlete, parent, or coach noticing warning signs — or a physician or athletic trainer who wants a referral partner for these cases — RICERP offers outpatient evaluation and treatment for RED-S and related conditions in Rhode Island.